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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 and chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with hx of afib on coumadin, CAD s/p DESx3 in ___,
___, with recent fall 4 days ago, who presents with SOB and
chest pain.
Patient was admitted to plastic surgery on ___ after she
fell and suffered facial trauma s/p exploration of L orbital
floor fracture and L maxillary sinus w/ removal of foreign body.
Today, she experienced sudden onset SOB and CP 45 minutes before
ED arrival.
In ED initial VS: T 98.6, HR 135, BP 155/119, 94-99% NC
(intermittently)
Labs significant for:
-Normal Chem7 with Cr 0.8
-WBC 15.4
-H/H 10.1/30.5 -> 8.2/25.5
-INR 1.4
-Lactate 2.9 -> 1.6
-Trop negative
Patient found to be in afib with RVR in 130s and received 2
doses of IV and 1 dose of PO diltiazem. ALso placed on a
diltiazem drip which was stopped after she became hypotensive to
73/57. At that point she received an LIJ and started on
levophed.
Worked up for PE with CTA that was negative for embolus but
suggested pulmonary edema and pleural effusions with possible
superimposed infection. Started on levofloxacin. Also
empirically treated for C. diff for foul smelling stool with IV
flagyl.
Of note, patient had a Hb drop from 10.1 to 8.2 and had guaic
positive stools. She received 500 cc and 1U RBC in total in ED.
On arrival to the MICU, patient was not in acute distress, in
positive mood, speaking with providers. She denied recent fever,
cough, lower extremity edema, weight gain, abdominal pain,
dysuria. Her symptoms of SOB and chest pain were very acute.
Besides that, she only endorsed having episodes of nonbloody
diarrhea. No melena.
Past Medical History:
- Atrial Fibrillation (on diltiazem, metoprolol and warfarin at
home)
- Moderate-Severe Mitral Regurgitation
- Heart failure with PRESERVED ejection fraction (had transient
severe reduction in ___ in setting of acute MI caused by RCA
lesion in ___, EF at that time 20% as measured by LV-gram)
- CAD s/p 3 DES ___ (on review of ___ records: s/p MI c/b
cardiogenic shock in ___ after R total hip replacement
surgery with peak TropI of 30.5, at which time she had 2x stent
to RCA and 1x stent to LAD and also required an IABP x2 days;
also had a smaller MI in ___ with peak TropI of 0.10)
- Hypertension
- Hyperlipidemia
- H/o CBD stone s/p mechanical lithotripsy, ERCP w/ CBD stent
placement, repeat ERCP for successful removal of CBD stent
(___)
- H/o scoliosis and extensive lumbar spondylosis
PAST SURGICAL HISTORY:
- Phacoemulsification with posterior chamber intraocular lens
implant (left eye, ___
- S/p right total hip replacement surgery ___, ___
___)
- S/p lumbar decompression L2-L3, L3-L4, L4-L5 ___, ___
___)
- S/p bilateral laminectomy of L4 and L5 for sciatic symptoms
___, ___)
- H/o fracture of anterior arch of C1 and small nondisplaced
fracture of left nasal bone
Social History:
___
Family History:
Father died of an MI at ___ years of age.
Mother died of MI at age ___. Has a sister who has no heart
problems.
Physical Exam:
=======================
ADMISSION PHYISCAL EXAM
=======================
VITALS: ___ F HR 105 BP 118/90 98% RA
GENERAL: Alert, oriented, no acute distress
HEENT: multiple facial ecchymoses,, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: transient mild crackles in left mid-lung, no wheezes
CV: tachycardic, irregular rate and rhythm, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Neither warm nor cold, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
=======================
DISCHARGE PHYISCAL EXAM
=======================
VITALS: T98.2 BP 118 / 82 HR 88 RR 18 SpO2 95 Ra
WEIGHT: 60.69 kg
TELEMETRY: Afib, HR ___ to ___ with occasional spikes to 130s
when patient moving.
PHYSICAL EXAM:
GENERAL: Elderly woman with multiple contusions and lacerations
on face, comfortably lying in bed in NAD.
HEENT: Facial contusions and laceration present. Sclera
anicteric. +R conjuncitivtis. MMM.
CARDIAC: Normal rate, irregularly irregular, normal S1, S2. No
murmurs/rubs/gallops. No rashes observed.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No BLE edema. RUE in splint.
SKIN: Facial contusions and lacerations.
PSYCH: No visual hallucinations today. Alert and oriented x3.
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 10:08PM ___ PTT-25.2 ___
___ 10:08PM WBC-15.4*# RBC-2.90* HGB-10.1* HCT-30.5*
MCV-105* MCH-34.8* MCHC-33.1 RDW-12.8 RDWSD-48.4*
___ 10:08PM proBNP-4394*
___ 10:08PM ALBUMIN-3.9
___ 10:08PM cTropnT-<0.01
___ 10:08PM ALT(SGPT)-13 AST(SGOT)-22 ALK PHOS-70 TOT
BILI-0.7
___ 10:08PM GLUCOSE-175* UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17
___ 10:40PM ___ PO2-25* PCO2-37 PH-7.45 TOTAL CO2-27
BASE XS-0
======================================
DISCHARGE/PERTINENT LABORATORY STUDIES
======================================
___ 06:45AM BLOOD WBC-10.0 RBC-3.28* Hgb-11.1* Hct-34.0
MCV-104* MCH-33.8* MCHC-32.6 RDW-14.5 RDWSD-54.1* Plt ___
___ 06:45AM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-138
K-5.0 Cl-99 HCO3-27 AnGap-12
___ 06:45AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.2
===============
IMAGING STUDIES
===============
---- P-MIBI ___ ----
FINDINGS: Study quality limited due to patient motion and
positioning.
Left ventricular cavity size is 49 mL. Rest and stress perfusion
images reveal moderate fixed defects of the septum and
inferolateral wall, however the quality of the images is
decreased secondary to patient motion. Therefore, attenuation
cannot be ruled out. Gated images reveal normal wall motion. The
calculated left ventricular ejection fraction is 57%
IMPRESSION: Evidence of moderate fixed septal and inferolateral
wall defects, please see above comments. Normal ventricular
size and systolic function.
---- CXR ___ ----
IMPRESSION: Bibasilar hazy opacities, which may reflect
combination of atelectasis and small effusions, slightly
increased. Minimal edema stable.
---- Echo ___ ----
IMPRESSION: Suboptimal image quality. Moderately depressed left
ventricular systolic function consistent with multivessel
coronary artery disease. Right ventricular apical hypokinesis.
Moderate to severe tricuspid regurgitation (clip#64). Mild
pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
the left ventricular systolic function is worse. The severity of
tricuspid regurgitation is worse; the regional wall motion
abnormalities are new. Severe pulmonary hypertension is no
longer appreciated.
---- Echo ___ ----
Overall left ventricular systolic function is low normal (LVEF
50-55%). There is no ventricular septal defect. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with normal free wall contractility. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is severe pulmonary artery systolic
hypertension.
---- CXR ___ ----
1. Cardiomegaly, mild pulmonary edema, and small bilateral
pleural effusions.
2. Increased prominence of right upper and lower lung opacities
may be due to pulmonary edema or infection.
---- CT Chest ___ ----
1. No pulmonary embolus or evidence of aortic injury.
2. Cardiomegaly, diffuse ground-glass opacity likely
representing moderate pulmonary edema, and small bilateral
nonhemorrhagic pleural effusions suggest cardiac decompensation
with possible superimposed infection.
3. Right lateral nondisplaced seventh rib fracture, possibly
subacute.
4. No pneumothorax. No evidence of intra-abdominal traumatic
injury.
5. 1.3 cm left adrenal nodule, incompletely assessed. See
radiology report
============
MICROBIOLOGY
============
___ Blood Culture: NO GROWTH.
___ C Diff: Negative
___ Urine Culture: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Atorvastatin 80 mg PO QPM
3. Furosemide 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Propranolol LA 60 mg PO DAILY
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Diltiazem Extended-Release 240 mg PO DAILY AFib
8. Lisinopril 5 mg PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
10. Iron Polysaccharides Complex ___ mg PO DAILY
11. Warfarin 1 mg PO QOD
12. Warfarin 2 mg PO QOD
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Digoxin 0.0625 mg PO DAILY
5. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
6. Metoprolol Succinate XL 150 mg PO DAILY
Please start on ___
7. Lisinopril 2.5 mg PO DAILY
8. Warfarin 1 mg PO DAILY16
9. Atorvastatin 80 mg PO QPM
10. Iron Polysaccharides Complex ___ mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until you follow up with your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Atrial fibrillation with rapid ventricular rate
Coronary artery disease
Acute on chronic heart failure with reduced ejection fraction
Urinary tract infection
SECONDARY:
Facial Contusions
Gastroesophageal Reflux Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with hypotension/gi bleed// central line placement?
TECHNIQUE: Portable supine AP chest
COMPARISON: Chest CT and radiograph from ___.
FINDINGS:
Interval left internal jugular central venous catheter terminating in the mid
to lower SVC. No pneumothorax. Lungs are moderately well expanded interval
improvement in pulmonary edema and right lower and upper lung opacities.
Cardiomediastinal silhouette remains prominent. Likely stable small bilateral
pleural effusions.
IMPRESSION:
1. Left internal jugular central venous catheter in appropriate position.
2. No pneumothorax. Stable small bilateral pleural effusions.
3. Improved pulmonary edema in right upper and lower lung opacities.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ year old woman with CHF who presented with acute SOB, found to
have hypotension of unclear etiology// Eval for change in pulmonary edema or
consolidation
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph ___
FINDINGS:
Interval increase in small left pleural effusion. Stable small right pleural
effusion. No acute focal consolidation or pneumothorax. Interval improvement
in mild pulmonary edema. Stable mild enlargement of the cardiomediastinal
silhouette. A left central venous catheter is seen in unchanged position.
IMPRESSION:
Interval increase in small left pleural effusion. Improvement in pulmonary
edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman af RVR with new SOB// eval for interval pulm
edema
TECHNIQUE: 2 frontal views of the chest
COMPARISON: ___
FINDINGS:
Minimal edema stable. Left basilar hazy opacity, which may be on the basis of
atelectasis and small left effusion, slightly increased. New hazy right
opacity, which could reflect combination of atelectasis and trace right
effusion. No pneumothorax. Left central line has been removed. Moderate
cardiomegaly stable.
IMPRESSION:
Bibasilar hazy opacities, which may reflect combination of atelectasis and
small effusions, slightly increased. Minimal edema stable.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Tachycardia
Diagnosed with Unspecified atrial fibrillation, Pneumonia, unspecified organism
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 1.0 | ================
PATIENT SUMMARY
================
Mrs. ___ is a delightful ___ yo woman with history of afib
on coumadin, CAD
s/p DESx3 in ___, HFpEF, with recent fall with resultant facial
fractures, who
presented with SOB, chest pain, and afib with RVR - initially
admitted to the CCU, however with transfer to the Cardiology
floor s/p Digoxin loading and improved heart rate, with course
complicated by UTI.
#CORONARIES: S/p stent (RCA x1, LADx2 at ___)
#PUMP: EF 35%
#RHYTHM: Af
==============
ACUTE ISSUES
==============
#CAD s/p stent (RCA x1, LADx2 at ___)
#Chest Pain: Not on Plavix, but is on aspirin. Mrs. ___
developed new chest pain during her hospitalization, with new
TWIs found in V4-V6. She was started on a Heparin gtt and
continued for 48 hours. Her Troponins were 0.03 x3. We obtained
a P-MIBI, which showed evidence of moderate fixed septal and
inferolateral wall defects and normal ventricular size and
systolic function. She was continued on ASA 81mg, Atorvastatin
80mg, a reduced dose of lisinopril 2.5mg, and an increased dose
of fractionated Metoprolol as per below.
#HFrEF (LVEF 35%): On furosemide 20 mg daily at home. Throughout
her hospitalization she has not seemed fluid overloaded, and as
such her home Lasix was held. She was started on an increased
dose of fractionated Metoprolol, and she was continued on home
Lisinopril. Of note, she will need a repeat TTE in ___ months
to re-evaluate her reduced LVEF. On discharge, her home
Furosemide was held. Discharge weight 60.69kg
#Atrial fibrillation with RVR: At home, was on propranolol and
diltiazem - both of which were discontinued during this
hospitalization. On admission she was found to have HR to 130s
and 140s. She initially required IV and PO Diltiazem, but then
developed hypotension requiring Levophed while in the CCU (which
was ultimately weaned). Of note, she had a CTA that was negative
for PE. She was loaded with Digoxin, which showed improvement in
her HR. She had Digoxin levels that were initially elevated, and
as such her Digoxin dose was held at times. She was discharged
on a Digoxin dose of 0.0625mg PO daily. She was continued on her
home warfarin and started on fractionated Metoprolol. She was
discharged home with the following medications: digoxin 0.0625mg
PO daily, metoprolol XL 150mg, and warfarin 1mg daily.
#UTI: UA showed large ___, 7 RBC, 12 WBC, few bacteria, and 1 Epi
- consistent with UTI. Mrs. ___ was treated with Augmentin
500mg q8 hours (initially per Plastic Surgery for her facial
contustions), as this provided good coverage. Urine culture
showed no growth. Augmentin continued for 10-day course from
last discharge, finished ___.
#Diarrhea
#Fecal incontinence: Noted upon transfer to the general
cardiology floor. No saddle paresthesias or lower extremity
weakness on exam, thus less likely cord compression. It seemed
most likely related to diarrhea (likely in the setting of
Augmentin) and difficulty ambulating to the restroom in time. We
obtained a C. Difficile test, which was negative. Diarrhea
improved and was resolved on discharge.
#Right eye conjunctivitis
Treated with erythromycin eye drops QID for 1 week ___ to
___. Resolved at discharge
===============
CHRONIC ISSUES
===============
#Facial sutures s/p plastics procedure: Continued Augmentin
500mg q8 hours x10 days from last discharge, finished ___
#GERD: Continued home pantoprazole 40 mg daily
====================
TRANSITIONAL ISSUES
====================
[ ] Stopped home propanolol and diltiazem and started on
metoprolol XL 150mg daily and digoxin 0.0625mg daily. Would
follow-up blood pressure and heart rate on these new medications
and adjust accordingly
[ ] Held home furosemide at discharge and patient euvolemic on
discharge. Would follow-up fluid status and weight as
outpatient. Restart furosemide if she gains ___ pounds above her
dry weight or develops any signs of volume overload.
[ ] Repeat TTE in ___ months to re-evaluate reduced LVEF
[ ] Please schedule appointment with PCP ___
(___) and Cardiologist Dr. ___
___ ___ weeks following discharge from rehab.
[ ] Check INR on ___ and adjust warfarin for INR goal of ___
#CODE STATUS: Full code
#CONTACT:
Name of health care proxy: ___
Relationship: spouse
Phone number: ___
DISCHARGE WEIGHT: 60.69 kg |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue, lower extremity weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old female h/o dCHF (TTE ___
showing LVH and EF>55%) who complains of fatigue. Of relevance,
pt s/p recent admission end of ___ for fatigue and weakness
at which time she was noted to have diastolic CHF and ___ on
CKD. troponins were 0.26 on admission and remained stable at
that level x3. BNP elevated at 27,000 and pt with pulm edema.
TTE similar to prior, did show LVH and dx of dCHF given. During
this admission VQ scan also performed (___) which was negative
for PE. Infectious workup was negative, and TSH wnl. She was
effectively diuresed and discharged on furosemide QOD (which she
had not been taking at home) with downtrending creatinine.
.
Pt recently admitted with weakness, and sent initially to rehab
and then home 1 week ago. Was doing well until two days ago,
when she woke up with sudden weakness of her lower extremities
(on chronic baseline leg weakness requiring use of a walker).
That same day she had 1 episode of vomiting, without nausea. For
the last 2 days has had decreased PO intake and leg weakness. No
SOB/CP/edema throughout. Called PCP who told her to go to the
ED. Pt continues to take her lasix QOD as per last discharge
instructions.
.
In the ___ ED, pt developed new chest pain described as
pressure in substernal area. Non radiating. no pleuritic. no
orthopnea. no dyspnea on exertion. "Just felt weak". No fevers
or cough. No urinary symptoms.
.
In the ED, initial vitals were 96.7 102 105/53 22 97% 3L. Labs
significant for MB 9, proBNP 16,000, Cr of 2.7 (last adm
presented with cr 3.0, down to 2.1 at DC), K of 5.0. HCT 36.6
from 28.9 on last DC. ECG showed 1mm ST depressions V4-6 with
inverted TW in these same leads, LAD, sr@75. (ST changes new
from ___ Patient given aspirin 325mg and heparin gtt was
started. Chest pain had resolved on its own without
intervention.
.
On arrival to the floor, patient expresses disgust re having
been admitted this time, for which she blames her son/HCP who
brought her to the hospital. She is comfortable lying in bed.
Denies lower extremity weakness at this time. Denies SOB/CP.
Ordered dinner.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: - Diabetes, +HTN, +HLD
2. CARDIAC HISTORY: congestive heart failure
3. OTHER PAST MEDICAL HISTORY:
congestive heart failure
Hypertension
Anxiety
Hyperlipidemia
Claudication in LLE
supraventricular tachycardia
degenerative arthritis, s/p L3-4 laminectomy
bilateral carpal tunnel s/p surgery
bilateral cataracts s/p surgery
left wrist fracture
diminished hearing
right lung hamartoma s/p resection
benign breast nodule s/p excision
uterine fibroids
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ON ADMISSION:
VS: T=97.8 AF BP=135/59, then 124/64 HR= 77 RR=18 O2 sat=
97%RA
GENERAL: well appearing female who looks several decades younger
than her stated age in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without perceptible JVD
CARDIAC: distant heart sounds. RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. mild bibasilar
crackles. no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+ ___ 2+
.
AT DISCHARGE:
97.5 114-138/41-60 60-70s 18 96%RA
exam otherwise unchanged.
Pertinent Results:
ADMISSION LABS:
___ 02:30PM BLOOD WBC-7.2 RBC-3.79* Hgb-11.6* Hct-36.6#
MCV-97# MCH-30.6 MCHC-31.7 RDW-14.2 Plt ___
___ 02:30PM BLOOD Neuts-88.1* Lymphs-6.9* Monos-1.4*
Eos-3.0 Baso-0.5
___ 02:30PM BLOOD ___ PTT-25.0 ___
___ 02:30PM BLOOD Glucose-110* UreaN-62* Creat-2.7* Na-139
K-5.0 Cl-104 HCO3-24 AnGap-16
.
CARDIAC ENZYMES:
___ 02:30PM BLOOD CK(CPK)-63
___ 06:30AM BLOOD LD(LDH)-220 CK(CPK)-10* TotBili-0.3
___ 02:30PM BLOOD CK-MB-9 ___
___ 02:30PM BLOOD cTropnT-2.15*
___ 09:30PM BLOOD CK-MB-8 cTropnT-2.43*
___ 04:00AM BLOOD CK-MB-6 cTropnT-2.68*
___ 06:30AM BLOOD CK-MB-2 cTropnT-2.56*
.
PERTINENT LABS OF HOSPITAL COURSE:
___ 06:30AM BLOOD calTIBC-220* ___ Ferritn-188*
TRF-169*
___ 06:30AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.0 Iron-69
___ 06:30AM BLOOD Ret Aut-1.8
.
URINE STUDIES:
___ 07:33PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 07:33PM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 07:51PM URINE RBC-2 WBC-5 Bacteri-NONE Yeast-NONE Epi-4
TransE-<1
___ 07:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 07:33PM URINE Hours-RANDOM UreaN-812 Creat-95
___ 07:33PM URINE Osmolal-502
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION
.
CXR ___:
FINDINGS: AP and lateral views of the chest are compared to
multiple prior
exams dating back to ___ with most recent from ___.
There are bibasilar opacities suggestive of atelectasis vs scar
given
persistence over time. There are trace bilateral effusions,
slightly smaller when compared to previous exam. There is no new
confluent consolidation. There is no evidence of overt failure.
Cardiac silhouette is enlarged but stable in configuration.
Osseous structures are unchanged.
IMPRESSION: Bibasilar opacities most suggestive of atelectasis
versus
scarring given persistence over time. Trace bilateral pleural
effusions, no evidence of acute cardiopulmonary process.
.
2D-ECHOCARDIOGRAM:
___
The left atrium is normal in size. 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 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. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a very
small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
.
TTE ___
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%) (cannot exclude focal apical hypokinesis). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. with
normal free wall contractility. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The left
ventricular inflow pattern suggests marked impairment of early
diastolic relaxation. There is mild pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, apical hypokinesis is now present.
Medications on Admission:
aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
metoprolol 25mg XL daily
lasix 20 mg QOD
pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. bromfenac 0.09 % Drops Sig: One (1) Ophthalmic twice a day:
OS.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: Four (4)
Tablet PO DAILY (Daily).
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
3. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day
as needed for constipation.
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. bromfenac 0.09 % Drops Sig: One (1) Ophthalmic BID (2 times
a day).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
non-ST elevation myocardial infarction
SECONDARY
gastrointestinal bleeding
hypertension
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ female complains of fatigue with history of CHF with
recent admission, doing well until two days ago, now feeling fatigue and
generalized weakness.
FINDINGS: AP and lateral views of the chest are compared to multiple prior
exams dating back to ___ with most recent from ___.
There are bibasilar opacities suggestive of atelectasis vs scar given
persistence over time. There are trace bilateral effusions, slightly smaller
when compared to previous exam. There is no new confluent consolidation.
There is no evidence of overt failure. Cardiac silhouette is enlarged but
stable in configuration. Osseous structures are unchanged.
IMPRESSION: Bibasilar opacities most suggestive of atelectasis versus
scarring given persistence over time. Trace bilateral pleural effusions, no
evidence of acute cardiopulmonary process.
Radiology Report
INDICATION: ___ female with persistent abdominal pain, constipation,
and guaiac-positive stool, here to evaluate for bowel obstruction or ileus.
COMPARISON: No prior studies available.
FINDINGS: Frontal and lateral decubitus images of the abdomen show gaseous
distention of the small and large bowel with borderline dilatation. No free
air is detected. A densely calcified rounded structure in the pelvis likely
represents a calcified uterine fibroid. Multiple pelvic phleboliths are
noted. Extensive vascular calcifications are present. Severe degenerative
changes are seen in the lower thoracic spine.
IMPRESSION: Gaseous distention without dilatation of the small and large
bowel. No free air.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FATIGUE
Diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE, ACUTE KIDNEY FAILURE, UNSPECIFIED, CHRONIC KIDNEY DISEASE, UNSPECIFIED, HYPERCHOLESTEROLEMIA
temperature: 96.7
heartrate: 102.0
resprate: 22.0
o2sat: 97.0
sbp: 105.0
dbp: 53.0
level of pain: 0
level of acuity: 3.0 | REASON FOR HOSPITAL ADMISSION:
___ with PMH HTN/HLD and h/o diastolic CHF last EF 55% ___
presenting with lower extremity weakness x3 days, found to have
elevated cardiac enzymes.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
PPD black rubber mix
Attending: ___.
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
___ - Bronchoscopy with bronchoalveolar lavage
History of Present Illness:
___ with hx of HTN, ILD, RA (on prednisone, MTX, Rituximab), HF
with preserved EF who presents with DOE. She was scheduled to
undergo PFTs as an outpatient today, however on presentation she
was noted to be dyspnic with sats 88% on room air and appeared
dypsnic. Sats reportedly improved while the patient was sitting,
however dropped to 81% on RA with 20ft ambulation. Patient was
also having trouble speaking in complete sentences. CXR
reportedly showed bilateral LL infiltrates. Patient was referred
to the ___ ED via ___ for further evaluation. On arrival to
the ED, patient reported acute SOB which began on ___ and has
been constant since. She denies CP. She has a productive cough
but no leg swelling, pain or orthopnea. She reports that she
always sleeps on ___ pillows
On arrival to the ED, initial vitals notable for afebrile, HR
86, BP 110/86, RR 22, 95% on NC. Exam notable for bibasilar
crackles, minimal bilateral ___ edema, normal JVD. Patient also
tolerated being supine with no exacerbation of symptoms. Labs
notable for Chem 7 with bicarb of 21, CBC without leukocytosis
and mild anemia with Hgb of 10.7. Lactate 2.2. Trop negative.
BNP elevated at 706. INR 1.3. UA with few bacteria but otherwise
unremarkable. EKG NSR without evidence of ischemia. CXR with
Blood Cx sent. CXR with diffuse interstitial opacities with
possible overlying pulmonary edema and a more focal patchy
opacity in the RUL. Patient was given a dose of levofloxacin,
20mg IV Lasix and 4mg of Zofran and admitted to the medical
service for further evaluation.
Upon arrival to the floor, patient resting comfortably in bed.
She confirms the above history. The SOB began on ___ and was
present when she woke up in the morning. It has been constant
and neighter worsening or improving. She has a chronic cough
productive of mucus but does not feel that has changed recently.
She reports chills but no fevers. She has also been nauseated
but has not vomited. No sick contacts. No recent leg swelling.
Of note, patient states that she has not taken her Prednisone
for ~ 1 week and skipped her Methotrexate dose on ___ as she
stops these medications when she feels ill.
Past Medical History:
Hypothyroidism
GErD
RA
HTN
Anemia
Interstitial Lung Disease - Rituxan
Osteoporosis
Obesity
OSA
Diverticulosis
Social History:
___
Family History:
CAD/PVD in parents. Colon cancer in maternal aunt.
Physical Exam:
===============================
PHYSICAL EXAM ON ADMSSION
===============================
VITALS: 98.6; 145/65; 98; 28; 92RA
GENERAL: Pleasant, well-appearing, in no apparent distress
speaking in complete sentences but becomes winded after several
minutes of talking during hx
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP not elevated
CARDIAC: RRR, normal S1/S2, faint ___ systolic murmur heard
along LSB
PULMONARY: Bibasilar velco-crackles. No wheezes, ronchi
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, grossly intact with normal sensation,
strength ___ throughout.
===============================
PHYSICAL EXAM ON DISCHARGE
===============================
VS: 98.5 PO 156 / 90 88 18 95 1L
GENERAL: Appears comfortable, sitting up in bed
HEENT: no scleral icterus, MMM
NECK: no JVD appreciated
CARDIAC: Regular rate and rhythm, normal S1/S2, no m/r/g
appreciated
PULMONARY: velco sounding bibasilar crackles, greatest at bases.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding
EXTREMITIES: Warm, well-perfused, no edema, no clubbing,
bilateral ulnar deviation with swan neck deformities
appreciated.
SKIN: Without rash
NEUROLOGIC: Alert, oriented, moving all extremities
spontaneously, fluent speech
Pertinent Results:
==========================
LABS ON ADMISSION
===========================
___ 05:12PM BLOOD WBC-6.3 RBC-4.14 Hgb-10.7* Hct-34.5
MCV-83 MCH-25.8* MCHC-31.0* RDW-15.7* RDWSD-47.0* Plt ___
___ 05:12PM BLOOD Neuts-75.2* Lymphs-12.8* Monos-7.6
Eos-3.8 Baso-0.3 Im ___ AbsNeut-4.75 AbsLymp-0.81*
AbsMono-0.48 AbsEos-0.24 AbsBaso-0.02
___ 04:35PM BLOOD ___ PTT-27.6 ___
___ 04:35PM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-140
K-4.0 Cl-103 HCO3-21* AnGap-20
___ 04:35PM BLOOD ALT-11 AST-20 AlkPhos-105 TotBili-0.7
___ 07:12AM BLOOD LD(LDH)-353*
___ 04:35PM BLOOD proBNP-706*
___ 04:35PM BLOOD cTropnT-<0.01
___ 07:12AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.4*
___ 04:35PM BLOOD TSH-0.26*
___ 05:04PM BLOOD Lactate-2.2*
___ 04:35PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:35PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.0 Leuks-SM
___ 04:35PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-2
___ 04:35PM URINE Mucous-RARE
___ 04:13PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
==========================
BRONCOALVEOLAR LAVAGE STUDIES (___)
===========================
___ 08:33AM OTHER BODY FLUID Polys-60* Lymphs-20* Monos-0
Eos-2* Mesothe-1* Macro-17*
INDEX VALUE 0.18 <0.50
ASPERGILLUS AG, EIA, BAL Not Detected Not Detected
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
~6OOO/ML Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
==========================
LABS ON DISCHARGE
===========================
___ 07:08AM BLOOD WBC-12.9* RBC-4.21 Hgb-10.8* Hct-34.0
MCV-81* MCH-25.7* MCHC-31.8* RDW-15.6* RDWSD-44.9 Plt ___
___ 07:08AM BLOOD Glucose-190* UreaN-20 Creat-0.8 Na-136
K-4.1 Cl-97 HCO3-24 AnGap-19
___ 07:08AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1
==========================
MICROBIOLOGY
===========================
___ - Fungitell (tm) Assay for (1,3)-B-D-Glucans
<31 pg/mL Negative Less than 60 pg/mL
Indeterminate 60 - 79 pg/mL
Positive Greater than or equal to
80 pg/mL
___ - Aspergillus Ag
INDEX VALUE 0.06 <0.50
ASPERGILLUS AG,EIA,SERUM Not Detected Not Detected
__________________________________________________________
___ 5:49 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
__________________________________________________________
___ 9:13 pm SPUTUM Source: Induced.
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
MTB Direct Amplification (Final ___:
M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT
cannot rule
out TB or other mycobacterial infection.
.
NAAT results will be followed by confirmatory testing with
conventional culture and DST methods. This TB NAAT method
has not
been approved by FDA for clinical diagnostic purposes.
However, ___
Laboratory Institute (___) has established assay
performance by
in-house validation in accordance with CLIA standards.
__________________________________________________________
___ 4:43 pm SPUTUM
SOURCE: INDUCED, AFB FOR NON TB MYCOBACTERIA.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
__________________________________________________________
___ 4:13 pm Rapid Respiratory Viral Screen & Culture
NASOPHRYNGEAL SWAB.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
__________________________________________________________
___ 4:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
==========================
IMAGING/STUDIES
===========================
Cardiovascular Report ECG Study Date of ___ 4:54:59 ___
Sinus rhythm. Baseline artifact. Poor R wave progression. Low
precordial
lead voltage. No previous tracing available for comparison.
Cardiovascular Report ECG Study Date of ___ 10:41:32 AM
Sinus rhythm. Possible old inferior wall myocardial infarction.
Poor R wave progression. Minor non-specific repolarization
abnormalities. Compared to the previous tracing of ___
findings are similar.
QTc 430
CHEST (PA & LAT) Study Date of ___ 5:27 ___
Diffusely increased interstitial opacities likely reflective of
chronic
interstitial lung disease, though a component of superimposed
interstitial
pulmonary edema is not excluded. More focal patchy opacity in
the right upper lobe could suggest infection. Moderate size
hiatal hernia.
Comparison with any previous chest CT imaging is recommended,
and if none are available, dedicated high-resolution chest CT is
suggested
CT CHEST W/O CONTRAST Study Date of ___ 6:14 ___
Fibrotic interstitial lung disease, most suggestive of UIP
pattern.
Widespread ground-glass opacification is nonspecific the
differential
considerations include atypical infection including PJP given
history of
immunosuppression, or acute exacerbation of interstitial lung
disease in the appropriate clinical setting.
CHEST (PA & LAT) Study Date of ___ 10:07 AM
Cardiomegaly and mediastinal contour are stable. Since the
prior study there is minimal improvement in diffuse interstitial
opacities. No interval development of pleural effusion or
pneumothorax is demonstrated. No evidence of new superimposed
focal consolidation is seen.
Large hiatal hernia is re- demonstrated.
==========================
PROCEDURES
===========================
BRONCHOSCOPY ___
Airways were visualized to the sub-segmental level bilaterally.
There were no endobronchial lesions. Airways were patent. The
mucosa was normal. There were no significant airway secretions
noted. Lavage was performed with 60 cc of normal saline in the
RML bronchus with good return of colorless fluid.
==========================
PATHOLOGY
===========================
BRONCHIAL LAVAGE - ___
NEGATIVE FOR MALIGNANT CELLS.
Pulmonary macrophages, neutrophils, and bronchial epithelial
cells, some reactive; no viral cytopathic changes seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO 6X/WEEK (___)
3. Methotrexate 12.5 mg PO 1X/WEEK (___)
4. FoLIC Acid 1 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Verapamil SR 180 mg PO Q24H
7. Levothyroxine Sodium 300 mcg PO 1X/WEEK (___)
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Omeprazole 40 mg PO BID
4. Verapamil SR 180 mg PO Q24H
5. GuaiFENesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 5 mL by mouth every six (6) hours
Disp ___ Milliliter Milliliter Refills:*0
6. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth Three times per week Disp #*12 Tablet Refills:*0
7. PredniSONE 60 mg PO DAILY Duration: 6 Doses
This is dose # 1 of 5 tapered doses
RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*18 Tablet
Refills:*0
8. PredniSONE 50 mg PO DAILY Duration: 7 Doses
This is dose # 2 of 5 tapered doses
Tapered dose - DOWN
RX *prednisone 10 mg 5 tablet(s) by mouth Daily Disp #*35 Tablet
Refills:*0
9. PredniSONE 40 mg PO DAILY Duration: 7 Doses
This is dose # 3 of 5 tapered doses
Tapered dose - DOWN
10. PredniSONE 30 mg PO DAILY Duration: 7 Doses
This is dose # 4 of 5 tapered doses
Tapered dose - DOWN
11. PredniSONE 20 mg PO DAILY Duration: 7 Doses
This is dose # 5 of 5 tapered doses
Tapered dose - DOWN
Discharge Disposition:
Home
Discharge Diagnosis:
Acute issues:
#Interstitial lung disease c/b hypoxia
#Community-acquired pneumonia c/b hypoxia
#Rheumatoid arthritis
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 shortness of breath
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size remains mildly enlarged. A moderate-sized hiatal
hernia is again noted. Increased interstitial opacities are noted diffusely,
more pronounced on the lung bases, likely reflective of chronic interstitial
lung disease. Mild superimposed interstitial pulmonary edema is not excluded.
More focal opacity within the right upper lobe could reflect an area of
infection. There is no pleural effusion or pneumothorax. No acute osseous
abnormality is demonstrated.
IMPRESSION:
Diffusely increased interstitial opacities likely reflective of chronic
interstitial lung disease, though a component of superimposed interstitial
pulmonary edema is not excluded. More focal patchy opacity in the right upper
lobe could suggest infection. Moderate size hiatal hernia.
Comparison with any previous chest CT imaging is recommended, and if none are
available, dedicated high-resolution chest CT is suggested.
Radiology Report
EXAMINATION: DIFFUSE LUNG DZ
INDICATION: ___ with hx of HTN, ILD, RA (on prednisone, MTX, Rituximab),
HFrEF // eval for worsening ILD, infection, acute pathology
TECHNIQUE: Multi detector helical scanning of the mid and lower chest was
performed with the patient prone at end inspiration, then of the full chest
with the patient supine, first at end inspiration then at end expiration.
Prone images were reconstructed as 1.25 mm thick axial images. Supine
inspiratory scanning was reconstructed as 1.25 and 5 mm thick axial images,
and 2.5 mm thick coronal and parasagittal images. Supine expiratory scanning
was reconstructed as 1.25 and 5 mm thick axial and 2.5 mm thick coronal
images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.1 s, 24.6 cm; CTDIvol = 9.1 mGy (Body) DLP = 223.2
mGy-cm.
2) Spiral Acquisition 0.8 s, 6.4 cm; CTDIvol = 5.2 mGy (Body) DLP = 32.9
mGy-cm.
3) Spiral Acquisition 4.1 s, 32.0 cm; CTDIvol = 13.0 mGy (Body) DLP = 416.1
mGy-cm.
4) Spiral Acquisition 3.9 s, 30.5 cm; CTDIvol = 12.4 mGy (Body) DLP = 378.6
mGy-cm.
Total DLP (Body) = 1,051 mGy-cm.
COMPARISON: None prior
FINDINGS:
MEDIASTINUM: The imaged thyroid is normal. No pathologically enlarged
supraclavicular, axillary, hilar or mediastinal lymph nodes.
HEART AND GREAT VESSELS: The aorta and pulmonary arteries are normal in size.
The heart size is mildly enlarged and there is no pericardial effusion.
Coronary artery calcifications are severe.
PLEURA: There is no pneumothorax. There is no pleural effusion.
LUNGS AND TRACHEOBRONCHIAL TREE: Heterogeneous areas of ground-glass
opacification without zonal predominance, and slightly asymmetrically worse in
the right upper and bilateral lower lobes. Subpleural honeycombing with a
basilar predominance. There is traction bronchiectasis also worse in the lung
bases. No substantial air trapping on the expiratory scan. Suture chain in
the left lower lobe, suggest prior wedge resection.
BONES AND CHEST WALL: There are no destructive focal osseous or chest wall
lesions concerning for malignancy within the imaged thoracic skeleton. There
is a bone island in the T4 vertebral body.
UPPER ABDOMEN:
Although this study is not designed for the evaluation of subdiaphragmatic
structures, the imaged upper abdomen demonstrates a large hiatal hernia and
uncomplicated cholelithiasis.
IMPRESSION:
Fibrotic interstitial lung disease, most suggestive of UIP pattern.
Widespread ground-glass opacification is nonspecific the differential
considerations include atypical infection including PJP given history of
immunosuppression, or acute exacerbation of interstitial lung disease in the
appropriate clinical setting.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with RA, ILD, HFpEF with hypoxemia and dyspnea
planning for steroid pulse // eval for interval change, acute process
eval for interval change, acute process
IMPRESSION:
Cardiomegaly and mediastinal contour are stable. Since the prior study there
is minimal improvement in diffuse interstitial opacities. No interval
development of pleural effusion or pneumothorax is demonstrated. No evidence
of new superimposed focal consolidation is seen.
Large hiatal hernia is re- demonstrated.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion
Diagnosed with Shortness of breath
temperature: 98.7
heartrate: 86.0
resprate: 22.0
o2sat: 95.0
sbp: 110.0
dbp: 86.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ YO F with ILD, RA (on prednisone, MTX,
Rituximab), and HF with preserved EF (~60% on ___ TTE) admitted
with dyspnea on exertion and acute hypoxemia.
#Hypoxemia/Dyspnea on exertion with Interstitial Lung Disease
The patient was admitted with acute onset of dyspnea without
evidence of antecedent viral UI, sick contacts or over
aspiration. Labs on admission notable for normal WBC count and
elevated pro BNP with a CXR notable for focal opacity in te
right upper lobe ad diffusely increased interstitial opacities.
Initially treated with furosemide and levofloxacin in the ED
prior to admission to the medicine floor, requiring ___ L of O2.
The patient has a history of early fibrotic lung disease
consistent with RA-ILD followed with PFTS and Chest CT. Both the
pulmonology and rheumatology teams were consulted. The
differential was broad in the setting of underlying ILD and
immunosuppression therapy, and included CHF, CAP, atypical
infections in the setting of immunosuppression, acute
exacerbation of ILD, and drug related pulmonary toxicity. The
patient underwent a high resolution chest CT with diffuse GGO
most consistent with acute exacerbation of ILD vs. atypical
infection. There was likely a contribution from reflux as well
given cough and sputum production in the setting of clear hiatal
hernia, and the patient was treated with BID omeprazole. The
patient completed a 7 day course of levofloxacin for presumed
CAP. Broad infectious workup including serum fungal markers,
urine strep/legionella/histo, viral respirator panel, induced
sputum for Gram stain/cx, funal Gx, AFB x3 and PCP DFA was
negative. Additionally the patient underwent bronchoscopy and
BAL with broad infectious workup which was also negative. Given
the extensive negative infectious workup, the diagnosis was most
likely acute exacerbation of RA-ILD. The patient underwent a
solumedrol pulse of 500 mg IV x 3 days followed by prednisone
taper. Methotrexate was held indefinitely due to possibility of
MTX related lung toxicity. In the setting of high dose
prednisone use, the patient was started on PCP prophylaxis with
___. Patient required home O2 on discharge given ambulatory
saturations <89% on RA.
#Rheumatoid arthritis:
The patient was evaluated by the rheumatology team in house in
the setting of above concern for acute exacerbation of RA-ILD.
She was determined to have decreased ROM and pain on exam
indicating a mildly active flare. The patient was initially
continued on prednisone 10 mg daily and then treated with
solumedrol pulse and high dose prednisone tape as above. Joint
pain improved. As above, MTX was held indefinitely given concern
for MTX related pulmonary toxicity. The patient will follow up
with outpatient rheumatologist after discharge for discussion of
restarting rituximab given negative infectious workup.
=====================
CHRONIC ISSUES
=====================
#Hypothyroidism: Patient was continued on Levothyroxine 150mcg
qD. Of note patient taking 300 mcg Q ___ at home, however tis
was deferred while inpatient in setting of low TSH on admission.
This will be followed as an outpatient by patient's PCP.
#HTN: Patient continued home verapamil 180 q24H.
#GERD: As above, increased omeprazole to BID due to concern for
GERD/aspiration contributing to dyspnea and hypoxemia as above.
#Chronic Diastolic CHF
=====================
TRANSITIONAL ISSUES
=====================
[ ] Patient discharged on prednisone taper as below:
60 mg (___)
50 mg (___)
40 mg (___)
30 mg (___)
20 mg (___)
10 mg ___ - )
[ ] Patient discharged with home O2 given ambulatory saturations
<89% on RA
[ ] Patient continued on levothyroxine 150 mcg daily - admitted
on 150 mcg 6x/week and 300 mcg on ___. TSH 0.26 on admission.
Please follow up outpatient TFTS after discharge.
[ ] Hold methotrexate given possibility of MTX related lung
injury
[ ] Patient started on Bactrim 1 DS three times weekly
[ ] Continue PPI BID
[ ] Monitor BP given high dose steroids at next PCP ___
[ ] Discussion of outpatient rituximab at next rheumatology
appointment |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Epinephrine / Ciprofloxacin / Vicodin / ___ Containing
/ Morphine
Attending: ___
Chief Complaint:
Fatigue and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH of kidney and pancreas transplant in ___ and
DM1 who p/w progressive weakness and fatigue for the past ___
weeks. Patient went to ___ who told her to go to ED which she
did via EMS. Patient states her balance has been off over same
period of time, and she attributes this to overall muscle
weakness. She has also had headaches since ___ that have
been getting worse, located "all over" her head. She describes
the pain as an "explosion" which can then feel like a "nail."
They occur daily, and last anywhere from a couple seconds to a
few hours. Noise makes it worse but she notes no photophobia. It
helps when she lays down and closes her eyes. She has not tried
any medications for headache. She denies any associated nausea
or vision changes. She notes that she feels the exact same way
as when she has previously presented to the hospital.
She has had stable dyspnea ascending 1.5 flights of stairs and
stable chest pain that comes on randomly. It feels like a
"poking" that goes away on its own since NSTEMI earlier this
year.
In the ED intial vitals signs were: 98.6, 88, 130/70, 18, 100%
RA. Exam was significant for minimal lower abdominal tenderness
and no CVA tenderness. She was given Bactrim and linezolid due
to previous VRE urine cultures. Nephrology was consulted and
they recommended admission and continued antibiotics for her
UTI. They recommended half dose bactrim, continued
immunosuppresion with a morning tacrolimus level.
Past Medical History:
- Type I diabetes and CKD s/p renal and pancreas transplant in
___ in ___. DM controlled after transplant but continues
to have proteinuria.
- Hyperlipidemia
- NSTEMI s/p PCI and DES x3 to RCA for 2VD (___)
- Hypothyroidism
- Obstructive sleep apnea
- C. difficile colitis (vancomycin finished ___
- Hiatal hernia
- Osteopenia
- Axonal peripheral neuropathy
- Restless leg syndrome
- Anxiety and depression
- ___ splenic vein thrombosis
- IPMN (benign pancreatic nodule)
Social History:
___
Family History:
Notable for mother with dementia. Father is healthy with some
cardiac disease. She has two brothers, one with hyperlipidemia
and another with some form of cardiovascular disease.
Physical Exam:
ADMISSION EXAM
VS: 98, 86, 127/77, 18, 98% RA
General: AAOx3, NAD, anxious
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no LAD, paracervical spinal muscles mildly tender
CV: RRR, nl S1/S2, ___ SEM at ___
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, mildy LLQ tenderness, normoactive bowel sounds
GU: Deferred
Ext: Warm, ___, no cyanosis/clubbing/edema
Neuro: CN ___ grossly intact
Skin: No concerning lesions
DISCHARGE EXAM
VS: 97, 76, 133/75, 20, 100% RA
General: AAOx3, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no LAD
CV: RRR, nl S1/S2, ___ SEM at ___
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, NTND, normoactive bowel sounds
GU: Deferred
Ext: Warm, ___, no cyanosis/clubbing/edema
Neuro: CN ___ grossly intact
Skin: No concerning lesions
Pertinent Results:
ADMISSION LABS
___ 06:24PM BLOOD ___
___ Plt ___
___ 06:24PM BLOOD ___
___
___ 06:24PM BLOOD ___
___
___ 06:24PM BLOOD ___ CK(CPK)-42 ___
___
___ 06:24PM BLOOD ___
___ 06:24PM BLOOD ___
___ 07:39PM BLOOD ___
___ 08:32PM BLOOD ___
___ 06:24PM URINE ___ Sp ___
___ 06:24PM URINE ___
___
___ 06:24PM URINE ___
Epi-<1
___ 06:24PM URINE ___
DISCHARGE LABS
___ 05:00AM BLOOD ___
___ Plt ___
___ 05:00AM BLOOD ___ ___
___ 05:00AM BLOOD ___
___
___ 05:00AM BLOOD ___
___ 05:00AM BLOOD ___
MICROBIOLOGY
Blood cultures pending on discharge.
URINE CULTURE (Preliminary):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
IDENTIFICATION AND Susceptibility testing requested by ___ ___
(___) ___.
- ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
- GRAM POSITIVE BACTERIA. ___ ORGANISMS/ML. Alpha
hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
- ESCHERICHIA COLI. <10,000 organisms/ml. PRESUMPTIVE
IDENTIFICATION.
IMAGING
Renal US (___): Mild renal transplant collecting system
fullness, similar to prior. Unremarkable renal transplant
vasculature with unchanged resistive indices. Urinary bladder
debris. PVR of 85 cc.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QSUN
2. Atorvastatin 80 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
5. Gabapentin 300 mg PO Q24H
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Metoprolol Succinate XL 12.5 mg PO HS
8. Multivitamins 1 TAB PO DAILY
9. Mycophenolate Mofetil 500 mg PO BID
10. Prasugrel 10 mg PO DAILY
11. PredniSONE 5 mg PO DAILY
12. Prograf (tacrolimus) 2 mg ORAL Q12H
13. Sodium Bicarbonate 650 mg PO TID
14. NexIUM (esomeprazole magnesium) 40 mg ORAL DAILY
15. Calcarb 600 With Vitamin D (calcium ___ D3)
600 mg(1,500mg) -400 unit Oral 2 tabs BID
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Gabapentin 300 mg PO Q24H
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO HS
6. Multivitamins 1 TAB PO DAILY
7. Mycophenolate Mofetil 500 mg PO BID
8. NexIUM (esomeprazole magnesium) 40 mg ORAL DAILY
9. Prasugrel 10 mg PO DAILY
10. PredniSONE 5 mg PO DAILY
11. Prograf (tacrolimus) 2 mg ORAL Q12H
12. Sodium Bicarbonate 1300 mg PO TID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times a
day Disp #*180 Tablet Refills:*1
13. Alendronate Sodium 70 mg PO QSUN
14. Calcarb 600 With Vitamin D (calcium ___ D3)
600 mg(1,500mg) -400 unit Oral 2 tabs BID
15. Linezolid ___ mg PO Q12H
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
16. Cefpodoxime Proxetil 400 mg PO Q24H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth DAILY Disp #*28
Tablet Refills:*0
17. Outpatient Lab Work
Please collect urine for culture in 3 weeks.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Urinary tract infection
Secondary diagnosis: Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with renal transplant, now with tenderness over
the graft site.
COMPARISON: Multiple prior exams, most recently renal transplant ultrasound
of ___.
FINDINGS:
Grayscale and Doppler ultrasound images of the renal transplant were obtained.
Mild fullness of the renal collecting system is unchanged. The renal
morphology is otherwise normal with normal cortical thickness and
echogenicity. The renal pyramids and the renal sinus fat have a normal
appearance. No perinephric fluid collection.
The resistive index of intrarenal arteries range from 0.71-0.80, similar to
the prior exam. Acceleration times and peak systolic velocities of main renal
artery are unchanged as well. The renal vein is patent and shows a normal
waveform. Vascularity is symmetric throughout the transplant.
The prevoid bladder contains a small amount of debris and has a volume of 197
cc. The postvoid bladder has a volume of 85 cc. Postsurgical changes are
present adjacent to the right aspect of the bladder.
IMPRESSION:
1. Mild renal transplant collecting system fullness, similar to prior.
2. Unremarkable renal transplant vasculature with unchanged resistive
indices.
3. Urinary bladder debris. Postvoid residual of 85 cc.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GENERALIZED WEAKNESS
Diagnosed with URIN TRACT INFECTION NOS
temperature: 98.6
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ yo F with PMH of renal and pancreas transplant who presents
with fatigue and weakness and was found to have a UTI.
ACTIVE ISSUES
# Fatigue and weakness: These are likely chronic issues that
have worsened in the setting of infection. Also on differential
diagnosis were increasing levels of sedating medications or
tacrolimus toxicity in the setting of her low GFR although these
are unlikely given patient's stable GFR and normal tacrolimus
levels. Hypothyroidism and statin toxicity were also considered
but TSH and CK were normal. Viral screen was also negative
arguing against influenza. Fatigue and weakness improved with
treatment of UTI and patient was feeling energetic and ready to
go home on day of discharge.
# Urinary tract infection: Positive UA. Given first dose of
linezolid and Bactrim in ED. Linezolid started due to recent
history of ___ Enterococcus on urine culture
from ___. Bactrim was subsequently discontinued due to
patient's history of C. diff. Started on ceftriaxone for gram
negative coverage. Given patient's long history of urinary
retention requiring frequent caths and the bladder debris on
renal ultrasound Urology was consulted. They determined that
patient was not complying with recommended cath regimen. They
recommended that she cath herself a minimum of twice per day and
void at least 400 cc with each cath. Urine culture returned as
contaminated on ___. Requested speciation and sensitivities
given the higher likelihood of a polymicrobial infection in a
transplant patient. These studies were pending on discharge.
Switched patient to linezolid and cefpodoxime for outpatient
therapy. Discharged her with a 2 week course of these
antibiotics and with Rx for repeat urine culture in 3 weeks.
CHRONIC ISSUES
# Chronic kidney disease: Patient remained at her stable low GFR
during admission. ___ ultrasound of renal graft.
Increased bicarbonate to 1300 mg TID. Renally dosed all
medications. Scheduled voiding and Urology consult as above.
# Renal and pancreas transplant: Performed in ___. Renal
function was at baseline and amylase and lipase were within
normal limits. Renal ultrasound on ___ was reassuring.
Continued immunosuppressive regimen including prednisone,
tacrolimus, and MMF at home doses.
# Hyperlipidemia: CK within normal limits. Continued
atorvastatin.
# Hypothyroidism: TSH within normal limits. Continued
levothyroxine.
# OSA: Patient uses a special machine at home that delivers PEEP
10 and pressure support that flexes between ___. Per
Respiratory, closest machine we had was BIPAP. Managed with
BiPAP per Respiratory.
# Peripheral neuropathy: Continued gabapentin and Flexeril.
# Depression: Continued citalopram.
TRANSITIONAL ISSUES
- Discharged on 14 day course of linezolid and cefpodoxime
- Now on a higher dose of bicarbonate tabs
- Instructed patient to HOLD Celexa and Flexeril while on
linezolid
- Continue weekly labs faxed to Dr. ___ at ___
- Urine culture 3 weeks after discharge
- ___ with PCP scheduled
- ___ with Transplant Nephrology scheduled
- ___ with Urology scheduled |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w h/o asthma per chart (no PFTs apparent), never been
intubated, obesity, HTN p/w 2 weeks of progressive SOB. Pt was
in
USOH until 2 weeks ago then developed progressive SOB with
wheezing and cough. Onset was gradual. No chest pain at onset
but
then with all the coughing, starting having pain only with
coughing. Denies ___, weight gain, ___ trauma, h/o clots.
Endorses
cough worse at night which limits sleeping. Some PND from this.
Denies f/n/v/d/rhinorrhea/sick contacts (but works in a hospital
as a ___)/recent abx/recent med changes. Has a cat. No large
dust exposure or cleaning or mold exposure. Got flu shot this
year (just prior to decompensation which she thinks is the
cause). Cough is non-productive. Denies abd pain, diarrhea,
constipation, rash, joint pain. Reports chronic LBP at baseline.
Reports "chills" for ___ years.
In the ED, 98.5 95 ___. -->98.6 96 150/67 20 95%
4L.
In ED, received: methylprednisolone 60, duoneb, azithromycin,
magnesium, azithromycin. CXR no intrahtoracic process.
Past Medical History:
- Obesity
- Hypertension
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
Discharge exam:
Constitutional: VSS, satting in mid ___ on RA
HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM
without exudate
CV: RRR no mrg, JVP difficult to assess
Resp: diffuse mild end expiratory wheezing, moderate air
movement
GI: sntnd, NABS
GU: no foley
MSK: no obvious synovitis
Ext: wwp, neg edema in BLEs
Skin: no rash grossly visible
Neuro: A&Ox3, DOWB intact, ___ BUE/BLE, SILT BUE/BLE, CN II-XII
intact
Psych: normal affect, pleasant
Pertinent Results:
RESULTS:
DATA: I have reviewed the relevant labs, radiology studies,
tracings, medical records, and they are notable for:
___ 02:20PM BLOOD WBC: 7.9 RBC: 5.26* Hgb: 13.9 Hct: 45.3*
MCV: 86 MCH: 26.4 MCHC: 30.7* RDW: 14.5 RDWSD: 45.___
___ 02:20PM BLOOD Neuts: 51.8 Lymphs: ___ Monos: 10.7 Eos:
4.2 Baso: 0.9 Im ___: 0.8* AbsNeut: 4.08 AbsLymp: 2.48 AbsMono:
0.84* AbsEos: 0.33 AbsBaso: 0.07
___ 02:20PM BLOOD Glucose: 94 UreaN: 11 Creat: 0.8 Na: 141
K: 4.8 Cl: 106 HCO3: 23 AnGap: 12
___ 02:20PM BLOOD Calcium: 9.8 Phos: 4.2 Mg: 2.1
___ 02:44PM BLOOD Type: ___ pO2: 53* pCO2: 47* pH: 7.37
calTCO2: 28 Base XS: 0
I personally reviewed the [X-ray, ECG] and my interpretation is:
CXR: I agree w radiology.
The lung volumes are low which accentuates the pulmonary
vasculature. Hazy and streaky opacities at the lung bases are
felt to be related to bibasilar atelectasis and overlying soft
tissues. There is no definite focal consolidation, pulmonary
edema, large pleural effusion or pneumothorax. The
cardiomediastinal silhouette is at the upper limit of normal,
unchanged.
EKG (my read): NSR, nl axis, QTc 490, Q in III, biphasic Ts in
V3-V4 (new since ___
Discharge labs:
___ 04:40PM BLOOD WBC-9.0 RBC-5.73* Hgb-14.8 Hct-48.8*
MCV-85 MCH-25.8* MCHC-30.3* RDW-14.4 RDWSD-44.7 Plt ___
___ 04:40PM BLOOD Glucose-335* UreaN-25* Creat-0.8 Na-135
K-4.6 Cl-94* HCO3-27 AnGap-14
___ 04:40PM BLOOD %HbA1c-6.4* eAG-137*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*5
2. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily
Disp #*30 Capsule Refills:*0
3. Montelukast - NEW medication
4. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough
RX *codeine-guaifenesin 10 mg-100 mg/5 mL 5 mL by mouth three
times daily Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine [Lidocaine Pain Relief] 4 % apply to back once
daily Disp #*10 Patch Refills:*5
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
8. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with dyspnea// evaluate for intra-thoracic process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
The lung volumes are low which accentuates the pulmonary vasculature. Hazy
and streaky opacities at the lung bases are felt to be related to bibasilar
atelectasis and overlying soft tissues. There is no definite focal
consolidation, pulmonary edema, large pleural effusion or pneumothorax. The
cardiomediastinal silhouette is at the upper limit of normal, unchanged.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Unspecified asthma with (acute) exacerbation
temperature: nan
heartrate: 95.0
resprate: 24.0
o2sat: 89.0
sbp: 217.0
dbp: 102.0
level of pain: 10
level of acuity: 1.0 | ___ w likely asthma, HTN p/w subacute asthma exacerbation.
# Hypoxemic respiratory failure, acute
# Asthma exacerbation, acute
# Steroid induced hyperglycemia
# Prediabetes (A1c 6.4)
Given her relatively mild smoking history as well as her mother
having "bronchitis" without a smoking history, this suggests
that
patient actually has asthma rather than COPD. Given the lack of
prominent sputum, that is another reason arguing against the
need
for abx (as well as her QTc prolongation which makes
azithromycin
a less ideal medication anyway). No other risk factors for PE,
and likelihood of sick contacts makes URI induced asthma much
more likely than PE induced asthma. No exam or history evidence
of CHF.
- Weaned O2 for goal sat >92. Satting at 94% on RA on day of
discharge
- prednisone burst 60mg po qd x5d, ___. Had
steroid induced hyperglycemia with this (A1c 6.4)
- s/p 1 dose azithromycin on ___ in ED, but as above, stopping
abx
- standing duonebs, prn albuterol
- Started controller med on discharge - has pre-diabetes so
favor LKA over ICS
- recommend o/p PFTs
# HTN: reports that her PCP was planning on increasing her BP
meds as o/p for HTN anyway, so likely this is chronic HTN in
poor
control
- cont home HCTZ
- added amlodipine
# chronic back pain: NSAIDs are a poor choice in her given her
HTN. She is frustrated by lack of good options
- increased home APAP to 1g TID prn for now
- added lidocaine patch
- may benefit from o/p ___
# QTc prolongation: has at baseline, may be worsened by azithro
dose in ED
- telemetry overnight
- rechecking EKG in AM, stopping tele
# TWFs on EKG
- troponin negative
Outstanding issues
[ ] Started on amlodipine in addition to hydrochlorothiazide for
better control of blood pressure. Some concern for nonadherence
as patient was out of her medicines when she was admitted and
systolics were in the 190s
[ ] Added montelukast to controller medications for possible
asthma. Will need pulmonary function test at outpatient
appointment as well as risk-benefit discussion of inhaled
corticosteroid. This was not provided on discharge due to high
blood sugars in the setting of prednisone use.
[ ] Patient had steroid-induced hyperglycemia. A1c was measured
at 6.4. ___ need further education on management of
prediabetes.
[ ] Complained of shortness of breath when climbing flights of
stairs. Presumption is that this is due to uncontrolled asthma.
If still persists after initiation of controller medications
may want to do further workup for dyspnea.
[ ] Patient has QTC prolongation. Avoid prolonging meds such as
azithromycin
>30 minutes spent on discharge planning including >50% face to
face time |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shrimp
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx recurrent DVT/PE on warfarin, pulmonary HTN, CKD
on 4L home O2 at night who presented with 1 week of right sided
pleuritic chest pain similar to previous PE. Pain is pleuritic,
dull, right sided. Denies associated fever, chills, cough, leg
swelling, n/v/d, abdominal pain, headache, dizziness. Does
report travelling to ___ last week.
In the ED, initial VS were: T98.3 HR72 BP138/87 RR18 90%RA. EKG
showed no ischemic changes and an s1q3t3 pattern. Labs were
fairly unremarkable. CTPA was performed, which showed a large
left lower lobar pulmonary embolism, which extends into multiple
segmental and subsegmental branches. It was not initially
appreciated that this was a chronic finding, so he was started
on heparin.
Admitted to medicine for further management.
Past Medical History:
Recurrent VTE since his ___ has been on long-term Coumadin
therapy. Patient states he had a thorough workup (to the extent
this was possible ___ years ago) with no etiology found. S/p
remote bilateral femoral vein ligation to prevent PEs.
Pulmonary hypertension (presumed WHO group IV) with chronic
hypoxic respiratory failure (documented as low as the 70's on
exertion). Last RHC was ___ at ___.
Hypercholesterolemia
Hypertension
Borderline diabetes- not on medications
BPH (s/p TURP)
CKD
Prior + PPD
Gout
s/p Hemorrhoidectomy
Primary open angle glaucoma
Left Cataract
Left Posterior Vitreous Detachment
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: 98.5 PO 143 / 78 R Lying 74 16 96 2l
GENERAL: NAD, no increased WOB
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: good airmovement through out, bibasilar crackles R>L
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:
=======================
Vitals: 98.6F BP 142/73 HR 68 RR 16 95% on 4L
General: Awake, alert, oriented, no acute distress, elderly man
laying in bed comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no LAD
Lungs: Normal respiratory effort. Decreased airflow throughout.
Bibasilar crackles (R>L). Otherwise clear.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no guarding, no organomegaly.
Ext: Warm, well perfused, 2+ pulses, 1+ edema to the mid-shins
bilaterally
Neuro: Alert and interactive, moves all extremities.
Psych: Normal mood and affect
Pertinent Results:
ADMISSION LABS:
==============
___ 02:10PM BLOOD WBC-6.0 RBC-4.99 Hgb-13.6* Hct-43.8
MCV-88 MCH-27.3 MCHC-31.1* RDW-15.0 RDWSD-48.0* Plt ___
___ 02:10PM BLOOD Glucose-90 UreaN-17 Creat-1.4* Na-140
K-5.3* Cl-101 HCO3-29 AnGap-10
___ 02:10PM BLOOD Neuts-63.8 ___ Monos-11.6 Eos-1.8
Baso-0.7 Im ___ AbsNeut-3.79 AbsLymp-1.30 AbsMono-0.69
AbsEos-0.11 AbsBaso-0.04
___ 02:10PM BLOOD CK-MB-2 proBNP-499
___ 02:30PM BLOOD pO2-20* pCO2-65* pH-7.33* calTCO2-36*
Base XS-4
PERTINENT LABS/MICRO:
====================
___ 02:10PM BLOOD cTropnT-0.02*
___ 02:10PM BLOOD CK-MB-2 proBNP-499
___ 07:40AM BLOOD ___ 02:30PM BLOOD Lactate-2.0
___ 02:30PM BLOOD pO2-20* pCO2-65* pH-7.33* calTCO2-36*
Base XS-4
___ Urine culture: No growth
___ Blood culture: NGTD
DISCHARGE LABS:
==============
___ 07:45AM BLOOD WBC-5.1 RBC-4.32* Hgb-12.1* Hct-38.0*
MCV-88 MCH-28.0 MCHC-31.8* RDW-14.9 RDWSD-47.9* Plt ___
___ 07:45AM BLOOD Glucose-101* UreaN-18 Creat-1.4* Na-147*
K-4.6 Cl-105 HCO3-23 AnGap-19*
PERTINENT IMAGING:
=================
___ Chest Xray:
Low lung volumes with bibasal atelectasis and scarring. Contour
abnormality at the left pulmonary hilum for which nonemergent
chest CT is recommended to further assess.
___ CTA Chest:
1. There is a large left lower lobar pulmonary embolism which
extends into multiple segmental and subsegmental branches. There
is dilatation of the main pulmonary artery, measuring up to 3.9
cm, as well as the bilateral pulmonary arteries. No CT evidence
of right heart strain.
2. The right lower lobar pulmonary arteries and veins are not
visualized. Recommend correlation with prior procedure. If
there are none, this may represent sequelae of prior pulmonary
embolism with atretic right lower lobe pulmonary artery,
although acute pulmonary embolism not entirely excluded. If
acute embolism, the 4.8 x 2.5 cm consolidation below may
represent a pulmonary infarction.
3. There is ground-glass opacity and 4.8 x 2.5 cm consolidation
in right lower lobe, concerning for aspiration with possible
superimposed pneumonia. Follow-up to resolution is recommended
to exclude underlying mass.
___ BLE Ultrasound:
1. Partially occlusive thrombus in the right mid superficial
femoral vein, which extends to the distal right superficial
femoral vein, where it becomes occlusive.
2. Partially occlusive thrombus in the left mid and distal
superficial veins.
___ TTE:
The left atrial volume index is normal. Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Doppler parameters are most consistent with
normal left ventricular diastolic function. Right ventricular
chamber size and free wall motion are normal. Tricuspid annular
plane systolic excursion is normal (1.9 cm; nl>1.6cm) consistent
with normal right ventricular systolic function. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is severe pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION:
1) Moderate to severe pulmonary hypertension with normal LV
diastolic/systolic function and normal LVEDP as well as no ___
___ suggestive of likely type III pulmonary hypertension
(considering patient's age). There is significant elevation of
pulmonary vascular resistance with calculated PVR ranging from 4
- 7 ___ (depending on method of calculation) corroborated by
mid-systolic notching of pulmonary VTI and short acceleration
time thereof. RV size and function appear normal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Finasteride 5 mg PO DAILY
3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
4. Warfarin 5 mg PO DAILY16
5. Furosemide 20 mg PO DAILY
6. Allopurinol ___ mg PO DAILY
7. Calcitriol 0.25 mcg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 80 mg sc every 12 hours Disp #*14
Syringe Refills:*0
3. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
inhaled daily Disp #*30 Capsule Refills:*0
4. Warfarin 7.5 mg PO DAILY16
RX *warfarin 2.5 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
5. Allopurinol ___ mg PO DAILY
6. Calcitriol 0.25 mcg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
10.Oxygen
Diagnosis: Pulmonary Hypertension (ICD I27.0)
Home oxygen at 4L/min continuous via nasal cannula; conserving
device for portability.
Length of Time: Indefinite
___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Primary: Pulmonary embolism
#Secondary: Severe pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with PE. Evaluate for further clot burden.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: CTA chest from ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common veins. However, there is partially occlusive thrombus in the right mid
superficial femoral vein extending to the distal superficial femoral vein,
where it becomes occlusive. There is also partially occlusive thrombus in the
left mid and distal superficial veins. There is poor visualization of the
right-sided peroneal veins, due to overlying edema. Normal color flow is
demonstrated in the bilateral posterior tibial and left peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Partially occlusive thrombus in the right mid superficial femoral vein,
which extends to the distal right superficial femoral vein, where it becomes
occlusive.
2. Partially occlusive thrombus in the left mid and distal superficial veins.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 10:46 on ___, 2 minutes after discovery.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Other chest pain
temperature: 98.3
heartrate: 72.0
resprate: 18.0
o2sat: 90.0
sbp: 138.0
dbp: 7.0
level of pain: 4
level of acuity: 2.0 | ___ with hx of recurrent DVT/PE on warfarin s/p bilateral
femoral vein ligation, pulmonary HTN, CKD who presented with
pleuritic chest pain and several months of increasing oxygen
requirement with ambulation, admitted due to concern for new
pulmonary embolism, found to have acute on chronic pulmonary
embolism, treated with lovenox. Also found to have worsening
severe pulmonary hypertension, for which he was given O2 for
ambulation. He will continue lovenox while bridging back to
warfarin with new INR goal range 2.5-3.5. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Meperidine / Fentanyl / Morphine / ciprofloxacin / Flagyl /
Demerol
Attending: ___.
Chief Complaint:
Abdominal Pain/Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of multiple abdominal surgeries/complications
since her Roux-en-Y gastric bypass in ___, previous ___
___ tear, iron deficiency, depression, recent c. diff
infection ___ (one positive c diff in OMR, pt reports
multiple recurrent infections), and ulcer noted at her
anastomosis site last month (___) presents with abdominal
pain. Pt reports sudden onset of LLQ pain at 1am ___ which
awakened her from sleep with ___ left-sided periumbilical pain
that was non-radiating, deep, cramping and sharp in quality. She
reports inability to tolerate PO due to nausea, vomited x5,
denies hematemesis, coffee ground emesis. She also has
associated loose BM diarrhea (___), no melena or BRBPR
recently (albeit reports small amount of blood in her stool 1
week ago). Reports a fever of ___ yesterday, measured with a
thermometer, +chills. No dysuria or hematuria. No sick contacts.
Pt reports that she has had recurrent c diff infections since
___ where she initially presented with n/v, diarrhea ___
BM/day, and abd pain; similar to her symptoms today. She states
that she completed one course of 10d Vanco, sxs did not improve.
She repeated another 10d course which did not improve her sxs.
Since sxs did not improve with the second course, she was
started on a taper which she is currently on and has not
decreased her dose from 125mg PO q6h yet. In ___, there is one
+c diff during her admission in late ___ (d/c ___. PCP
and bariatric surgeon appear to be based in ___ and we do not
have access to their notes. She attributes her current symptoms
to c diff.
Her most recent admission to ___ was from ___ for
abdominal pain, with unremarkable imaging. She was found to be C
Diff positive and was treated with 10 day course of PO Vanc. She
was also started on Reglan (and lidocaine which she is not
taking currently).
Previous to this admission, she had a similar presentation in
early ___. At that time, she was found to be c diff negative.
In addition, she left AMA after her EGD as she thought her
nausea and pain were not being well controlled. She was noted to
have a anastomotic ulcer for which she was prescirbed high dose
PPI and sulcrafate (meds she was already on, compliance was
stressed).
In the ED intial vitals were: 8 98.9 116 113/66 18 100% RA.
- Labs were significant for H/H of 9.2/ 32.4 which is her
baseline, no leukocytosis, normal chem 7, normal lactate, and
neg UA.
- Imaging: CT abd/pelvis w/ IV contrast showed no evidence of
obstruction, leakage, or intrabdominal abscess.
- Patient was given viscous lidociane, sucralfate, IV tylenol,
compazine, zofran, protonix, and PO Vanc, banana bag, and 2L NS.
- She was seen by bariatric surgery who recommended admission to
medicine with GI consult. Admitted given inability to tolerate
PO.
- GI was also made aware of pt and will see her on the floor.
Vitals prior to transfer were: 98.3 83 99/44 16 98% RA.
On the floor, she reports ___ abd pain in LLQ, and nausea.
Past Medical History:
- s/p ex-lap for appendectomy, washout of pelvic abscesses w/
SBR ___
- ex-lap LOA for SBO ___
- gastric bypass surgery ___ c/b multiple intraabdominal
perforations and SBOs, lost 225 lbs since, was originally 360
lbs, done at ___
- gastric ulcers
- cholecystitis s/p CCY
- "enlarged spleen" on imaging ___
- h/o prior cocaine abuse
- s/p L lumpectomy (benign pathology) in ___
- s/p tonsillectomy
- hx of headaches, eval by neuro ___
- depression
- iron-deficiency anemia
- ___ tear
- c diff infection ___, pt reports multiple infecitons (only
one + in OMR)
- perforated GJ ulcer with repair in ___
- perforated GJ ulcer with non-operative management ___
Social History:
___
Family History:
Grandmother with "colitis", aunt with ___ disease; no other
family history of GI illness.
Physical Exam:
On admission:
Vitals: 97 96/48 57 18 99%RA
GEN: A&Ox3, comfortable. Cigarette odor filled room, unable to
determine if from patient or boyfriend in room (also noted in
consult notes)
HEENT: NCAT, anicteric, pink conj, MMM, PERRLA
CV: S1S2 RRR no m/g/c/r
PULM: CTAB
ABD: Soft, nondistended, TTP in LLQ, no r/g, hypoactive BS, no
palpable masses
Ext: No ___ edema, WWP, 2+ peripheral pulses
Neuro: CN2-12 in tact grossly
Rectal: Guaic negative in ED
On discharge:
Not performed; patient eloped.
Pertinent Results:
=====================
Labs:
=====================
___ 10:10AM BLOOD WBC-7.1 RBC-4.08* Hgb-9.2* Hct-32.4*
MCV-79* MCH-22.6* MCHC-28.5*# RDW-14.8 Plt ___
___ 10:10AM BLOOD Neuts-67.5 ___ Monos-5.4 Eos-3.6
Baso-0.8
___ 10:10AM BLOOD ___ PTT-29.6 ___
___ 10:10AM BLOOD Glucose-88 UreaN-5* Creat-0.6 Na-139
K-4.5 Cl-104 HCO3-27 AnGap-13
___ 10:10AM BLOOD ALT-18 AST-22 LD(LDH)-209 AlkPhos-72
TotBili-0.3
___ 10:10AM BLOOD Lipase-40
___ 10:10AM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.9 Mg-1.9
___ 10:23AM BLOOD Lactate-1.3
=====================
Micro:
=====================
___ blood cultures x2: negative as of ___ at 2pm
___ urine culture pending
___ 6:22 am STOOL CONSISTENCY: SOFT Source: Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
=====================
Imaging:
=====================
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 5:20 ___
FINDINGS:
The lung bases are clear and the visualized heart and
pericardium are
unremarkable.
CT ABDOMEN: The patient is status post gastric bypass surgery.
At the
postsurgical anatomy is unremarkable, with a patent
gastrojejunostomy and
occasionally and jejunojejunostomy without dilatation to suggest
obstruction and absence of contrast in the biliary limb. There
is no evidence of leak or intraperitoneal fluid collection. No
free air is identified in the abdominal cavity.
The liver enhances homogeneously, without focal lesions or
intrahepatic
biliary duct dilatation. The patient is status post
cholecystectomy. The
portal vein is patent. The pancreas, spleen, adrenal glands are
within normal limits. The kidneys show symmetric nephrograms
and excretion of contrast.
There is no focal renal lesion or hydronephrosis bilaterally.
The small and large bowel are within normal limits, without
evidence of wall thickening or dilatation to suggest
obstruction. The appendix is not seen but there is no evidence
of appendicitis. The aorta and its main branches are patent and
nonaneurysmal. There is no mesenteric or retroperitoneal lymph
node enlargement by CT size criteria. There is no ascites or
abdominal wall hernia.
CT PELVIS: The urinary bladder and ureters are unremarkable.
The uterus and adnexae are unremarkable. Two dropped surgical
clips are seen in the pouch of ___. There is no pelvic wall
or inguinal lymphadenopathy. No pelvic free fluid is observed.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions
concerning for
malignancy.
IMPRESSION:
No CT findings to explain the symptoms. Unremarkable post
gastric bypass
anatomy. No evidence of obstruction, leakage or intra-abdominal
abscess.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sucralfate 1 gm PO QID
2. Metoclopramide 10 mg PO TID
3. Ondansetron 8 mg PO BID
4. Omeprazole 40 mg PO BID
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
6. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Medications:
Patient eloped from hospital; no specific changes made to
preadmission medications.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain of unclear etiology
Discharge Condition:
Not evaluated: pt eloped from hospital
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with gastric bypass in ___ with history of
perforations and a small bowel obstruction now with recurrent abdominal pain.
COMPARISON: Multiple prior CT abdomen and pelvis, most recent on ___
TECHNIQUE: Axial helical MDCT images were obtained from the lung bases to the
pubic symphysis after administration of IV and oral contrast. Coronal and
sagittal reformations were generated.
DLP: 686 mGy-cm
FINDINGS:
The lung bases are clear and the visualized heart and pericardium are
unremarkable.
CT ABDOMEN: The patient is status post gastric bypass surgery. At the
postsurgical anatomy is unremarkable, with a patent gastrojejunostomy and
occasionally and jejunojejunostomy without dilatation to suggest obstruction
and absence of contrast in the biliary limb. There is no evidence of leak or
intraperitoneal fluid collection. No free air is identified in the abdominal
cavity.
The liver enhances homogeneously, without focal lesions or intrahepatic
biliary duct dilatation. The patient is status post cholecystectomy. The
portal vein is patent. The pancreas, spleen, adrenal glands are within normal
limits. The kidneys show symmetric nephrograms and excretion of contrast.
There is no focal renal lesion or hydronephrosis bilaterally.
The small and large bowel are within normal limits, without evidence of wall
thickening or dilatation to suggest obstruction. The appendix is not seen but
there is no evidence of appendicitis. The aorta and its main branches are
patent and nonaneurysmal. There is no mesenteric or retroperitoneal lymph
node enlargement by CT size criteria. There is no ascites or abdominal wall
hernia.
CT PELVIS: The urinary bladder and ureters are unremarkable. The uterus and
adnexae are unremarkable. Two dropped surgical clips are seen in the pouch of
___. There is no pelvic wall or inguinal lymphadenopathy. No pelvic free
fluid is observed.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions concerning for
malignancy.
IMPRESSION:
No CT findings to explain the symptoms. Unremarkable post gastric bypass
anatomy. No evidence of obstruction, leakage or intra-abdominal abscess.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: n/v/d, BRBPR
Diagnosed with CLOSTRIDIUM DIFFICILE
temperature: 98.9
heartrate: 116.0
resprate: 18.0
o2sat: 100.0
sbp: 113.0
dbp: 66.0
level of pain: 8
level of acuity: 3.0 | ___ s/p Roux-en-Y in ___ s/p multiple complications, and a
recent c diff infection who presents with nausea, abdominal
pain, and diarrhea.
Pt was admitted overnight ___. On the morning of ___
patient eloped and left the hospital prior to evaluation by the
day team. The day team spoke to her by phone. She reported
leaving due to a personal matter that she needed to attend to.
She was advised to return to the hospital if she felt unwell or
if symptoms persisted or worsened.
# Abdominal pain:
Patient had acute LLQ abdominal pain and no obvious cause on
imaging, ruling out such etiologies as SBO. Exam was also very
benign making a surgical process less likely. Recent c diff
infection; pt reports multiple c diff infections in the past.
States that current sxs started and had not improved since she
was initially diagnosed w/ c diff. This is occuring despite
being treated with Vanco twice, and currently on a taper.
Reports fever but no leukocytosis on labs. Other considerations
for LLQ pain include diverticulitis (negative CT), IBS. Less
likely are referred pain from ulcers, but pt does have a
recently diagnosed anastomotic ulcer - was instructed to stop
NSAIDs and smoking. Stool studies including c diff were sent.
Blood and urine cultures were sent. She was given an IV PPI and
oxycodone for pain control. She did not have known diarrhea
after admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cephalexin
Attending: ___.
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year-old lady residing at the dementia
unit ___ with a history of HTN, hearing loss and
eczema who presents referred by her PCP with new cellulitis.
Per daughter and health aide she had a mechanical fall on her
right lower extremity about a week ago that resulted in skin
erosions right below her right knwee that were healing well.
Last night her home health aide noticed some subtle redness in
the area. This morning she was found to have edema, erythema and
pain extending from the area of the wound until her ankle. Her
PCP was made aware and referred her to the ED for evaluation.
In the ED, initial vitals were: 97.4 66 143/48 16 100%
- Labs were significant for
*CBC: 7.6> 9.7/29.6 < 266
*mild hyperkalemia at 5.3, mild alkalosis at 29, BUN 25 / Cr 1.1
(b/l 0.9-1.0), normal lactate
*UA: negative for leuk esterase, nitrites, ketones
- Imaging revealed :
*tib/fib XR negative for fractures
___ negative for DVT
- The patient was given: CTX 1g iv, Vancomycin 1g iv, APAP 1g Po
- Admission was discussed with geriatrics fellow
Vitals prior to transfer were: 98.0 88 152/65 16 100% RA
Upon arrival to the floor, the patient complained of mild pain
in her right lower extremity but mostly of pruritus in the
anterior surfaces of both lower extremities.
Past Medical History:
- Alzheimer's type dementia,
- four episodes of breast cancer BRCA1 negative
- hypothyroidism
- elevated cholesterol
- GERD
- hypertension
- COPD
Social History:
___
Family History:
- Brother: prostate cancer
- Father: MI in ___
Physical Exam:
ADMISSION LABS
Vitals: 97.9 | 156/56 | 85 | 18 | 95%RA
General: Alert, oriented to self, pleasant, repeatedly
scratching the skin of her lower extremities.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated.
CV: Regular rate and rhythm, normal S1 + S2, harsh mid-systolic
murmur radiating to carotids. No rubs, gallops
Lungs: Clear to auscultation bilaterally, diffuse wheezes, no
ronchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses.
Skin: RLE with slightly tender indurated erythematous lesion
extending from below the knee into the ankle. No purulence. Rest
of the skin in lower extremities and upper torso with multiple
erythematous nodules with licheniphication and chronic
excoriations.
Neuro: AOx1 (self), very hard of hearing in spite of hearing
aid, moves all four extremities at will, speech is fluent, gait
deferred.
DISCHARGE LABS
Vital Signs: 98.2, 143/48, 74, 18, 98% on RA
General: Alert to self, no acute distress
HEENT: Sclera anicteric, MMM
Lungs: diffuse wheeze in posterior lung fields
CV: RRR, nl S1 S2, systolic ejection murmur RUSB/LUSB, radiating
to the LLSB and the carotids b/l
Abdomen: soft, non-tender, non-distended
Ext: WWP, right leg with tender, erythematous, crusted lesion on
upper calf, with erythema surrounding crusted abrasion extending
to the ankle and above the knee, regressed x 1 inch below
initial markings
Skin: lower extremities and upper torso with multiple
hypopigmented nodules with lichenophication and chronic
excoriation
Neuro: hard of heading, moves all extremities spontaneously
Pertinent Results:
ADMISSION LABS
___ 12:49PM BLOOD WBC-7.6 RBC-3.24* Hgb-9.7* Hct-29.6*
MCV-91 MCH-29.9 MCHC-32.8 RDW-13.3 RDWSD-44.1 Plt ___
___ 12:49PM BLOOD Neuts-71.1* Lymphs-11.7* Monos-13.9*
Eos-2.6 Baso-0.3 Im ___ AbsNeut-5.40 AbsLymp-0.89*
AbsMono-1.06* AbsEos-0.20 AbsBaso-0.02
___ 12:49PM BLOOD Plt ___
___ 12:49PM BLOOD Glucose-83 UreaN-25* Creat-1.1 Na-141
K-5.3* Cl-103 HCO3-29 AnGap-14
___ 12:49PM BLOOD Phos-4.1
___ 12:59PM BLOOD Lactate-1.3
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
RIGHT ___ ULTRASOUND ___
Please note that this study is slightly limited by significant
tenderness
elicited with the transducer probe.
There is normal compressibility, flow and augmentation of the
right common femoral, femoral, and popliteal veins. Normal color
flow is demonstrated in the posterior tibial veins. Peroneal
veins are not well visualized. There is normal respiratory
variation in the common femoral veins bilaterally. No evidence
of medial popliteal fossa (___) cyst. There is significant
subcutaneous edema in the right calf.
IMPRESSION:
1. Limited evaluation of the right peroneal veins. No evidence
of deep
venous thrombosis in the visualized right lower extremity veins.
2. Subcutaneous edema in the right calf.
XRAY TIB/FIB ___
The bones diffusely demineralized. There is no acute fracture.
Well
corticated rounded calcific density seen adjacent to the
inferior aspect of the right fibula appears chronic. No
significant degenerative changes
identified. Diffuse subcutaneous edema is noted. There is no
radiopaque
foreign body.
IMPRESSION: No acute fracture.
DISCHARGE LABS
___ 06:25AM BLOOD WBC-7.7 RBC-3.35* Hgb-9.8* Hct-30.6*
MCV-91 MCH-29.3 MCHC-32.0 RDW-13.2 RDWSD-44.1 Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-91 UreaN-18 Creat-1.0 Na-143
K-4.5 Cl-106 HCO3-26 AnGap-16
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID
2. Cyanocobalamin 1000 mcg PO 1X/WEEK (MO)
3. Vitamin D 1000 UNIT PO DAILY
4. Donepezil 5 mg PO QAM
5. Ferrous GLUCONATE 240 mg PO 3X/WEEK (___)
6. Melatin (melatonin) 3 mg oral QHS
7. Albuterol 2 mg PO BID
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
9. Atorvastatin 10 mg PO QPM
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Acidophilus (L.acidoph &
___ acidophilus) 10 mg oral
DAILY
12. ammonium lactate 12 % topical DAILY dry scaly skin
13. Clobetasol Propionate 0.05% Cream 1 Appl TP BID rash
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Albuterol 2 mg PO BID
3. Atorvastatin 10 mg PO QPM
4. Donepezil 5 mg PO QAM
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Acidophilus (L.acidoph & ___
acidophilus) 10 mg oral DAILY
8. ammonium lactate 12 % topical DAILY dry scaly skin
9. Cyanocobalamin 1000 mcg PO 1X/WEEK (MO)
10. Ferrous GLUCONATE 240 mg PO 3X/WEEK (___)
11. Melatin (melatonin) 3 mg oral QHS
12. Amoxicillin 500 mg PO Q8H Duration: 8 Days
Please take until ___
RX *amoxicillin 500 mg 1 capsule(s) by mouth every 8 hours Disp
#*24 Capsule Refills:*0
13. Sulfameth/Trimethoprim DS 1 TAB PO Q12H Duration: 8 Days
Please take until ___
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth every 12 hours Disp #*16 Tablet Refills:*0
14. Betamethasone Valerate 0.1% Cream 1 Appl TP BID
apply to affected area, do not apply to right lower calf while
patient has cellulitis
RX *betamethasone valerate 0.1 % Apply to affected area two
times per day Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Cellulitis
Mechanical Fall, skin abrasion
Secondary Diagnosis:
Eczema, prurigo nodularis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ with RLE pain, swelling, ? cellulitis // eval ? DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
Please note that this study is slightly limited by significant tenderness
elicited with the transducer probe.
There is normal compressibility, flow and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the posterior tibial veins. Peroneal veins are not well visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. There is significant
subcutaneous edema in the right calf.
IMPRESSION:
1. Limited evaluation of the right peroneal veins. No evidence of deep
venous thrombosis in the visualized right lower extremity veins.
2. Subcutaneous edema in the right calf.
Radiology Report
INDICATION: ___ with injury // r/o fracture, osteo
TECHNIQUE: AP, oblique, and lateral views of the right knee. AP and lateral
views the right tibia and fibula.
COMPARISON: None.
FINDINGS:
The bones diffusely demineralized. There is no acute fracture. Well
corticated rounded calcific density seen adjacent to the inferior aspect of
the right fibula appears chronic. No significant degenerative changes
identified. Diffuse subcutaneous edema is noted. There is no radiopaque
foreign body.
IMPRESSION:
No acute fracture.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Leg pain, R Leg swelling
Diagnosed with CELLULITIS OF LEG
temperature: 97.4
heartrate: 66.0
resprate: 16.0
o2sat: 100.0
sbp: 143.0
dbp: 48.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old female with a past medical
history of alzheimer's dementia, HTN, eczema, prurigo nodularis
presenting a week after a fall leading to RLE abrasion found to
have cellulitis.
# Cellulitis: The patient presented 1 week following a
mechanical fall with erythema and edema on her right lower
extremity surround an abrasion on her right lateral calf. The
patient was evaluated with a RLE US which was negative for DVT.
She was also evaluated with a RLE xray tib/fib which showed no
fracture. The patient remained afebrile and hemodynamically
stable. It was thought that her recent abrasion predisposed her
to infection in this region. The patient also has a history of
skin conditions (below) which she often scratches which may have
contributed to her risk. The patient was treated with vancomycin
and ceftriaxone which was transitionned to amoxicillin and
tmp/smx to cover strep and MRSA given her risk factors (living
in a dementia unit). The patient should continue these
antibiotics for a total of 10 days (to end on ___. The
patient's leg was wrapped in an ace bandage to prevent her from
scratching the area. The patient should follow up with her PCP
for ___ management.
# Arthlagias: The patient reported pain in her knees and hips.
Per report of her daughter, the patient had recenty been given a
walker and schedued acetaminophen for management of her leg pain
and weakness. The patient was continued on her acetaminophen
TID.
# Pruritus, eczema, prurigo nodularis: The patient has a history
of several skin conditions and she was found to have diffuse
nodules on her upper and lower extremities. The patient had
significant pruritus and, as above, it was thought this may
further predispose her to infection. The patient had been
treated with clobetasol cream in the past with good effect. This
had recently been transitionned to triamcinolone cream due to
problems with insurance coverage. The patient was discharged on
betasone valerate 0.1% cream BID, for equivalent steroid dosing.
The patient should follow up with her PCP for further management
of these medications.
# Dementia: The patient's mental status was thought to be at
baseline. She was continued on donepezil.
# Hyperkalemia, mild elevated in Cr: The patient presented with
elevated potassium to 5.3 and Cr elevated to 1.1 from baseline
0.9-1.0. This was thought to be caused by decreased PO intake
and because of her albuterol being held. The patient did not
have any ECG changes. Her K and Cr were monitored and returned
to baseline.
# COPD: The patient was found to have some wheezing while
hospitalized when her albuterol 2mg PO BID was held due to
difficulty with medication reconciliation. The patient was
treated with an albuterol nebulizer and restarted on her home
medication with improvement in her symptoms. The patient should
f/u with her PCP in the future for further management of this
condition. Can consider albuterol neb treatement in the future
if needed as the patient tolerated this well in the hospital.
# Systolic Murmur: The patient was found to have a systolic
murmur at the RUSB radiating to the LUSB/LLSB and the carotids
bilaterally. This was thought to represent aortic stenosis. No
further imaging was ordered as it was thought that a TTE would
be unlikely to change management. The patient should f/u with
her PCP as needed.
# HLD: Continued atorvastatin
# Hypothyroidism: Continued levothyroxine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / Penicillins / Oxycodone / Clindamycin / Vagifem /
Latex
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with multiple prior abdominal operations and
small bowel
obstructions managed non-operatively who presented at this
admission with 24 hours of abdominal pain associated with
nausea. She denied flatus and had one small BM on the day of
admission. She reported nausea without emesis. Review
of systems notable for URI, mild lightheadedness and dizziness,
and increased urinary frequency. She denies fever, chills, and
dysuria.
Past Medical History:
Past Medical History: Irritable bowel syndrome, Diverticulitis,
constipation, allergic rhinitis, benign breast mass, chronic low
back pain, small bowel obstructions, chronic pelvic pain, DJD,
gastritis, GERD, migraine headaches, optic neuritis,
pancreatitis
and positive PPD
Past Surgical History: ___ - Open appendectomy, ___ - Partial
hysterectomy, ___ - Ovarectomy, ___ - R shoulder surgery
Social History:
___
Family History:
Mother died of "intestinal perforation," otherwise
non-contributory
Physical Exam:
Discharge Physical Exam
VS: 98.4 67 117/60 18 99%ra
Gen: alert and oriented x3 NAD
CV: RRR
Pulm: CTAB
Abd: soft, mildly distended, no palpable masses, no
rebound/gaurding
Ext: WWP
Pertinent Results:
___ CT abd/pelvis
IMPRESSION:
1. Dilated segment of ileum demonstrating mural edema,
thickening, and
adjacent stranding with a transition point noted in the caliber
of the lumen in the mid abdomen. Findings are worrisome for an
early small bowel
obstruction with ischemia.
2. No evidence of diverticulitis.
Medications on Admission:
butalbital-acetaminophen-caff 50/325 prn migraine,
omeprazole 20'', valacyclovir 500'', biotin, bisocodyl 5,
docusate, polyethylene glycol
Discharge Medications:
1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO three times a day as needed for headache.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
3. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. biotin 1 mg Tablet Sig: One (1) Tablet PO three times a day.
5. bisacodyl 10 mg Suppository Sig: One (1) Rectal twice a day
as needed for constipation.
6. docusate calcium 240 mg Capsule Sig: One (1) Capsule PO once
a day as needed for constipation.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
once a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chronic abdominal pain including diverticulitis. Severe pain
localized most to the left lower quadrant.
TECHNIQUE: MDCT images were obtained from the lung bases to the pelvic outlet
after administration of intravenous contrast. Coronal and sagittal images
were acquired.
COMPARISON: None.
CT ABDOMEN:
The lung bases are clear. The visualized portions of the heart and
pericardium are unremarkable.
A segment of ileum is dilated to 2.7 cm with mural edema and thickening, as
well as surrounding mesenteric fat stranding. A transition point in the
caliber of the small bowel is noted in the anterior mid abdomen (2:47).
The liver enhances homogenously and there is no focal liver lesion. The
gallbladder, pancreas, spleen, and adrenals are normal. The kidneys enhance
symmetrically and excrete contrast without evidence of hydronephrosis or
stone. The stomach is 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 appendicitis. The colon, adnexa, and urinary bladder are unremarkable.
The uterus is not visualized. There is no pelvic lymphadenopathy or free
fluid.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion suspicious for
malignancy.
IMPRESSION:
1. Dilated segment of ileum demonstrating mural edema, thickening, and
adjacent stranding with a transition point noted in the caliber of the lumen
in the mid abdomen. Findings are worrisome for an early small bowel
obstruction with ischemia.
2. No evidence of diverticulitis.
Findings were discussed by Dr. ___ with Dr. ___ by phone at 8:49
p.m. on ___.
Gender: F
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.2
heartrate: 84.0
resprate: 18.0
o2sat: 100.0
sbp: 134.0
dbp: 89.0
level of pain: 3-10
level of acuity: 3.0 | Ms. ___ was admitted to the ___ surgery service for
conservative management of her small bowel obstruction. She was
initially made NPO with IVF; as she had no episodes of emesis an
NGT was not placed. Labs were monitored daily. On HD 2 she began
to pass flatus and was advanced to clears, which she tolerated
without difficulty. She had no further nausea and continued to
pass gas. She was advanced to a regular diet on HD 3 which she
tolerated. She is discharged home on HD 3 in good condition
after successful conservative management of SBO. She is passing
flatus, tolerating a regular diet, voiding and ambulating
normally, with no abdominal pain or nausea. She will follow up
with ACS surgery in clinic in ___ weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Augmentin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
___ w/ Crohn's s/p L hemicolectomy and diverting colostomy ___
and recent C. diff s/p fecal transplant on ___ who presents
with abdominal pain and fevers.
Patient was admitted ___ to ___ for Crohn's flare. She was
initially covered with Cipro/flagyl but stool studies including
CDiff were negative. She was started on prednisone 60mg daily
and has been tapering as an outpatient with good improvement in
her symptoms. She then underwent FMT on ___, and biopsies at
that time showed severe active colitis. Following her FMT she
noted some mild abdominal pain. She then developed new diarrhea
and was diagnosed with CDiff colitis at ___ in ___
approximatley 10 days ago. She then restarted po vanco. Her
diarrhea improved but starting approximately 5 days ago, she
developed new and worsening lower abdominal pain, described as
up to ___ stabbing pain radiating from her lower abdomen
around to her back. She presented to urgent care and underwent
an ultrasound NOS which was apparently normal. She was started
on cefixime for possible UTI, which she has been taking for the
last three days. Due to progressive pain and new fevers over the
last few days, she then presented to the ___ ED.
In the ED intial vitals were pain 10, T 98.4, HR 115, BP 120/77,
RR 18, O2 99%RA. Initial labs were notable for WBC 23.3 with
93%PMN, 847 Plt, and HCT 35.4. UA was negative and remainder of
chem7 and lactate were wnl. KUB showed no evidence of
obstruction and CT A/P showed colitis. Patient was given flagyl,
IV morphine, IV dilaudid, and IV zofran along with 2LNS and
admitted to medicine for further management.
On the floor, patient notes abdminal pain and fevers as above.
Her stools remain formed, and denies frank blood in stool but
has noticed her stoma is irritated and occasionally bleeds. She
has mild nausea but no emesis. No recent headaches, shortness of
breath or cough. No dysuria. She is sexually active with her
boyfriend, but reports a monogomous relationship and no history
of STD. ROS is otherwise unremarkable.
Past Medical History:
- Crohns disease, diagnosed age ___, no past surgeries
- c. diff ___
- asthma
- migraines since age ___, previously had a neurologist
- depression
Social History:
___
Family History:
CAD, GF with colon cancer, cousin with UC, another cousin with
autoimmune hepatitis.
Physical Exam:
Admission Physical Exam
Vitals-98.4 97/63 18 98%RA
General- Pleasant, 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, left ostomy in place with reddish pink stoma and
brown stool, TTP suprapubically and LLQ, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge Physical Exam
Vitals: 98.0 75 104/64-120/79 18 100% RA
General: Alert, Oriented, NAD
HEENT: Sclera anicteric, MMM, no scleral injection, no mouth
ulcers
Neck: supple, no JVD
Lungs: CTAB
CV: RRR no murmurs
Abdomen:+BS ostomy in place mild ttp around site, no rebound or
guarding
Ext:WWP, no erythema nodosum, no clubbing, cyanosis, or edema
Neuro: A+Ox3,
Pertinent Results:
Admission Labs
=====================================
___ 07:53PM URINE MUCOUS-RARE
___ 07:53PM URINE RBC-4* WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 07:53PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:53PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:53PM URINE UCG-NEGATIVE
___ 07:53PM URINE HOURS-RANDOM
___ 09:40PM PLT COUNT-847*#
___ 09:40PM NEUTS-93.2* LYMPHS-4.4* MONOS-2.0 EOS-0.1
BASOS-0.3
___ 09:40PM WBC-23.3*# RBC-4.33 HGB-10.8* HCT-35.4*
MCV-82 MCH-24.9*# MCHC-30.5* RDW-12.9
___ 09:40PM ALT(SGPT)-20 AST(SGOT)-16 ALK PHOS-91 TOT
BILI-0.2
___ 09:40PM estGFR-Using this
___ 09:40PM GLUCOSE-93 UREA N-7 CREAT-0.6 SODIUM-139
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-24 ANION GAP-19
___ 09:56PM LACTATE-1.8
___ 08:15AM PLT COUNT-689*
___ 08:15AM WBC-16.8* RBC-3.47* HGB-8.8* HCT-28.1*
MCV-81* MCH-25.3* MCHC-31.2 RDW-12.9
___ 08:15AM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-1.9
___ 08:15AM GLUCOSE-84 UREA N-6 CREAT-0.6 SODIUM-137
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13
___ 11:46PM URINE MUCOUS-RARE
___ 11:46PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-<1
___ 11:46PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:46PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:46PM URINE UHOLD-HOLD
Imaging
KUB ___
Nonspecific bowel gas pattern without findings to suggest
obstruction.
CT Abd/pelvis ___
Mucosal edema with mural thickening and surrounding inflammatory
changes along the distal left colon leading to left lower
quadrant diverting colostomy are consistent with colitis, likely
secondary to underlying Crohn disease flare. Mild inflammatory
changes are also present about the rectal stump with adjacent
mild pelvic lymphadenopathy. No evidence of abscess or
obstruction.
US abdomen ___ cm subcutaneous fluid collection medial to the stoma, which
is not amenable to percutaneous drainage. Aspiration could be
considered if clinically indicated.
CXR ___
In comparison with study of ___, there is little change and no
evidence of acute cardiopulmonary disease. No pneumonia,
vascular congestion, or pleural effusion.
MICRO DATA
___ 7:53 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 11:03 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
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.
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.
___ 7:30 pm BLOOD CULTURE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:46 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.
___ 7:00 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Discharge Labs
___ 06:00AM BLOOD WBC-14.8* RBC-3.95* Hgb-9.7* Hct-32.6*
MCV-83 MCH-24.6* MCHC-29.8* RDW-14.0 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-140
K-4.4 Cl-99 HCO3-31 AnGap-14
___ 06:00AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheeze
3. Citalopram 40 mg PO DAILY
4. Montelukast Sodium 10 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Vancomycin Oral Liquid ___ mg PO Q6H
7. PredniSONE 15 mg PO DAILY
Tapered dose - DOWN
8. Suprax (ceFIXime) unknown oral unknown
9. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraine
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheeze
3. Citalopram 40 mg PO DAILY
4. Montelukast Sodium 10 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. DiCYCLOmine 20 mg PO QID
This medication may cause drowsiness or sedation
RX *dicyclomine 20 mg 1 tablet(s) by mouth four times a day Disp
#*60 Tablet Refills:*0
7. Hyoscyamine 0.25 mg SL QID
This medication may cause drowsiness or sedation
RX *hyoscyamine sulfate 0.125 mg 2 tablets sublingually four
times a day Disp #*120 Tablet Refills:*0
8. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraine
pls do not take this medication and oxycodone at the same time.
9. PredniSONE 30 mg PO DAILY
RX *prednisone 20 mg 1.5 (One and a half) tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
10. Calcium Carbonate 1000 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. OxycoDONE (Immediate Release) 25 mg PO Q4H:PRN break
through pain
RX *oxycodone 20 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. Crohn's Colitis
2. Clostridium Difficile Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with Crohn's, with right lower quadrant and left
lower quadrant pain and blood from the left lower quadrant stoma. Evaluation
for intra-abdominal abscess.
TECHNIQUE: MDCT images were obtained of the abdomen and pelvis after the
administration of intravenous and oral contrast. Reformat coronal and
sagittal images were also reviewed.
DLP: 289.66 mGy-cm.
COMPARISON: Comparison is made to CT of the abdomen and pelvis from ___.
FINDINGS:
CT ABDOMEN: The liver enhances homogeneously, with no evidence focal lesions.
There is no intra or extrahepatic biliary ductal dilatation. The portal vein
is patent. The pancreas, spleen, bilateral adrenal glands, bilateral kidneys
and gallbladder are unremarkable. The stomach, duodenum and proximal small
bowel are normal in appearance, with no evidence of wall thickening or
obstruction. Enteric contrast material is seen to the level of the distal
ileum. There is no evidence of intra-abdominal fluid collection or abscess.
The patient is status post left colectomy, with left lower quadrant ostomy.
The ostomy and the distal left colon again demonstrates mucosal edema, and
surrounding inflammatory changes, consistent with colitis (2:33), the
extending to the ostomy site (2:42). The findings are similar when compared
to the prior study, and are concerning for colitis in the setting of acute
Crohn's flare. There is no evidence of obstruction.
CT PELVIS: The rectal pouch again seen, and demonstrates mild mucosal edema,
likely inflammatory, with a trace amount of fluid in the pelvis (2:62). The
terminal ureters and bladder are unremarkable. The uterus is normal in
appearance. No adnexal masses are seen. Several prominent lymph nodes are
identified.
OSSEOUS STRUCTURES: No lytic or blastic lesions suspicious for malignancy is
identified.
IMPRESSION:
Mucosal edema with mural thickening and surrounding inflammatory changes along
the distal left colon leading to left lower quadrant diverting colostomy are
consistent with colitis, likely secondary to underlying Crohn disease flare.
Mild inflammatory changes are also present about the rectal stump with
adjacent mild pelvic lymphadenopathy. No evidence of abscess or obstruction.
Radiology Report
INDICATION: History of Crohn's disease status post colectomy with left lower
quadrant ostomy, now with fever and leukocytosis and palpable swelling around
the ostomy site, here to evaluate for underlying fluid collection.
COMPARISON: Same day CT of the abdomen and pelvis with contrast.
TECHNIQUE: Targeted sonographic assessment was performed in the region of the
patient's palpable abnormality medial to the left lower quadrant ostomy site.
FINDINGS: Corresponding to the patient's palpable abnormality medial to the
left lower quadrant stoma, there is a relatively hypoechoic collection in the
subcutaneous fat of the anterior abdominal wall, measuring 14 x 8 x 7 mm with
internal echoes compatible with debris. There is no internal vascularity on
color Doppler analysis. This likely corresponds to a focal subcutaneous
hypodensity on a same day CT.
IMPRESSION: 1.4 cm subcutaneous fluid collection medial to the stoma, which
is not amenable to percutaneous drainage. Aspiration could be considered if
clinically indicated.
Radiology Report
HISTORY: Fever.
FINDINGS: In comparison with study of ___, there is little change and no
evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion,
or pleural effusion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with CLOSTRIDIUM DIFFICILE, REGIONAL ENTERITIS NOS
temperature: 98.4
heartrate: 115.0
resprate: 18.0
o2sat: 99.0
sbp: 120.0
dbp: 77.0
level of pain: 10
level of acuity: 3.0 | ___ is a ___ w/ Crohn's s/p L hemicolectomy and
diverting colostomy ___ and recent C. diff s/p fecal transplant
on ___ who presents with abdominal pain and fevers.
ACUTE ISSUES
#Abdominal pain, presumed Crohn's flare: Patient with marked
colitis on CT and inflammation of rectal stump. Patient was
recently diagnosed with CDiff at ___ and she was on a steroid
taper for a Crohn's flare as well. She was continued on PO
vancomycin and GI was consulted for colonoscopy to further
evaluate colitis. Colonoscopy revealed mucosal ulceration
without evidence of CMV infection in the colon/sigmoid, however
tissue within the rectal stump was not inspected. Given that
the patient's pain was lower in the pelvis than her usual
Crohn's flares, there was concern for PID vs inflammation of the
rectal pouch itself. A pelvic US was considered to evaluate the
adnexa, however radiology felt that the CT abdomen pelvis was
sufficient to evaluate the pelvis. Given her clinical picture,
ovarian torsion was thought to be unlikely, and inflammation of
the rectal stump observed on CT was thought to be the primary
cause of her pain. Cortifoam enemas coupled with antispasmodics
(dicyclomine and hyoscyamine) were attempted and the patient had
significant pain with enemas. After 48 hours, and after
consultation with Dr. ___ primary GI, She was started on
IV methyl prednisolone 20 TID, with improvement in her pain. She
was then transitioned to prednisone 30mg PO daily with
instructions to continue this regimen until her follow-up
appointment with GI (Dr. ___. Per the GI team, PCP prophylaxis
was not needed while taking prednisone. She was discharged with
instructions to take calcium and vitamin D supplements to help
prevent bone demineralization in the setting of steroid
treatment.
- ___ virus negative
#Crohn's Disease
She was continued on her home dose of 20mg prednisone daily.
With continued pain she was transitioned to 20 TID of IV methyl
prednisolone on ___. The patient endorsed improvement in pain
with IV methyl prednisolone, and was transitioned to prednisone
30mg PO daily on day of discharge (___). As above, per GI,
she was instructed to continue taking prednisone 30mg daily
until her follow up appointment with Dr. ___. She was also
instructed to take vitamin D and calcium supplements given her
steroid treatment.
CHRONIC ISSUES
#GERD:
The patient was continued on her home regimen of BID omeprazole
#Asthma-
The patient has known diagnosis of asthma and was continued on
her home Montelukast and prn albuterol and remained clinically
stable.
# Depression
The patient has a history of depression and was continued on her
home Celexa regimen.
Transitional Issues
**Pt will need DEXA scan as out-patient given long term steroids
**Pt was discharged with instructions to start calcium and
vitamin D to prevent bone demineralization in the setting of
steroid treatment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HMED ATTENDING ADMISSION NOTE
ADMIT DATE: ___
ADMIT TIME: ___
.
___ yo F with h/o GERD and cholelithiasis, s/p lap chole ___
for gallstone pancreatitis complicated by bile leak s/p ERCP
with stent placement ___ and right abdominal hematoma s/p
percutaneous abdominal drain who is transferred from ___
___ with abdominal pain, new fluid collection and dilated
common bile duct.
.
Patient initially presented to ___ on ___
with abdominal pain, nausea and vomiting and was found to have
gallstone pancreatitis (also with facial cellulitis and otitis
externa). Patient underwent a lap chole on ___ complicated
by a cystic duct bile leak for which she was transferred to
___. Patient underwent ERCP with stent placement on ___.
Patient was discharged home on ___ however continued to
have persistent abdominal pain, nausea and vomiting. She was
evaluated by her PCP, found to have a bili of 2 and CT scan
showed an intra-abdominal fluid collection. Patient was
admitted to the hospitalist service on ___. ___ performed a
CT-guided placement of drain in the fluid collection on ___
which was consistent with a hematoma. She had a HIDA scan which
was negative for bile leak. Drain was pulled and patient was
discharged on ___.
.
Patient initially felt well after hospital discharge - minimal
pain and nausea (never fully resolved). Approximately one week
ago, RUQ pain returned. Described as intermittent,
sharp/cramping, ___ at maximum. Two days ago developed nausea
and anorexia. No vomiting. No fever, + chills. No cp, sob,
diarrhea, brbpr or melena.
.
Presented to ___ ED yesterday and found to have a
dilated CBD of 1.8 cm (per ED report, no imaging in chart) with
normal bilirubin. Transferred to ___ for ERCP evaluation.
.
ED: 97.7 73P 109/69 16 98%RA; zofran 4mg iv, unasyn 3gm, CT
a/p with contrast - extruded biliary stent in duodenum, stable
moderate biliary ductal dilatation, decrease in RLQ fluid
collection; surgery consulted - fluid collection seen on CT scan
prior to lap chole - biloma vs hematoma, no surgical
intervention, consider drainage. ERCP consulted with plan for
ERCP and stent replacement in the am.
.
ROS as per HPI, otherwise 10 pt ROS negative
Past Medical History:
GERD
MVC with head injury
Nasal drip
Right hydronephrosis
Cholelithiasis s/p CCY, c/b bile leak and abdominal hematoma;
s/p subsequent ERCP with stent placement
Social History:
___
Family History:
Father deceased from pancreatic cancer
Physical Exam:
VS 96.8 126/70 80 18 99%RA
Appearance: alert, NAD
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, obese, + RUQ ttp, no distension, +bs, no
rebound/guarding, neg ___
Msk: ___ strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn ___ grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical ___
___ Results:
___ 05:13PM LACTATE-0.9
___ 05:02PM GLUCOSE-84 UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
___ 05:02PM ALT(SGPT)-49* AST(SGOT)-39 ALK PHOS-272* TOT
BILI-0.9
___ 05:02PM LIPASE-83*
___ 05:02PM WBC-5.7 RBC-4.26 HGB-12.2 HCT-36.6 MCV-86
MCH-28.7 MCHC-33.4 RDW-13.3
___ 05:02PM NEUTS-64.3 ___ MONOS-3.7 EOS-2.5
BASOS-0.4
___ 05:02PM PLT COUNT-291
.
___ BCx: pending, no growth to date
.
___ CT a/p with contrast: wet read
-Extruded biliary stent - now located in the ___ portion of the
duodenum
-Stable moderate intra- and extrahepatic biliary ductal
dilatation.
-Pancreatic ductal dilatation - 4 mm - unchanged. Normal
enhancement of the pancreatic parenchyma without signs of acute
inflammation or necrosis
-Known RLQ fluid collection decreased in size since ___
though still
measuring 3.4 x 6.7 x 8.1 cm. Fluid remains hyperdense and could
represent a biloma or contained hematoma. Collection
demonstrates rim enhancement which could represent
superinfection - correlate clinically.
-Normal bowel - no obstruction or inflammation
.
___ 06:55AM BLOOD WBC-5.5 RBC-4.07* Hgb-12.0 Hct-35.4*
MCV-87 MCH-29.6 MCHC-33.9 RDW-13.4 Plt ___
___ 06:55AM BLOOD Glucose-50* UreaN-5* Creat-0.5 Na-136
K-3.8 Cl-102 HCO3-19* AnGap-19
___ 09:05AM BLOOD ALT-45* AST-37 AlkPhos-255* TotBili-1.1
___ 06:55AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.7
.
___ HIDA Scan - Normal post-operative hepatobiliary scan,
specifically with no evidence of biliary leak.
.
___ MRCP -
1. Patient is status post cholecystectomy with mild central
intrahepatic and extrahepatic biliary dilatation with no
evidence for choledocholithiasis. Of note, the stent is noted
still within the distal common bile duct and is draining freely
into the third portion of the duodenum.
2. Normal hepatobiliary excretion of the contrast agent Eovist
from the liver with no evidence of bile leak from the cystic
duct remnant.
3. Right upper abdominal collection with imaging characteristics
consistent with a liquefied hematoma. No evidence for biloma.
4. Moderate narrowing at the origin of the celiac axis with
associated
post-stenotic dilatation.
.
Medications on Admission:
1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily) as needed for rhinitis.
Discharge Medications:
1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily) as needed for rhinitis.
3. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. promethazine 12.5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
Disp:*56 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
MRCP
INDICATION: History of laparoscopic cholecystectomy for gallstones,
pancreatitis with common cystic duct leak postoperatively. Had ERCP with
stent placement. Evaluate an abdominal wall hematoma, which had an ___
drain. He has had one week of abdominal pain. Please evaluate fluid
collection, evidence for bile leak.
COMPARISON: Gallbladder scan ___, CT abdomen and pelvis
___, CT interventional procedure ___ and CT abdomen
and pelvis ___.
TECHNIQUE: Multiplanar T1- and T2-weighted imaging was acquired on a 1.5
Tesla magnet including dynamic 3D imaging obtained prior to, during, and after
the uneventful intravenous administration of 7.5 mL of Magnevist and 7.5 mL of
Eovist. In addition, 5 mL of Magnevist was administered orally with 75 mL of
water.
FINDINGS:
The imaged lung bases are clear. There are small bilateral pleural effusions.
There is normal hepatic parenchymal signal intensity without focal liver
lesion. There is mild central intrahepatic biliary dilatation and the common
bile duct is dilated measuring up to 12 mm in its more proximal portion,
however, tapers normally towards the head of the pancreas. There is evidence
of pneumobilia, but no evidence for choledocholithiasis. The biliary stent is
noted within the lower one-third of the common bile duct (series 6, image 1)
extending into the duodenum distally. Post administration of Eovist there is
prompt excretion of the hepatobiliary agent from the intra- and extra-hepatic
biliary tree with no evidence for bile leak. There is normal filling of the
cystic duct remnant with no evidence for a leak from the cystic duct stump.
There is conventional hepatic arterial anatomy, and the visualized hepatic and
portal veins are patent.
The spleen measures 11 cm. The pancreas has homogeneous signal intensity and
enhances uniformly. There is mild prominence of the pancreatic duct in the
head of the pancreas measuring up to 4 mm without irregularity. No focal
concerning cystic lesions are identified. Both adrenal glands are
unremarkable. Both kidneys are normal with a simple cyst noted in the
interpolar region of the right kidney measuring 8 mm which is hyperintense
relative to renal parenchyma on T2-weighted imaging (series 12, image 30) and
does not enhance post-contrast.
Incidental note is made of moderate narrowing of the origin of the celiac axis
with associated post-ostial dilatation (series 901, image 722). The
visualized superior mesenteric and inferior mesenteric arteries are patent.
The abdominal aorta is normal in caliber with no evidence for focal aneurysm
or dissection.
Within the mid abdomen on the right side, a collection is identified which
measures 7.4 craniocaudal x 6.0 cm AP x 3.4 cm in transverse diameter, which
previously measured 9.1 cm x 10.7 cm x 5.3 cm on ___. On T1-weighted
imaging there is a bright rim (series 7, image 126) which is dark on
T2-weighted imaging (series 12, image 42). The central component of the
collection is of high signal intensity on T2-weighted imaging, consistent with
liquidation within the collection. There is no significant enhancement
post-contrast administration and findings are consistent with a hematoma.
There are no retroperitoneal masses or adenopathy. No abnormally dilated or
thickened small or large bowel loop in the visualized upper abdomen. No free
fluid.
Bone marrow signal is normal and no osseous lesions were identified.
IMPRESSION:
1. Patient is status post cholecystectomy with mild central intrahepatic and
extrahepatic biliary dilatation with no evidence for choledocholithiasis. Of
note, the stent is noted still within the distal common bile duct and is
draining freely into the third portion of the duodenum.
2. Normal hepatobiliary excretion of the contrast agent Eovist from the liver
with no evidence of bile leak from the cystic duct remnant.
3. Right upper abdominal collection with imaging characteristics consistent
with a liquefied hematoma. No evidence for biloma.
4. Moderate narrowing at the origin of the celiac axis with associated
post-stenotic dilatation.
Findings were discussed with Dr. ___ via telephone by Dr. ___
___ at 10:30 a.m. on ___.
Gender: F
Race: ASIAN - ASIAN INDIAN
Arrive by AMBULANCE
Chief complaint: HEMATOMA SURG SITE
Diagnosed with DIS OF BILIARY TRACT NEC, ABDOMINAL PAIN OTHER SPECIED
temperature: 97.7
heartrate: 73.0
resprate: 16.0
o2sat: 98.0
sbp: 109.0
dbp: 69.0
level of pain: nan
level of acuity: 3.0 | ___ yo F with h/o GERD and cholelithiasis, s/p lap chole ___
for gallstone pancreatitis complicated by bile leak s/p ERCP
with stent placement ___ and right abdominal hematoma s/p
percutaneous abdominal drain now with recurrent nausea and
abdominal pain and found to have an extruded biliary stent with
stable ductal dilatation.
.
#Abdominal pain/nausea: initial ddx included extruded biliary
stent vs recurrent bile leak vs possible infected fluid
collection.
--following admission, the patient was made NPO, placed on IVF,
given IV antiemetics and started on IV antibiotics for empiric
cholangitis treatment. The ERCP and Surgical Consult services
were also asked to see the patient. ___ d/w both consult
services, the pt first had a HIDA scan performed to evaluated
for biliary leak, which was negative. She then underwent a MRCP
to further evaluate the fluid collection. Initially the MRI was
read as a possible biloma, so a plan was made to have ___ place a
drain into the collection. However, on further review with
Radiology, it was felt that the collection was most likely a
resolving hematoma. Surgery felt that the hematoma could be
managed conservatively as long as the patient's symptoms
improved. The pt's abdominal pain resolved quickly and her
nausea was well controlled with antiemetics. Her diet was
advanced and her IVF were stopped. Given that there was no
evidence of cholangitis, the patiet had the IV antibiotics
stopped as well. The patient was able to tolerate a full diet
with no pain and nausea. She will be discharged to home with
follow-up with GI as an outpatient. She was discharged with PRN
oral antiemetics. She will need a follow-up KUB in
approximately 2 weeks by GI to confirm passage of the biliary
stent. If it remains in place, she will need a repeat ERCP to
have it removed.
.
#GERD:
--continued on ranitidine. She has not tolerated PPI in the
past.
.
#Post-nasal drip:
--continued on Singulair and PRN fluticasone.
.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pyelonephritis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M h/o of reflux nephropathy, BPH, presents with 1 week of
chills, sweats, fevers, found to have pyelonephritis. Began to
feel unwell 1 week prior to admission with a feeling of
"wooziness," malaise that progressed over several days. He then
presented to urgent care 1 day prior to admission where he was
diagnosed with pyelonephritis and prescribed Ciprofloxacin.
Despite taking several doses he continued to have fevers to 102
at home and felt unwell. He called urgent care the day of
admission who told him to present to the ED. He was started on
Ceftriaxone/Vancomycin and given 4L IVF in the ED. Lactate
normal. His blood pressure briefly dipped into the mid ___
systolic without change in mental status and this quickly
improved with fluids. His heart rate was in the ___
throughout. On arrival to the floor he is feeling much better.
He
continues to have some chills. He relays a recent history of
urinary urgency with mild dysuria and flank pain. CT urogram
revealed right-sided pyelo w/o abscess.
Past Medical History:
Psoriasis
Hypercholesterolemia
ADHD, predominantly inattentive type
Reflux nephropathy
Benign non-nodular prostatic hyperplasia
Social History:
___
Family History:
Family history of Liver Cancer in his mother.
___ Cancer in his father.
Physical Exam:
ADMISSION EXAM:
VS: Afebrile and vital signs stable (reviewed in bedside
record)
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, no JVD,
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ strength throughout.
fluent speech.
Psychiatric: pleasant, appropriate affect
GU: R sided CVAT
Patient was examined on day of discharge, afebrile, no
costovertebral angle tenderness.
Pertinent Results:
LABORATORY RESULTS:
___ 05:00PM BLOOD WBC-18.8* RBC-4.26* Hgb-13.3* Hct-38.5*
MCV-90 MCH-31.2 MCHC-34.5 RDW-12.6 RDWSD-41.5 Plt ___
___ 06:50AM BLOOD WBC-11.3* RBC-3.91* Hgb-12.2* Hct-35.4*
MCV-91 MCH-31.2 MCHC-34.5 RDW-12.5 RDWSD-41.9 Plt ___
___ 05:00PM BLOOD Glucose-109* UreaN-20 Creat-1.0 Na-132*
K-3.7 Cl-94* HCO3-23 AnGap-15
___ 06:50AM BLOOD Glucose-116* UreaN-10 Creat-0.9 Na-138
K-3.4* Cl-99 HCO3-22 AnGap-17
___ 05:00PM BLOOD ALT-24 AST-23 AlkPhos-81 TotBili-0.5
___ 05:00PM BLOOD Albumin-3.9
___ 05:34PM BLOOD Lactate-1.4
CTU Abd/Pelvis
1. Right pyelonephritis and mild ureteritis. No perinephric
abscess is
identified.
2. No additional acute process within the abdomen or pelvis.
3. Mild splenomegaly.
MICROBIOLOGY:
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Amphetamine-Dextroamphetamine 15 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Twice daily
Disp #*8 Tablet Refills:*0
2. Amphetamine-Dextroamphetamine 15 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis due to pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with right flank to RLQ pain, rigors despite ___//
assess for pyelonephritis, infected stone, perinephric abscess
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
prone position. The non-contrast scan was done with low radiation dose
technique. The contrast scan was performed with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 10.7 mGy (Body) DLP = 551.5
mGy-cm.
2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
3) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 10.8 mGy (Body) DLP = 556.9
mGy-cm.
Total DLP (Body) = 1,120 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: Minimal dependent atelectasis. Otherwise no focal consolidation
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 measures 13.5 cm without focal lesion.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Striated appearance of the right kidney is consistent with
pyelonephritis. The left kidney demonstrate normal nephrogram. There is no
nephrolithiasis or ureterolithiasis. There is no hydronephrosis. There is no
perinephric abnormality. There is no evidence of focal renal lesions. The
right ureter demonstrate mild surrounding stranding (series 4, image 67),
consistent with mild ureteritis. The left ureter is unremarkable. The
urinary bladder is unremarkable. No perinephric abscess is identified.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. Appendix is unremarkable.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is mildly enlarged. The seminal vesicles
are unremarkable.
LYMPH NODES: Scattered retroperitoneal lymph nodes are not enlarged by CT
criteria. No 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.
Degenerative changes of the lumbar spine are mild.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Right pyelonephritis and mild ureteritis. No perinephric abscess is
identified.
2. No additional acute process within the abdomen or pelvis.
3. Mild splenomegaly.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, R Flank pain
Diagnosed with Fever, unspecified, Unspecified abdominal pain, Weakness
temperature: 99.1
heartrate: 79.0
resprate: 20.0
o2sat: 98.0
sbp: 108.0
dbp: 50.0
level of pain: 2
level of acuity: 3.0 | Mr. ___ is a ___ year-old man with a history of BPH and reflux
nephropathy who presented with severe sepsis from
pyelonephritis. His urine grew a sensitive enterococcus; blood
cultures were negative. He was treated with IV ceftriaxone, and
received a total of five liters of IV fluids. He continued to
have fevers through HD#2. He was discharged on PO ciprofloxacin
on HD#3 to complete a 7-day course of therapy.
1. Severe sepsis d/t enterococcal pyelonephritis
- ciprofloxacin 500 mg BID x 4 additional days
2. HLD.
- home atorvastatin
3. ADHD. Home Adderal
4. CV Risk. Asa 81 mg.
> 35 minutes spent on discharge activities. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
___: Left hip hemiarthroplasty
History of Present Illness:
___ male history of hypertension, prostate cancer, left
patella fracture status post ORIF ___, ___ who
presents with left hip pain status post mechanical fall.
Patient
was walking home from the assisted living facility in which his
wife with dementia resides, when he tripped and fell on the
sidewalk today. He tried to get up and then fell again. He was
unable to bear weight on his left side. EMS brought him into
the
hospital for evaluation. He currently complains of pain "all
over". He is accompanied by his son who states that he has been
recently seen by neurology for evaluation of his cognitive
decline. He denies any numbness or tingling in his left lower
extremity. Positive head strike, negative loss of
consciousness.
Patient son states that he has been prescribed some home
medications, however he has not been taking any.
Past Medical History:
HTN, prostate cancer, MGUS, PUD, depression
Social History:
___
Family History:
non-contributory
Physical Exam:
Exam:
Vitals: ___ 0451 Temp: 98.1 PO BP: 129/73 R Lying HR: 95
RR:
18 O2 sat: 97% O2 delivery: Ra
General: Well-appearing, NAD
Resp: Normal WOB, symmetric chest rise
CV: Extremities WWP
MSK:
Left Lower Extremity:
SILT ___ distributions
Firing ___, FHL, TA, GSC
Incisional dressing clean dry and intact
Pertinent Results:
___ 07:07AM BLOOD WBC-7.6 RBC-3.39* Hgb-10.7* Hct-32.4*
MCV-96 MCH-31.6 MCHC-33.0 RDW-12.2 RDWSD-42.7 Plt Ct-86*
___ 07:07AM BLOOD Glucose-131* UreaN-22* Creat-1.0 Na-140
K-3.8 Cl-108 HCO3-23 AnGap-9*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
2. Guaifenesin-CODEINE Phosphate 5 mL PO Q4H:PRN cough
3. LORazepam 0.5 mg PO Q6H:PRN anxiety
4. TraZODone 50 mg PO QHS:PRN Insomnia
5. Valsartan 80 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous Once nightly
Disp #*30 Syringe Refills:*0
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Third Line
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet by mouth Every 4 hours as needed
Disp #*25 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY constipation
8. Senna 17.2 mg PO HS
9. Citalopram 10 mg PO DAILY
10. Guaifenesin-CODEINE Phosphate 5 mL PO Q4H:PRN cough
11. LORazepam 0.5 mg PO Q6H:PRN anxiety
12. TraZODone 50 mg PO QHS:PRN Insomnia
13. Valsartan 80 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femoral neck fracture
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: FEMUR (AP AND LAT) LEFT
INDICATION: History: ___ with left hip fx, had recurrent fall out of bed//
eval ich; eval knee injury
TECHNIQUE: Frontal, lateral and cross-table lateral views of the right knee
were obtained.
COMPARISON: Multiple prior knee radiographs, most recently ___.
Hip radiograph dated ___.
FINDINGS:
A single view of the left hip again demonstrates foreshortening of the left
femoral neck, consistent with femoral neck fracture. Brachy therapy seeds are
again noted overlying the lower pelvis. Moderate degenerative change at the
left hip joint is again noted.
No additional fracture or dislocation is seen. Depression of the anterior
surface of the patella is likely chronic and related to the prior patellar
fracture. Re-demonstrated are cerclage wires and pins in the patella. There
is a fracture through one of the superior cerclage wire loops, similar to
prior. Re-demonstrated is mild degenerative change along the medial
compartment as evidenced by tiny osteophytes. There is no knee joint
effusion. There is normal osseous mineralization. No suspicious lytic or
sclerotic lesions are identified. Note is made of a fabella posteriorly.
IMPRESSION:
1. Re-demonstrated is foreshortening of the left femoral neck, consistent
with a femoral neck fracture.
2. There are new fractures within the cerclage wires since the ___
study with irregularity of the anterior aspect of the patella on the lateral
view. Please correlate with patellar pain to exclude an acute on chronic
patellar fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST.
INDICATION: History: ___ with left hip fx, had recurrent fall out of bed//
eval ich; eval knee injury.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 9.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 4.0 s, 8.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
401.4 mGy-cm.
Total DLP (Head) = 1,304 mGy-cm.
COMPARISON: Head CT dated ___ at 22:11.
FINDINGS:
The examination is partially limited due to patient motion, within this
limitation, grossly there is no evidence of acute territorial infarction,
intracranial hemorrhage, edema, or mass effect. The ventricles and sulci are
prominent keeping with age-related involutional change. Moderate
periventricular and subcortical white matter hypodensities are nonspecific,
but likely represent sequela of chronic ischemic microvascular disease.
No acute fractures are seen. Re-demonstrated is a small subgaleal hematoma
overlying the left frontal bone measuring up to 7 mm in thickness (03:47).
There is new soft tissue swelling overlying the right frontal bone measuring
up to 5 mm in thickness. A small amount of subcutaneous gas likely reflects
known laceration. Aside from mild mucosal thickening in the bilateral ethmoid
air cells, the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The orbits are unremarkable.
IMPRESSION:
1. There is a new small subgaleal hematoma overlying the right frontal bone.
2. Re-demonstrated is a small hematoma overlying the left frontal bone with
an overlying laceration, and subcutaneous emphysema.
3. No acute intracranial hemorrhage or fracture.
Radiology Report
EXAMINATION: GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT
INDICATION: History: ___ with R shoulder pain s/p fall// eval fx
TECHNIQUE: AP and Y-view of the right shoulder were obtained.
COMPARISON: None
FINDINGS:
There is no fracture or dislocation involving the glenohumeral or AC joint.
There are mild degenerative changes in the right acromioclavicular joint. No
suspicious lytic or sclerotic lesions are identified. No periarticular
calcification or radio-opaque foreign body is seen. The visualized portion of
the lungs are clear,
IMPRESSION:
1. No acute fracture.
2. Mild degenerative disease in the acromioclavicular joint.
Radiology Report
EXAMINATION: Left hip radiograph, single AP portable view, intraoperative.
INDICATION: Immediately status post left hip hemiarthroplasty.
COMPARISON: Prior study from ___.
FINDINGS:
Patient is immediately status post left hip hemiarthroplasty. Hardware
appears intact. Brachy therapy seeds again project along the lower central
pelvis.
IMPRESSION:
Anticipated postoperative appearance immediately status post left hip
hemiarthroplasty.
Gender: M
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Facial injury, L Hip pain, s/p Fall
Diagnosed with Fracture of unsp part of neck of left femur, init, Unspecified fall, initial encounter
temperature: 98.1
heartrate: 84.0
resprate: 18.0
o2sat: 97.0
sbp: 184.0
dbp: 88.0
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 left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left 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 left extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, diarrhea, hematochezia
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
___ year old male w/no significant PMH who presents for 3 weeks
of diarrhea and bloody stools. He endorses a baseline stool of
___ and now is stooling large, loose stools with mucus and
blood approximately ___ daily for the last 3 weeks. He has had
red clot and blood streaked stool but no melena. He has not
traveled recently, only has eaten sushi in terms of
raw/undercooked foods. He is not aware of a family history of
IBD or autoimmune disease. He has cut lactose out of his diet
w/out effect. He thinks he may have hemorrhoids. He has been
having gradually worsening crampy abdominal pain that is
exacerbated by eating and has not been able to tolerate PO for
the last 24h. He describes it as sharp pain that occurs all over
the abdomen 5 minutes after eating, which is not immediately
resolved with defecation, as he has had tenesmus, but is unable
to pass stool at times. He had a scheduled GI appointment as an
outpatient but couldn't wait. He presented today for worsening
pain to ___. He endorses chills, denies fevers. + NS. He
endorses nausea, denies vomiting. He does note some pain when
hitting a pothole while driving.
In the ED, initial vitals were: 97.9 64 122/74 16 99%
- Labs were significant for Lipase 120, Lactate 1.2. AP140.
- Imaging revealed panproctocolitis.
- The patient was given IVF and zofran.
Vitals prior to transfer were: 98.0 62 127/78 16 100% RA
Upon arrival to the floor, patient notes pain is much better
(___) since not eating. Notes the zofran given to him in the ED
helped with nausea, as well as some of the gas discomfort.
REVIEW OF SYSTEMS:
(+) Per HPI. otherwise negative.
Past Medical History:
History of exercise-induced asthma
Social History:
___
Family History:
Negative for inflammatory bowel disease. Diabetes mellitus in
maternal grandmother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Tmax 98.8 Tc 98.8 HR ___ BP 106/56-116/65 RR ___
SpO2 100% RA
General: Well-appearing in NAD
SKIN: Warm and well perfused, no lesions or rashes
HEENT: Sclera clear, moist mucus membranes, no oropharynx
lesions or ulcers
NECK: No jugular venous distension, supple
Heart: Regular rate and rhythm, no murmurs or rubs
Lungs: Clear to auscultation bilaterally, no ronchi, rales, or
wheezes
Abdomen: Soft, tenderness to palpation diffusely. Slight rebound
tenderness.
Genitourinary: No foley
Extremities: No cyanosis, clubbing, or edema
Neurological: Moving all extermities, grossly within normal
limits
DISCHARGE PHYSICAL EXAM:
VS: 97.7, afebrile overnight BP 116/61 HR 58 RR 20, O2 98% on RA
GENERAL: No acute distress
SKIN: Warm and well perfused, no lesions or rashes
HEENT: Anicteric sclerae, pink conjunctivae. MMM
NECK: Nontender supple neck
CARDIAC: Regular rate and rhythm, normal S1/S2; no murmurs,
gallops, or rubs
LUNG: Breathing comfortably without use of accessory muscles,
clear to auscultation bilaterally, no wheezes, rales, or rhonchi
ABDOMEN: + Bowel sounds. Soft, nontender, nondistended, no
organomegaly. No rebound or guarding.
EXTREMITIES: No cyanosis, clubbing or edema, 2+ dorsalis pedis
pulses bilaterally
NEURO: Alert and appropriate, normal gait
Pertinent Results:
ADMISSION LABS:
___ 03:22PM BLOOD WBC-9.9 RBC-5.89 Hgb-15.5 Hct-47.1
MCV-80* MCH-26.3* MCHC-32.8 RDW-14.8 Plt ___
___ 03:22PM BLOOD Neuts-69.4 ___ Monos-7.0 Eos-4.5*
Baso-0.2
___ 03:22PM BLOOD Glucose-79 UreaN-13 Creat-1.0 Na-140
K-4.2 Cl-102 HCO3-29 AnGap-13
___ 03:22PM BLOOD ALT-33 AST-26 AlkPhos-140* TotBili-1.2
___ 03:22PM BLOOD Lipase-120*
___ 03:22PM BLOOD Albumin-4.2 Iron-45
___ 03:22PM BLOOD calTIBC-303 Ferritn-123 TRF-233
___ 03:27PM BLOOD Lactate-1.2
___ 03:22PM BLOOD CRP-3.0
___ 07:25AM BLOOD CRP-5.1*
___ 03:44PM BLOOD SED RATE-17
___ 07:25AM BLOOD SED RATE-6
___ 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 09:00AM BLOOD HCV Ab-NEGATIVE
___ 09:00AM QUANTIFERON(R)-TB GOLD-NEGATIVE
___ 02:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:45PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:45PM URINE MUCOUS-MANY
DISCHARGE LABS:
___ 07:00AM BLOOD CRP-7.1*
___ 07:25AM BLOOD WBC-8.4 RBC-5.29 Hgb-14.3 Hct-41.2
MCV-78* MCH-27.0 MCHC-34.7 RDW-14.0 Plt ___
___ 09:00AM BLOOD Na-139 K-4.1 Cl-103
___ 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
MICROBIOLOGY:
___ OVA + PARASITES (Final ___: NO OVA AND PARASITES
SEEN. MANY POLYMORPHONUCLEAR LEUKOCYTES. FEW RBC'S.
___
- C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
- FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
- CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
- OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN.
- 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.
IMAGING/STUDIES:
___ CT ABD & PELVIS WITH CONTRAST
IMPRESSION:
Proctocolitis, with wall thickening involving the entire ___,
most pronounced in the cecum and ascending ___, findings which
are likely infectious or inflammatory in etiology. No small
bowel involvement.
___ Sigmoidoscopy
Impression:
Ulceration, granularity, friability, erythema, congestion and
abnormal vascularity in the rectum, sigmoid, and descending
___ compatible with moderate-severe colitis. Otherwise normal
sigmoidoscopy to distal descending ___.
___ Sigmoidoscopy
PATHOLOGIC DIAGNOSIS:
___, mucosal biopsy (sigmoidoscopy): Chronic moderately active
colitis. No granulomata or dysplasia identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Calcium Carbonate 500 mg PO TID W/MEALS
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth TID W/MEALS Disp #*90 Tablet Refills:*0
2. PredniSONE 40 mg PO ONCE Duration: 1 Dose
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
3. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half)
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Ulcerative colitis
Secondary diagnosis:
History of exercise-induced asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with 3 weeks of bloody diarrhea, abdominal pain,
evaluate for colitis.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after the administration of intravenous contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats. Oral contrast
was administered.
DLP: 470 mGy-cm
COMPARISON: None available.
FINDINGS:
CHEST: The visualized lung bases are clear. The heart is normal in size and
there is no evidence of pericardial effusion.
ABDOMEN:
The liver enhances homogeneously and is without focal lesions. The portal
venous system is patent. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is normal and without radiopaque
gallstones.
The spleen and adrenal glands are unremarkable. The pancreas enhances
homogenously and is without focal lesions.
The kidneys display symmetric nephrograms and excretion of contrast.
Subcentimeter hypodensity in the upper pole of the left kidney posteriorly is
too small to characterize. There is no hydronephrosis. The ureters are normal
in caliber and course to the bladder.
The distal esophagus is normal without a hiatal hernia. The small bowel,
including the terminal ileum, is normal without focal wall thickening. Oral
contrast extends through the colon and rectum. There is diffuse wall
thickening of the entire colon and rectum, with wall thickening most
pronounced in the cecum and ascending colon. There is no evidence of
obstruction. The appendix is well-visualized and normal. There is no
intra-abdominal free fluid or free air.
The abdominal aorta and its major branches are patent. There is no
retroperitoneal or mesenteric lymphadenopathy by CT size criteria.
PELVIS:
The bladder is well distended and normal. There is no pelvic side-wall or
inguinal lymphadenopathy by CT size criteria. No free pelvic fluid is
identified.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
Proctocolitis, with wall thickening involving the entire colon, most
pronounced in the cecum and ascending colon, findings which are likely
infectious or inflammatory in etiology. No small bowel involvement.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, MELENA
temperature: 97.9
heartrate: 64.0
resprate: 16.0
o2sat: 99.0
sbp: 122.0
dbp: 74.0
level of pain: 8
level of acuity: 3.0 | ___ year-old male with no significant past medical history who
presents with abdominal pain, hematochezia, and diarrhea, found
to have moderate to severe ulcerative colitis.
# New-onset, moderate to severe ulcerative colitis:
Patient presented with abdominal pain, hematochezia, and
diarrhea. He was also unable to eat during the day prior to
admission, but began eating on his first day in-hospital.
During this admission, he remained afebrile and without
peritoneal signs on abdominal exam. CT abdomen and pelvis
showed proctocolitis without small bowel involvement.
Sigmoidoscopy showed diffuse colitis involving the rectum with
continuous involvement proximally, consistent with ulcerative
colitis. Sigmoidoscopy biopsy showed moderately active colitis
without granulomas or dysplasia. Infectious work-up was
negative for C. difficile, salmonella, shigella, campylobacter,
vibrio, yersinia, E. Coli O157:H7, and ova and parasites. Given
these findings, he was diagnosed with moderate to severe
ulcerative colitis. He received five days of IV
methylprednisolone, and then was transitioned to oral prednisone
his day of discharge. On discharge, the patient's bloody
diarrhea slowed down, had minimal abdominal pain, and was
tolerating PO intake without difficulty. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Compazine / IV Dye, Iodine Containing
Attending: ___.
Chief Complaint:
RLE numbness and weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old R-handed woman with PMHx of partial
seizures and a recent dental infection with numerous
complications who presents with RLE weakness and numbness on the
R foot. The patient's recent history begins on ___ when she
had a cavity filled and then had air tracking into the R side of
her face with eyelid swelling. This then tracked into her neck
and mediastinum. She was seen at ___ where she had unequal
pupils, nystagmus, blurred vision and difficulty with tandem
gait. She had a NCHCT there that was read as no acute
intracranial abnormalities and a CT neck that showed extensive
subcutaneous emphysema throughout the bilateral cervical soft
tissues extending to the right orbit superiorly and right
supraclavicular fossa and superior mediatsium inferiorly. She
was given IV augmentin and pain medication and was discharged on
___ on PO augmentin after her neurological sx resolved. She
continued to have facial pain at home, which slowly resolved.
Then on ___ around 7pm she had the sudden onset of
"excruciating" abdominal pain in the middle of her abdomen. She
lay upside down on the stairs and this made it feel "a little
bit
better". She went to the ___ where she was
noted
to have a temperature of 102.5. She had blood cultures done
which
were negative and a CXR which was also negative. She was
changed
from augmentin to clindamycin (which she was supposed to take
until ___. She also at this time started to notice a dull
chest pressure. On ___ in the morning she noticed that the
tip of her R ___ finger and the tips of her L ___ and ___ R
finger were dusky and dark. She saw her PCP also on the ___,
and
he ordered an echo for concern of endocarditis. The echo was
read as normal. She also got a "spiral CT of the torso" at ___
given her chest pain and this was read as normal except for some
incidentaal small granulomas, per the patient that they felt
could be worked up non-urgently. The CT showed interval
resolution of the cutaneous emphysema and pneumomediastinum.
Then on ___ and ___ she felt "better", but still with
some mild chest pressure. She went for a run on the ___
without
any issues. She also flew to ___ on ___. On
___ she had "terrible diarrhea" so she stopped her
clindamycin 1 day early. She returned home without incident
from
her trip. She saw her oral surgeon who prescribed her with an
antibiotic mouthwash on ___, but that same evening she had
the onset of the same mid jaw pain up to her R eardrum that she
had had previously with the crepitus, but this time there was no
sensation of "crackling" under her skin. She did feel feverish
on that day also. She still ahd some augmentin left over from
her previous Rx, so she took that BID. On ___ she no longer
had jaw pain.
Then today (___) she went to church, and when looking up she
felt "dizzy" and "funky", but when pressed to explain the
sensation more she was unable to better describe it. This went
away if she looked straight or down and would return when she
looked up again. This happened at 11am. Shortly after that she
felt like she had difficulty paying attention. She went home
and
at around 1pm she went for a run. She was able to run ___ of a
mile before she felt her R leg "fly out from under me". She
slumped to the ground but didn't fall. She tried to "walk it
off" and had no difficulty with walking. Then she tried to run
again and her R leg "flew out again". She again slumped to the
ground but didn't fall. She had numbness of her R foot below
her
ankle at this time. She was again able to walk, and then again
tried to run and this time also had the same sensation and was
forced to walk the rest of the distance to her car. When she
got
into her car, she felt unsafe driving home because she "could
barely press down on the accelerator" and so she called her
husband, who brought her to the ___. There, she had a
___ that was read as showing a "basilar artery issue". She
was
transferred to ___ for further workup as there was no MRI tech
available there.
In the ___ at ___, the patient reported that her numbness
improved slowly. However, she had some involuntary movements
that she felt were seizures in the ___. Starting at 5:30pm she
had ___ seconds of bilateral leg shaking, which self-resolved.
She had 4 more episodses like this between 5:30pm and 6:15pm and
each time she felt that the shaking got a "little bit more
severe". Then at 6:15pm she had an episode lasting 5 seconds
where her bilateral arms and legs were shaking. She reports
that
she "looked down and thought, I can't stop these". Her husband
witnessed the shaking. She had another episode with arm and leg
shaking shortly after this one. She was given 2mg IV ativan.
She did not have any further shaking episodes after the ativan
but did feel "shaky" still.
Past Medical History:
seizures
depression/anxiety
four cesarean sections
multiple hernia repairs
hypothyroidism
Social History:
___
Family History:
Her paternal grandfather and father had "fits of rage" which she
believes was undiagnosed TLE. She also believes her father had
generalized convulsions after having meningitis. He also had a
known history of PD and dementia. She has one older brother who
is healthy. She has one son with refractory epilepsy.
Physical Exam:
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to red pin testing.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Subtle low amplitude high frequency tremor with arms
outstretched, slightly worse on the R than L. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5* 5 5 5 5 5 5
* unable to determine if she had giveway weakness at R IP versus
very very subtle ___ weakness
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
MRI/MRA w/ and w/out contrast: (prelim read) Head MRI: No acute
intracranial process. Scattered bilateral FLAIR hyperintense
foci
were seen on the prior MRI from ___ and are likely
secondary to chronic small vessel ischemic disease.
Head /neck MRA: No large vessel occlusion, flow limiting
stenosis, or
aneurysm greater than 3 mm.
Medications on Admission:
- clonezepam 1mg QHS
- hydroquinone microsphere ER 4% topical cream ER QHS
- lamictal XR 225mg BID
- synthroid 75mcg QD (recently increased from 75mcg QOD and
50mcg
QOD)
- ativan 1mg QD PRN seizures
- methylphenidate ER 36mg QAM
- propranolol 10mg PRN public speaking
- vitamin D 400mg BID
- docusate 100-200mg QHS PRN constipation
- omega 3 1,000mg BID
Discharge Medications:
1. Clonazepam 1 mg PO QHS
2. Vitamin D 400 UNIT PO DAILY
3. Lorazepam 1 mg PO DAILY:PRN increased seizure frequency
4. Levothyroxine Sodium 75 mcg PO DAILY
5. LaMICtal XR *NF* (lamoTRIgine) 225 mg Oral BID
6. Concerta *NF* (methylphenidate) 36 mg Oral QAM prn
inattention
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Transient neurologic event: Migraine varient vs Seizure varient
vs other?
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with right lower extremity foot drop. Basilar
artery abnormality on CT. Evaluate vascular pathology.
COMPARISON: MRI brain, ___. Head CT, ___.
TECHNIQUE: Multi sequence multi planar imaging of the brain was performed
both prior to and following the intravenous administration of 15 mL MultiHance
as per standard department protocol. An MRA of the brain was performed
utilizing 3D time-of-flight technique with rotational reconstructions. Two
dimensional time-of-flight MRA of the neck was performed with coronal VIBE
imaging during infusion of intravenous contrast. Rotational reformatted
images were prepared.
FINDINGS:
MRI head: The ventricles, sulci, and subarachnoid spaces are normal in size
and configuration. There is no evidence of acute infarct or hemorrhage.
Scattered punctate foci of nonspecific T2 FLAIR signal hyperintensity are
noted in the periventricular, subcortical, and deep white matter bilaterally,
most likely representing the sequela of chronic small vessel disease. There
is no abnormal intra or extra-axial fluid collection, no shift of normally
midline structures, and no mass lesion or mass effect. There is no abnormal
enhancement.
The visualized paranasal sinuses, mastoids, and orbits are unremarkable.
MRA brain: The vertebral and basilar arteries are normal in appearance with a
normal branching pattern. There is no evidence of significant stenosis,
occlusion, dissection, or aneurysm.
The intracranial internal carotid arteries and the anterior, middle, and
posterior cerebral arteries are normal in appearance without evidence of
significant stenosis, occlusion, dissection, or aneurysm.
MRA neck: The right common, internal, and external carotid arteries are
normal in appearance without evidence of a hemodynamically significant
stenosis, dissection, or occlusion. The distal right internal carotid artery
measures 6 mm.
The left common, internal, and external carotid arteries are normal in
appearance without evidence of hemodynamically significant stenosis,
dissection, or occlusion. The distal left internal carotid artery measures
5.5 mm.
The bilateral vertebral arteries are normal in appearance without evidence of
dissection, stenosis, or occlusion.
The aortic arch and the origins of the great vessels are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality. No evidence of infarct.
2. Unremarkable MR angiography of the head and neck.
3. Nonspecific white matter signal abnormality most likely represents the
sequela of chronic small vessel disease.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: NEURO CHANGES
Diagnosed with MUSCSKEL SYMPT LIMB NEC, HYPOTHYROIDISM NOS
temperature: 98.6
heartrate: 72.0
resprate: 18.0
o2sat: 99.0
sbp: 128.0
dbp: 76.0
level of pain: 2
level of acuity: 1.0 | Neuro# No further symptoms reported since admit and overnight on
the neurologic unit. She had an MRI which did not demonstrate
any new significant pathology. She also had a lumbar puncture
and the initial CSF results were all within normal limits. Her
examination in the morning was also at baseline without focal
deficit. Her symptoms may have been secondary to a seizure but
this is not entirely clear at this time. No changes to her
medications were made and she was discharged the next day. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diverticulitis
Major Surgical or Invasive Procedure:
CT guided aspiration of intraabdominal collection
___ Procedure
History of Present Illness:
___ no sig PMH p/w ___ weeks of abdominal pain. He states that
for the past ___ weeks he's had LLQ abdominal pain, fatigue,
malaise, fevers/chills, and anorexia. He does state that he
typically has hard stools and chronic constipation. He denies
melena, BRBPR, dysphagia, chest pain, shortness of breath,
cough, edema, urinary frequency, urgency. He has never had a
colonoscopy, and never had symptoms like this before.
Past Medical History:
Past Medical History: HTN, HLD, ___ abscess s/p I+D
Past Surgical History: ___ abscess I+D
Social History:
___
Family History:
Family History: No hx of Crohn's, UC, or cancer
Physical Exam:
Admission Physical Exam:
Temp: 98.2 HR: 89 BP: 131/89 Resp: 18 O(2)Sat: 97 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Neck is supple
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, moderate LLQ tenderness and minimal RLQ
tenderness with palpation, Nondistended
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
Discharge Physical Exam:
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Neck is supple
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, mid line incision- skin open dressed with VAC,
LLQ colostomy- functional and viable, abdomen soft and
Non-distended
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
Pertinent Results:
___ CT Abdomen Pelvis:
Successful CT-guided aspiration of the 2 largest fluid pockets
of the
collection without drainage catheter placement due to multiple
septations
within the collection. Samples were sent for microbiology
evaluation.
___ CXR:
No acute findings.
___ 08:18AM BLOOD WBC-10.5* RBC-3.64* Hgb-10.3* Hct-30.9*
MCV-85 MCH-28.3 MCHC-33.3 RDW-14.4 RDWSD-43.8 Plt ___
___ 08:18AM BLOOD Plt ___
___ 07:40AM BLOOD ___
___ 08:18AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-135 K-4.2
Cl-98 HCO3-20* AnGap-21*
___ 08:18AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
___ 07:45AM BLOOD Ferritn-1002*
___ 07:45AM BLOOD Triglyc-78
Medications on Admission:
atenolol 50 mg tablet once daily
Hydrochlorothiazide 25 mg tablet once daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. 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
4. Atenolol 50 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diverrticular abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT-GUIDED ASPIRATION
INDICATION: ___ year old man with complicated diverticulitis and complex
anterior pelvic collection.
COMPARISON: CT abdomen/pelvis from ___ (Atrius)
PROCEDURE: CT-guided aspirate of anterior pelvic collection.
OPERATORS: Drs. ___ and ___, radiology fellows and Dr.
___, attending radiologist. Dr. ___ supervised the
trainees 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 aspiration was chosen. The
site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. A WIRE WAS ADVANCED THROUGH THE NEEDLE
IN anticipation of catheter placement, however the wire coiled at the tip of
the needle, due to septations in the collection. The ___ needle was then
repositioned into a different pocket which again was too small for catheter
placement. Approximately 5 cc of purulent fluid were aspirated at both needle
positions with a sample sent for microbiology evaluation. The needle was then
removed. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.5 s, 26.1 cm; CTDIvol = 20.4 mGy (Body) DLP = 506.0
mGy-cm.
2) Stationary Acquisition 9.8 s, 1.4 cm; CTDIvol = 101.6 mGy (Body) DLP =
146.3 mGy-cm.
Total DLP (Body) = 662 mGy-cm.
SEDATION: Analgesia was provided by administering divided doses of 50 mcg
fentanyl throughout the total intra-service time of 20 minutes during which
patient's hemodynamic parameters were continuously monitored by an independent
trained radiology nurse.
FINDINGS:
Complex anterior pelvic collection with a small fluid component amenable to
aspiration.
IMPRESSION:
Successful CT-guided aspiration of the 2 largest fluid pockets of the
collection without drainage catheter placement due to multiple septations
within the collection. Samples were sent for microbiology evaluation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with diverticulitis, febrile// please eval for
injury
TECHNIQUE: Chest single view
COMPARISON: None
FINDINGS:
Right cardiophrenic angle fullness may represent prominent cardiophrenic angle
fat pad, diaphragmatic hernia, less likely cyst. Shallow inspiration
accentuates heart size. Normal pulmonary vascularity. No edema. No
infiltrates. Trace left pleural effusion or thickening. No pneumothorax.
IMPRESSION:
No acute findings.
Gender: M
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Abnormal CT
Diagnosed with Dvtrcli of lg int w perforation and abscess w/o bleeding
temperature: 98.2
heartrate: 89.0
resprate: 18.0
o2sat: 97.0
sbp: 131.0
dbp: 89.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ is a ___ yo M admitted to the Acute Care Surgery
service on ___ from outside hospital with a CT scan
concerning for perforated sigmoid diverticulitis with a
multiseptated abscess collection. ___ aspiration was preformed.
He was made NPO given IV fluids and IV antibiotics and admitted
to the surgical floor for continued monitoring and management.
On HD4 he was febrile with temperature of 102, white blood cell
count continued to rise to 17.8 - antibiotic therapy was changed
to zosyn. On HD5, due to increasing white blood cell count, the
decision was made to operate. Informed consent was obtained and
on ___ he underwent ___ procedure. He received 6
units of FFP intraoperatively for elevated INR of 2.0. Post
operatively he was exutbated and taken to the PACU in stable
condition then transferred to the surgical floor once recovered.
On POD1 he was hemodynamically stable, afebrile, NPO on IV
fluids and dilaudid PCA for pain control. Wound vac was applied
to midline surgical incision. The patient recovered from his
surgery well. His WBC trended down he had no more fever episodes
and was HD stable. He began to pass gas and than BM per
colostomy and his wound VAC was changed every 3 days. His Jp
drain that was left in his pelvic during surgery was removed on
the day of discharged. the patient was ambulating easily
resumed regular diet and tolerated it well. pathology report
showed Diverticular disease with peridiverticulitis and mural
abscess formation. Six lymph nodes with reactive changes.
The patient received ostomy teaching and was discharged home
with ___ for VAC change and with the following recommendations: |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman found down by ___ after an unwitnessed fall.
The patient states that she was laying in bed and accidentally
rolled off the edge onto the floor striking her head and left
shoulder. She does not recall feeling dizzy, lightheaded, SOB,
chest pain, palpitations, or any other preceeding symptoms.
However, the EMS reports state that the patient reported falling
as she was returning from the bathroom when she became dizzy and
fell. Unclear whether she lost consciousness. She reports pain
in her head, left shoulder, lower back, and right knee.
.
In the ED, initial VS were 97.6, 62, 177/67/14, 96% RA. Labs
notable for HCT 33.1, UA with a few bacteria and trace leuk
esterase. CT head neg for acute process. CT c-spine with severe
DJD and congenital non-fusion of posterior arch of C1. CXR neg
for acute process. EKG showed sinus at 58, incomplete LBBB.
Patient was given 4mg IV morphine.
Past Medical History:
- Known chronic left shoulder dislocation, which orthopedics has
advised previously does not warrant urgent repair ___ chronicity
- Chronic LUE lymphedema ___ lymph node resection
- Breast CA s/p partial mastectomy on R and lumpectomy on L
- Diastolic HF
- Likely CAD given apical reversible defect on stress test
___
- Borderline DM
- Hypertension
- Hyperlipidemia
- PVD
- Depression
- Anxiety
- S/p bilateral hip and knee replacements
Social History:
___
Family History:
Has 2 daughters, one who passed away several years ago from an
unknown type of cancer and another who has cerebral palsy.
Physical Exam:
ADMISSION EXAM:
VS: 98.0, 150/70, 61, 16, 96% RA, 62.8 kg
GENERAL: NAD, comfortable, appropriate
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK: Supple, no thyromegaly, no JVD
HEART: ___ SEM at ___
LUNGS: Scattered rales at both bases, no wheezing
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: LUE with significant edema (chronic), 2+ pitting
edema bilaterally to knees
SKIN: no rashes or lesions
NEURO: Awake, A&Ox3 but forgetful, CNs II-XII grossly intact,
muscle strength ___ throughout (limited by arthritis in her
hands and knees), sensation grossly intact throughout, gait not
assessed
.
DISCHARGE EXAM:
GENERAL:VSS 98.6 (98.6)- 132/46 - 64 - 18 - 96%RA
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK: Supple, no thyromegaly, no JVD
HEART: ___ SEM at ___
LUNGS: Scattered rales at both bases, no wheezing
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: LUE with significant edema (chronic),
SKIN: no rashes or lesions
NEURO: Awake, A&Ox3 but forgetful, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___ 11:59AM BLOOD WBC-4.8 RBC-3.60* Hgb-11.2* Hct-33.1*
MCV-92 MCH-31.1 MCHC-33.8 RDW-14.7 Plt ___
___ 11:59AM BLOOD Neuts-55.5 ___ Monos-7.6 Eos-1.9
Baso-0.5
___ 11:59AM BLOOD Glucose-122* UreaN-17 Creat-0.8 Na-141
K-3.7 Cl-103 HCO3-28 AnGap-14
___ 11:59AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7
___ 11:59AM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:59AM BLOOD CK(CPK)-41
___ 12:10PM BLOOD Lactate-1.5
___ 12:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 12:35PM URINE RBC-0 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
.
DISCHARGE LABS:
.
MICROBIOLOGY:
___ Blood cultures: no growth to date
___ Urine culture: <10,000 organisms
.
IMAGING:
___ CT Head w/o con: No acute intracranial process.
.
___ CT C-spine w/o con:
1. No evidence of fracture or traumatic malalignment. Congential
non-fusion of posterior arch of C1.
2. Severe degenerative changes as noted in full report.
.
___ PA/LAT CXR:
1. Left anterior shoulder dislocation.
2. Pulmonary vascular congestion.
.
___ AP/LAT Lumbosacral spine x-ray: Multilevel severe
degenerative changes, difficult to assess the lumbosacral
junction particularly L5. If there is high clinical concern for
acute fracture, CT is more sensitive and should be considered.
.
___ Right knee x-ray: Status post right knee arthroplasty
with prosthesis in anatomic alignment. On the oblique image,
there is a linear lucency projecting over the lateral distal
femur thought to most likely be artifactual. Not seen on the
additional images. Small suprapatellar joint effusion.
.
___ Left shoulder x-ray: Persistent anterior inferior
displacement of the left humeral head in relation to the
glenoid.
Medications on Admission:
1. Acetaminophen 325 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Hydrocortisone Cream 1% 1 Appl TP QID
apply to skin on chest BID until healed
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Nystatin Cream 1 Appl TP BID
apply to groin and abdominal folds until healed
7. Oxybutynin 2.5 mg PO BID
8. Simvastatin 80 mg PO DAILY
9. Acetaminophen 325 mg PO Q4H:PRN pain
10. nystatin *NF* 100,000 unit/g Topical apply to groin twice
daily as needed
11. Aspirin 81 mg PO DAILY
12. Milk of Magnesia 15 mL PO DAILY:PRN constipation
13. Naproxen 500 mg PO Q12H
14. BusPIRone 5 mg PO BID
Discharge Medications:
1. Acetaminophen 325 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Simvastatin 80 mg PO DAILY
6. Acetaminophen 325 mg PO Q4H:PRN pain
7. BusPIRone 5 mg PO BID
8. Hydrocortisone Cream 1% 1 Appl TP QID
apply to skin on chest BID until healed
9. Milk of Magnesia 15 mL PO DAILY:PRN constipation
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Naproxen 500 mg PO Q12H
12. nystatin *NF* 100,000 unit/g Topical apply to groin twice
daily as needed
13. Nystatin Cream 1 Appl TP BID
apply to groin and abdominal folds until healed
14. Oxybutynin 2.5 mg PO BID
15. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Mechanical fall
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: Spine and left shoulder pain.
TECHNIQUE: Supine frontal radiograph.
COMPARISON: Chest radiograph ___
FINDINGS:
The heart size is mildly enlarged. The cardiomediastinal silhouette and hilar
contour is stable. There is stable mild widening of the mediastinal contour
likely related to tortuous aorta. There is stable cephalization of the
pulmonary vasculature compatible with congestion. There is no focal
consolidation, effusion or pneumothorax. There is anterior dislocation of the
left shoulder better visualized on same date dedicated glenohumeral joint
radiographs. There are extensive degenerative changes of the right
glenohumeral joint.
IMPRESSION:
1. Left anterior shoulder dislocation.
2. Pulmonary vascular congestion.
Radiology Report
EXAM: Left shoulder, three views.
CLINICAL INFORMATION: Left shoulder pain.
___.
FINDINGS: Three views of the left shoulder were obtained. Again seen, there
is persistent anterior dislocation/subluxation of the left humeral head in
relation to the glenoid. No definite acute fracture is seen. Degenerative
changes are seen involving the left shoulder as well as the left
acromioclavicular joint. A surgical clip is again seen projecting over the
left mid hemithorax. Partially imaged left lung demonstrates low lung volumes
and please see dedicated chest radiograph for further evaluation.
IMPRESSION: Persistent anterior inferior displacement of the left humeral
head in relation to the glenoid.
Radiology Report
EXAM: Lumbar spine, AP and lateral views.
CLINICAL INFORMATION: Head and spine pain.
COMPARISON: None.
FINDINGS: AP and lateral views of lumbar spine were obtained. There are
multilevel degenerative changes including severe intervertebral disc space
narrowing throughout and marginal sclerosis with anterior osteophytosis. It
is difficult to exclude a subtle fracture particularly at the lumbosacral
junction and if it is of high clinical concern, CT is more sensitive and
should be considered. There is minimal dextroscoliosis of the lumbar spine.
Patient is status post bilateral hip replacement with prosthesis partially
imaged; the femoral component of the prosthesis on the right appears to be
slightly superior in location in relation to the acetabular cup, unclear
whether this is due to positioning. The pubic symphysis is intact as there
are vascular calcifications. The sacrum is partially obscured by bowel gas.
IMPRESSION: Multilevel severe degenerative changes, difficult to assess the
lumbosacral junction particularly L5. If there is high clinical concern for
acute fracture, CT is more sensitive and should be considered.
Radiology Report
EXAM: Right knee, three views.
CLINICAL INFORMATION: Right knee pain.
COMPARISON: None.
FINDINGS: Three views of the right knee were obtained. Patient is status
post right knee replacement with prosthesis in anatomic alignment. On the
oblique image, there is a subtle lucency projecting obliquely along the
lateral distal femur which is felt to most likely be artifactual, not well
seen on the other images. There appears to be a small suprapatellar joint
effusion.
IMPRESSION: Status post right knee arthroplasty with prosthesis in anatomic
alignment. On the oblique image, there is a linear lucency projecting over
the lateral distal femur thought to most likely be artifactual. Not seen on
the additional images. Small suprapatellar joint effusion.
Radiology Report
HISTORY: Status post unwitnessed fall presenting with head and spine pain.
TECHNIQUE: Contiguous axial MDCT images of the head were obtained without IV
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone algorithm images.
DLP: 1538.57 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no acute intracranial hemorrhage, edema, mass effect or acute large
territory infarct. Prominent ventricles and sulci are suggestive of
age-related involutional change. The basal cisterns appear patent and there
is preservation of gray-white matter differentiation. No fracture is
identified. The visualized paranasal sinuses, mastoid air cells and middle
ear cavities are clear. Atherosclerotic calcifications are visualized in the
vertebral arteries and carotid siphons.
IMPRESSION:
No acute intracranial process.
Radiology Report
HISTORY: Status post unwitnessed fall presenting with head and spine pain.
TECHNIQUE: Axial helical MDCT images were obtained from skull base to the
level of C3-C4. Multiplanar reformatted images were generated in the coronal
and sagittal planes.
DLP: 830.25 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is posterior non-fusion of C1 which is likely congenital. No acute
fracture is identified. No traumatic malalignment is identified. There are
severe degenerative changes of the cervical spine with most severe
degenerative change and complete fusion of C5-C6. Grade 1 anterolisthesis of
C7 on T1 is likely chronic and degenerative in nature. Prominent posterior
osteophytes at the level of C3-C4 and C5-C6 minimally indents the thecal sac.
There is significant facet joint and uncovertebral hypertrophy which narrow
the neural foramina at multiple levels. Coarse calcifications medial to the
right mandible in the soft tissue possibly represent sialoliths however there
is no enlargement of the associated submandibular gland. The imaged lung
apices are clear.
IMPRESSION:
1. No evidence of fracture or traumatic malalignment.
2. Severe degenerative changes as noted above.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with SYNCOPE AND COLLAPSE, UNSPECIFIED FALL, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE, HYPERTENSION NOS
temperature: 97.6
heartrate: 62.0
resprate: 14.0
o2sat: 96.0
sbp: 177.0
dbp: 67.0
level of pain: 13
level of acuity: 2.0 | ___ year old woman s/p mechanical fall.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dark stools, lightheadedness
Major Surgical or Invasive Procedure:
___ Esophagogastroduodenoscopy (EGD)
History of Present Illness:
Mr ___ is a ___ yo male with h/o ESRD on HD, CAD, distant
seizure, gout, who presents from ___ with concern for
UGIB. The patient reports had black stools for ___ days and was
feeling nauseous and weak, so he went to ___. There, he
was found to have BP 84/51 and HCT of 22. He was given 500cc NS
with improvement. His stools were guaiac positive. He was
started on protonix 80mgbolus then 8mg/hr, given 1U pRBCs and
transferred here. Upon arrival here, the patient had no
complaints in ED.
In the ED, initial VS were: 99.5 64 129/71 15 100% 2L. HCT here
was 23, hgb 8, WBC 11.2 w/ neutrophil predominance CK: 38 MB: 2
Trop 0.21 @1:15am, K 5.4, Bicarb 21 with AG 12 and Lactate:0.9,
BUN/creat 105/6.3. . EKG NSR 67, RBBB, LAD, ST depressions in V4
to V5. hemodynamically stable. CXR with no acute changes. He was
ordered for 2 more units of PRBCs, transfused 1L NS infusing at
125cc/hr, 2 18g IVs were placed, protonix drip at 8Mg/hr. Prior
to transfer the patients VS were 125/70 - 64 - 20 - 98% RA.
Upon arrival to the MICU the patient was comfortable and denied
chest pain, palpitations, shortness of breath or abdominal pain.
He did reports occasional lower abdominal cramping and some
loose watery stools. He denies fevers, chills, or sick contacts.
The patient also reports that he has recently been taking plavix
and ASA 325mg. He originally discontinued Plavix as recommended
by his cardiologist and increased ASA from 81mg to 325mg.
However, he resumed Plavix inadvertently and so was on plavix
and ASA 325mg. In addition, he was treated last week with
prednisone and indomethacin for a gout flare.
The patient had an EGD done today, and is subsequently
transferred to the floor.
Currently, he denies complaint. His most recent BM was several
hours ago, and he reports this as being formed, but is unsure of
the color. He feels better than when he was admitted, but is
still feels tired. No CP, SOB, cough, f/c/s.
Past Medical History:
- HTN
- hyperlipidemia
- NSTEMI
- chronic LBP and h/o spinal stenosis
- peripheral neuropathy
- h/o head injuries ___ left forehead vs window in MVA, age
___ boxing injury to right side of head; neither of these with
reported LOC)
- chronic renal failure on HD ___, and
on transplant list
- left upper arm graft for HD since ___ s/p mult thrombectomies
and stent
- MRA showed small basilar stenosis (50%), 1-2 mm aneurysm of
the A2 segment and carotid US with ulcerative plaque in the left
bulb area recently evaluated by Dr. ___ in ___ without
recommendation of further intervention
- h/o of gout attack in left elbow
-simple partial seizures consisting of left arm jerking with
occasional secondary generalization
-Diverticulosis of the sigmoid and ascending colon on
colonoscopy
-Prostate cancer
Past Surgical History:
- s/p coronary stent in ___, per patient was told that he may
have had a small stroke associated with this procedure
- right hip replacement ___
- total knee replacement in ___ & ___
- prostate surgery
Social History:
___
Family History:
Denies family history of seizures or psych history. Mother with
?esophageal and liver disease. Father with prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:144/51 62 100RA
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, ___ systolic
murmur LSB
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, ___ strength upper/lower extremities,
grossly normal sensation
Discharge:
Vitals: 98.1 146/75 97%RA
General: Alert, oriented, no acute distress, pleasant
HEENT: MMM
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur LSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
ADMISSION LABS:
___ 01:15AM BLOOD WBC-11.2*# RBC-2.35* Hgb-8.0* Hct-23.9*
MCV-102* MCH-33.8* MCHC-33.3 RDW-15.6* Plt ___
___ 01:15AM BLOOD Neuts-87.5* Lymphs-9.1* Monos-2.5 Eos-0.7
Baso-0.2
___ 01:15AM BLOOD ___ PTT-27.1 ___
___ 01:15AM BLOOD Glucose-128* UreaN-105* Creat-6.3* Na-139
K-5.4* Cl-106 HCO3-21* AnGap-17
___ 01:15AM BLOOD ALT-19 AST-15 CK(CPK)-38* AlkPhos-54
TotBili-0.2
___ 01:15AM BLOOD CK-MB-2
___ 01:15AM BLOOD cTropnT-0.21*
___ 01:15AM BLOOD Albumin-3.6
___ 01:24AM BLOOD Lactate-0.9
CHEST X-RAY (___): The lungs are clear. Again seen is an
azygos fissure. Mild-to-moderate cardiomegaly is unchanged.
There is no central venous
congestion or pulmonary edema. No significant pleural effusions
or
pneumothorax. IMPRESSION: Stable cardiomegaly. No evidence of
volume overload.
EGD ___
Esophagus:
Mucosa: Localized granularity, friability and erythema of the
mucosa with a small nodular area with contact bleeding were
noted in the gastroesophageal junction. These findings are
compatible with esophagitis.
Protruding Lesions A single 4 mm nodule of benign appearance
was seen in the upper third of the esophagus.
Stomach:
Excavated Lesions A single superficial non-bleeding 1.5 cm
ulcer was found in the pylorus extending into the pyloric
channel.
Duodenum:
Mucosa: Friability and erythema with ulceration of the mucosa
with contact bleeding were noted in the duodenal bulb and second
part of the duodenum.
Impression: Nodule in the upper third of the esophagus
Granularity, friability and erythema with a small nodular area
in the gastroesophageal junction compatible with esophagitis
Ulcer in the pylorus
Friability and erythema with ulceration in the duodenal bulb and
second part of the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: Omeprazole 40mg BID. Hpylori serology. ADAT.
Outpatient repeat egd in ___ weeks for biopsies of esophageal
nodule, GE junction and evaluation to ensure ulcer healing.
Discharge labs:
___ 08:48AM BLOOD WBC-8.0 RBC-3.01* Hgb-9.6* Hct-29.4*
MCV-98 MCH-31.7 MCHC-32.5 RDW-14.8 Plt ___
___ 08:48AM BLOOD Glucose-97 UreaN-70* Creat-6.2*# Na-141
K-4.2 Cl-102 HCO3-27 AnGap-16
___ 08:48AM BLOOD Calcium-8.0* Phos-5.0* Mg-2.1
LABS PENDING RESULTS:
___ 8:05 am HELICOBACTER PYLORI ANTIBODY TEST
Medications on Admission:
-Atenolol 12.5 mg a day
-amlodipine 10 mg a day
-simvastatin 20mg a day
-Dyazide
-aspirin 325 mg
-Renal Caps
-Sensipar 60mg daily
-Renagel (Sevelamer)
-lamotrigine 100 b.i.d. (100 mg extra after dialysis)
-levetiracetam 250 b.i.d.
-plavix 75mg daily
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. cinacalcet 60 mg Tablet Sig: One (1) Tablet PO once a day.
5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): As previously prescribed,
discuss dosing with your nephrologist.
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 100mg extra after HD.
7. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Esophagitis
Pyloric ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with GI bleeding and end-stage renal disease.
___.
CHEST, AP UPRIGHT: The lungs are clear. Again seen is an azygos fissure.
Mild-to-moderate cardiomegaly is unchanged. There is no central venous
congestion or pulmonary edema. No significant pleural effusions or
pneumothorax.
IMPRESSION: Stable cardiomegaly. No evidence of volume overload.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LGIB
Diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS
temperature: 99.5
heartrate: 64.0
resprate: 15.0
o2sat: 100.0
sbp: 129.0
dbp: 71.0
level of pain: 4
level of acuity: 2.0 | Mr ___ is a ___ yo male with h/o ESRD on HD, CAD, distant
seizure, gout, who presented from ___ with concern for
UGIB, found to have HCT drop to 22 from baseline ~30.
# Acute Anemia: Initially unstable at OSH, stable at ___,
initially in MICU, rec'd total 3 u pRBC at ___, additional
transfusions at OSH. Most likely secondary to PUD in setting of
NSAID use (was recently prescribed endomethacin), platelet
dysfunction, and use of plavix (was not supposed to be taking
this medication any longer). He underwent EGD which revealed
esophagitis with friability and erythema of the gastric mucosa
with contact bleeding in the gastroesophageal junction as well
as in duodenal bulb and second part of the duodenum. A single
superficial non-bleeding 1.5 cm ulcer was found in the pylorus
extending into the pyloric channel. Also notable was a single 4
mm nodule of benign appearance in the upper third of the
esophagus. The patient was treated initially with IV PPI then
transitioned to Omeprazole 40mg BID. Gastroenterology
recommended outpatient repeat egd in ___ weeks for biopsies of
esophageal nodule, GE junction and evaluation to ensure ulcer
healing. They also requested H pylori serologies to be sent as
an inpatient, and this request was carried out. He was stable,
with brown stool at discharge.
# CAD: The patient has a history of NSTEMI with stent in ___.
Patient was supposed to be off plavix and only on ASA 325mg per
his primary cardiologist, however the patient had been taking
plavix because "I didn't think it would hurt and I had some
extras lying around." He had some ST depressions in the absence
of chest pain, so was ruled out for an MI with serial EKGs and
cardiac enzymes. ASA 325mg was restarted after the patient
stablized and please note he does NOT need plavix at this time.
# CKD: ___ dialysis schedule, continued Renal Caps,
Sensipar 60mg daily, Renagel (Sevelamer).
# HTN: held amlodipine, atenolol, diazide given hypotension,
instructed patient to re-start these medications as tolerated
after dialysis.
# Seizure d/o: continued lamotrigine and levitiracetam.
=== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending: ___.
Chief Complaint:
Acute Kidney Injury / Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o man with hx of CAD s/p NSTEMI, T1DM
(last A1c 8.5%), ___, and multiple prior debridements for
non-healing L foot ulcers recently hospitalized for cellulitis
of right foot. He was discharged home and when he came back for
follow up four days, he was found to have hyperkalemia and ___
from his bloodwork. For his cellulitis, he was initially treated
with empiric IV vancomycin and zosyn, transitioned to PO
bactrim, cipro, and flagyl per wound culture showing
polymicrobial growth (notably MRSA and GNR's).
His foot ulcer and cellulitis improved significantly and the
pain subsided. Additionally, the leg swelling associated with
cellulitis improved. However, he reports that he did not feel
great even after the treatment. He reported frequent large
volume urination, even though he was drinking just ___ coffees a
day. He reported that he was feeling tired, and he did not want
to move because of aches. The abnormal elevated Creat,
hyperkalemia and hyponatremia prompted ED admission.
Notably, the patient reported constipation for 6 days. Today he
had a small bowel movement but he still feels bloated. He
reported that he had a rectal exam in the ED yesterday and the
MD did not think that he was impacted or had stool in the rectal
vault.
In the ED, initial vitals were:
22:11 0 97.8 63 167/55 16 99% RA
- Labs were significant for initial K 6.0 with creat 1.7,
Na130, u/a negative.
- ECG showed QWI in I/AVL and TWI AVL consistent with prior
with no peaked T waves
- Foot xray showed a foreign object - needle inside his foot.
- The patient was given 500cc NS, 10U regular insulin, 25gm 50%
dextrose, 2g calcium gluconate, 1500mg IV vancomycin.
Vitals prior to transfer were:
Today 04:46 0 97.8 64 138/95 20 96% RA
Upon arrival to the floor, the patient reported that he was
tired from staying up in the ED. He slept well and did not
complain of pain, shortness of breath or fevers.
Past Medical History:
-T1DM (most recent A1c 8.5% in ___
-Hypertension
-Hypercholesterolemia
-Diastolic CHF
-GERD
-Depression
-Neuropathy
-History of fungal bloodstream infections, polymicrobial wound
infections (enterobacter, MRSA, prevotella, corynebacterium,
-CAD: NSTEMI ___ with PCI of an OM branch with DES.
-UGIB
PAST SURGICAL HISTORY:
-DES to OM1
-cholecystectomy
-Hx of multiple debridement on L foot for non-healing ulcers
-Tonsilectomy
Social History:
___
Family History:
Father - leukemia
Mother - colon ca
Physical Exam:
===============
ADMISSION EXAM:
===============
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, ___ systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, moderately distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, palpable AT and DP, no clubbing,
cyanosis or edema. Large partially open ulcer in the R bug toe,
no surrounding erythema or tenderness.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
LABS: See below
===============
DISCHARGE EXAM:
===============
Vitals: 98.0, 144/62, 68, 20, 98% on 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, ___ systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, moderately distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, palpable AT and DP, no clubbing,
cyanosis or edema. Large partially open ulcer in the R bug toe,
no surrounding erythema or tenderness.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 10:00PM GLUCOSE-265* UREA N-25* CREAT-1.6*
SODIUM-132* POTASSIUM-6.0* CHLORIDE-103 TOTAL CO2-21* ANION
GAP-14
___ 10:00PM estGFR-Using this
___ 10:00PM CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.7
___ 03:20PM GLUCOSE-296* UREA N-25* CREAT-1.6*
SODIUM-131* POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-22 ANION
GAP-14
___ 03:20PM CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-1.8
___ 09:35AM GLUCOSE-302* UREA N-25* CREAT-1.6*
SODIUM-131* POTASSIUM-6.2* CHLORIDE-100 TOTAL CO2-21* ANION
GAP-16
___ 09:35AM CALCIUM-9.5 PHOSPHATE-3.1 MAGNESIUM-1.7
___ 02:13AM URINE HOURS-RANDOM
___ 02:13AM URINE UHOLD-HOLD
___ 02:13AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:13AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:16PM K+-5.5*
___ 11:00PM GLUCOSE-169* UREA N-26* CREAT-1.7*
SODIUM-130* POTASSIUM-5.6* CHLORIDE-99 TOTAL CO2-21* ANION
GAP-16
___ 11:00PM WBC-6.6 RBC-3.62* HGB-10.3* HCT-31.4* MCV-87
MCH-28.5 MCHC-32.8 RDW-14.1 RDWSD-43.9
___ 11:00PM NEUTS-76.2* LYMPHS-15.6* MONOS-6.9 EOS-0.0*
BASOS-0.8 IM ___ AbsNeut-5.05 AbsLymp-1.03* AbsMono-0.46
AbsEos-0.00* AbsBaso-0.05
___ 11:00PM ___ PTT-30.3 ___
___ 02:50PM GLUCOSE-107* UREA N-28* CREAT-1.8*
SODIUM-132* POTASSIUM-6.0* CHLORIDE-98 TOTAL CO2-23 ANION GAP-17
==================
PERTINENT RESULTS:
==================
___ 09:36PM BLOOD K-5.1
___ 04:18PM BLOOD K-5.4*
___ 11:16PM BLOOD K-5.5*
XR R Foot (___):
Retained needle adjacent to the second metatarsal.
===============
DISCHARGE LABS:
===============
___ 07:15AM BLOOD WBC-6.3 RBC-3.54* Hgb-10.2* Hct-31.6*
MCV-89 MCH-28.8 MCHC-32.3 RDW-14.6 RDWSD-46.0 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-211* UreaN-20 Creat-1.4* Na-133
K-5.1 Cl-100 HCO3-24 AnGap-14
___ 05:40AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.7
___ 07:15AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.8
___ 09:36PM BLOOD ___ pO2-60* pCO2-44 pH-7.37
calTCO2-26 Base XS-0 Comment-GREEN-TOP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Carvedilol 6.25 mg PO BID
5. Chlorthalidone 25 mg PO DAILY
6. Gabapentin 600 mg PO QHS
7. HydrALAzine 25 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Sertraline 50 mg PO DAILY
11. Cetirizine 10 mg PO DAILY:PRN pruritis
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Ciprofloxacin HCl 500 mg PO Q12H
14. Sulfameth/Trimethoprim DS 2 TAB PO BID
15. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
16. Glargine 66 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Carvedilol 6.25 mg PO BID
5. Cetirizine 10 mg PO DAILY:PRN pruritis
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
Please take for total of 14 days with last dose on ___
7. Gabapentin 600 mg PO QHS
8. HydrALAzine 25 mg PO BID
9. Glargine 66 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Omeprazole 20 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Sertraline 50 mg PO DAILY
13. Clindamycin 300 mg PO Q6H Duration: 5 Days
Take for 5 days (Last Dose evening of ___
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*20 Capsule Refills:*0
14. Outpatient Lab Work
Hyperkalemia
Repeat Chem-7
To be drawn at follow-up on ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Acute Kidney Injury
- Hyperkalemia
Secondary Diagnosis:
-T1DM
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old man with recent admission for RLE cellulitis, hx of
stepping on insulin needle with ?retention // any retained foreign body
any retained foreign body
TECHNIQUE: Three views right foot
COMPARISON: None.
FINDINGS:
Extensive postsurgical changes are seen in the right foot including amputation
of the second metatarsal head and phalanges as well as osteotomy of the fifth
digit. There is moderate soft tissue swelling. A linear foreign body is
noted adjacent to the residual distal second metatarsal, consistent with
needle per patient's history. No definite bony erosions are noted to suggest
osteomyelitis.
IMPRESSION:
Retained needle adjacent to the second metatarsal.
NOTIFICATION: These results were discussed with The findings were discussed
by Dr. ___ with Dr. ___ on the ___ ___ at
approximately 745 am.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Non-prs chronic ulcer oth prt right foot w unsp severity, Acute kidney failure, unspecified
temperature: 97.8
heartrate: 63.0
resprate: 16.0
o2sat: 99.0
sbp: 167.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ y/o man with hx of CAD s/p NSTEMI, T1DM
(last A1c 8.5%), dCHF, and multiple prior debridements for
non-healing L foot ulcers recently hospitalized for cellulitis
of right foot, found to have hyperkalemia and ___ on most recent
bloodwork, likely secondary to Bactrim and lisinopril further
complicated by poor PO fluid intake prior to admission.
# HYPERKALEMIA: Patient presented with a serum potassium of 6,
which prompted his admission to the hospital. Hyperkalemia
occurred in the setting of recent uptrend in creatinine on his
prior hospitalization (at that time attributed to prerenal
azotemia) in the setting of recent discharge for foot infection
on Bactrim, flagyl, and ciprofloxacin. Both Bactrim and the
patient's home dose of Lisinopril were thought to worsen the
patient's electrolyte abnormality. Upon further review of OMR,
patient was noted to often have serum potassium levels between
4.5 and 4.7, which could be suggestive of underlying renal
etiology for high normal potassium at baseline. With a minor
renal insult, this potassium level became supratherapeutic.
Hyperkalemia was treated with multiple bouts of D50 + IV Insulin
10 units, with kayexalate, lactulose, and calcium glucose
administered (for concerning T wave peaking noted). Hyperkalemia
improved with improvement in renal function (see below). Patient
was discharged with a stable K of 5.1, and will repeat labs at
the time of his follow-up appointment with primary care on
___.
# ACUTE KIDNEY INJURY (baseline Cr 1.1-1.2): Patient presented
with increased Creatinine, which was noted on his discharge labs
on his prior hospitalization. Uptrend at that time as attributed
to a prerenal etiology, and patient was encouraged to increase
his PO fluid intake. Patient's Lisinopril and Bactrim were held
upon admission in the setting of acute kidney injury and
hyperkalemia. Patient was initially hydrated with IV fluids, and
encouraged to increase his PO fluid intake. Cr peaked at 1.7,
and eventually began to downtrend. Lisinopril was held at the
time of discharge; the patient will repeat a Chem-7 at the time
of his outpatient follow-up appointment, with the decision to
restart Lisinopril to be re-addressed at that time.
# R diabetic foot diabetic ulcer complicated by recent
cellulitis: Patient was recently admitted for cellulitis of his
R foot, and was discharged on Cipro/Flagyl/Bactrim. On current
presentation, Bactrim/Flagyl were discontinued in the setting of
___, and the patient was transitioned to PO
Clindamycin and Ciprofloxacin. Admission foot X-ray remarkable
for retained foreign body (insulin needle); patient was
evaluated by his outpatient podiatrist while in-house, who
recommended no further intervention at this time, as any
procedure to remove the foreign body would likely cause more
discomfort and possible infection risk in comparison to leaving
it in place. The patient will follow-up with podiatry on an
outpatient basis.
# T1DM: Patient with hx of T1DM diagnosed at age ___, presenting
with most recent A1c of 8.5 in ___. He continued his home
insulin regimen while in-house.
# Chronic/compensated diastolic CHF: Patient with hx of dCHF
with most recent EF >55% in ___. Patient was euvolemic on
examination, and was continued on his home medication regimen
(with the exception of lisinopril, which was held in the setting
of ___
CHRONIC/STABLE/RESOLVED PROBLEMS:
# Coronary Artery Disease: Continued home regimen of ASA,
carvedilol, atorva
# Hypertension: Continued home hydralazine, carvedilol, and
chlorthalidone. Lisinopril was held on admission, and was not
restarted at the time of discharge.
# Hyperlipidemia: Continued home atorvastatin.
# Gastroesophageal Reflux Disease: Continued home omeprazole
# Depression: Continued home sertraline.
# Neuropathy: Continued home gabapentin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
ibuprofen
Attending: ___.
Chief Complaint:
Aphasia
Major Surgical or Invasive Procedure:
Thrombectomy
History of Present Illness:
THis is a ___ with significant history of tobacco use who
presented with aphasia. Last known well ___ AM when his
wife left him to go to work. Per wife, the patient had returned
from early AM shift and she had prepared breakfast for him. He
ate breakfast and was quite jovial. He then went to lie down at
08:45. Wife left to work at that time. The patient's brother
randomly called throughout the day and noted that the patient
wasn't making sense on the phone. Wife was alerted and EMS was
called. He was taken to OSH and subsequently transferred for
left
M1 occlusion for evaluation of thrombectomy as he was outside
tPA
window on arrival to OSH.
Past Medical History:
Glaucoma
Tobacco use
Social History:
___
Family History:
did not obtain prior to thrombectomy
Physical Exam:
ON ADMISSION:
PHYSICAL EXAMINATION:
Vitals: 96.8 83 12 130/67
General: Awake, semi-cooperative with exam, visibly frusturated
HEENT: no scleral icterus noted, MMM
Pulmonary: Normal work of breathing. Breath w tobacco essence.
Cardiac: warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Neurologic:
-Mental Status: Alert, oriented to self and to wife and
daughters
at bedside. Unable to relate history. Attentive to examiner and
to exam. Expressive aphasia with possible component of
conductive
aphasia. Can only follow some one-step commands with verbal
request. Can follow commands with mimic. Cannot repeat. Speech
output is spontaneous but mostly nonsensical, although
occasional
he says "I'm ok" to his wife. Can only name some high frequency
objects but not low frequency objects. Perseverates over objects
"hand hand hand" in response to different objects, although
first
one was indeed a glove. Cannot describe scene around him or
cookie cutter image.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Right NLFF w delayed activation.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 4 5 5- 5- 5- 5- 5- 5 5 5 5 5
-Sensory: No deficits to light touch. Extinguishes on right on
repeat attempts, appears consistent and not in setting of
aphasia
and inability to appropriately identify side.
-Reflexes: Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF or HKS.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
ON DISCHARGE:
General: Comfortable, awake, NAD
HEENT: NC/AT
Pulmonary: Breathing comfortably on room air
Cardiac: Well-perfused
Abdomen: soft, ND
Extremities: WWP, no C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-MS: Brightly awake, alert, oriented x3. Naming intact to high
and low frequency words though with some hesitation. Spontaneous
speech with slight delay, word finding difficulty, and with
slightly shortened but grammatically normal phrases. Slowed
reading (unclear baseline). Writes simple sentences with some
grammatical errors. Repetition intact to complex phrases.
Evidence of left-right confusion, subtle finger agnosia, and
acalculia but able to do simple additions. Amble to follow
simple
and two step commands.
-CN: R pupil 4mm nonreactive, L pupil 4-3mm. R eye poor vision.
L
eye VF full. EOMI, no nystagmus. Mild R NLFF. Tongue midline
with
equal excursions bilaterally.
-Motor: Normal bulk and tone.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory- Intact to LT throughout. No extinction.
-Coordination- FNF intact bilaterally.
-Gait- Good initiation. Narrow-based, normal stride and arm
swing.
Pertinent Results:
___ 10:22PM BLOOD WBC-8.0 RBC-4.86 Hgb-12.0* Hct-36.5*
MCV-75* MCH-24.7* MCHC-32.9 RDW-16.9* RDWSD-44.7 Plt ___
___ 04:16AM BLOOD WBC-6.5 RBC-4.58* Hgb-11.2* Hct-33.9*
MCV-74* MCH-24.5* MCHC-33.0 RDW-16.4* RDWSD-43.3 Plt ___
___ 10:22PM BLOOD Neuts-46.2 ___ Monos-6.6 Eos-1.6
Baso-0.2 Im ___ AbsNeut-3.70 AbsLymp-3.63 AbsMono-0.53
AbsEos-0.13 AbsBaso-0.02
___ 01:53AM BLOOD Neuts-43.8 ___ Monos-6.3 Eos-1.7
Baso-0.2 Im ___ AbsNeut-2.81 AbsLymp-3.06 AbsMono-0.40
AbsEos-0.11 AbsBaso-0.01
___ 10:22PM BLOOD ___ PTT-27.5 ___
___ 07:00AM BLOOD ___ PTT-27.9 ___
___ 10:22PM BLOOD UreaN-15 Creat-1.2
___ 07:00AM BLOOD Glucose-100 UreaN-9 Creat-1.0 Na-145
K-4.1 Cl-108 HCO3-24 AnGap-13
___ 10:22PM BLOOD ALT-13 AST-17 AlkPhos-66 TotBili-0.4
___ 01:53AM BLOOD ALT-11 AST-14 LD(LDH)-141 CK(CPK)-172
AlkPhos-59 TotBili-0.4
___ 10:22PM BLOOD cTropnT-<0.01
___ 01:53AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:22PM BLOOD Albumin-3.7
___ 07:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0
___ 01:53AM BLOOD %HbA1c-5.5 eAG-111
___ 01:53AM BLOOD Triglyc-61 HDL-46 CHOL/HD-3.3 LDLcalc-92
___ 01:53AM BLOOD TSH-2.0
___ 01:53AM BLOOD CRP-1.9
___ 10:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 10:30PM BLOOD Glucose-85 Na-140 K-4.2 Cl-105 calHCO3-25
CT PERFUSION
IMPRESSION:
1. CBF<30%: 0 ml
2. Mildly increased MTT in the left MCA territory. No
significant missmatch
on the CBV and CBF.
THROMBECTOMY
IMPRESSION:
Left M1/2 occlusion of the middle cerebral artery.
TICI 2B to be revascularization of left middle cerebral artery
following
successful mechanical thrombectomy.
TTE:
IMPRESSION: No intracardiac source of thromboembolism
identified. Normal biventricular cavity
sizes, regional/global systolic function. Mild mitral
regurgitation. Normal estimated pulmonary artery
systolic pressure.
MR HEAD W/O CONTRAST
IMPRESSION:
1. Scattered cortical, subcortical and white matter DWI
hyperintensities in
the left frontal and parietal lobes are consistent with acute
infarction after
incomplete revascularization of a distal left M1 occlusion.
2. Punctate focus of microhemorrhage in the left parietal lobe.
3. Mild paranasal sinus disease as described above.
Medications on Admission:
sildafenil PRN
eye drops
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with L M1 occlusion s/p thrombectomy// please
perform ___ at 2300. eval extent of L MCA infarct
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 from ___ and cerebral angiogram from ___.
FINDINGS:
Cortical DWI hyperintensities along the left insula (series 4, image 15 and
16), left anterior frontal lobe (series 4, image 17 and 19) and cortical and
subcortical DWI hyperintensities in the left parietal lobe (series 4, image
___ scattered DWI foci are seen in the left periventricular white matter.
There is an ADC correlate for the majority of these lesions, compatible with
acute infarct after incomplete revascularization of a distal left M1
occlusion. Punctate focus of subcortical microhemorrhage in the left parietal
lobe (series 11, image 15
Caliber and configuration of the ventricles and sulci is within normal limits.
Mild mucosal thickening in the left frontoethmoidal junction, ethmoid air
cells and bilateral maxillary sinuses with a small mucous retention cyst in
the left maxillary sinus. The sphenoid sinuses are clear. The mastoid air
cells are clear. The orbits are normal.
IMPRESSION:
1. Scattered cortical, subcortical and white matter DWI hyperintensities in
the left frontal and parietal lobes are consistent with acute infarction after
incomplete revascularization of a distal left M1 occlusion.
2. Punctate focus of microhemorrhage in the left parietal lobe.
3. Mild paranasal sinus disease as described above.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Aphasia, Transfer
Diagnosed with Other cerebral infarction
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | In brief, Mr ___ is a ___ man with h/o tobacco use,
glaucoma who presented as transfer from OSH for Left M1
occlusion. LWK ___ at 0845. He came home from work, took a nap.
Spoke to his brother over the phone after his nap and was
speaking word salad. His wife came home and called EMS. Sent to
OSH where CT head showed L M1 occlusion. Outside the window for
TPA. Transferred to ___ for thrombectomy. NIHSS at ___ 8.
Thrombectomy TICI IIb, admitted to Neuro ICU post angio. Patient
continued with aphasia with word finding difficulties but
occasionally could be fluent. Naming deficit. Patient's speech
improved. Patient has full strength throughout on motor exam.
Patient started on aspirin and atorvastatin. LDL 92. Very poor
vision in R eye but pt says it is chronic. Urine tox positive
for cocaine but patient denies use. Patient counseled on
abstaining from cocaine. Patient was monitored on telemetry;
found to have asymptomatic sinus bradycardia. MRI brain showed
scattered cortical, subcortical and white matter DWI
hyperintensities in the left frontal and parietal lobes are
consistent with acute infarction after incomplete
revascularization of a distal left M1 occlusion, focus of
microhemorrhage in the left parietal lobe. TTE performed,
showing no intracardiac source of thromboembolism. Normal
biventricular cavity sizes, regional/global systolic function.
Mild mitral regurgitation. Normal estimated pulmonary artery
systolic pressure. Remained stable for the remainder of the
admission. Recommendation for outpatient speech therapy. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / Macrolide Antibiotics / clindamycin / antiemetic
Attending: ___.
Chief Complaint:
ovarian mass
ovarian torsion
Major Surgical or Invasive Procedure:
right salpingo-oophorectomy via mini-laparotomy
History of Present Illness:
This is a ___ yo G3P___ with several days of intermittent,
colicky RLQ pain. Reports that ___ night she awoke from
sleep with well localized RLQ pain, and was able to go back to
sleep and go into work. Same thing happened ___ night.
___ morning she awoke from sleep with pain again, was able to
drink some tea, do some yoga, and eventually had significant
enough resolution to go to work. She has a one episode of
diarrhea and a BM that day with worsening of her pain, and noted
that it continued to come and go. She was seen at the ___ in
___ where blood tests, urine tests, and a KUB were
reassuring, and she was called with these results. ___
mornign the pain came again, but resolved enough for her to go
out to dinner ___ night. This morning the pain awoke her
from sleep at 3am and did not abate. She felt it ___, intense
pain, radiating from her RLQ down her anterior leg. During
these pain episodes, she felt she could not sit still, and would
instead move all around. Today she has had nausea and ___
episodes of vomitting. She has been NPO since 3am. She has
never had any similar episodes prior. In the ED she has
required 3 doses of morphine 4mg IV.
Past Medical History:
GynHx:
LMP ___ or ___. No hx of abn Pap or STI. No hx
of
ovarian cyst.
ObHx:
- LTCS x3 via Phannensteil, all term, first for NRFHT. Kids
ages
___, ___, ___ now.
PMH:
- autoimmune hepatitis ___, normalization of LFTs per pt
- depression
PSH: LTCS x3 only
Social History:
___
Family History:
denies t/e/d
Physical Exam:
on day of discharge:
afebrile, VSS
NAD, comfortable
RRR, CTAB
abd soft, appropriately tender, ND
mini-laparotomy intact, no erythema or drainage
no edema
Pertinent Results:
___ 05:09PM BLOOD WBC-8.8 RBC-3.96* Hgb-12.2 Hct-35.0*
MCV-88 MCH-30.9 MCHC-34.9 RDW-12.4 Plt ___
___ 07:45AM BLOOD WBC-6.8 RBC-4.34 Hgb-13.6 Hct-38.4 MCV-88
MCH-31.3 MCHC-35.4* RDW-12.3 Plt ___
___ 07:45AM BLOOD Glucose-119* UreaN-13 Creat-0.8 Na-136
K-4.2 Cl-103 HCO3-26 AnGap-11
___ 07:45AM BLOOD ALT-23 AST-25 AlkPhos-72 TotBili-0.2
Medications on Admission:
- unknown antidepression, likely SSRI, 10mg qd
- lorazepam prn sleep
- MVI, Vitamins C, D, calcium, fish oil, probiotic
Discharge Medications:
1. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*2*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ovarian torsion, adnexal mass (pathology pending)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with lower abdominal pain. Evaluate for
kidney stone or other source of abdominal pain.
COMPARISON: None.
TECHNIQUE: Non-contrast followed by post-contrast MDCT imaging of the abdomen
and pelvis performed. Axial, coronal, and sagittal reformats were prepared
and reviewed.
CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST:
Visualized lung bases are clear. There is no nodule, mass, or consolidation.
There is no pleural or pericardial effusion.
The liver is normal in size and attenuation. There is no intra- or
extra-hepatic biliary ductal dilation, and the gallbladder is normal. The
hepatic and portal veins are patent. The spleen, pancreas, and adrenal glands
are normal. There is symmetric renal parenchymal enhancement. There is no
hydronephrosis. Incidental note is made of partial duplication of the left
renal collecting system, extending to the level of the mid ureter.
Stomach, duodenum, and intra-abdominal loops of small and large bowel are
normal. There is no bowel distension or bowel wall thickening. There is no
free air. The aorta and mesenteric vessels are normal in caliber. There is
no mesenteric or retroperitoneal adenopathy.
CT PELVIS WITH INTRAVENOUS CONTRAST:
Distal ureters and bladder are normal. Uterus is unremarkable, as is the left
adnexa. However, at the right posterior aspect of the uterus, there is a
mixed solid and cystic lesion likely representing ovary, measuring up to 7.5 x
6.0 x 7.1 cm. There is no significant surrounding inflammatory change, though
small amount of fluid is seen dependently adjacent to the anterior abdominal
wall (scanned prone). Portions of this right adnexal lesion are hyperdense on
pre-contrast images, which could represent hemorrhage, with no enhancement
following contrast administration. There is no associated fat within the
lesion. There is no calcification.
BONE WINDOWS: There are degenerative changes in the lower lumbar spine at
L4-5 and L5-S1. There are no lytic or sclerotic lesions concerning for
malignancy.
IMPRESSION:
1. Right adnexal mass, likely ovarian in origin. Given the clinical history,
resulting ovarian torsion cannot be excluded, and ultrasound of the pelvis is
recommended for further evaluation. Trace dependent free fluid.
2. Incidentally noted partially duplicated left renal collecting system.
Dr. ___ was informed by phone by Dr. ___ at 9:45 a.m. on ___.
Radiology Report
INDICATION: ___ female with abdominal pain and right ovarian
abnormality seen on CT.
COMPARISON: CT, ___.
LMP: Unknown. The patient is perimenopausal.
PELVIC ULTRASOUND:
Transabdominal and endovaginal imaging of the pelvis was performed, the latter
to better evaluate the endometrium and adnexa.
The uterus measures 10.5 x 4.2 x 5.9 cm. There are no focal uterine
abnormalities. The endometrium is 9 mm in thickness, without focal
abnormality.
The left ovary is normal in size and appearance, with normal arterial and
venous waveforms.
However, what appears to be the right ovary is markedly enlarged, measuring up
to 7.8 x 3.6 x 6.2 cm. It contains a single large simple cyst, measuring up
to 3.7 cm, and a second rounded echogenic lesion, measuring 3.9 cm, which
could represent a solid mass or a markedly complex hemorrhagic cyst. No flow
can be demonstrated within this; however, flow can also not be well seen
within the remainder of the right ovary, which could all be secondary to
ovarian torsion given the patient's pain, with these large ovarian lesions
acting as lead points.
Moderate amount of complex free fluid is also seen in the pelvis.
IMPRESSION:
1. Large right ovary, measuring up to 7.8 cm, with two lesions within. One
is a simple cyst, the other may be a solid mass or a complex hemorrhagic cyst.
No flow is seen within the possible mass or the ovary in general, which
strongly suggests a consideration of ovarian torsion.
2. Moderate free complex fluid, likely hemorrhage.
3. Thickened endometrium measuring 9 mm, should be correlated with the
patient's hormonal status.
Discussed in detail with OB-GYN service by Dr ___. Operative exploration
was performed.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RT.LQPAIN
Diagnosed with ABDOMINAL PAIN RLQ, ABDOM/PELV SWELL/MASS UNSP SITE
temperature: 97.6
heartrate: 64.0
resprate: 18.0
o2sat: 100.0
sbp: 121.0
dbp: 90.0
level of pain: 7
level of acuity: 2.0 | Ms. ___ was taken from the ED to the OR for an exploratory
lapartotomy via small Phannensteil incision, evacuation of
hemoperitoneum, right salpingoopherectomy of torsed complex
right ovary and tube. Please see operative report for full
details. From the recovery room, she was transported to ___
___, where her recovery was uncomplicated.
She was discharged home on POD#1 in good condition, ambulating,
voiding, tolerating a full diet and with pain well controlled on
po pain medications. She will follow up at the ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet / Percodan
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
R tibial IMN
History of Present Illness:
___ ped struck by ___ green line, brought in by EMS with R leg
pain and deformity. Patient was struck directly in the R leg by
train. Per report, the mirror struck her on the back of her
head. She reports brief LOC.
Past Medical History:
Glaucoma, vertigo, stress incontinence
Social History:
___
Family History:
nc
Physical Exam:
A&O, NAD, Pain well controlled
AFVSS
RLE: Incision c/d/i, ___, SILT s/s/sp/dp/pt, WWP
Pertinent Results:
xray of right tibia fracture and after surgical fixation of the
fracture
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxybutynin 5 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H Pain
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*2
3. Enoxaparin Sodium 40 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe sq qpm Disp #*14 Syringe
Refills:*0
4. Senna 8.6 mg PO BID
5. Oxybutynin 5 mg PO QHS
6. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*80 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Right tibia fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance
Followup Instructions:
___
Radiology Report
INDICATION: ___ with MVC // ICH? Fx?
TECHNIQUE: Portable chest and pelvis films.
COMPARISON: None.
FINDINGS:
Chest: The lungs are clear within limitation of overlying trauma board and
external hardware. The cardiomediastinal silhouette is within normal limits.
No displaced fractures identified.
Pelvis: Within the limitation of overlying trauma board, there is no
visualized fracture. The pubic symphysis and SI joints are preserved. Soft
tissues are unremarkable.
IMPRESSION:
No acute cardiopulmonary process. No pelvic fracture.
Radiology Report
EXAMINATION: DX TIB/FIB AND ANKLE
INDICATION: ___ with MVC // ICH? Fx?
TECHNIQUE: Right knee, tib/fib, and ankle radiographs, 2 views.
COMPARISON: None available.
FINDINGS:
RIGHT KNEE: There is no fracture or dislocation identified involving the
right knee. Mild tricompartmental degenerative changes are noted, most
prominent with the patellofemoral compartment with superior and posterior
spurring.
RIGHT TIBIA/FIBULA: There is an transverse fracture through the mid diaphysis
of the right tibia. Comminuted mid fibular fracture is also identified. There
is significant rotation at the fracture site with the distal fracture
fragments rotated laterally. Significant lateral displacement and
foreshortening seen at the tibial fracture fragment.
RIGHT ANKLE: A transversely oriented, lucent line is seen extending through
the distal tibial metaphysis, suggestive of a nondisplaced fracture extending
to the syndesmosis. The ankle mortise is symmetric and preserved. Plantar
calcaneal spurring is noted.
IMPRESSION:
Fractures through the mid diaphysis of the right tibia and fibula.
Nondisplaced distal fibular fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with MVC // ICH? Fx?
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDIvol: 52.8 mGy
DLP: 1003.42 mGy-cm
COMPARISON: None available.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect, or
large territorial infarction. Prominent ventricles and sulci suggest
age-related involutional changes or atrophy. The basal cisterns appear patent
and there is preservation of gray-white matter differentiation.
A large, subgaleal hematoma and soft tissue swelling is noted extending along
the right frontoparietal region. A rounded, focal high-density structure
adjacent overlying the right parietal region has the appearance of a partially
calcified sebaceous cyst, although foreign body following a head striking
against the ground is also possible. No displaced skull fracture is
identified. The paranasal sinuses, middle ear cavities, and mastoid air cells
are clear. The orbits are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Large right frontoparietal subgaleal hematoma with possible calcific
foreign body material versus partially calcified sebaceous cyst. No underlying
displaced fracture is identified.
3. Moderate cerebral volume loss.
Radiology Report
EXAMINATION: CT C-spine without contrast.
INDICATION: ___ with MVC // ICH? Fx?
TECHNIQUE: 2.5 mm helical axial MDCT sections were obtained from the skull
base through the cervical spine. Axial images were interpreted in conjunction
with coronal and sagittal reformats.
CTDIvol: 36.98 MGy
DLP: ___ MGy-cm
COMPARISON: None available.
FINDINGS:
There is no definitive evidence of acute fracture or traumatic malalignment.
There is no prevertebral soft tissue abnormality. Mild anterolisthesis of C4
on C5 and retrolisthesis of C5 on C6 is age indeterminate, but likely
degenerative. Moderate, multilevel degenerative changes are noted throughout
the cervical spine, most significant at the level of C5-C6 with loss of
intervertebral disc height, endplate sclerosis, uncovertebral joint
hypertrophy, and osteophytosis. There is a least mild canal narrowing and
moderate to severe right foraminal narrowing at this level. Sclerosis with
irregularity of endplates suggests degenerative changes potentially Schmorl's
nodes at the inferior endplates of C5 and C6.
A 3 mm, hypodense, right thyroid nodule is noted. No lymphadenopathy is
present by CT size criteria. Incidentally noted is a 5 mm pulmonary nodule in
the right lung apex. The visualized lung apices are otherwise clear.
IMPRESSION:
1. No definitive evidence of acute fracture.
2. Mild anterolisthesis of C4 on C5 and retrolisthesis of C5 on C6, age
indeterminate and likely degenerative. Recommend clinical correlation.
3. Moderate degenerative changes of the cervical spine, most notable at C5-C6.
4. Incidental, 5 mm right upper lobe solid pulmonary nodule. If the patient is
at high risk for malignancy, recommend chest CT in ___ months. If at low
risk, recommend chest CT in 12 months to establish stability.
Radiology Report
INDICATION:
___ with tib fib fracture s/p reduction // post reduction
COMPARISON: Films from earlier the same day.
TECHNIQUE:
AP and lateral views of the proximal distal right tibia and fibula.
FINDINGS:
Overlying cast obscures fine bony detail. There has been interval reduction in
the degree of displacement and angulation of the fractures of the mid right
tibia and fibula. Known distal right fibular fracture is not clearly
delineated.
Radiology Report
Images from the operating suite show fixation device scratch that
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: RT TIB FIB ORIF IN THE OR
IMPRESSION:
Fluoroscopic images from the operating suite shows placement of a
intramedullary rod across a fracture of the midshaft of the tibia. Adjacent
fibular fracture is seen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PED STRUCK
Diagnosed with FX TIBIA W FIB NOS-OPEN, MV COLL W PEDEST-PEDEST, TETANUS-DIPHT. TD DT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have open right tibia fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right tibial IMN which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is tdwb in the right lower extremity,
and will be discharged on lovenox for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / penicillin G / Erythromycin
Base
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None this admission
History of Present Illness:
___ F s/p lap hiatal hernia repair ___ gastroplasty by Dr
___ on ___ presented initially to ___
___ with weakness, decreased appetite since surgery. She
reports less PO intake but is tolerating what she eats. She
experienced some nausea today but denies emesis. She is passing
flatus and having formed regular bowel movements. Denies abd
pain or drainage fro incsion. She is able to do activities
around house but has experienced weakness since surgery. No
fevers, chills, CP, SOB. On imaging at ___ was found to have
a hemothorax and possible extravasatation from the left gastric
artery. She was transferred to ___ for further work up and
care.
Past Medical History:
PMH: Paraesophageal hernia, Pelvic floor dysfunction, Spinal
stenosis Lumbar fracture
PSH: Laparoscopic paraesophageal hernia repair with graft
___ gastroplasty, Fundoplication ___ ___
salpingo-oopherectomy; blader supension; hysterectomy; rotator
cuff surgery
Social History:
___
Family History:
Notable for father with laryngeal cancer and a mother who died
secondary to complications from a perforated appendix in her
___.
Physical Exam:
VS: 98.1, 85, 114/76, 18, 97% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, incisions CDI
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
CBC:
___ 12:50AM BLOOD WBC-5.7 RBC-3.50* Hgb-10.6* Hct-32.8*
MCV-94 MCH-30.3 MCHC-32.4 RDW-13.5 Plt ___
___ 04:20AM BLOOD Hct-31.8*
___ 12:50AM BLOOD Plt ___
Coags:
___ 01:00AM BLOOD ___ PTT-31.4 ___
Lytes:
___ 12:50AM BLOOD Glucose-103* UreaN-10 Creat-0.8 Na-136
K-4.1 Cl-101 HCO3-24 AnGap-15
___ 09:00AM BLOOD Glucose-136* UreaN-12 Creat-1.0 Na-137
K-4.2 Cl-101 HCO3-26 AnGap-14
___ 09:00AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4
LFTs:
___ 12:50AM BLOOD ALT-17 AST-16 AlkPhos-73 TotBili-0.2
___ 12:50AM BLOOD Lipase-17
Other labs:
___ 12:50AM BLOOD Albumin-3.6
___ 12:57AM BLOOD Lactate-1.1
U/A:
___ 01:20AM URINE Color-Straw Appear-Clear Sp ___
___ 01:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Shoulder X-rays ___:
IMPRESSION: No evidence of acute fracture or dislocation of the
left shoulder.
Medications on Admission:
oxycodone 5' Q4H PRN, Acetaminophen 650' Q6H PRN, bupropion
150'', clonazepam 0.5'', fluticasone 50 2 sprays', omeprazole
20', ropinirole 1.5''
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain.
3. bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. ropinirole 1 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
s/p laparoscopic hiatal hernia repair with ___ gastroplasty
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
LEFT ___
No prior studies for comparison.
FINDINGS: Radiographs of the left ___ demonstrate no evidence of acute
fracture, dislocation, or soft tissue calcifications. Degenerative changes
are seen at the glenohumeral joint and minimal degenerative changes were also
present at the acromioclavicular joint. Left humeral head appears to be
relatively high riding, a finding that can be associated with chronic rotator
cuff degeneration.
IMPRESSION: No evidence of acute fracture or dislocation of the left
___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: WEAKNESS, R/O BLEEDING FROM GASTRIC ART
Diagnosed with OTHER SPEC COMPL S/P SURGERY, OTHER MALAISE AND FATIGUE, ACCIDENT NOS
temperature: 98.1
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 130.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ F s/p lap hiatal hernia repair ___ gastroplasty by Dr
___ on ___ presented initially to ___
___ with weakness and decreased appetite since surgery. Her
original CT read at ___ indicated there may be active
extravasation from the gastric artery so she was transferred to
___ for further workup. Here her main complaint was that she
has had trouble caring for herself and she feels "weak." EKG
did not show any acute changes. Labs WNL. Additionally she was
complaining of left shoulder pain so left shoulder x rays were
obtained which did not show acute fracture or dislocation. Upon
further review of her images it does not appear that she has any
active extravasation of any vessels within her abdomen and that
the radiologist may have been seeing staples from her surgery.
She has been completely hemodynamically stable while in house.
She was started on her home medications and a regular diet. She
was seen by social work, case management and Physical therapy
who all agreed she was safe to d/c home with services for home
health and meals on wheels. She agreed with this plan. She
will follow up closely in clinic with her PCP ___ ___ and in
surgery clinic later this week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
shortness of breath, large left hemothorax
Major Surgical or Invasive Procedure:
___: Left VATS washout with chest tube placement
History of Present Illness:
Mr. ___ is a ___ male who had a motorcycle accident 2
days before presenting to an outside hospital. At the time of
presentation he was having
significant shortness of breath and was noted to have a large
left hemothorax. Chest tube was emergency placed. Initial
placement drained 2.2 L blood. He was transferred to BID for
further management. On arrival he was hemodynamically unstable
and felt responded to blood and resuscitation. A chest tube
continued to have significant output, which then dropped off
over the course of approximately 48 hours.
Past Medical History:
Hep C (no treatment), prior heroin abuse now on suboxone (clean
since ___
PSH: orchiopexy for testicular torsion
Social History:
___
Family History:
noncontributory
Physical Exam:
VS 120/47 HR 92 O2 99% NRB RR 18
General: Appears anxious, alert and oriented x3
HEENT: PEERL
Neck: Trachea midline
CV: Regular
Lungs: Diminished sounds on left side, mild crackles right
base, CT left chest wall, draining dark red blood
Abdomen: soft
GU: foley draining clear yellow urine
Ext: No edema
Neuro: moves all extremities
Skin: bruising over left ankle
Discharge Physical Exam:
VS: 98.2, 83, 138/46, 18, 97%ra
Gen: A&O x3, calm, cooperative, NARD
CV: HRR, sinus tachycardia to 110's with ambulation
Pulm: Crackles throughout left lobe, diminished LS in base. No
crepitus or hypoxia, O2 98% room air. VATS site CDI; CT sites
covered with occlusive dressing
Abd: Soft, NT/ND
Ext: No edema
Neuro: Intact
Pertinent Results:
Labs on admission:
___ 09:45PM BLOOD WBC-14.5* RBC-4.16* Hgb-11.5* Hct-33.8*
MCV-81* MCH-27.6 MCHC-34.0 RDW-13.6 RDWSD-39.8 Plt ___
___ 01:15AM BLOOD WBC-11.1* RBC-4.17* Hgb-11.6* Hct-34.1*
MCV-82 MCH-27.8 MCHC-34.0 RDW-13.8 RDWSD-40.4 Plt ___
___ 04:42AM BLOOD WBC-11.5* RBC-3.79* Hgb-10.5* Hct-31.0*
MCV-82 MCH-27.7 MCHC-33.9 RDW-13.8 RDWSD-40.7 Plt ___
___ 08:56AM BLOOD WBC-10.4* RBC-3.65* Hgb-10.1* Hct-30.3*
MCV-83 MCH-27.7 MCHC-33.3 RDW-13.6 RDWSD-41.4 Plt ___
___ 07:25AM BLOOD WBC-9.6 RBC-3.95* Hgb-11.0* Hct-32.7*
MCV-83 MCH-27.8 MCHC-33.6 RDW-13.8 RDWSD-41.5 Plt ___
___ 10:30AM BLOOD WBC-8.8 RBC-3.49* Hgb-9.6* Hct-29.5*
MCV-85 MCH-27.5 MCHC-32.5 RDW-13.7 RDWSD-42.5 Plt ___
Labs on discharge:
___ 07:19AM BLOOD WBC-9.5 RBC-3.27* Hgb-8.9* Hct-26.7*
MCV-82 MCH-27.2 MCHC-33.3 RDW-12.8 RDWSD-37.5 Plt ___
Radiology:
___ CXR:
Left-sided chest tube terminates over the left hemi thorax.
Moderate
left-sided pleural effusion with adjacent compressive
atelectasis of the left lung.
___ CXR:
new small left apical pneumothorax. Left pleural effusion and
adjacent atelectasis are not appreciably changed.
___ Chest CT:
Moderate size left hemopneumohydrothorax.
Complete atelectasis of the left lower lobe and lingular
segments.
The tip of the left-sided ICD is inseparable from the left lower
lobe
pulmonary parenchyma and repositioning is advised.
Peribronchial opacity in the right lower lobe may represent
aspiration or
pneumonia.
___ CXR:
There is no significant improvement in the left-sided effusion
with adjacent airspace opacification in the left mid to lower
lung zone.
___ CXR:
Interval placement of a second left chest tube. No discernible
pneumothorax is identified.
___ CXR:
Unchanged left pleural effusion/hemothorax and left lower lobe
___ CT Chest:
1. Interval repositioning of a left-sided chest tube, with its
tip
terminating in the upper pleural space posteriorly. Near
complete resolution of a left-sided hemothorax, with residual
small left-sided hydropneumothorax.
2. Interval re- expansion of the left lower lobe, with residual
subsegmental atelectasis noted.
3. Splenomegaly.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
2. ClonazePAM 1 mg PO BID
3. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*75 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipationj
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*20
Tablet Refills:*0
6. TraMADol 50 mg PO BID
RX *tramadol 50 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
7. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
8. Citalopram 40 mg PO DAILY
9. ClonazePAM 1 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Left posterior rib fractures ___
Left hemothorax with trapped lung
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: ___ year old man with L hemothorax, increased resp distress //
eval for interval change
TECHNIQUE: Portable AP view
COMPARISON: Reference chest CT on ___ at outside hospital.
FINDINGS:
A left-sided chest tube terminates over the left hemi thorax. The
cardiomediastinal and hilar contours are within normal limits. The right lung
appears clear. There is a moderate left pleural effusion and and adjacent
compressive atelectasis. No pneumothorax is identified. No nondisplaced rib
fractures are identified.
IMPRESSION:
Left-sided chest tube terminates over the left hemi thorax. Moderate
left-sided pleural effusion with adjacent compressive atelectasis of the left
lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with L hemothorax s/p Ct placement // eval for
interval change
IMPRESSION:
In comparison to prior radiograph of 1 day earlier, a left-sided chest tube
remains in place with persistent moderate to large left pleural effusion and
adjacent atelectasis or consolidation in the lingula and left lower lobe. New
linear atelectasis is present at the right lung base and there remains a
persistent linear left perihilar focus of atelectasis.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: ___ year old man with motorcycle accident, bruising left ankle //
?left ankle fracture ?left ankle fracture
TECHNIQUE: Frontal, oblique, and lateral view radiographs of left ankle none
available
FINDINGS:
No definite acute fracture, dislocation, or degenerative change is detected.
The mortise is congruent on this non stress view. A well corticated osseous
density is present at the inferior aspect of the fibula and may reflect an
accessory ossicle or the residua of old injury. Soft tissue swelling is mild
and symmetrical in distribution. The
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p motorcycle crash ___ now presenting as transfer from osh
with L hemothorax s/p chest tube placement // interval change of hemothorax
IMPRESSION:
In comparison to ___ radiograph, a left chest tube remains in
place, with an apparently new small left apical pneumothorax. Left pleural
effusion and adjacent atelectasis are not appreciably changed when
consideration is given to technical differences between the studies.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with hemothorax // evaluate hemothorax, chest
tube placement evaluate hemothorax, chest tube placement
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Combination of left lower lobe atelectasis and some left pleural effusion
unchanged. Small left apical pneumothorax not appreciably changed since
___. Left pleural drainage tube unchanged in position in the left lower
hemi thorax, precise location indeterminate. Chest CT on ___ one was
equivocal regarding placement of the tube in the collapse left lower lobe. If
repeat chest CT is performed for that determination,intravenous contrast agent
should be administered. Right lung clear.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with hemothorax // Evaluate hemothorax, chest
tube placement, pulmonary vasculature
TECHNIQUE: Contrast enhanced multidetector CT performed of the entire volume
of the thorax with multi planar reformations and MIP reconstructions.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 36.1 cm; CTDIvol = 19.6 mGy (Body) DLP = 707.2
mGy-cm.
Total DLP (Body) = 707 mGy-cm.
COMPARISON: ___
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: No thyroid lesions. No
supraclavicular or axillary adenopathy. No gross breast lesions.
UPPER ABDOMEN: This study was not tailored to evaluate the subdiaphragmatic
organs. No hiatal hernia. No adrenal lesions. No intra-abdominal free
fluid.
MEDIASTINUM: Subcentimeter mediastinal lymph nodes.
HILA: Subcentimeter left hilar lymph nodes.
HEART and PERICARDIUM: Normal cardiac configuration. No pericardial effusion.
A few subcentimeter pericardial lymph nodes. The thoracic aorta appears
normal.
PLEURA: Moderate sized left hemopneumohydrothorax. Left-sided IC drain in
situ which terminates in close proximity to the left lower lobe pulmonary
parenchyma. Loculated simple fluid (hydrothorax) component seen in the left
pleural space (4, 76)
LUNG:
-PARENCHYMA: Complete collapse of the lingula and left lower lobe. The left
upper lobe is aerated. Peribronchial opacification in the medial and
posterior basal segments of the left lower lobe.
-AIRWAYS: Patent to the subsegmental level.
-VESSELS: The pulmonary arteries not enlarged. Suboptimal opacification of
the pulmonary arterial system.
CHEST CAGE: Spondylotic changes of the thoracic spine. No displaced rib
fractures.
IMPRESSION:
Moderate size left hemopneumohydrothorax.
Complete atelectasis of the left lower lobe and lingular segments.
The tip of the left-sided ICD is inseparable from the left lower lobe
pulmonary parenchyma and repositioning is advised.
Peribronchial opacity in the right lower lobe may represent aspiration or
pneumonia.
Radiology Report
INDICATION: ___ y/o M ___ s/p MCC, L hemothorax with CT placement // interval
change
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Left-sided ICD in situ with its position unchanged. There is no significant
improvement in the left-sided effusion with adjacent airspace opacification in
the left mid to lower lung zone. Small left apical pneumothorax measuring 6
mm in diameter. The right lung is clear.
IMPRESSION:
As above.
Radiology Report
INDICATION: ___ year old man with hemothorax s/p VATS washout chest tube
placement x2 // ?interval change
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
CT chest tubes project over the left hemithorax. There is a retrocardiac
opacity noted likely a combination of atelectasis and pleural fluid. Mild
atelectasis in the right lower lung zone. No discernible pneumothorax
identified. The size of the cardiac silhouette is enlarged but overall
unchanged.
IMPRESSION:
Interval placement of a second left chest tube. No discernible pneumothorax
is identified.
Persisting retrocardiac opacity likely reflects a combination of atelectasis
and a pleural effusion.
Radiology Report
INDICATION: ___ year old man with hemothorax s/p VATS washout chest tube
placement x2 // ?interval change
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The patient is status post left VATS. 2 left chest tubes are present. No
definitive pneumothorax identified. Persisting retrocardiac opacity which may
reflect post procedural changes/atelectasis. Mild atelectasis in the right
lower lung zone. No right pleural effusion or pneumothorax. The size of the
cardiac silhouette is enlarged but unchanged.
IMPRESSION:
No significant interval change since yesterday's radiograph given slight
differences in technique. No discernible pneumothorax identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hemothorax s/p VATS washout chest tube
placement x2 // ?interval change, please do at 7 am ?interval change,
please do at 7 am
IMPRESSION:
Left chest tubes are in place. There is no interval increase in pleural
effusion. Heart size and mediastinum are stable. There is no pneumothorax.
There is no pulmonary edema
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hemothorax s/p VATS washout // evaluate
hemothorax, chest tubes evaluate hemothorax, chest tubes
IMPRESSION:
2 left chest tubes are in place. There is no pneumothorax. There is left
pleural effusion, moderate, unchanged. Minimal atelectasis at the right lung
base has not changed substantially. No pulmonary edema. Cardiomediastinal
silhouette is stable.
Radiology Report
INDICATION: ___ s/p motorcycle crash ___ now presenting as transfer from osh
with L hemothorax s/p VATS washout and chest tube placementx2 // ?interval
change s/p anterior chest-tube DCd, please do at 0800
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___ and CT from ___
FINDINGS:
There has been interval removal of the left anterior chest tube. The left
pleural effusion correlating to a hemothorax on recent CT and left lower lobe
collapse are largely unchanged in the interval. Platelike atelectasis of the
right lung base is stable. No new pleural effusions pneumothoraces. The
cardiomediastinal and hilar contours are stable. Left chest tube terminates
in left apex.
IMPRESSION:
Unchanged left pleural effusion/hemothorax and left lower lobe
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man s/p VATS, 1 Chest tube remain. Opacities seen on
CXR. Chest tube low output past 2 days // ? Opacity, other etiology
TECHNIQUE: Single phase contrast. MDCT axial images were acquired through
the chest following intravenous contrast administration. Oral contrast was
not administered. Coronal and sagittal reformats were performed and reviewed
on PACs.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.4 s, 39.9 cm; CTDIvol = 16.5 mGy (Body) DLP =
632.2 mGy-cm.
Total DLP (Body) = 644 mGy-cm.
COMPARISON: CT chest from ___.
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The left lateral chest musculature
is enlarged, likely due to underlying hematoma. Again noted is small
left-sided subcutaneous emphysema. There is no axillary lymphadenopathy.
UPPER ABDOMEN: Limited evaluation of the upper abdomen shows no acute
abnormality. There is splenomegaly measuring up to 16.2 cm in craniocaudal
dimension.
MEDIASTINUM: There are mildly prominent mediastinal lymph nodes, likely
reactive.
HILA: No hilar lymphadenopathy is noted.
HEART and PERICARDIUM: There is no pericardial effusion.
PLEURA: Left-sided chest tube has been repositioned and is now located in the
superior aspect of the left pleural space. There has been near complete
resolution of the left-sided hemothorax and decreased pneumothorax, with a
residual small left-sided hydropneumothorax. The right lung is clear with
interval resolution of the previously described opacity in the medial right
lung base.
LUNG:
-PARENCHYMA: There has been re-expansion of the left lower lobe, with
residual subsegmental atelectases.
-AIRWAYS: The airway is patent to the subsegmental level.
-VESSELS: There is poor opacification of the pulmonary vessels, however no
large central pulmonary embolus is noted.
IMPRESSION:
1. Interval repositioning of a left-sided chest tube, with its tip
terminating in the upper pleural space posteriorly. Near complete resolution
of a left-sided hemothorax, with residual small left-sided hydropneumothorax.
2. Interval re- expansion of the left lower lobe, with residual subsegmental
atelectasis noted.
3. Splenomegaly.
Radiology Report
INDICATION: ___ y/o POD5-VATS s/p ___ CT removal // post-pull fim to eval for
new ptx. *Pls obtain film at 1pm
TECHNIQUE: Chest PA and lateral
FINDINGS:
There has been interval removal of the left chest tube. Interval increase in
left mediastinal shift and decrease of left lung volume suggesting worsening
atelectasis. The left pleural effusion correlating to a hemothorax on recent
CT and largely unchanged. Improved platelike atelectasis of the right lung
base. No new pleural effusions or pneumothoraces. The cardiomediastinal and
hilar contours are stable.
IMPRESSION:
Worsening left lung atelectasis. Unchanged left pleural effusion/hemothorax.
No evidence of pneumothorax.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Motorcycle accident, Transfer, HEMOTHORAX
Diagnosed with Multiple fractures of ribs, left side, init for clos fx, Traumatic hemothorax, initial encounter, Mtrcy driver injured pick-up truck, pk-up/van nontraf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Mr. ___ was admitted to the ICU for close hemodynamic
monitoring. On admission he received 2uPRBCs-however he remained
hemodynamically stable since admission. There was concern if his
chest tube output remained high or if he was requiring
continuous transfusions he would need a thoracotomy. However his
chest tube output remained minimal and his pain was well
controlled while in the ICU. On hospital day two he was then
transferred to the floor
Serial chest x-rays showed minimal improvement in the
hemothorax. A repeat chest CT on HD4 showed a trapped collection
in the left lower lobe. Given the failure to clinically
progress, a discussion was had with the patient and a decision
was made to proceed with a left VATS with washout of the
retained hemothorax. On HD7, the patient was taken to the
operating room and underwent a left VATS washout with chest tube
placement, which went well without complication (reader referred
to the Operative Note for details). After a brief, uneventful
stay in the PACU, the patient arrived on the floor tolerating
sips, on IV fluids, and PCA for pain control. The patient was
hemodynamically stable and had 2 chest tubes in place.
POD2 the chest tubes were placed to water seal. On POD3 the left
anterior chest tube was removed. POD4 a chest CT showed near
complete resolution of the left hemthorax. POD5 the remaining
chest tube was removed.
.
Chronic pain was consulted early on during the admission given
the patient's history of heroin abuse and current use of
suboxone. Pain was well controlled. Postoperatively, diet was
progressively advanced as tolerated to a regular diet with good
tolerability. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge on POD5, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, pulling
2500 on the IS, and pain was well controlled. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cardizem CD
Attending: ___
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
Right CVL ___
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Ms. ___ is a ___ with PMH of gout, HTN, ESRD s/p LRRT
(___) c/b diabetes and CMV viremia, with multiple recent
admissions for hypotension and c/f infection presents with
fevers and hypotension.
Patient recently discharged from ___ ___. On this
admission, she was hypotensive, initially concerning for septic
shock, covered empirically with antibiotics, but felt to be more
consistent with adrenal insufficiency given all cultures
negative (including CMV VL). Endocrinology consulted at the
time, who recommended stress dose steroids, discharged on
prednisone 10mg daily.
Patient was doing well at home until the day of presentation.
She reports feeling diffusely weak. She fell out of her bed and
was unable to stand ___ weakness. Her husband called EMS and she
was taken initially to ___. BP there 90/60
with T104. She was treated with 1.5L IVF and given IV
vancomycin, meropenem and hydrocortisone. CXR without
infiltrate, UA without pyuria.
In ED initial VS: 98.1 75 91/57 16 97% 3L NC
- Patient noted to be AAOX3, but somnolent particularly during
CVL placement.
- Labs significant for: Hgb 7.7, Plt 71, Cr 1.4, ALT 50, AST 51,
AP 160, TB 2.4, lactate 1.2, pH 7.26, pCO2 36
- Patient was given: received in total 4L IVF (5.5L in total
including OSH), NE at 0.12 gtt, valganciclovir 450mg, prednisone
5mg, metronidazole 500mg IV
- Imaging notable for: CXR s/p R IJ
- Consults: renal transplant, agree with IVF resuscitation, hold
abx for now, continue home cyclosporine, hold AZA, continue
stress dose steroids and continue valgancyclovir maintenance
VS prior to transfer: 74 134/74 18 100% 2L NC
On arrival to the MICU, patient is asking when she can eat and
when she can go home. She denies any preceding infectious
symptoms, only diffuse weakness. She wants to not have to keep
coming back to the ICU. No changes to her medications since
being discharged from the hospital several days ago. She missed
her outpatient appointments and would like her renal doctors to
be aware.
REVIEW OF SYSTEMS: (+) per HPI, all other ROS otherwise negative
Past Medical History:
-End-stage renal disease of unclear etiology. Previously
hemodialysis for ___ years, s/p living related renal transplant
from herbrother in ___
-CMV viremia
-Hypertension
-History of post-posttransplant diabetes mellitus
-History of cholecystectomy
-Gout [no recent flares](onset ___ when Cr was up to 2.0)
Social History:
___
Family History:
gout
Physical Exam:
ADMISSION EXAM
==============
VITALS: Reviewed in metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD, right IJ in place
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Bilateral ___ fingers with swollen PIP joints
SKIN: No rash noted
NEURO: AOx3, moving all extremities, strength ___ in bilateral
lower extremities but symmetric
DISCHARGE EXAM
==============
24 HR Data (last updated ___ @ 858)
Temp: 98.8 (Tm 98.8), BP: 101/73 (95-122/62-79), HR: 78
(77-84), RR: 18, O2 sat: 100% (95-100), O2 delivery: Ra
GENERAL: no apparent distress
HEENT: anicteric sclerae, oropharynx clear
NECK: supple, JVP flat, no cervical LAD, RIJ dressing c/d/i
LUNGS: unlabored, CTAB
CV: RRR, S1/S2, no m/r/g
ABD: soft, non-distended, non-tender
EXT: warm, well perfused, 1+ pitting pretibial edema
NEURO: non-focal
Pertinent Results:
ADMISSION LABS
==============
___ 01:06AM WBC-4.9 RBC-2.32* HGB-7.7* HCT-25.6* MCV-110*
MCH-33.2* MCHC-30.1* RDW-22.0* RDWSD-85.4*
___ 01:06AM NEUTS-76* BANDS-1 LYMPHS-13* MONOS-8 EOS-0
BASOS-0 ___ METAS-1* MYELOS-1* AbsNeut-3.77 AbsLymp-0.64*
AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00*
___ 01:06AM HYPOCHROM-NORMAL ANISOCYT-1+*
POIKILOCY-OCCASIONAL MACROCYT-1+* MICROCYT-NORMAL POLYCHROM-1+*
TEARDROP-OCCASIONAL
___ 01:06AM CORTISOL-104.7*
___ 01:06AM TRIGLYCER-552*
___ 01:06AM HAPTOGLOB-172
___ 01:06AM ALBUMIN-1.9* CALCIUM-7.6* PHOSPHATE-3.2
MAGNESIUM-1.7
___ 01:06AM cTropnT-<0.01
___ 01:06AM LIPASE-52
MICRO
=====
__________________________________________________________
___ 1:41 pm STOOL CONSISTENCY: SOFT
VIRAL CULTURE (Pending):
__________________________________________________________
___ 1:41 pm STOOL CONSISTENCY: SOFT
FECAL CULTURE (Preliminary):
CAMPYLOBACTER CULTURE (Preliminary):
OVA + PARASITES (Final ___:
CANCELLED.
Three separate stool specimens collected EVERY OTHER
DAY are
recommended for optimum sensitivity. Duplicate
specimens collected
on the same day will not be processed, since this does
not
increase diagnostic yield. Make sure to label date and
time of
collection on each stool specimen submitted to ensure
appropriate
processing.
__________________________________________________________
___ 1:41 pm STOOL CONSISTENCY: SOFT
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 1:41 pm STOOL CONSISTENCY: FORMED Source:
Stool.
OVA + PARASITES (Pending):
__________________________________________________________
___ 3:22 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 2:47 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 1:06 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 3:09 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-central.
BLOOD/FUNGAL CULTURE (Pending): No growth to date.
BLOOD/AFB CULTURE (Pending): No growth to date.
__________________________________________________________
___ 3:00 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:50 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES
=======
CT A/P
IMPRESSION:
1. No acute process in the abdomen or pelvis.
2. Diffuse anasarca. The previously described area of induration
in the soft tissues of the right flank is less conspicuous, is
felt to represent sequela of volume overload.
3. Diverticulosis, without evidence of diverticulitis.
CT Chest
IMPRESSION:
1. Patchy areas of ground-glass opacity in bilateral lung
apices, slightly
worse on the right worrisome for a multifocal infectious or
inflammatory
process.
2. Similar appearance of the asymmetrically enlarged left breast
with skin
thickening, previously evaluated by diagnostic mammography.
3. Small nonhemorrhagic pleural effusions bilaterally.
DISCHARGE LABS
==============
___ 04:31AM BLOOD WBC-8.0 RBC-2.25* Hgb-7.5* Hct-24.0*
MCV-107* MCH-33.3* MCHC-31.3* RDW-22.2* RDWSD-80.5* Plt Ct-87*
___ 04:31AM BLOOD Plt Ct-87*
___ 04:31AM BLOOD ___ PTT-25.6 ___
___ 04:31AM BLOOD Glucose-180* UreaN-37* Creat-1.5* Na-134*
K-3.6 Cl-105 HCO3-23 AnGap-6*
___ 02:01AM BLOOD ALT-45* AST-27 LD(LDH)-454* AlkPhos-198*
TotBili-0.9
___ 04:31AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1500 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Ranitidine 150 mg PO DAILY
4. pen needle, diabetic 33 gauge x ___ miscellaneous QID
5. Furosemide 20 mg PO BID
6. PredniSONE 5 mg PO DAILY
7. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
8. ValGANCIclovir 450 mg PO Q24H
9. AzaTHIOprine 50 mg PO DAILY
Discharge Medications:
1. Humalog 7 Units Breakfast
Humalog 9 Units Lunch
Humalog 10 Units Dinner
NPH 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Levofloxacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
3. Sodium Bicarbonate 650 mg PO TID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
4. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. PredniSONE 15 mg PO DAILY
RX *prednisone 10 mg 1.5 tablet(s) by mouth daily Disp #*45
Tablet Refills:*0
6. ValGANCIclovir 450 mg PO EVERY OTHER DAY
7. Calcium Carbonate 1500 mg PO BID
8. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
9. Multivitamins 1 TAB PO DAILY
10. pen needle, diabetic 33 gauge x ___ miscellaneous QID
11. Ranitidine 150 mg PO DAILY
12. HELD- AzaTHIOprine 50 mg PO DAILY This medication was held.
Do not restart AzaTHIOprine until cleared by your kidney
doctors.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypotension
Insulin dependent Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with s/p CVL placement// cvl placement
COMPARISON: Multiple prior chest radiographs the most recent dated ___
FINDINGS:
Portable semi-upright view of the chest provided.
Patient is status post placement of right IJ central venous catheter with the
catheter tip terminating at the cavoatrial junction. Persistent streaky right
basilar opacity is unchanged likely reflecting atelectasis. There is pleural
effusion or pneumothorax. The cardiomediastinal silhouette is unchanged.
IMPRESSION:
Status post placement of right IJ central venous catheter which terminates at
the cavoatrial junction.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old woman with LRRT ___ on immunosuppression,
representing with fever and hypotension. No localizing infectious symptoms.//
Evaluate for any abscess, PNA other infectious sources
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 996 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___
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 homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The bilateral native kidneys are shrunken and atrophic, and contain
multiple calcified foci. A right lower quadrant renal transplant is present,
with an unremarkable, unenhanced appearance. No evidence of hydronephrosis
within the renal transplant.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Diverticulosis of the 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 a
small amount of free fluid.
REPRODUCTIVE ORGANS: There is a fibroid uterus. No adnexal abnormalities are
present.
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: There is diffuse anasarca. The previously described soft tissue
induration in the right flank is less conspicuous.
IMPRESSION:
1. No acute process in the abdomen or pelvis.
2. Diffuse anasarca. The previously described area of induration in the soft
tissues of the right flank is less conspicuous, is felt to represent sequela
of volume overload.
3. Diverticulosis, without evidence of diverticulitis.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ woman status post renal transplant on
immunosuppression fever and hypotension, evaluate for infection.
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous 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) Spiral Acquisition 15.9 s, 61.1 cm; CTDIvol = 16.5 mGy (Body) DLP =
979.9 mGy-cm.
Total DLP (Body) = 996 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: Prior chest CT dated ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal.
Supraclavicular and axillary lymph nodes are not enlarged.
MEDIASTINUM: Mildly enlarged subcarinal lymph node measuring up to 11 mm in
short axis is likely reactive (4:124).
HILA: Hilar lymph nodes are not enlarged.
HEART: The heart is not enlarged and there is no coronary arterial
calcification. There is no pericardial effusion.
VESSELS: A retroesophageal right subclavian artery is noted, a normal
anatomic variant. A right IJ central venous catheter terminates the
cavoatrial junction. Aortic caliber is normal. The main, right, and left
pulmonary arteries are normal caliber.
PULMONARY PARENCHYMA: Patchy areas of ground-glass opacity in bilateral lung
apices, right slightly worse than left, and the right lower lobe is worrisome
for an infectious process. There is no lobar consolidation. There is no
interlobular septal thickening. There is no emphysema.
AIRWAYS: The airways are patent to the subsegmental level bilaterally.
PLEURA: Small nonhemorrhagic pleural effusions are present bilaterally.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion.
Multilevel degenerative changes are mild. Similar to the immediate prior
study there is asymmetric enlargement of the left breast with extensive edema
and skin thickening in
UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen.
Allowing for this, the partially visualized upper abdomen is notable for
cholecystectomy clips..
IMPRESSION:
1. Patchy areas of ground-glass opacity in bilateral lung apices, slightly
worse on the right worrisome for a multifocal infectious or inflammatory
process.
2. Similar appearance of the asymmetrically enlarged left breast with skin
thickening, previously evaluated by diagnostic mammography.
3. Small nonhemorrhagic pleural effusions bilaterally.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Fever, Hypotension
Diagnosed with Sepsis, unspecified organism, Hypotension, unspecified, Other cytomegaloviral diseases, Anemia, unspecified, Nonspec elev of levels of transamns & lactic acid dehydrgnse
temperature: 98.1
heartrate: 75.0
resprate: 16.0
o2sat: 97.0
sbp: 91.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | **LEAVING AMA**
Patient expressed understanding of the risks and consequences of
leaving AMA.
___ female with a history of ESRD s/p remote LRRT c/b
CMV viremia, type II diabetes, and multiple recent
hospitalizations for hypotension re-admitted for fevers and
hypotension presumably secondary to rapid steroid taper and
adrenal crisis in that regard, though suspicious for
undifferentiated systemic illness.
#) Adrenal insufficiency: Initially hypotensive concerning for
septic shock, though rapidly improved with stress-dose steroids
in keeping with secondary adrenal insufficiency in the context
of
chronic exogenous corticosteroids. Definitive prednisone taper
to
be determined with mindfulness of supra-physiologic needs.
Tapered to 15 mg prednisone daily, will need prolonged
outpatient taper and close follow-up.
#) Hospital acquired pneumonia: biapical ground glass opacities
by CT. Initially received empiric vanc/cefepime for said
opacities, which were then transitioned to levofloxacin for 7
day course for treatment of HAP. Smoldering PJP in the context
of elevated LDH and prior positive B-D-glucan is conceivable,
though never hypoxemic. Could alternatively be a manifestation
of pulmonary edema. Evaluated by ___ with plan for bronchoscopy
though patient declined and left AMA. Last day of levofloxacin
___. Repeat B-glucan pending on discharge, please refer to
___ if required.
#) ESRD s/p LRRT: c/b chronic allograft nephropathy secondary to
IFTA of uncertain etiology and CMV viremia, which has since
cleared. Renal function at baseline. Immunosuppression lessened
in the setting of probable pneumonia. Holding home azathioprine.
Continued home cyclosporine, level on d/c: 69. Prednisone as
above. Changed home valganciclovir 450 mg QD to Q48H for
maintenance dosing. CMV-VL negative.
#) Pancytopenia, dual lineage: Presence of macrocytic anemia and
thrombocytopenia since at least ___ concerning for MDS or
plasma cell dyscrasia in the context of abnormal SPEP of
uncertain significance and elevated B2 macroglobulin. No
outpatient hematology oncology follow-up due to frequent
hospitalizations. Evaluated by inpatient heme-onc team with plan
for inpatient bone marrow biopsy though patient decline and left
AMA.
#) Type II diabetes, insulin-dependent: Labile in the
setting of steroids, in the 200s on d/c. Increased home insulin
regimen to NPH 30U QAM and Humalog 7U, 8U, 9U standing with
meals. Arranged ___ f/u on d/c.
#) ___ edema: s/p 40 mg IV lasix while inpatient. Changed home
regimen to 40 mg lasix daily from 20 mg BID, please uptitrate as
tolerated.
TRANSITIONAL ISSUES
===================
- Holding home azathioprine on d/c, restart when able.
- Discharge prednisone dose of 15 mg daily, please taper to
physiologic dose as able.
- Unable to obtain inpatient bronchoscopy and bone marrow biopsy
for further evaluation as patient left AMA. Please arrange to
obtain outpatient.
- Pending rheumatologic w/u and b-glucan on d/c. Please
follow-up.
- Discharge insulin regimen: NPH 30U QAM and Humalog 7U, 8U, 9U
standing with meals
- Changed valganiclovir dose to Q48H for maintenance dosing.
- Please uptitrate lasix as tolerated. Unable to titrate while
inpatient as patient left AMA. Changed dose to 40 mg daily from
20 mg BID.
- Started on Na bicarb while inpatient. Continued on d/c. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex / Latex / Lipitor / Zosyn
Attending: ___.
Chief Complaint:
febrile x 2 days, acute onset of SOB and mental
status changes
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mrs ___ is well known to the cardiac surgery service. She
originally underwent CABG x3 on ___. She was readmitted on
___ for sternal wound dehisence and on ___ underwent
bilaterl pectoral flaps and plating with
Dr. ___. She was discharged to rehab on ___ on a 6 week
course of Vanco and Cipro despite negative OR cultures. Sternal
drains placed by plastics remained in place. She was due to f/u
with Dr. ___ week to have them removed. Over the past
48hrs she spiked fever and zosyn was added. Today she became
acutely SOB and lethargic. She was brought to the ER and was
intubated. Head CT was negative (recent hx of stroke after
CABG),
CTA of chest suggestive OF PE. ALabs, EKG and bedside Echo was
unremarkable. During her ER stay she became mildly hypotensive.
Central line was placed and she was started on levo. She was
admitted cardiac surgery service for further evaluation
Past Medical History:
Coronary Artery Disease
s/p Coronary artery bypass grafting x 3 ___
Hypertension
insulin dependent Diabetes
peripheral vascular disease
Hypercholesterolemia
Right Breast CA in ___ s/p lumpectomy and radiation therapy
with recurrence in ___ s/p right breast mastectomy and
reconstruction
Left great toe to left shin cellulitis s
Depression
Restless leg syndrome
Hypothyroidism
h/o deep vein thrombophlebitis
s/p appendectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
Pulse: 80 SR Resp: 24 O2 sat:100 vented
B/P Right:120/89 Left:
Height: Weight:
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [] hyperactive
bowel sounds + []
Extremities: Warm [x], well-perfused [x] Edema [x] _+1____
Varicosities: None [x]
Neuro: Intubated and sedated
Pulses:
Femoral Right:+2 Left:+2
DP Right:+1 Left:+1
___ Right:+1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right: None Left:None
Pertinent Results:
ECHO: ___ The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is at least 15
mmHg. Mild symmetric left ventricular hypertrophy with normal
cavity size. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is low normal (LVEF 50%) with
abnormal septal motion and septal hypokinesis. The right
ventricular cavity is mildly dilated 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. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal study. Low-normal global left ventricular
systolic function and hypokinesis of the septum. Mildly dilated
right ventricle with mild free wall hypokinesis.
___ 05:45AM BLOOD WBC-11.0 RBC-3.41* Hgb-9.3* Hct-28.8*
MCV-85 MCH-27.2 MCHC-32.1 RDW-15.4 Plt ___
___ 06:01AM BLOOD WBC-10.0 RBC-3.24* Hgb-9.0* Hct-27.8*
MCV-86 MCH-27.7 MCHC-32.2 RDW-15.2 Plt ___
___ 07:20PM BLOOD WBC-13.5* RBC-3.94* Hgb-10.9* Hct-32.9*
MCV-84 MCH-27.6 MCHC-33.0 RDW-15.2 Plt ___
___ 05:45AM BLOOD Glucose-76 UreaN-22* Creat-1.0 Na-145
K-4.2 Cl-111* HCO3-29 AnGap-9
___ 06:01AM BLOOD Glucose-99 UreaN-29* Creat-1.1 Na-146*
K-3.9 Cl-112* HCO3-27 AnGap-11
Medications on Admission:
ciprofloxacin 500 mg q 12hrs, vancomycin 750mg q 24hrs, 81 mg
daily, pravastatin 20 mmg DAILY, pantoprazole 40 mg daily,
ergocalciferol weekly, levothyroxine 50 mcg daily, heparin sc
tid,clopidogrel 75 mg daily, citalopram 20 mg daily, metoprolol
25mg TID, tramadol 50 mg prn,Imdur 60 mg q 24hrs, hydralazine 50
mg q 6hrs, Norvasc 5 mg daily,lomotil prn, lantus 80 units q am
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
12. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for loose stools.
13. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
14. glargine
___very morning at breakfast
15. novolin -R
dose based on sliding scale fingerstick before meals and at
bedtime
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
mental status changes
s/p sternal dehiscence, debridement, sternal plating
Coronary artery disease
s/p coronary artery bypass grafts
hypertension
insulin dependent Diabetes
peripheral vascular disease
hyperlipidemia
Breast CA in ___
s/p lumpectomy (radiation therapy with recurrence in ___ s/p
right breast mastectomy and reconstruction
Left great toe to left shin cellulitis problem
Depression
Hypothyroidism
s/p appendectomy
Obesity
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait and assist of onw
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+ bilateral lower extremities
Followup Instructions:
___
Radiology Report
EXAM: Chest, single AP portable view.
CLINICAL INFORMATION: ___ female with history of shortness of breath
and pneumonia.
___.
FINDINGS: Single AP portable view of the chest was obtained. The patient is
status post median sternotomy hardware/sternal fixation devices are again
seen. There has been interval placement of a left subclavian central venous
catheter, possibly a PICC, terminating in the distal SVC. Cardiac and
mediastinal silhouettes are stable. There is moderate pulmonary vascular
congestion. Minimal blunting of the right costophrenic angle may be due to a
trace effusion. Left base retrocardiac opacity most likely represents
atelectasis, less likely consolidation. Otherwise, no definite focal
consolidation is seen. There is no pneumothorax.
Radiology Report
EXAM: Chest, single supine AP portable view.
CLINICAL INFORMATION: ___ female status post intubation with
increased work of breathing:
___.
FINDINGS: Supine AP portable view of the chest was obtained. There is
interval placement of an endotracheal tube terminating just above the level of
the clavicles. The exact level of the carina is difficult to determine due to
patient's overlying sternotomy hardware. An orogastric tube is seen coursing
below the level of the diaphragm, inferior aspect not included on the images.
Left subclavian central venous catheter terminates at the distal
SVC/cavoatrial junction. Mild pulmonary vascular congestion appears improved.
There is mild bibasilar atelectasis.
Radiology Report
INDICATION: Mental status change.
COMPARISON: CT available from ___.
TECHNIQUE: MDCT-acquired 5-mm axial images of the head were obtained without
the use of IV contrast. Coronal and sagittal reformations were performed at
2-mm slice thickness.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass,
mass effect, or large vascular territorial infarction. The ventricles and
sulci are mildly prominent, reflective of diffuse cortical atrophy. There is
relative hypoattenuation of the periventricular white matter, compatible with
chronic microvascular ischemic disease. Mild mucosal thickening within the
ethmoid and left maxillary sinus is again seen (2:8). The middle ear cavities
and mastoid air cells are clear. Oropharyngeal secretions are seen likely
secondary to intubation.
IMPRESSION: No acute intracranial process.
Radiology Report
INDICATION: Hypoxia.
COMPARISON: CT available from ___.
TECHNIQUE: MDCT-acquired 2.5-mm axial images of the chest were obtained prior
to and following the uneventful administration of 100 cc of Omnipaque
intravenous contrast. Coronal and sagittal reformations were performed at
5-mm slice thickness. Additional right and left oblique reconstructions were
also obtained for further evaluation of the pulmonary vessels.
FINDINGS:
The patient is status post median sternotomy and CABG, with broken sternal
wires and multiple metallic sternal plates denoting sternal dehiscence repair.
Partially calcified 2-cm circumscribed subcutaneous structure anterior to the
sternum (3:28) is unchanged, likely reflecting a focus of fat necrosis. No
adjacent fluid collections are detected.
The heart size is top normal. The great vessels are normal in caliber. No
aortic dissection is detected.
Apparent filling defects are seen at the lateral edge of the right distal main
pulmonary artery (3:25). However, there is marked patient motion throughout
the study, and this may represent a false positive from motion-related
artifact. On the oblique reconstructions, there is an apparent right
posterior segmental filling defect (___), however, this is also
incompletely assessed due to motion. No other filling defects are
appreciated. There are trace bilateral pleural effusions (3:51). There is
mild central venous congestion with minimal interstitial edema.
An endotracheal tube terminates within the distal trachea (2:10). An
orogastric tube terminates within the lumen of the stomach. Included views of
the spleen, adrenal glands, liver, pancreas, stomach, and kidneys are normal.
OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or
lytic lesions are identified.
IMPRESSION:
1. Equivocal linear filling defects within the right lower lobar and
segmental pulmonary arterial branches may represent artifact from severe
patient motion vs pulmonary embolism. Consilder followup examination in 24
hours for further assessment.
2. Trace bilateral pleural effusions.
3. Post-CABG and sternal dehiscence repair surgeries.
Radiology Report
INDICATION: Evaluate for effusions.
COMPARISONS: Chest radiograph ___. CTA chest ___.
FINDINGS: Since the prior radiograph, a right internal jugular central line
has been placed and ends in the upper SVC. There is no pneumothorax. A left
PICC ends in the mid SVC. An endotracheal tube is approximately 5.5 cm from
the carina and unchanged in appearance. A feeding tube is seen within the
stomach. Sternal hardware is intact and unchanged. The cardiomediastinal
silhouette is stable and has a normal postoperative expected appearance.
There is mild pulmonary vascular congestion but no pulmonary edema. Bibasilar
atelectasis is unchanged. There are no definite pleural effusions. There is
no new consolidation.
IMPRESSION:
1. New right internal jugular central line ends in the upper SVC. No
pneumothorax.
2. Stable bibasilar atelectasis.
Radiology Report
INDICATION: ___ female with sepsis and acidosis, status post CABG and
sternal wound re-plating, here to assess for ___ source of
infection.
COMPARISON: No prior studies available.
TECHNIQUE: CTA of the abdomen and pelvis was performed prior to and after the
uneventful administration of 100 cc of Visipaque intravenous contrast.
Coronally and sagittally reformatted images were generated and reviewed.
FINDINGS:
CTA OF THE ABDOMEN: Limited supradiaphragmatic evaluation shows the patient
is status post median sternotomy and CABG, now with metallic sternal plate
denoting sternal dehiscence repair. No adjacent fluid collections are
detected anterior to the pericardium. Two mediastinal drains are in place.
Limited evaluation of the heart shows top normal size but no pericardial
effusion. Trace bilateral pleural effusions with associated compressive
atelectasis are present in the lung bases. No pulmonary nodule, opacity, or
focal consolidation is seen.
The liver enhances homogeneously without focal liver lesions. The hepatic
arterial anatomy is conventional. No intra- or extra-hepatic biliary dilation
is seen. The gallbladder, spleen, pancreas, and bilateral adrenal glands are
unremarkable. Both kidneys demonstrate striated nephrograms which is more
pronounced on the right than the left, but excrete contrast normally. No
perinephric stranding is appreciated. No intrarenal stones, hydronephrosis,
or solid renal masses are appreciated. A small exophytic hypodensity in the
right kidney measures 1 cm and cannot be accurately characterized by CT, but
likely represents a renal cyst.
A nasogastric tube is seen terminating in the stomach. The ___
loops of small and large bowel are unremarkable without evidence of wall
thickening or obstruction. No free air or ascites is present. No
pathologically enlarged lymph nodes are identified in the retroperitoneal or
mesenteric regions. There is calcified atherosclerosis of the infrarenal
abdominal aorta extending into the iliac arteries bilaterally.
CTA OF THE PELVIS: The rectum, sigmoid colon, uterus, and bilateral adnexa
are unremarkable. The urinary bladder is almost completely decompressed by a
Foley catheter in appropriate position. There is no free pelvic fluid or
inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
1. Evidence of bilateral pyelonephritis more pronounced on the right than the
left without associated nephrolithiasis or hydronephrosis.
2. No other findings to suggest ___ infection.
Radiology Report
PA AND LATERAL CHEST
COMPARISON: ___, chest radiograph.
FINDINGS: Left PICC and endotracheal tube have been removed as well as
midline drains and nasogastric tube. Right internal jugular vascular catheter
remains in standard position. Cardiomediastinal contours are stable in the
postoperative period in this patient, status post prior cardiovascular surgery
and sternal closure procedure. No confluent areas of consolidation are
present in either lung. Scattered areas of linear atelectasis are present
bilaterally, and note is also made of small pleural effusions bilaterally.
IMPRESSION: Small bilateral pleural effusions. No evidence of pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with RESPIRATORY ABNORM NEC, FEVER, UNSPECIFIED, HYPOTENSION NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Mrs ___ arrived in the ER from rehab after becoming acutely
short of breath, lethargic and developing a rash after receiving
a one time dose of zosyn for fever. She was also mildly
hypotensive and neo was started. She was intubated and sent for
a CTA and head CT to r/o PE. Both were negative for acute
processes. ECHO was unremarkable.
She was admitted to the CVICU, weaned from the vent and
extubated on HD#2. She was pan cultured and continued on Vanco,
Zosyn, and Cipro. ID was consulted and recommended all
antibiotics be discontinued since previous OR cultures were
negative and event was thought to be related to a Zosyn
reaction. She was seen by Plastic Surgery - Dr. ___- and one
of two JP drains was removed. The remaining JP will be removed
at subsequent follow up visit to Dr. ___.
On HD #3 she was transferred to the stepdown unit. Her foley was
removed but was re-inserted after failing to void. She continued
to progress, remained afebrile with normal WBC. She did have
large volumes of loose stool which was negative for c-diff and
O+P. It was noted that due to her very poor appetite she was
only consuming Glucerna whicih caused diarrhea. She was started
on banana flakes with significant improvement. She was noted to
have a Stage II pressure ulcer on coccyx and was seen by the
wound care specialist and regimen of Criticaide and DXeroform
gauze was recommended.
She was discharged on ___ to ___ Rehab with appropriate
follow up appointments. |
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:
None
History of Present Illness:
Mr. ___ is an ___ year old man with dementia, TIA, pulmonary
fibrosis, ataxia with prior falls (most recently ___
who presented from his assisted living facility after a fall. He
is very demented at baseline and does not recall any of the
circumstances surrounding the fall. The staff at the nursing
home noted scrapes on his knees and they were concerned that his
mental status was "not normal." In speaking with his health care
proxy, he was not as interactive as he usually is and it was
difficult to get him to respond to any questions, so he was sent
into the the hospital. No other trauma was noted aside from the
scraped knees.
In the ED, initial vitals were 97.8 95 151/120 18 98%. Exam was
notable for his baseline dementia, with knee abrasions
bilaterally. His labs were notable for creatinine of 1.2 (from
baseline of 1.0) and BUN of 28. His WBC count was 11.5 with 92%
PMNs (prior hospitalization 10.4 - 11.5). He had a CT head and
C-spine which were unremarkable, CXR without pneumonia, and
hip and pelvis x-rays which were unremarkable as well. He was
noted to be in atrial fibrillation with RVR with rates in the
130s for approximately one hour. This resolved with 2L NS
without the need for rate control medications. He also received
500 mg acetaminophen before being admitted to medicine for
monitoring for a complaint of back pain.
On arrival to the floor, vital signs were 98.1 119/73 82 18
95%RA. He has no specific complaints and clearly reports that he
is not in any pain. In speaking with his neice who is his health
care proxy, the circumstances surrounding the fall are unclear.
She was worried in the Emergency Department because the patient
was not speaking as much as he normally does. She also noted
that they recently discontinued many of his medications in an
effort to simplify his medication regimen.
On review of systems, denies fever, chills, headache, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria. All other 10-system review negative in
detail.
Past Medical History:
- Dementia
- Prior TIAs
- Hyperlipidemia
- Paroxysmal atrial fibrillation (CHADS2 of 4, not
anticoagulated due subarachnoid hemorrhage and frequent falls)
- Pulmonary fibrosis ___ syndrome)
- Ataxia
- Positive for hepatitis A and hepatitis B
- BPH s/p laser surgery
- Glaucoma
- Chronic constipation
- Depression
Social History:
___
Family History:
Father- myocardial infarction
Mother- dementia
Brother- healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.1 119/73 82 18 95%RA
GEN - altert, oriented x1, follows commands
HEENT - NC/AT, dry MMM, EOMI, right pupil 3mm with surgical
scar, left 2mm, both reactive, sclera anicteric, OC/OP clear.
NECK - thin, no JVD, no LAD
PULM - adequate air entry/chest expansion, fine rales at right
base
CV - Irregularly irregular, normal rate, S1/S2, no m/r/g
ABD - soft, NT/ND, normoactive bowel sounds, no guarding or
rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO - CN II-XII intact, slight left sided facial droop most
prominent at the corner of his mouth, motor function grossly
normal, no pronator drift
SKIN - abrasions on his knees bilaterally
DISCHARGE PHYSICAL EXAM:
VS - 97.___/98.1 134/68 60-112 18 95%RA
GEN - altert, oriented to self, follows commands
HEENT - NC/AT, dry MMM, EOMI, right pupil 3mm with surgical
scar, left 2mm, both reactive, sclera anicteric, OC/OP clear.
NECK - thin, no JVD, no LAD
PULM - adequate air entry/chest expansion, no wheezes, rales,
rhonchi
CV - Regular rate and rhythm, normal S1/S2, no m/r/g
ABD - soft, NT/ND, normoactive bowel sounds, no guarding or
rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO - CN II-XII intact, slight left sided facial droop most
prominent at the corner of his mouth with ? right sided ptosis,
motor function grossly normal, no pronator drift
SKIN - abrasions on his knees bilaterally
Pertinent Results:
On admission:
___ 09:55AM BLOOD WBC-11.5* RBC-4.21* Hgb-13.1* Hct-40.7
MCV-97 MCH-31.2 MCHC-32.2 RDW-12.7 Plt ___
___ 09:55AM BLOOD Neuts-92.9* Lymphs-2.2* Monos-3.8 Eos-0.6
Baso-0.5
___ 09:55AM BLOOD Glucose-96 UreaN-28* Creat-1.2 Na-137
K-4.2 Cl-100 HCO3-25 AnGap-16
___ 02:57PM BLOOD Lactate-1.5
On discharge:
___ 06:50AM BLOOD WBC-8.9 RBC-3.68* Hgb-11.4* Hct-35.9*
MCV-98 MCH-30.9 MCHC-31.6 RDW-12.8 Plt ___
___ 06:50AM BLOOD Glucose-69* UreaN-26* Creat-1.1 Na-138
K-3.7 Cl-103 HCO3-25 AnGap-14
Micro:
___ Urine culture: pending
___ Blood culture: pending
Studies:
___ CT head:
There is no evidence of acute hemorrhage, edema, mass effect, or
infarction. The previously seen foci of subarachnoid hemorrhage
and intraparenchymal hemorrhage have resolved. The ventricles
and sulci are widened which suggests age-related involutional
changes. Periventricular white matter hypodensities are
consistent with chronic small vessel ischemic disease. No
fracture is seen. Again seen is a diastasis of a suture in the
right occipital region. There is partial opacification of the
right mastoid air cells, as well as secretions in the right
ethmoid air cells.
IMPRESSION: No evidence of acute intracranial process.
___ CT C-spine:
1. No fracture or traumatic malalignment of the cervical spine.
Stable multilevel degenerative changes present.
2. Chronic fibrotic biapical opacities with small nodular
opacities and bronchial wall thickening, bronchiectasis. This is
concerning for small airways infection versus inflammation
superimposed on a background of chronic interstitial lung
disease. Chest x-ray is recommended for further evaluation.
___ CXR:
Similar appearance of the chest with chronic fibrotic
interstitial changes most pronounced in the lung apices. These
findings could reflect sarcoidosis, but considerations for
___ pneumocosis or silicosis should be considered with
the appropriate clinical history.
___ Hip and pelvis x-ray:
No acute fracture or dislocation is seen. Mild degenerative
changes of both hips are noted with joint space narrowing. There
is no diastasis of the pubic symphysis or sacroiliac joints. No
suspicious lytic or sclerotic osseous abnormalities are
detected.
IMPRESSION: No acute fracture or dislocation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO BID
2. Memantine 10 mg PO BID
3. Polyethylene Glycol 17 g PO DAILY
4. timolol maleate *NF* 0.25 % ___ BID
5. travoprost *NF* 0.004 % ___ BID
6. Senna 1 TAB PO BID
7. Docusate Sodium 100 mg PO BID
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Memantine 10 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 1 TAB PO BID
7. timolol maleate *NF* 0.25 % ___ BID
8. travoprost *NF* 0.004 % ___ BID
9. Metoprolol Succinate XL 25 mg PO DAILY
Hold for systolic BP less than 100 or heart rate less than 55
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Syncope with fall
- Advanced dementia
- Paroxysmal atrial fibrillation
Secondary diagnoses:
- Prior TIAs
- Hyperlipidemia
- Pulmonary fibrosis ___ syndrome)
- Ataxia
- Glaucoma
- Chronic constipation
- Depression
Discharge Condition:
Mental Status: Confused - always. Alert and oriented to self
only.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Unwitnessed fall.
TECHNIQUE: Upright AP view of the chest.
COMPARISON: ___.
FINDINGS:
Cardiac and mediastinal contours are unchanged with the heart size within
normal limits. The aortic knob is calcified. Again demonstrated are upper
lobe predominant parenchymal opacities with architectural distortion,
bronchiectasis and slight superior hilar retraction. Additionally, patchy
opacities are also noted within the right lung base. No new focal
consolidation is seen. There is no pleural effusion or pneumothorax. No
acute osseous abnormalities are demonstrated.
IMPRESSION:
Similar appearance of the chest with chronic fibrotic interstitial changes
most pronounced in the lung apices. These findings could reflect sarcoidosis,
but considerations for coalworkers pneumocosis or silicosis should be
considered with the appropriate clinical history.
Radiology Report
HISTORY: Right hip pain after fall.
TECHNIQUE: AP view of the pelvis, 2 views of the right hip.
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen. Mild degenerative changes of both
hips are noted with joint space narrowing. There is no diastasis of the pubic
symphysis or sacroiliac joints. No suspicious lytic or sclerotic osseous
abnormalities are detected.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
HISTORY: Unwitnessed fall, altered mental status.
TECHNIQUE: Contiguous axial CT images were obtained through the brain without
the administration of IV contrast. Coronal and sagittal reformats were also
obtained.
DLP: 1025.72 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass effect, or infarction.
The previously seen foci of subarachnoid hemorrhage and intraparenchymal
hemorrhage have resolved. The ventricles and sulci are widened which suggests
age-related involutional changes. Periventricular white matter hypodensities
are consistent with chronic small vessel ischemic disease.
No fracture is seen. Again seen is a diastasis of a suture in the right
occipital region. There is partial opacification of the right mastoid air
cells, as well as secretions in the right ethmoid air cells.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
HISTORY: Fall, altered mental status.
TECHNIQUE: Contiguous axial MDCT images were taken from the skull base
through the T2 level. Coronal and sagittal reformats were also examined.
DLP: 787.37 mGy-cm.
COMPARISON: CT cervical spine ___.
FINDINGS:
There is no fracture, traumatic malalignment, or prevertebral soft tissue
swelling. Again seen is a stable grade 1 anterolisthesis of C7 on T1, likely
degenerative. There are stable multilevel degenerative changes with posterior
disc osteophyte complexes in mild contact with the ventral thecal sac, worse
at C2-3.
Fibrotic changes are again seen at the right lung apex. Small ___
nodular opacities at both lung apices, right greater than left, with increased
bronchiectasis and bronchial wall thickening is noted.
IMPRESSION:
1. No fracture or traumatic malalignment of the cervical spine. Stable
multilevel degenerative changes present.
2. Chronic fibrotic biapical opacities with small nodular opacities and
bronchial wall thickening, bronchiectasis. This is concerning for small
airways infection versus inflammation superimposed on a background of chronic
interstitial lung disease. Chest x-ray is recommended for further evaluation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: S/P FALL, ALT MS
Diagnosed with ATRIAL FIBRILLATION, ABRASION HIP & LEG, UNSPECIFIED FALL, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
temperature: 97.8
heartrate: 95.0
resprate: 18.0
o2sat: 98.0
sbp: 151.0
dbp: 120.0
level of pain: it hurts
level of acuity: 2.0 | ___ year old man with advanced dementia, prior TIAs, pulmonary
fibrosis, hyperlipidemia, and BPH who presented ___nd was found to have paroxysmal atrial fibrillation with
RVR in the ED.
# s/p fall: Patient has a history of falls, most recently he was
admitted ___ - ___ for a fall resulting in small
subarachnoid hemorrhages and an ear laceration repaired by
plastics. Given lack of witnesses or history surrounding his
current fall, it is difficult to elucidate the underlying
etiology. Regarding the trauma, his imaging was all unremarkable
(CT head, C-spine, pelvis/hip x-rays). He was noted to be in
afib with RVR in the ED. Volume depletion could have caused him
to be orthostatic or may have prompted his RVR, which may have
contributed to his fall. Stroke or TIA is possible, but he is
demented at his baseline and does not have any new focal
deficits (slight facial droop and left eye ptosis noted on prior
discharge). His orthostatic BPs were positive with SBP dropping
from 150s supine to 120s standing. He was monitored on
telemetry which revealed paroxysmal atrial fibrillation in
addition to his baseline rhythm with what appears to be a first
degree heart block. His mental status returned to baseline prior
to arrival to the floor and he remained alert and oriented to
self only and is interactive and follows commands. He was
maintained on strict fall precautions with low bed height and
bed alarm.
# Atrial fibrillation with RVR: He was noted to be Afib with RVR
to the 130s in the ED which resolved with 2L of IVF. The patient
was likely volume depleted on presentation, which is supported
but slight increase in Cr from 1.0 to 1.2. Patient has CHADS2
score is 4 (hypertension, age, hx of TIA) but is not
anticoagulated given recent subarrachnoid hemorrhages, history
of falls, and dementia patient does not seem to be a good
candidate for anticoaguation at this time. In discussion with
HCP, they are not interested in pursuing anticoagulation. He was
started on low dose metoprolol as this could potentially
decrease his frequency of falls if his atrial fibrillation is
contributing. His underlying rate appears to be a first degree
heart block with intermittently dropped beats. He was continued
on aspirin 81 mg and discharged on new metoprolol succinate 25
mg daily.
# Leukocytosis: WBC count of 11.5 on admission which is stable
from prior admission. He has a left shift with 92% PMNs, but he
remains afebrile without localizing signs or symptoms of
infection. CT chest showed increased tree and ___ opacities and
bronchial wall thickening with bronchiectasis concerning for
small airway infection vs inflammation, however CXR unchanged
and patient without respiratory symptoms. Urine and blood
cultures were pending at the time of discharge without growth to
date. His WBC count fell to 8.9 with fluids indicating that
hemoconcentration was possibly playing a role.
# Hematuria: Patient incontinent of pink tinged urine while on
the floor. This is likely related to foley trauma in the ED.
This should continue to be monitored while he is back at his
assisted living facility and urology follow up can be considered
if this continues and it is within the patient's goals of care.
# Pulmonary fibrosis ___ syndrome): Noted on admission
CXR as stable from prior.
# Hypertension: Recently discontinued lisinopril in an effort to
simplify medications.
# Dementia/ataxia: Alzheimers vs vascular. recent TSH, RPR, B12
returned within normal limits. He was continued on Namenda 10 mg
BID.
# Glaucoma: Continued on timolol and travaprost eye drops BID.
# Chronic constipation: He was continued on colace, senna, and
miralax as needed.
# Depression: Patient's mood was stable. His venlafaxine was
recently discontinued in an effort to simplify his medication
regimen.
# Hyperlipidemia: Recently discontinued simvastatin in an effort
to simplify medication regimen.
# BPH: s/p laser surgery. previously on vesicare however this
worsened his mental status. Not currently on medications.
# Transitional issues:
- Code status: DNR/DNI (confirmed with HCP ___
- Emergency contact: ___ (neice) who is HCP, ___
- Blood and urine cultures pending at the time of discharge.
- Patient was started on metoprolol 25 mg PO daily given
paroxysmal afib.
- Patient was not anticoagulated despite CHADS2 of 4 given
recent subarachnoid hemorrhages and frequent falls.
- Patient's HCP interested in continued discussions regarding
goals of care, specifically having a higher threshold to
hospitalize the patient and possibly considering comfort focused
care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
regurgitation, SOB
Major Surgical or Invasive Procedure:
conservative management
History of Present Illness:
___ with a history of esophageal adenocarcinoma s/p neoadjuvant
treatment and then minimally invasive esophagectomy on
___, who presents with 3 weeks of regurgitation of solids
and SOB. For the past 3 weeks, she has been unable to keep down
any solid food; she can swallow, but a few minutes later feels
as though the food is stuck, feels nauseated, she begins
coughing, and will cough the food back up. No trouble with
liquids. She has also felt SOB intermittently, usually when
walking or working, but also occasionally at rest. The patient
was seen by her PCP ___ 3 weeks ago when this started, and has
since taken courses of azithromycin and levofloxacin, with
subjective improvement in SOB when on antibiotics; SOB returned
after completing the
anitbiotics. No chest pain. No fevers, but occasional chills.
Some diarrhea about a week ago.
Her postoperative course in last ___ was complicated by
development of gastric outlet obstruction and recurrent
aspiration pneumonia, treated with balloon dilation and botox
injection at the pylorus in ___. In ___, she noted nausea
and abdominal pain with eating; this was evaluated with a barium
swallow which did not demonstrate obstruction. She has been
relatively well since then.
Past Medical History:
PMH:
esophageal adenocarcinoma s/p MIE ___, asthma
Social History:
___
Family History:
Mother - rectal cancer
Father - oral cancer
Physical Exam:
GEN: NAD, A&Ox3
CV: RRR, no MRG, nl s1/s2
PULM: CTAB, tachypneic
ABD: s/nt/nd; well-healed scars
EXT: WWP
Pertinent Results:
___ 09:55PM BLOOD WBC-7.6 RBC-3.52* Hgb-11.2* Hct-32.7*
MCV-93 MCH-31.9 MCHC-34.4 RDW-13.0 Plt ___
___ 09:55PM BLOOD Glucose-108* UreaN-14 Creat-0.6 Na-140
K-4.1 Cl-103 HCO3-27 AnGap-14
___ 09:55PM BLOOD Calcium-9.6 Phos-4.9*# Mg-1.8
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
10:17 ___
1. No evidence of pulmonary embolism.
2. Status post partial esophagectomy with gastric pull-through.
The
remaining esophagus is distended and contains ingested material.
3. Bronchial wall thickening at right base could represent
bronchitis,
possible from chronic aspiration given patient history.
UGI SGL CONTRAST W/ KUB Study Date of ___ 9:34 AM
IMPRESSION: Status post esophagectomy with gastric pull-through
with no
evidence of obstruction.
Medications on Admission:
protonix 20', ativan 0.5" prn
Discharge Medications:
1. Protonix 40 mg Susp,Delayed Release for Recon Sig: One (1) 40
mg PO once a day.
Disp:*45 dose* Refills:*2*
2. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
-Esophageal adenocarcinoma s/p MIE ___
-Dysphagia
-Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female status post esophagectomy (___), now
presenting with regurgitation. Evaluate for gastric outlet obstruction.
EXAMINATION: Fluoroscopic upper GI series.
COMPARISONS: ___ and CTs from ___.
PROCEDURE AND FINDINGS: The patient was brought to the fluoroscopic suite and
placed upright on an imaging platform. The patient under fluoroscopic
surveillance self-administered thin barium. Contrast was administered orally.
Initial scout radiographs demonstrate the patient to be status post
esophagectomy with gastric pull-through with relatively high anastomosis. The
lungs are clear. There is no pleural effusion or pneumothorax. The
cardiomediastinal and hilar contours are otherwise unremarkable. Pulmonary
vascularity is not increased. Contrast flows freely through both the
anastomosis and also the distal stomach through the pylorus. There is no
evidence of outlet obstruction.
IMPRESSION: Status post esophagectomy with gastric pull-through with no
evidence of obstruction.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SOB
Diagnosed with RESPIRATORY ABNORM NEC, VOMITING, MAL NEO ESOPHAGUS NOS
temperature: 99.8
heartrate: 109.0
resprate: 24.0
o2sat: 100.0
sbp: 139.0
dbp: 76.0
level of pain: 4
level of acuity: 2.0 | The patient was admitted to the thoracic surgery service for
evaluation of her regurgitation and shortness of breath, after
having been ruled out for PE and PNA in the emergency
department. She was kept NPO overnight with IV fluids. She had a
swallow study the next morning, which demonstrated contrast
flowing freely through both the anastomosis and also the distal
stomach through the pylorus, with no evidence of obstruction. By
morning, her symptoms had also resolved; she was breathing
comfortably and was tolerating solids and liquids by mouth. She
never showed signs of infection, and she was hemodynamically
stable. She was then discharged home in stable condition, to
continue her protonix and anxiolytic medication, and to follow
up with Dr ___ in clinic in 1 month. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with H/O breast cancer S/P breast
reconstructive surgery, insomnia, depression, and recent
hospital admission (___) for hyponatremia thought due
to Effexor presenting with chest pain. Patient noticed onset of
sudden, sharp left sided chest pain that radiated to the back
and left arm the night prior to admission. She had just finished
walking home from the ___ in her ___ building and
had sat down in her residence when she noticed onset of sharp
left sided chest pain. The pain occurred at rest and was not
associated with exertion. She denied any nausea, vomiting,
diaphoresis, palpitations, shortness of breath or
lightheadedness. She took a baby aspirin but the pain persisted
so she presented to the ___ emergency department.
At the ___, exam was notable for left chostochondral
junction tenderness. CTA was done which was originally read as
no pulmonary embolus and no dissection. She was placed in
observation status for 2 sets of cardiac biomarkers and was
going to be discharged, but radiology reread the CTA as possible
small focal type B dissection. She was transferred to ___ ___
for further monitoring and workup. At ___, she received ASA
324 mg, morphine, and Zofran 5 mg.
In the ___ ___, initial vitals were T 98.6 HR 96 BP 123/64 RR
18 SaO2 98% on RA. Labs were notable for a normal troponin, CK
and CK-MB. EKG showed sinus rhythmn with left axis deviation and
left ventricular hypertrophy. Vascular surgery was consulted
regarding the possible aortic dissection. After their review of
the images, they felt a dissection was not present and
recommended admission to medicine to complete the biomarker
series to exclude myocardial infarction, BP control, and repeat
aortic imaging. Patient was given morphine 2 mg and Dilaudid 1
mg IV for pain control and admitted to cardiology.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
On arrival to the floor, patient stated that she feels well and
that her pain is well controlled. On further questioning,
patient reports that she exercises regularly and is active in
water aerobics. She never has this kind of pain while doing
aerobics and says she can walk 'quite a distance' without
getting short of breath, has not been limited in her activities
by shortness of breath.
Past Medical History:
1. CAD RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
PMH
1. Hot flashes.
2. Insomnia.
3. breast cancer in ___, now on hormonal therapy, S/P left
mastectomy with reconstruction from abdominal flap (multiple
node-positive breast cancer, ER positive, HER-2/neu negative;
T2, N1 lesion with ___ positive nodes with extranodal
extension; treated with left modified radical mastectomy,
reconstruction, Cytoxan and Adriamycin, followed by Taxol as
adjuvant chemotherapy followed by ___ years of tamoxifen and ___
years of letrozole)
4. Osteopenia.
5. Hyponatremia
PAST SURGICAL HISTORY: Significant for bilateral cataracts and
mastectomy on the left with surgical reconstruction using a
right rectus flap.
Social History:
___
Family History:
Her father died at age ___ he had diabetes ___
esophagus, and esophageal cancer. Her mother died at age ___ she
had a central tremor and anxiety. She has two sisters who are
healthy.
Physical Exam:
ADMISSION EXAM
GENERAL: awake, alert, pleasant elderly Caucasian woman in NAD
VS: Tc 98.5 BP 110/52 HR 91 RR 16 SaO2 95% on RA.
left arm BP: 115/65 right arm BP: 124/72
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Oral mucosa moist,
no lesions
NECK: Supple, no appreciable JVP
CARDIAC: RRR, S1, S2; no murmurs, rubs or gallops appreciated
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
CHEST: has pain to palpation over ___ left costochondral
junction
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
Abd aorta not enlarged by palpation. No abdominal bruits.
EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: distal radial and dorsalis pedis pulses 2+ and equal
bilaterally
NEURO: CN II-XII intact, no asymmetry, UE and ___ strength ___
with no focal defecits, sensory grossly intact
DISCHARGE EXAM
GENERAL: awake, alert, pleasant woman in NAD
VS: Tc 97.8 Tm 98.8 BP 122/58 (110-126/52-62) HR 75 (75-91) RR
18 SaO2 97% on RA
NECK: Supple, no appreciable JVP
CARDIAC: RRR, S1, S2; no murmurs, rubs or gallops appreciated
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
CHEST: has pain to palpation over ___ left costochondral
junction, chronic changes of left breast reconstruction without
erythema or swelling
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
Abd aorta not enlarged by palpation. No abdominal bruits.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: distal radial and dorsalis pedis pulses 2+ and equal
bilaterally
NEURO: CN II-XII intact, no asymmetry, UE and ___ strength ___
with no focal defecits, sensory grossly intact
Pertinent Results:
ADMISSION LABS
___ 11:25AM WBC-7.1 RBC-4.48 HGB-13.8 HCT-40.7 MCV-91
MCH-30.8 MCHC-33.9 RDW-12.6
___ 11:25AM NEUTS-72.6* ___ MONOS-8.4 EOS-0.4
BASOS-0.1
___ 11:25AM ___ PTT-28.1 ___
___ 11:25AM GLUCOSE-129* UREA N-20 CREAT-0.7 SODIUM-137
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12
___ 11:25AM CK(CPK)-62
___ 11:25AM CK-MB-3 cTropnT-<0.01
DISCHARGE LABS
___ 07:45AM BLOOD WBC-5.4 RBC-4.22 Hgb-12.6 Hct-38.1 MCV-90
MCH-29.9 MCHC-33.1 RDW-12.2 Plt ___
___ 07:45AM BLOOD Glucose-93 UreaN-16 Creat-0.7 Na-142
K-4.3 Cl-105 HCO3-30 AnGap-11
ECG ___ 11:17:04 AM
Sinus rhythm. Left ventricular hypertrophy. No significant
change compared with previous tracing of ___.
___ - CT/CT TORSO WITH CONTRAST ___ - PRELIM
1. NO EVIDENCE OF PULMONARY EMBOLISM. QUESTIONABLE FOCAL
LINEAR AREA IN THE AORTIC ARCH THAT MIGHT POTENTIALLY REFLECT
SMALL FOCAL DISSECTION. ATTENTION TO THIS AREA IN THE SUBSEQUENT
STUDIES SHOULD BE OBTAINED IN 24 HOURS IS RECOMMENDED.
2. STATUS POST LEFT BREAST SURGERY AND RADIATION WITH
UNCHANGED APPEARANCE OF THE CALCIFIED NODULE IN THE LEFT LATERAL
BREAST.
3. FOCAL HYPODENSITY IN THE UNCINATE PROCESS OF THE
PANCREAS THAT SHOULD BE FURTHER ASSESSED WITH ___. THESE
FINDINGS WERE ALSO DISCUSSED WITH THE RESIDENT TAKING CARE OF
THE PATIENT, ___. ___.
4. LIVER HYPODENSITY AND LEFT KIDNEY HYPODENSITY, TOO SMALL
TO CHARACTERIZED MAY BE ASSESSED ON ULTRASOUND.
5. SMALL UMBILICAL HERNIA. ATROPHY OF THE RIGHT RECTUS
ABDOMINUS MUSCLE, UNCLEAR IF PRIOR SURGERY OR CONGENITAL. LARGE
LEFT ILIOPSOAS LIPOMA
6. CALCIFIED FIBROID.
___ - CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of
___ 11:26 AM
No lower cervical adenopathy. 3 vessel aortic arch. The great
vessels are patent without evidence of dissection. Scattered sub
cm prevascular, peritracheal and subcarinal lymph nodes lymph
nodes are noted as well as sub cm bilateral hilar nodes which do
not meet CT criteria for adenopathy.
The ascending aorta, arch and descending aorta are normal in
caliber. There are minimal atherosclerotic vascular
calcifications. There is no evidence of aortic these dissection
to the level of the diaphragmatic crus.
Limited evaluation of the upper abdomen demonstrates a sub cm
cystic lesion in the hepatic dome which is too small to
characterize but likely represents a simple cyst. There is a
small hiatal hernia. There is diffuse thickening of the left
adrenal gland without discrete nodule or mass. Incidental note
of anomalous origin of the left portal vein from the anterior
right portal vein. The remainder is unremarkable.
Lungs demonstrate normal background parenchymal pattern without
mildly volume loss on the left as well as an area of
ground-glass opacity of the left upper lung and scarring in the
lingula which likely represents radiation changes related to
breast cancer treatment. Bilateral mild dependent atelectasis is
present. The central airways are patent. The central pulmonary
arteries are also patent without evidence of filling defects.
Patient is status post left mastectomy. There is a calcified
partially calcified collection in the left axilla which likely
represents a postoperative seroma. The no suspicious or acute
osseous abnormalities are seen.
IMPRESSION:
1. No evidence of aortic dissection.
2. Postsurgical changes in the left breast and likely
postradiation changes involving the lingula and left upper lobe
lung apex.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Aspirin 81 mg PO DAILY
3. Vitamin D 800 UNIT PO DAILY
4. letrozole *NF* 2.5 mg Oral daily
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Vitamin D 800 UNIT PO DAILY
3. Aspirin 81 mg PO DAILY
4. letrozole *NF* 2.5 mg Oral daily
5. Acetaminophen 1000 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: costochondritis
Secondary:
-aortic atherosclerosis
-insomnia
-depression
-breast cancer
-radiographic pancreatic lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: History of breast cancer presenting with the tip chest pain.
Transferred to both ___ when the CT chest angiogram suggested a possible
small dissection of the descending aorta.
TECHNIQUE: Helical CT acquisition through the chest following uneventful
administration of 100 cc Omnipaque IV contrast. Coronal and sagittal
reformats provided by technologist. 3 d curved planar reformats were
performed on an independent 3D workstation.
DLP: 381 mGy-cm.
COMPARISON: CT torso ___.
FINDINGS:
No lower cervical adenopathy. 3 vessel aortic arch. The great vessels are
patent without evidence of dissection. Scattered sub cm prevascular,
peritracheal and subcarinal lymph nodes lymph nodes are noted as well as sub
cm bilateral hilar nodes which do not meet CT criteria for adenopathy.
The ascending aorta, arch and descending aorta are normal in caliber. There
are minimal atherosclerotic vascular calcifications. There is no evidence of
aortic these dissection to the level of the diaphragmatic crus.
Limited evaluation of the upper abdomen demonstrates a sub cm cystic lesion in
the hepatic dome which is too small to characterize but likely represents a
simple cyst. There is a small hiatal hernia. There is diffuse thickening of
the left adrenal gland without discrete nodule or mass. Incidental note of
anomalous origin of the left portal vein from the anterior right portal vein.
The remainder is unremarkable.
Lungs demonstrate normal background parenchymal pattern without mildly volume
loss on the left as well as an area of ground-glass opacity of the left upper
lung and scarring in the lingula which likely represents radiation changes
related to breast cancer treatment. Bilateral mild dependent atelectasis is
present. The central airways are patent. The central pulmonary arteries are
also patent without evidence of filling defects.
Patient is status post left mastectomy. There is a calcified partially
calcified collection in the left axilla which likely represents a
postoperative seroma. The no suspicious or acute osseous abnormalities are
seen.
IMPRESSION:
1. No evidence of aortic dissection.
2. Postsurgical changes in the left breast and likely postradiation changes
involving the lingula and left upper lobe lung apex.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with CHEST PAIN NOS, HX OF BREAST MALIGNANCY
temperature: 98.6
heartrate: 96.0
resprate: 18.0
o2sat: 98.0
sbp: 123.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | ___ year old woman with H/O breast cancer S/P chemotherapy,
radiation therapy and left breast reconstruction using a right
rectus flap, insomnia, depression, and recent hospital admission
(___) for hyponatremia thought due to Effexor
presenting with chest pain. While awaiting a biomarker series to
exclude acute coronary syndrome, she was transferred to ___
when the ___ CTA was interpreted as possibly suggestive
of a small aortic dissection.
# ? Aortic dissection: CTA at ___ was interpreted
formally as "The assessment of the aorta demonstrates focal
minimal area of calcification in the distal portion of the
aortic arch with associated linear low density opacity most
likely representing part of the plaque but focal minimal area of
dissection cannot be excluded." Patient had limited risk factors
for dissection (no HTN, no reported atherosclerosis), pulses and
BPs were noted to be equal in both arms. She was admitted to the
cardiology floor where blood pressures were monitored and
remained in the 110s-120s systolic. Repeat CTA was done on ___
which showed no evidence of aortic dissection. The imaging
finding on the other CTA was presumably an atherosclerotic
plaque, perhaps slightly ulcerated.
# Chest pain: Patient presented with pain in left chest
reproducible with palpation on exam. Troponins were negative x3
between the outside hospital and labs done in the ___. EKG was
unchanged from prior. She notably has minimal risk factors for
CAD. Echocardiogram in ___ was normal without evidence of
post-chemotherapy LV systolic dysfunction, and she had a stress
test in ___ that was negative. Given the fact her pain was
reproducible by palpation and not provoked by physical activity,
a musculoskeletal cause, such as costochondritis, was deemed
much more likely than ischemia. Patient was given acetaminophen
overnight with good effect. On day of discharge, patient did
recall that she had this problem a few years ago after reading
for a long time and thought it could be due to her body position
while reading. Since she presumably has a pedicled abdominal
flap that was redirected to her left chest as part of her
reconstructive surgery, it is conceivable that when she sits in
certain positions, the circulation to part of her chest wall via
the neurovascular bundle originating in her abdomen might be
compromised. It was recommended to the patient that she be
mindful of ergonomics and change positions often while seating
for long periods of time.
# Insomnia and depression: Recent admission for hyponatremia due
to effexor. Mood reported as stable, currently getting ECT on an
outpatient basis. Continued buproprion.
# Breast cancer: on maintenance hormonal therapy, stable
# Pancreatic hypodensity: CT imaging from OSH incidentally noted
a hypodenisty in pancreatic uncus and recommended ___. Official
interpretation commented that it could also be artifact due to
shadowing. Patient was informed of this result on day of
discharge and recommendation for f/u ___.
TRANSITIONAL ISSUES
1. Patient remained full code
2. PCP can consider ___ for further characterization of
incidental pancreatic finding on CT from ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zestril
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with PMHx of DM, HTN, HLD, hypothyroidism, essential
tremor, who presents with an unwitnessed fall. She reports that
she has had two falls in the last week. She was found by her
neighbor on the ground this morning when the neighbor came over
to check on her. She denied any headache, dizziness, chest pain,
shortness of breath, neck, back, or extremity pain at this time.
Of note, the patient has been having increased tremors and has
been started on carbidopa levodopa recently. She reports that
since starting this medication, her tremors have improved, but
she reports some mental fogginess or confusion since beginning
this medication.
In the ED, initial VS were 98.5 81 140/71 18 97% RA.
Labs significant for WBC of 18.0, H/H of 10.6/34.1, Plt 307. CK
elevated at 1072. BMP WNL with BUN/Cr of ___. Anion gap was
elevated at 19 and lactate 2.1. UA grossly positive.
CT head negative for acute intracranial process.
CT c-spine without acute fracture.
She received PO carbidopa-levodopa ___ .5 tablet, 10 mg
propranolol, 4 units subQ insulin, 1 g ceftriaxone.
Upon my arrival, the patient is at the bedside with her son. She
reports that she fell first on ___ afternoon when standing
up from bed. She remembers the fall and denies headstrike or
loss
of consciousness. On the day of admission, she fell again. She
reports she was using her walker to rise to standing when she
had
some lightheadedness or "fogginess" and fell down. She denies
loss of consciousness and reports she remembers the event. She
denies chest pain or palpitations at the time of the fall. She
reports after falling that she felt a wave of nausea. She felt
very weak and was unable to get up again and did not want to try
again because she was worried she would fall. She stayed on the
ground until her neighbor arrived.
She denies recents fevers, chills, shortness of breath, chest
pain, exertional chest pain or shortness of breath. She does
endorse a chronic mild cough. She reports some dysuria occurring
over the past month with a significant increase in urinary
frequency. She denies abdominal pain. She denies blood in urine
or blood in her stools. She endorses chronic stable neuropathic
pain which she associates with her diabetes, but denies new
numbness or tingling.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
IDDM2 with neuropathy,
hypothyroidism,
essential tremor,
HTN,
HLD
Macular degeneration
Osteoporosis
Lumbar stenosis
Anemia
Social History:
___
Family History:
Brother with CAD/PVD, DM2
Two grandchildren with UC
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.
CV: Heart regular, systolic ___ murmur
RESP: Lungs diminished at bases. 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, with minimal <4 Hz
truncal/head/neck/arm tremor improved further than on admission.
SKIN: No rashes or ulcerations noted
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
Pertinent Results:
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {ESCHERICHIA COLI}; Aerobic Bottle Gram
Stain-FINAL EMERGENCY WARD
___ URINE URINE CULTURE-FINAL {ESCHERICHIA
COLI} EMERGENCY WARD
___ 1:15 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 06:15 7.4 3.54* 9.3* 29.8* 84 26.3 31.2* 16.8*
52.0* 246
___ 06:15 11.4* 3.67* 10.0* 31.1* 85 27.2 32.2 17.1*
53.3* 261
___ 11:45 18.0* 4.03 10.6* 34.1 85 26.3 31.1* 16.6*
50.8* 307
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 06:15 ___ 139 3.4 98 27 142
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 06:15 12 34 50 0.3
CARDIAC MARKERS cTropnT
___ 06:15 <0.011
___ 15:10 <0.011
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate
___ 07:20 1.71
___ 12:16 2.1*2
GENERAL URINE INFORMATION Type Color ___
___ 11:30 Straw Hazy* 1.015
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
___ 11:30 SM* POS* 30* 300* 40* NEG NEG 6.0 LG
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
___ 11:30 3* >182* FEW* NONE 0 <1
OTHER URINE FINDINGS WBC Clm Mucous
___ 11:30 MANY* OCC*
=====================
___ Imaging CT HEAD W/O CONTRAST
FINDINGS:
There is no evidence of large territorial
infarction,hemorrhage,edema,or mass
effect. There is prominence of the ventricles and sulci
suggestive of
involutional changes. Bilateral periventricular white matter
hypodensities
are nonspecific but most likely reflect sequela of chronic small
vessel
ischemic changes.
There is no evidence of fracture. There is mild mucosal
thickening of ethmoid
air cells. There is minimal opacification of the dependent
portion of the
right mastoid air cells. The remaining paranasal sinuses and
middle ear
cavities are clear. Patient is status post bilateral lens
replacement.
IMPRESSION:
1. No acute intracranial process. Specifically no intracranial
hemorrhage.
2. No fracture.
=====================
___-SPINE W/O CONTRAST
FINDINGS:
There is mild retrolisthesis of C3 over C4 and anterolisthesis
of C4 over C5,
most likely degenerative changes.No acute fractures are
identified.There is
anterior posterior bridging osteophytes throughout the cervical
spine, most
severe at C6-7, C7-T1. There is moderate to severe loss of disc
heights at
C6-7 and C7-T1. There is no spinal canal stenosis.
Uncovertebral and facet
osteophytes cause moderate left neural foraminal narrowing at
C2-3 and C4-5,
moderate bilateral neural foraminal narrowing at C5-6 and
C6-7..There is no
prevertebral soft tissue swelling. Visualized thyroid and
bilateral lung
apices are unremarkable.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes of the cervical spine most
severe at C6-7
and C7-T1.
=================
___ Imaging CHEST (PA & LAT)
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or
pneumothorax.
The aorta is calcified and tortuous. The cardiac silhouette
size is top
normal to mildly enlarged. Mitral annulus calcification is
seen.
IMPRESSION:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) ODT 0.5 TAB PO BID
2. Glargine 18 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. amLODIPine 5 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Propranolol 10 mg PO BID
11. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
Last day to take is on ___
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 10 mg PO DAILY
4. Carbidopa-Levodopa (___) 1 TAB PO BID
5. Glargine 18 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Citalopram 20 mg PO DAILY
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Propranolol 10 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
E coli UTI
E coli bacteremia
Sepsis
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 fall, doesn't recall event but found down on
floor// r/o SDHr/o cspine fxr/o PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
The aorta is calcified and tortuous. The cardiac silhouette size is top
normal to mildly enlarged. Mitral annulus calcification is seen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall, doesn't recall event but found down on
floor//rule out subdural hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of large territorial infarction,hemorrhage,edema,or mass
effect. There is prominence of the ventricles and sulci suggestive of
involutional changes. Bilateral periventricular white matter hypodensities
are nonspecific but most likely reflect sequela of chronic small vessel
ischemic changes.
There is no evidence of fracture. There is mild mucosal thickening of ethmoid
air cells. There is minimal opacification of the dependent portion of the
right mastoid air cells. The remaining paranasal sinuses and middle ear
cavities are clear. Patient is status post bilateral lens replacement.
IMPRESSION:
1. No acute intracranial process. Specifically no intracranial hemorrhage.
2. No fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with fall, doesn't recall event but found down on
floor//rule out C-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 5.4 s, 21.3 cm; CTDIvol = 22.6 mGy (Body) DLP = 481.1
mGy-cm.
Total DLP (Body) = 481 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is mild retrolisthesis of C3 over C4 and anterolisthesis of C4 over C5,
most likely degenerative changes.No acute fractures are identified.There is
anterior posterior bridging osteophytes throughout the cervical spine, most
severe at C6-7, C7-T1. There is moderate to severe loss of disc heights at
C6-7 and C7-T1. There is no spinal canal stenosis. Uncovertebral and facet
osteophytes cause moderate left neural foraminal narrowing at C2-3 and C4-5,
moderate bilateral neural foraminal narrowing at C5-6 and C6-7..There is no
prevertebral soft tissue swelling. Visualized thyroid and bilateral lung
apices are unremarkable.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes of the cervical spine most severe at C6-7
and C7-T1.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Weakness, Urinary tract infection, site not specified, Fall on same level, unspecified, initial encounter
temperature: 98.5
heartrate: 81.0
resprate: 18.0
o2sat: 97.0
sbp: 140.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES:
-She will need follow up regarding the carbidopa-levodopa
started as an outpatient for the essential tremor. They may be
causing a feeling of slower mentation that the patient has been
describing.
-She will finish a course of antibiotics (PO cipro) on ___.
-She has a murmur on auscultation. Echo was done, but no report
yet at time of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / Ciprofloxacin / Coumadin
Attending: ___.
Chief Complaint:
Arm Pain, Shortness of Breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms ___ is a very pleasant ___ year old female with hx CHF
w/preserved EF, and pAFib on Xarelto who presents with arm pain.
Pt states she had L arm pain starting at the shoulder and
radiating down the hand, which she states is worse with
urination. The pain resolved in the ED however she was noted to
be hypoxic to the low ___ on RA which is new for her. Of note
she recently also had dysuria and was treated with fosfomycin on
___, however her dysuria symptoms have persisted x2 days.
On further questioning about her respiratory status, pt states
that she has had SOB and nighttime cough, which she attributes
to PND, for ___ years. She notes that she used to be able to walk
3 miles but now she is only able to walk 10 min before getting
SOB. She also tells me that she sleeps on 2 pillows at night.
Denies CP/n/v/d/f/c/ wheezing. She states that she is currently
thirsty, denies recent dietary indiscretion or increased salt
intake, has been taking all her meds as prescribed.
In the ED, initial vitals were: 98.5 72 143/68 16 RA. Labs were
unremarkable except for proBNP of 1773 and UA with large leuks,
trace blood. CXR showed no pleural effusions, increased
interstitial markings are similar to slightly increased compared
the prior study which may be due to chronic lung disease or/and
interstitial edema. Pt was given Lasix, ceftriaxone, and
aspirin.
On the floor, pt has no new complaints however endorses
constipation and arthritis pain in her lower back. She denies
arm pain or SOB currently.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, or abdominal pain. 10 pt ros
otherwise negative.
Past Medical History:
- Heart failure with preserved ejection fraction.
- Paroxismal atrial fibrillation
- Hypertension.
- Dyslipidemia.
- Osteoarthritis s/p R knee arthroscopy
- Osteopenia
- Sciatica
- Recurrent UTIs
- ___ cataracts
- Thyroid nodule
- R auricular perichondritis
- Hx falls w/ T12 compression fracture in ___
- HTN
- essential tremor
Social History:
___
Family History:
Father with heart problems, mother with arthritis. Both were
killed in the ___.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.9 PO 149 / 74R Lying 80 20 90 RA
Constitutional: Alert, oriented x3, no acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENT: MMM, oropharynx clear
Neck: JVP at 8 cm
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Bibasilar crackles
GI: Soft, non-tender, mildly distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, 1+ bilat edema to mid shin, no calf
tenderness
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: no rashes or lesions
98 135/74 88 20 97 2L NC
aox3, calm, becomes anxious talking about her memories of the
holocaust
jvp lower ___ of neck
irregular s1 and s2, slight murmur RUSB
faint early insp crackles at bases
trace ___ edema to lower leg just above ankle
Pertinent Results:
ADMISSION LABS:
___ 06:00PM BLOOD WBC-5.8 RBC-3.83* Hgb-11.8 Hct-34.0
MCV-89 MCH-30.8 MCHC-34.7 RDW-13.4 RDWSD-43.2 Plt ___
___ 06:00PM BLOOD Neuts-54.4 ___ Monos-10.3 Eos-1.5
Baso-0.5 Im ___ AbsNeut-3.16 AbsLymp-1.92 AbsMono-0.60
AbsEos-0.09 AbsBaso-0.03
___ 06:00PM BLOOD Glucose-109* UreaN-18 Creat-1.1 Na-133
K-5.8* Cl-95* HCO3-24 AnGap-20
___ 06:00PM BLOOD proBNP-1773*
___ 06:00PM BLOOD cTropnT-<0.01
___ 06:10AM BLOOD cTropnT-<0.01
___ 02:30PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 02:30PM URINE RBC-6* WBC->182* Bacteri-NONE Yeast-NONE
Epi-0
___ 02:30PM URINE Color-Yellow Appear-Hazy Sp ___
CXR - IMPRESSION:
Hyperinflated lungs. Increased interstitial markings are
similar to slightly increased compared to the prior study from
___, concerning for moderate interstitial edema and/or
chronic lung disease.
TTE - The left atrium is mildly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>65%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild aortic valve
stenosis. Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild pulmonary artery systolic hypertension. Mild mitral
regurgitation. Increased PCWP.
Compared with the prior study (images reviewed) of ___,
the estimated PA systolic pressure is now lower. The other
findings are similar.
___ 06:25AM BLOOD WBC-5.4 RBC-3.81* Hgb-11.5 Hct-34.3
MCV-90 MCH-30.2 MCHC-33.5 RDW-13.2 RDWSD-43.6 Plt ___
___ 06:00AM BLOOD Glucose-94 UreaN-25* Creat-1.2* Na-137
K-4.0 Cl-96 HCO3-26 AnGap-19
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 10 mg PO EVERY OTHER DAY
4. Propranolol 10 mg PO TID
5. Rivaroxaban 15 mg PO DAILY
6. Furosemide 40 mg PO QAM
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral
BID
9. Multivitamins 1 tab Other DAILY
10. Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY Duration: 2 Days
in ___, no later than 3;30pm, then resume 20mg ___ dose
2. Furosemide 20 mg PO QPM
start on ___. Acetaminophen 650 mg PO Q6H:PRN pain
4. Amiodarone 200 mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. Atorvastatin 10 mg PO EVERY OTHER DAY
8. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral
BID
9. Furosemide 40 mg PO QAM
10. Losartan Potassium 100 mg PO DAILY
11. Multivitamins 1 tab Other DAILY
12. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral DAILY
13. Propranolol 10 mg PO TID
14. Rivaroxaban 15 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on Chronic Diastolic Heart Failure
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with a history of CHF, presents emergency room today
with hypoxia.// ? CHF ? pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The lungs are hyperinflated. No pleural effusion is seen. Increased
interstitial markings are similar to slightly increased compared the prior
study which may be due to chronic lung disease or/and interstitial edema.
Cardiac and mediastinal silhouettes are stable with the cardiac silhouette
enlarged. The aorta is calcified.
IMPRESSION:
Hyperinflated lungs. Increased interstitial markings are similar to slightly
increased compared to the prior study from ___, concerning for
moderate interstitial edema and/or chronic lung disease.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Arm pain
Diagnosed with Urinary tract infection, site not specified
temperature: 98.5
heartrate: 72.0
resprate: 16.0
o2sat: nan
sbp: 143.0
dbp: 68.0
level of pain: 0
level of acuity: 3.0 | Ms ___ is a very pleasant ___ year old female with hx multiple
falls, CHF w/ preserved EF, and pAFib on ___ who presents
with arm pain and found to be hypoxic.
# Acute on Chronic dCHF: Pt presenting with hypoxia and reports
of DOE and possible PND. Also with ___ edema as well as some
recent weight gain. ECG reassuring, and Tn negative x 2. She was
given IV diuresis on presentation and then transitioned to Lasix
40mg BID which she will continue for 2d after discharge and then
continue 40mg Lasix in AM and 20mg in ___ afterwards. Her weight
prior to discharge was 151.9 lb. Creat rose slightly before
discharge and she declined to have labs repeated on dday of
discharge.
# UTI: Unclear if this is truly an ongoing infection, as she
gave conflicting reports as to whether she was still having
dysuria. Urine cx with mixed flora. Decided to continue CTX for
3 day course for uncomplicated UTI as unclear if pt has a true
infection.
# Paroxysmal atrial fibrillation: Stable, currently rate
controlled. Continued home Rivaroxaban, propranolol, and
amiodarone.
# Hypertension: continued home meds
# HLD: continued statin
# CODE: confirmed full
# CONTACT:
Name of health care proxy: ___
Relationship: daughter
Phone number: ___
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
tachypnea
Major Surgical or Invasive Procedure:
arterial line- ___
CVL placement- ___
History of Present Illness:
___ with AF on Coumadin, history of digoxin use, who presented
with tachypnea.
In the ED, pt initially triggered for hypotension, tachypnea and
tachycardia. Trachycardic to 130 in afib with RVR and was
intubated shortly after.
Labs were notable for severe lactic metabolic acidosis,
hyperkalemia, ___ from unknown baseline, a positive UA, and a
CXR concerning for layering effusion vs pneumonia.
Renal was consulted given his severe acidosis and hyperkalemia.
They recommended serial EKGs, beginning IV bicarbonate and an
isotonic bicarbonate gtt, insulin/dextrose, 40mg IV Lasix.
The patient was additionally given an calcium gluconate, 3L NS
bolus, 2g cefepime, 1000mg vancomycin, 750mg of levofloxacin,
and started on norepinephrine for hypotension.
On arrival to the MICU, the patient is intubated and sedated.
Review of systems:
unable to obtain ___ pt being intubated
Past Medical History:
-AF on Coumadin (on dig)
- hypothyroidism
- G6PD def
- nephrolithiasis
- nightly clonazepam (weaned recently over the last week)
- urinary incontinence
Social History:
___
Family History:
No family history of nephrolithiasis or CKD.
Physical Exam:
PHYSICAL EXAM:
Vitals: Reviewed in MetaVision
GENERAL: Intubated and sedated
HEENT: Sclera anicteric, PERRL, ETT in place
NECK: supple, JVP not elevated, no LAD
LUNGS: Rhonchi anteriorly
CV: Tachycardic, irregularly irregular, normal S1 S2, no
murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Cool, 2+ pulses, no clubbing, cyanosis, trace edema
SKIN: scattered ecchymoses
NEURO: intubated and sedated
DISCHARGE PHYSICAL EXAM:
Reviewed in MetaVision
NAD, breathing comfortably
RRR
CTAB
S/nt/nd
1+ pitting edema
A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 10:05PM ___
___ 10:05PM PLT COUNT-106*
___ 10:05PM ___ PTT-36.3 ___
___ 10:05PM WBC-19.0* RBC-3.48* HGB-13.0* HCT-41.1
MCV-118* MCH-37.4* MCHC-31.6* RDW-17.1* RDWSD-74.4*
___ 10:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:05PM LIPASE-69*
___ 10:05PM UREA N-93* CREAT-2.9*
___ 10:11PM freeCa-1.05*
___ 10:11PM HGB-14.2 calcHCT-43 O2 SAT-68 CARBOXYHB-3 MET
HGB-0
___ 10:11PM GLUCOSE-139* LACTATE-7.5* NA+-137 K+-7.2*
CL--112* TCO2-9*
___ 10:11PM PO2-51* PCO2-18* PH-7.27* TOTAL CO2-9* BASE
XS--16
___ 10:20PM URINE RBC-176* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0
___ 10:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-600
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 10:20PM URINE COLOR-YELLO APPEAR-Cloudy SP ___
___ 10:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 10:21PM PLT COUNT-102*
___ 10:21PM ___ PTT-30.1 ___
___ 10:21PM NEUTS-85.0* LYMPHS-4.4* MONOS-9.5 EOS-0.0*
BASOS-0.1 NUC RBCS-1.4* IM ___ AbsNeut-14.30* AbsLymp-0.74*
AbsMono-1.59* AbsEos-0.00* AbsBaso-0.02
___ 10:21PM WBC-16.8* RBC-3.27* HGB-12.0* HCT-39.4*
MCV-121* MCH-36.7* MCHC-30.5* RDW-16.6* RDWSD-75.0*
___ 10:21PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:21PM DIGOXIN-<0.2*
___ 10:21PM ALBUMIN-3.4* CALCIUM-8.6 PHOSPHATE-6.7*
MAGNESIUM-2.8*
___ 10:21PM cTropnT-0.01 ___
___ 10:21PM LIPASE-67*
___ 10:21PM ALT(SGPT)-127* AST(SGOT)-94* ALK PHOS-208*
TOT BILI-1.8*
___ 10:21PM GLUCOSE-145* UREA N-91* CREAT-2.9* SODIUM-134
POTASSIUM-7.7* CHLORIDE-100 TOTAL CO2-9* ANION GAP-33*
___ 10:31PM HGB-12.6* calcHCT-38
___ 10:31PM GLUCOSE-132* LACTATE-7.2* NA+-133 K+-7.3*
CL--111* TCO2-11*
IMAGING:
ECHO ___
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is markedly dilated. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated with moderate to severe global
hypokinesis (LVEF = ___ %). Left ventricular cardiac index is
markedly depressed (<2.0L/min/m2). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. No masses
or thrombi are seen in the left ventricle. The right ventricular
cavity is mildly dilated with moderate global free wall
hypokinesis. There is abnormal septal motion/position. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
dilation with severe global hypokinesis most c/w diffuse
process. Moderate mitral regurgitation. Mild pulmonary artery
systolic hypertension. Mild aortic regurgitation. Dilated
ascending aorta.
CT CHEST w/out CONTRAST ___
1. Right middle lobe wedge-shaped peripheral consolidation.
Infarct could be considered in the appropriate clinical setting.
Follow-up in 3 months is recommended to ensure resolution.
2. Bilateral pleural effusions with overlying compressive
atelectasis.
3. Extensive vascular calcifications, compatible with
atherosclerotic change.
4. Please see CT abdomen pelvis that was performed concurrently
for detailed intra-abdominal findings.
CT ABD/PELVIS w/out CONTRAST ___
1. Circumferential thickening of the urinary bladder and
stranding is
concerning for cystitis. Correlation with UA is recommended.
2. Bladder diverticulum containing a 12 mm stone. Non-urgent
urology
consultation recommended.
3. Small volume intraperitoneal ascites.
4. Left nonobstructing renal calculi. No hydronephrosis.
5. Please see CT chest performed concurrently for detailed
intrathoracic
findings.
Micro:
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefepime sensitivity testing performed by Microscan.
ESCHERICHIA COLI. >100,000 CFU/mL. SECOND MORPHOLOGY.
Cefepime sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 8 S 8 S
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- 16 R 16 R
CEFTAZIDIME----------- 4 S 2 S
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 10:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS:
___ 04:11AM BLOOD WBC-10.4* RBC-2.99* Hgb-10.9* Hct-33.1*
MCV-111* MCH-36.5* MCHC-32.9 RDW-16.7* RDWSD-68.1* Plt Ct-80*
___ 10:21PM BLOOD WBC-16.8* RBC-3.27* Hgb-12.0* Hct-39.4*
MCV-121* MCH-36.7* MCHC-30.5* RDW-16.6* RDWSD-75.0* Plt ___
___ 03:14AM BLOOD Neuts-83.9* Lymphs-6.5* Monos-8.9
Eos-0.1* Baso-0.1 NRBC-0.3* Im ___ AbsNeut-12.47*
AbsLymp-0.96* AbsMono-1.32* AbsEos-0.01* AbsBaso-0.02
___ 04:11AM BLOOD ___ PTT-34.5 ___
___ 11:26AM BLOOD Glucose-108* UreaN-38* Creat-1.4* Na-146*
K-3.2* Cl-113* HCO3-20* AnGap-16
___ 04:01AM BLOOD ALT-62* AST-36 LD(LDH)-162 AlkPhos-105
TotBili-2.0*
___ 11:26AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.0
___ 04:01AM BLOOD ___ 04:01AM BLOOD 25VitD-48
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Warfarin 2.5 mg PO DAILY16
3. Tamsulosin 0.4 mg PO QHS
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Digoxin 0.25 mg PO DAILY
Discharge Medications:
1. Ampicillin-Sulbactam 3 g IV Q6H
End date ___. Docusate Sodium 100 mg PO BID
3. Metoprolol Tartrate 25 mg PO TID
4. OLANZapine 5 mg PO DAILY
5. Senna 8.6 mg PO BID
6. ___ MD to order daily dose PO DAILY16
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Septic shock secondary to urinary tract infection
Hypoxic respiratory failure
Severe metabolic acidosis
___ secondary to acute tubular necrosis
Acute HFrEF
Hyperkalemia
Atrial fibrillation
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
INDICATION: ___ with intubated // intubated
COMPARISON: No priors
FINDINGS:
Supine AP portable view the chest provided. The endotracheal tube is seen
with its tip projecting approximately 6 cm above the carina. The nasogastric
tube descends below the left hemidiaphragm. Tapering opacity is noted in the
right mid to lower lung likely representing layering effusion. Which could
represent a layering right pleural effusion. The heart appears moderately
enlarged. Left lung appears relatively clear. Aortic calcifications noted.
Bony structures are intact.
IMPRESSION:
As above. ETT somewhat high-riding and may benefit from slight advancement.
Radiology Report
EXAMINATION: CT abdomen pelvis without contrast.
INDICATION: ___ year old man with septic shock, likely urinary vs pulmonary
source, with initial lactate of 7 and history of abdominal discomfort and
lethargy, now intubated in the MICU with ongoing pressor requirement //
please eval acute intra-abdominal process, RML/RLL layering effusion
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 595 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please see CT chest performed concurrently for detailed
intrathoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. Multiple hyperdense stones are identified
within the dependent portion of the gallbladder. No pericholecystic fluid 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, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is bilateral renal cortical atrophy, with bilateral parapelvic
cysts, largest of which measures up to 5.4 cm on the right. Multiple
nonobstructing renal calculi are identified at the lower pole of the left
kidney. There is no evidence of focal renal lesions or hydronephrosis. There
is no perinephric abnormality.
GASTROINTESTINAL: Enteric tube is identified with its tip in the proximal
stomach. Small bowel loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal limits. There
is colonic diverticulosis without inflammatory changes to suggest
diverticulitis. Appendix is not well visualized appear
PELVIS: There is diffuse circumferential thickening of the urinary bladder
with adjacent stranding, containing a Foley catheter. There is a diverticulum
at the right lateral aspect of the urinary bladder containing a 12 mm
hyperdense stone (series 3, image 106). Small volume perihepatic and
perisplenic ascites.
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. Moderate to severe
atherosclerotic disease is noted. Partially visualized right femoral l
catheter.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Moderate multilevel degenerative changes of the visualized spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Circumferential thickening of the urinary bladder and stranding is
concerning for cystitis. Correlation with UA is recommended.
2. Bladder diverticulum containing a 12 mm stone. Non-urgent urology
consultation recommended.
3. Small volume intraperitoneal ascites.
4. Left nonobstructing renal calculi. No hydronephrosis.
5. Please see CT chest performed concurrently for detailed intrathoracic
findings.
Radiology Report
EXAMINATION: CT chest without contrast.
INDICATION: ___ man with septic shock, likely urinary versus
pulmonary source with initial lactating 7 history are abdominal discomfort, at
the GE. An to be in the MICU with ongoing pressor requirement. Evaluate for
acute intra-abdominal process.
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: None.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart,
pericardium, and great vessels are within normal limits based on an unenhanced
scan. No pericardial effusion is seen. Mild coronary artery calcifications.
There are extensive vascular calcifications, compatible with atherosclerotic
change.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: Small bilateral pleural effusions. No pneumothorax.
LUNGS/AIRWAYS: An endotracheal tube is noted with the tip 3.6 cm above the
carina. A wedge-shaped opacity abutting the pleura anteriorly within the
right middle lobe may represent consolidation or infarct. Bilateral lower
lobe compressive atelectasis. The airways are patent to the level of the
segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Please see CT abdomen pelvis that was performed concurrently for
detailed intra-abdominal findings.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Moderate multilevel degenerative changes of the visualized spine.
IMPRESSION:
1. Right middle lobe wedge-shaped peripheral consolidation. Infarct could be
considered in the appropriate clinical setting. Follow-up in 3 months is
recommended to ensure resolution.
2. Bilateral pleural effusions with overlying compressive atelectasis.
3. Extensive vascular calcifications, compatible with atherosclerotic change.
4. Please see CT abdomen pelvis that was performed concurrently for detailed
intra-abdominal findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with AF on Coumadin, history of digoxin use, who presented
with tachypnea. // eval extent of opacities, edema eval extent of
opacities, edema
IMPRESSION:
NG tube tip is in the stomach. ET tube tip is 5.5 cm above the carinal.
Heart size and mediastinum are unchanged including cardiomegaly.
Bilateral pleural effusions, right more than left are substantial. Right
basal more nodular opacity represents a right middle lobe lesion, better
characterized on ___ chest CT.
No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with septic shock, hypoxic resp failure. // ?
pulm edema, infiltrate ? pulm edema, infiltrate
IMPRESSION:
Comparison to ___. The effusion on the right. Is still
moderate in extent and has not substantially changed. A minimal left effusion
and a left retrocardiac atelectasis is also stable. Moderate cardiomegaly
persists. In the interval, the patient has been extubated. No pulmonary
edema. No pneumothorax.
Radiology Report
EXAMINATION: Video oropharyngeal swallow
INDICATION: ___ year old man w/ AF on Coumadin, history of digoxin use
(stopped 1 mon prior), hx nephrolithiasis, hypothyroidism, urinary
incontinence and G6PD def who presented to ED with tachypnea ___ and was
found to have ___ (baseline Cr 1.0), metabolic acidosis, hyperkalemia and
septic shock. // eval for aspiration risk, quality of swallow
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 2 minutes and 53 seconds .
COMPARISON: None
FINDINGS:
There is gross aspiration with thin and nectar thick liquids. There is
abundant amount of residue within the valleculae. Barium passes freely
through the oropharynx and esophagus without evidence of obstruction.
IMPRESSION:
1. Gross aspiration with thin and nectar thick liquids.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
INDICATION: ___ year old man with septic shock now requiring IV abx therapy
for bacteremia // insertion of PICC line
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: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.6 min, 5 mGy
PROCEDURE:
1. Double lumen PICC placement through the left brachial vein.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the left
brachial vein was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before and after
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A double lumen PIC line measuring 47 cm
in length was then placed through the peel-away sheath with its tip positioned
in the distal SVC under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the skin, flushed,
and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Brachialvein approach double lumen left PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a left 47 cm basilic approach double lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 3 EXAMS
INDICATION: ___ year old man with aspiration, dysphagia // TWO SERIES DOBHOFF
PLACEMENT
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Interval placement of Dobhoff tube with tip coiled in the stomach. Left PICC
tip terminates in the cavoatrial junction.
Well-circumscribed opacity in the right lower lobe adjacent to the right heart
border viewed in conjunction with recent CT is concerning for a possible mass
and should be followed with subsequent radiographs.
Interval decrease in moderate right pleural effusion. Minimal left pleural
effusion with retrocardiac atelectasis unchanged. There is no pneumothorax.
Moderate cardiomegaly unchanged.
IMPRESSION:
Dobhoff tube is coiled in the stomach.
Interval decrease in moderate right pleural effusion.
Right lung lesion is concerning for possible lung mass and should be followed
closely with subsequent radiographs.
NOTIFICATION: The findings were discussed with Dr. ___ , M.D. by ___
___, M.D. on the telephone on ___ at 8:16 AM,
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Respiratory distress
Diagnosed with Sepsis, unspecified organism, Severe sepsis with septic shock, Hypokalemia
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | PATIENT
Mr ___ is an ___ year old man with a history of AF on
warfarin, nephrolithiasis, hypothyroidism, urinary incontinence
and G6PD def admitted to the ICU ___ and with ___ (baseline Cr
1.0), refractory acidemia, hyperkalemia and septic shock.
ACUTE ISSUES
# Septic Shock: Initial presumed source pulmonary vs urinary.
Started on vanco, cefepime, and levofloxacin for broad coverage.
Lactate initially severely elevated, but resolved with volume
resuscitation. Weaned off pressors ___. Small volume ascites
non-tapable. GNRs in urine ultimately speciated two colonies of
E. coli, antibiotics subsequently changed to IV unasyn. MRSA
screen negative. The patient should continue the IV unasyn until
___ to complete a 14d course of antibiotics.
# Hypoxic respiratory failure: Felt multifactorial from volume
resuscitation ISO sepsis, moderate right sided pleural effusion,
and possible aspiration. TTE demonstrated that new global
systolic hypokinesis / LV dilation with EF of ___ and 2+
mitral regurgitation, which was felt to be in the setting of
septic shock and myocardial stunting. Extubated successfully to
facemask on ___ (HD #2) and was weaned to room air.
# ___: Patient developed Non-oliguric ATN, likely secondary to
septic shock. Baseline cr 1.0, with peak value of 2.9. After
resolution of sepsis, patient began to urinate and autodiurese
(post-ATN diuresis). Acidemia and hyperkalemia improved with
concurrent improvement of renal function. Renal was consulted,
but patient did not require RRT at any time this
hospitalization.
# CHF: Patient noted to have elevated BNP at admission, with
hypoxia as noted above. TTE demonstrated that new global
systolic hypokinesis / LV dilation with EF of ___ and 2+
mitral regurgitation. Unclear etiology at this time, unclear if
chronic (from tachymyopathy) or acute (from myocardial
suppression of sepsis). Started on metoprolol and uptitrated for
rate control.
# Severe academia: Pt admitted with pH 7.09, due to severe
lactic acidosis (initial lactate 7.5) and uremia. Patient was
initially treated with bicarb amps and a bicarb drip. With
volume repletion and correction of underlying sepsis, academia
improved. However, he continued to have a non-anion gap
metabolic acidosis (with concurrent respiratory alkalosis) later
during his hospitalization.
# Hyperkalemia: in the setting ___ and ___ academia,
patient's intial potassium (non-hemolyzed) was 7.3. EKG without
concerning changes. Initially temporized with furosemide,
insulin/dextrose, and calcium gluconate. Bicarbonate treatment
for academia also reduced serum levels considerably. After
volume repletion and treatment of sepsis, potassium levels
normalized.
# AFib: Previously on dig, stopped ___ PTA. On warfarin. Tachy in
the setting of sepsis, but rates improved with volume
resuscitation, and later initiation of metoprolol. Once
coagulopathy was reversed, the patient's home warfarin was
restarted.
# Bladder Diverticulum: Likely ___ chronic renal stones.
Outpatient f/u.
TRANSITIONAL ISSUES
[ ] check thigh blood pressure (BP on arms SBP 30mmHg lower than
A line, thigh was congruent)
[ ] TTE in 1 month to follow-up newly reduced EF
[ ] CXR in ___ weeks for evaluation of pleural effusion on R
sided lung mass
[ ] needs ACE inhibitor restarted as an outpatient
[ ] Pt will complete a 14d course of antibiotics for sepsis, end
date of unasyn ___
[] Pt needs urology follow-up as an outpatient for bladder
diverticula |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
lisinopril / Cymbalta / hydrochlorothiazide / Prozac
Attending: ___.
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
___: Right knee irrigation & debridement
History of Present Illness:
___ hx DM2, dementia, HTN, HLD, who presented to the ED
yesterday with complaint of right knee pain x 2 days. She
reports that 2 days prior to presentation, she bent over while
standing to pick up her cane and she felt a "pop" in the knee.
Since this time, she's had increased difficulty bearing weight,
and ranging that knee. She reports increased swelling and warmth
in the knee, though denies any fevers, chills, sweats. Denies
any other trauma to the knee. She does report mild pain in the
left knee as well as in her right shoulder, though pain there is
chronic.
At baseline, she ambulates with a cane or walker. She lives with
her daughter and does not leave the house without her daughter's
assistance - either with a walker or wheelchair.
Past Medical History:
PAST MEDICAL HISTORY
Hyperlipidemia
Hypertension
Osteoarthritis (R knee)
Anxiety
Back pain
Cataract
Colonic adenoma
Constipation
Dementia (cant remember daily activities)
Depression
Diabetes mellitus (insulin)
Diverticulosis
Glaucoma
Fibroids
PAST SURGICAL HISTORY
Discectomy
Hysterectomy d/t fibroids
Shoulder surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Vitals: AFVSS
General: A&Ox3, NAD
CAM/MINICOG: Negative
Heart: Regular rate and rhythm peripherally
Lungs: Breathing comfortably on room air.
Right lower extremity:
- Skin intact
- Erythema, diffuse swelling, and warmth in the knee. No
deformity, induration or ecchymosis
- Diffuse TTP about the knee and joint line. Soft, non-tender
thigh and lower leg
- Unable to extend or flex knee from 45 degree position of
flexion without exquisite pain. Full, painless active/passive
ROM of hip and ankle
- ___ fire
- Sensation intact to light touch in
SPN/DPN/Tibial/saphenous/Sural distributions
- 1+ ___ pulses, foot warm and well perfused
Pertinent Results:
___ 12:00PM BLOOD WBC-8.0 RBC-4.18 Hgb-12.7 Hct-38.8 MCV-93
MCH-30.4 MCHC-32.7 RDW-13.8 RDWSD-46.8* Plt ___
___ 08:40AM BLOOD Neuts-60.8 ___ Monos-14.1*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.47# AbsLymp-2.20
AbsMono-1.27* AbsEos-0.00* AbsBaso-0.03
___ 08:40AM BLOOD Glucose-232* UreaN-7 Creat-0.8 Na-135
K-3.5 Cl-103 HCO3-21* AnGap-15
___ 11:35AM JOINT FLUID ___ Polys-89*
___ Monos-9 Eos-2* Macro-0
___ 11:35AM JOINT FLUID Crystal-NONE
___ 11:35AM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
ATORVASTATIN - atorvastatin 80 mg tablet. 1 (One) tablet(s) by
mouth once a day - (Prescribed by Other Provider)
BUSPIRONE HCL - BUSPIRONE HCL 5MG tablet. TAKE ONE TABLET BY
MOUTH TWICE A DAY
CITALOPRAM - citalopram 20 mg tablet. 1.5 (One and a half)
tablet(s) by mouth once a day - (Prescribed by Other Provider)
INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL subcutaneous
solution. 14 units once a day - (Prescribed by Other Provider)
LOSARTAN - losartan 25 mg tablet. 3 tablet(s) by mouth once a
day - (Prescribed by Other Provider)
METOPROLOL SUCCINATE - metoprolol succinate ER 200 mg
tablet,extended release 24 hr. 1 Tablet(s) by mouth DAILY
(Daily) - (Prescribed by Other Provider)
NIFEDIPINE - nifedipine ER 90 mg tablet,extended release. 1
Tablet(s) by mouth DAILY (Daily) - (Prescribed by Other
Provider)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
Capsule(s) by mouth once a day - (Prescribed by Other Provider)
VORTIOXETINE [BRINTELLIX] - Brintellix 10 mg tablet. 1 tablet(s)
by mouth once a day - (Prescribed by Other Provider)
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by
mouth once a day - (Prescribed by Other Provider; ___)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 1,000
unit tablet. 1 tablet(s) by mouth qday - (Prescribed by Other
Provider)
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 Capsule(s)
by mouth twice a day - (Prescribed by Other Provider)
LIDOCAINE-MENTHOL [LIDOPATCH] - Dosage uncertain - (Prescribed
by Other Provider)
MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth once a
day - (___)
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. CefePIME 2 g IV Q12H
3. Enoxaparin Sodium 40 mg SC QHS Duration: 30 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous at bedtime Disp
#*30 Syringe Refills:*0
4. Gabapentin 100 mg PO TID
5. Losartan Potassium 25 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO TID
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
9. QUEtiapine Fumarate 25 mg PO QHS:PRN agitation/insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Septic right knee (native)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with pain s/p fall // fx?
TECHNIQUE: AP, oblique, and lateral views of the right knee.
COMPARISON: ___.
FINDINGS:
Tricompartmental degenerative changes are again noted with osteophyte
formation and joint space narrowing. Chondrocalcinosis again seen at the
femorotibial compartments. Moderate suprapatellar effusion is noted,
increased from prior. Atherosclerotic calcifications are identified.
IMPRESSION:
Tricompartmental degenerative changes without acute fracture. Moderate
suprapatellar effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with right septic arthritis // pre op Surg:
___ (I D R knee)
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the lung volumes have slightly
decreased and a platelike atelectasis is seen at the right lung bases.
Otherwise no relevant changes. No pneumonia, no pleural effusions, no
pulmonary edema.
Radiology Report
INDICATION: 40cm R basilic SL PICC - ___ ___
___ year old woman with new R PICC // 40cm R basilic SL PICC - ___ ___
Contact name: ___: ___
EXAMINATION: CHEST PORT. LINE PLACEMENT
TECHNIQUE: Portable Chest radiograph, frontal view
COMPARISON: Chest radiograph ___
FINDINGS:
Right PICC terminates in upper to mid SVC. There is no consolidation, pleural
effusion, or pneumothorax. Cardiomediastinal and hilar silhouettes are normal
size.
IMPRESSION:
Right PICC terminates in mid to upper SVC.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: R Knee injury
Diagnosed with PYOGEN ARTHRITIS-LOWER LEG
temperature: 99.0
heartrate: 74.0
resprate: 16.0
o2sat: 100.0
sbp: 168.0
dbp: 65.0
level of pain: 10
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a septic right native knee and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right knee irrigation and
debridement, 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
infectious disease team followed her during this admission for
her joint infection. She will be maintained on IV Cefepime 2g
q12h for 6 weeks (end date: ___. She has been scheduled with
follow-up appointments in ___ clinic for monitoring of her native
knee infection. She will receive antibiotics through a PICC line
that was placed during this hospitalization. Please see
infectious disease instructions in the discharge paperwork for
antibiotic and lab testing follow-up, and for where lab results
should be faxed (OPAT note also in OMR). 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
weight bearing 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 ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Unsteady Gait
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ old man with a history of
idiopathic unilateral vocal cord paralysis, left paraclinoid
aneurysm s/p clipping c/b visual loss, transient L ICA occlusion
and asymptomatic parietooccipital stroke who presents with
unsteady gait and worsening vision which started ten days ago
and
worsened eight days ago.
He was last in his normal state of health ten days ago when he
awoke. As he was driving to work, he noticed a sensation that
things were "cloudy and in slow motion." When he got to work he
felt that his walking was not quite right, and that there was a
"skip in the step." There were ___ other associated symptoms and
he brushed it off. His symptoms were similar the next day, but
on
___ (eight days ago) he woke up with significantly worsened
gait. He went to work, where he was "staggering around" so much
that they drove him home. The main symptom seems to have been
unsteadiness at this time. He does not recall feeling any
sensation of vertigo. He denies diplopia, dysarthria,
incoordination, weakness or numbness. He saw his PCP briefly on
___, who prescribed him meclizine and prednisone. He took
these faithfully over the next week without improvement or clear
worsening in his symptoms. He was in communication with his PCP
throughout and when he did not improve with this treatment, his
PCP recommended that he come to the ED for evaluation and MRI.
Regarding his history of L ICA aneurysm, he initially presented
to an OSH is ___ with transient symptoms of dizziness. He had
an
MRI brain which was concerning for aneurysm, and a CTA head
confirmed this. As a result, he underwent open clipping with Dr.
___ in ___. The procedure was complicated by L ICA
occlusion. During his hospitalization he had transient right
pronator drift which resolved prior to discharge. One week after
discharge he presented to OSH ED with a sensation of fullness
after sneezing; at that point a CT head was done. Per my review
this showed a new small left parietooccipital junction infarct
(watershed vs distal MCA). He subsequently complained of
persistent diplopia and blurry vision and was evaluated in
___ clinic. That examination was notable for
"Left relative afferent pupillary defect was present.
Confrontation fields were full in the right eye. In the left
eye, he was able to count fingers in the upper quadrants, but
could only see hand movements in the inferotemporal quadrant and
could not see hand movements in the inferonasal quadrant." This
was thought to be most likely due to a branch retinal artery
occlusion, and ___ further intervention was performed. One year
after the initial procedure he underwent removal of the
microplate and screw which was protruding. Then, in ___
presented with month-long headache (he tells me it was midline
and deep). MRI/MRA was performed at OSH and was concerning for
recanalization of aneurysm. CTA head was repeated here and
appeared consistent with recanalization. He reports that he
spoke
with neurosurgery and was told that this was likely an artifact.
Several years ago he had the acute onset of right vocal cord
paralysis which was worked up at ___ and ___ etiology was found.
He underwent a surgical procedure to medialize the vocal cord
and
since that time has had persistent but stable hoarseness.
On neuro ROS, the pt reports since the aneurysm clipping he has
intermittent "thunderclap headache," which improves with
ibuprofen and rest, chronically blurred vision in the left eye,
diplopia initially which subsequently resolved. He denies
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. ___ bowel or bladder incontinence or retention.
On general review of systems, he endorses fatigue; he has been
napping during the day for the past week which is unusual for
him. Otherwise, the pt denies recent fever or chills. ___ 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. ___
recent change in bowel or bladder habits. ___ dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
PMHx:
L paraclinoid aneurysm (4 mm)
superior branch retinal artery occlusion in the left eye
R vocal cord paralysis (etiology could not be determined)
hyperlipidemia
PSHx:
___ L craniotomy for aneurysm clipping
___ Incision and removal of microplate.
Medialization thyroplasty (vocal cord repositioning)
hernia repair
Social History:
___
Family History:
Mother died of emphysema (non-smoker); father died of unknown
causes at age ___. Siblings and children are healthy. ___ known
history of aneurysm, stroke, seizure, MS. ___ known history of
inflammatory disease or hypercoagulability.
Physical Exam:
Vitals: T: 97.7 HR: 68 BP: 134/75 RR: 16 SpO2: 100% RA
General: Well-nourished, fit appearing man sitting up in bed in
NAD.
HEENT: NC/AT. ___ scleral icterus, mucus membranes are moist.
Could not appreciate supraorbital pulses bilaterally.
Neck: Supple, ___ carotid or vertebral bruits appreciated. ___
nuchal rigidity.
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, ___ wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, RRR, ___ M/R/G.
Abdomen: Soft, nontender, nondistended
Extremities: ___ lower extremity edema
Skin: ___ rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent and intact to
repetition,
naming of high and low frequency objects, comprehension of cross
body, grammatically complex, multi-step commands. Able to
register ___ items and recall ___ at 5 minutes. Calculations
intact to subtraction and multiplication. Attentive to
examination. There was ___ evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils equal in light, R 4 to 2mm and brisk, L 4 to 3 mm and
sluggish with L RAPD. Visual acuity to snellen chart is OD
___ and OS ___. VFF to confrontation on the R. On the L,
there was intact vision in superonasal quadrant, decreased red
saturation in superotemporal quadrant, absent vision in inferior
quadrants. Macula was spared. Funduscopic exam on the left
revealed a pale, round disk with ___ edema. ___ hemorrhages noted.
On the right there was ___ papilledema noted.
III, IV, VI: EOMI. There was left-beating nystagmus most
prominent on leftward gaze but also noted on upward and downward
gaze. There was ___ nystagmus in primary position or on rightward
gaze. There was saccadic breakdown of smooth pursuit in all
directions. On HIT, he had to catchup in both directions.
V: Facial sensation intact to light touch and pinprick in all
distributions, with the exception of a patch extending along the
left lateral and inferior jaw which is reportedly post-surgical.
VII: ___ 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 tone throughout. Decreased bulk in ___
bilaterally. L pronator drift, R subtle pronation without drift.
___ tremor or asterixis. Slight proximal ataxia with eyes closed.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 4 4
R ___ ___ ___ 5 5 5 4 4
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2 2+ 2+ 2+
R 2+ 2 2+ 2+ 2+
- Plantar response was extensor bilaterally, more prominent on
the right.
-Sensory: ___ deficits to light touch, pinprick throughout.
Proprioception intact to large and small mvt in great toes
bilaterally. ___ extinction to DSS.
-Coordination: Increased rebound on LUE. Mild ataxia on L FNF,
finger tapping is slowed but accurate on the L. Normal on R. ___
dysmetria HKS bilaterally, toe tapping is slower but accurate on
left than right. There is mild truncal ataxia sitting with eyes
closed.
-Gait: Good initiation. Wide based, ataxic. Takes step to the
left consistently. Able to walk on heels and toes but cannot
walk
in tandem. Sways with feet together, takes step with eyes
closed.
###DISCHARGE EXAM###
Patient with resolved nystagmus and dysmetria. Symmetric, slight
rebound with arms extended. Wide-based gait but ambulating
independently without falling to the L.
Pertinent Results:
___ 08:09AM BLOOD cTropnT-<0.01
___ 08:09AM BLOOD %HbA1c-5.2 eAG-103
___ 08:09AM BLOOD Triglyc-218* HDL-43 CHOL/HD-4.5
LDLcalc-108
___
1. Dental streak artifact, left ophthalmic artery aneurysm clip,
and left
frontal craniotomy or hardware streak artifact limits
examination.
2. A 5 mm aneurysm is identified at the left paraclinoid ICA
slightly larger compared to ___, finding is suggestive of
recanalization.
3. A 2 mm aneurysm at the superior wall of right MCA M1 segment
is unchanged.
4. Likely sequela of old infarct in the left parieto-occipital
regions appear similar to before.
5. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
___ Brain MRI
1. ___ acute intracranial hemorrhage or infarct.
2. Encephalomalacia of the left precentral gyrus, left parietal
and left
parietal occipital lobe likely represents sequela of interval
infarcts since examination of ___.
3. A single FLAIR hyperintense focus of the left centrum
semiovale likely also represent sequela prior infarct. This is
not in a distribution commonly seen in setting of demyelinating
process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Meclizine 25 mg PO TID
2. Omeprazole 40 mg PO DAILY
3. Ibuprofen 600 mg PO TID
4. PredniSONE 20 mg PO BID
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Vestibular neuronitis
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: ___ male with history of left ophthalmic aneurysm
clipping, now with gait instability and headache. Evaluate for aneurysm, or
steno-occlusive disease.
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 7.0 s, 0.5 cm; CTDIvol = 76.2 mGy (Head) DLP =
38.1 mGy-cm.
3) Spiral Acquisition 5.2 s, 40.9 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,309.5 mGy-cm.
Total DLP (Head) = 2,245 mGy-cm.
COMPARISON: ___ head CTA
FINDINGS:
Dental streak artifact, left ophthalmic artery aneurysm clip, and left frontal
craniotomy or hardware streak artifact limits examination.
CT HEAD WITHOUT CONTRAST:
The areas of hypodensity in the left parieto-occipital region are unchanged
(03:16, 22). The hypodensity located more medially (03:20) appear more
conspicuous than before.
There is no evidence of no evidence of hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is left frontotemporal craniotomy. 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:
A 5 mm aneurysm is identified at the left paraclinoid ICA (5:246), slightly
larger compared to ___ (previously 4 mm) Finding is suggestive of
recanalization. Left ophthalmic ICA aneurysm clip is in unchanged position.
A 2 mm outpouching in the superior wall of the right MCA M1 segment (5:256,
___:1, 602b:32) appears unchanged.
The vessels of the circle of ___ and their principal intracranial branches
are patent. 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.
Left internal jugular vein is obliterated from the C4-5 level and up to the
jugular foramen. Left internal jugular vein below C4-5 level is small caliber
and does not opacify with IV contrast. Right internal jugular vein is large,
likely compensatory.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. Scattered subcentimeter nonspecific
lymph nodes are noted throughout the neck bilaterally, with no lymphadenopathy
by CT size criteria. Chronic right lamina papyracea fracture is noted (see
5:244).
IMPRESSION:
1. Dental streak artifact, left ophthalmic artery aneurysm clip, and left
frontal craniotomy or hardware streak artifact limits examination.
2. A 5 mm aneurysm is identified at the left paraclinoid ICA slightly larger
compared to ___, finding is suggestive of recanalization.
3. A 2 mm aneurysm at the superior wall of right MCA M1 segment is unchanged.
4. Likely sequela of old infarct in the left parieto-occipital regions appear
similar to before.
5. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
NOTIFICATION: The findings regarding slightly increased size of left ICA
aneurysm were discussed with ___, M.D. by ___, M.D. on the telephone on
___ at 5:31 ___, 3 minutes after discovery of the findings.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with history of idiopathic vocal cord paralysis,
L ICA aneurysm s/p clipping, who presents with eight days of gait instability.
No clear vessel cutoff. // please evaluate for stroke or demyelinating
disease
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA head and neck from ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration.
Encephalomalacia of the left pre central gyrus (series 10, image 23 and left
parietal lobe (series 10, image 18 through 20) and of the left occipital
parietal lobe (series 10, image 13) are new from examination of ___, suggesting sequela of interval embolic infarcts. Additional new rounded
focus of FLAIR signal in the left centrum semiovale (Series 10, image 20) may
also represent an additional region of infarct. There is no evidence of acute
infarct or intracranial hemorrhage.
The orbits are unremarkable. There is mild mucosal thickening in bilateral
ethmoid air cells. The remaining visualized paranasal sinuses and mastoid air
cells are clear. Intracranial flow voids are maintained.
IMPRESSION:
1. No acute intracranial hemorrhage or infarct.
2. Encephalomalacia of the left precentral gyrus, left parietal and left
parietal occipital lobe likely represents sequela of interval infarcts since
examination of ___.
3. A single FLAIR hyperintense focus of the left centrum semiovale likely also
represent sequela prior infarct. This is not in a distribution commonly seen
in setting of demyelinating process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ataxia and old strokes, no new stroke on MRI
// infection? nodes? infection? nodes?
IMPRESSION:
Compared to chest radiograph ___.
Aside from the new linear atelectasis or scarring in the left midlung, lungs
are clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are
normal.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with Dizziness and giddiness
temperature: 97.7
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 134.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to the neurology service given concern
for possible cerebellar stroke. However, upon repeat exam, it
was thought his presentation was more likely consistent with a
peripheral vestibular dysfunction, possibly post-infectious
given a recent illness.
He had L beat nystagmus on L gaze with falling/swinging to the
left; nystagmus resolved and he was ambulating indepdently with
___. The rapid resolution of symptoms was also more suggestive of
a post-infectious transcient peripheral process.
Of note, his clipped L left paraclinoid ICA aneurysm is 5mm,
from 4mm previously and may represent recanalization as seen on
prior imaging. This should be followed by neurosurgery as an
outpatient. His MRI revealed ___ acute/subacute infarct.
LDL 102 and A1C 5.2%. Patient was continued on atorvastatin 20mg
and started on aspirin 81mg upon admission. ASA 81mg was
discontinued after his MRI revealed ___ infarct, and his
atorvastatin 20mg home dose was continued.
He was monitored on telemetry without abnormality.
He will be discharged to home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
Closed loop small bowel obstruction with periaortic mass causing
the closed loop bowel obstruction.
-Open exploratory laparotomy, small bowel resection
History of Present Illness:
___ with history of sigmoid colectomy for colon cancer in ___,
now with 1-day history of nausea and abdominal pain. She was in
her usual state of health until yesterday, when she developed
epigastric abdominal pain and nausea. She had 2 episodes of
non-bloody, non-bilious emesis. She last passed gas and had a
bowel movement yesterday. She has no history of bowel
obstruction. Had a normal colonoscopy earlier this month.
Past Medical History:
Sigmoid adenocarcinoma s/p resection ___ c/b pulmonary
metastases
Hyperlipidemia
Hypertension
GERD
HBV
Social History:
___
Family History:
non-contributory
Physical Exam:
Temp: 97.3; P: 75; BP: 142/83; RR: 16: O2: 97%RA
General: alert, oriented X3; in no acute distress
HEENT: atraumatic, normocephalic, oral mucosa moist
Resp: clear breath sounds bilaterally
CV: RRR, no murmurs, rubs, or gallops
ABD: midline incision C,D,I; abdomen soft, non-distended;
appropriate ___ tenderness
Extr: atraumatic, skin intact
Pertinent Results:
COMPLETE BLOOD COUNT
WBC RBC Hgb Hct MCV MCH MCHC RDW
RDWSD Plt Ct
___ 09:10 7.0 4.72 9.7* 31.8* 67* 20.6* 30.5* 15.4
36.6 327
___ 04:41 8.4 4.48 9.3* 30.6* 68* 20.8* 30.4* 15.3
37.1 299
___ 10:04 8.7 4.01 8.4* 27.8* 69* 20.9* 30.2* 15.9*
39.6 223
___ 05:29 9.9 4.66 9.7* 31.6* 68* 20.8* 30.7* 15.6*
37.2 248
___ 14:45 5.5 5.88* 12.2 39.6 67* 20.7* 30.8* 16.5*
36.7 326
___ 23:25 8.2 6.40* 13.4 43.8 68* 20.9* 30.6* 17.2*
36.6 341
___
CT ABD & PELVIS WITH CO
IMPRESSION:
Small bowel obstruction with two transitions at the same
location, 3 cm medial and superior to the sigmoidectomy
anastamosis, concerning for closed loop obstruction from a
single adhesion/band. The intervening small bowel is thickened
with mesenteric edema, concerning for early ischemia. No
pneumatosis or free air.
___
PATHOLOGIC DIAGNOSIS:
1. Jejunum, resection:
- Metastatic serosal deposit of adenocarcinoma at site of
iatrogenic enterotomy; see note.
2) "Mass at base of mesentery":
- Serosal deposit of metastatic adenocarcinoma; see note.
3) Omentum:
- Unremarkable omental tissue; no malignancy identified.
Note: The carcinoma is histologically similar to the patient's
previous colon carcinoma (___).
Medications on Admission:
viread 300', vitamin D2, gabapentin 300 ohs, ibuprofen,
losartan 100', omeprazole 20", ranitidine 300', simvastatin 40'
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
2. Gabapentin 300 mg PO QHS
3. Omeprazole 20 mg PO BID
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*25 Capsule Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 cap by mouth twice a day Disp
#*30 Capsule Refills:*0
6. Simvastatin 40 mg PO QPM
7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Evaluate for pneumothorax or pneumoperitoneum, in a patient with
abdominal pain.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___.
FINDINGS:
Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal
silhouette and fairly well-aerated lungs without focal consolidation, pleural
effusion, or pneumothorax. Surgical changes in the let lung are noted, with
mild atelectasis in the left mid lung. The visualized upper abdomen is
unremarkable. Gaseous distension of the colon is noted, similar in appearance
to multiple exams from ___.
IMPRESSION:
No acute cardiopulmonary process or evidence of pneumoperitoneum.
Radiology Report
INDICATION: Evaluate for acute abdominal pathology in a patient with
abdominal pain and a history of colon cancer.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 8.2 mGy (Body) DLP = 453.0
mGy-cm.
Total DLP (Body) = 461 mGy-cm.
COMPARISON: CT abdomen/ pelvis from ___.
FINDINGS:
LOWER CHEST: Other than mild dependent atelectasis, the visualized lung bases
are clear without pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is homogeneous in attenuation. A simple hepatic cyst
in segment 5 is unchanged. Other hepatic hypodensities are too small to
characterize but again likely represent simple hepatic cysts or biliary
hamartomas. No concerning focal lesion is identified. There is no evidence
of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains
gallstones without wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are symmetric and normal in size, demonstrating normal
nephrograms and excreting contrast promptly. A large simple cyst arising from
the interpolar region of the left kidney is unchanged, measuring 5.0 x 4.9 cm
(series 2, image 40). Other smaller hypodensities are too small to
characterize but again likely represent simple renal cysts. There is no
concerning focal lesion or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There are dilated small bowel
loops, with a sharp transition point and distal decompression in the mid
abdomen (02:56), approximately 3 cm superior and medial to the sigmoidectomy
anastomosis. There is moderate fecalization at this level (series 2, image
57). Just proximal to this is a 10-15 cm of small bowel bowel demonstrating
wall thickening and mesenteric edema (series 602b, image 40, 37, series 601b,
image 21). Immediately proximal is a second focus of small bowel narrowing,
at the same location as the distal transition point (series 602b, image 43,
series 601b, image 26). The upstream small bowel is dilated with smooth
tapering more proximally. There is no pneumatosis or free air. The patient is
status post partial sigmoid colectomy, with the expected postsurgical changes
and a patent anastomosis. A normal air-filled appendix is visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid within the pelvis.
REPRODUCTIVE ORGANS: The uterus is of normal size and enhancement. There is no
evidence of adnexal abnormality bilaterally.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Small bowel obstruction with two transitions at the same location, 3 cm medial
and superior to the sigmoidectomy anastamosis, concerning for closed loop
obstruction from a single adhesion/band. The intervening small bowel is
thickened with mesenteric edema, concerning for early ischemia. No
pneumatosis or free air.
NOTIFICATION: The findings were discussed in person and over the phone by Dr.
___ with Dr. ___, 5 minutes after discovery, approximately
___:40 on ___.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Epigastric pain
temperature: 98.4
heartrate: 88.0
resprate: 16.0
o2sat: 97.0
sbp: 142.0
dbp: 89.0
level of pain: 5
level of acuity: 3.0 | Patient is a ___ year old female with a known history of colon
cancer s/p resectionx2 and HBV who presented to ___ ED on
___ due to abdominal pain and several episodes of emesis.
Abdominal CT was consistent with a small bowel obstruction with
concern for a close-loop obstruction and early ischemia. The
patient was evaluated by the surgical staff expeditiously and
due to her positive exam and concerning radiological findings
that patient was consented and taken to the OR for an
exploratory laparotomy, please view the operative note for
further details. The patient tolerated the procedure well, and
transferred to the floor in stable condition. In the initial
post-op period the patient was managed with NPO/IVF, PCA for
pain control, and serial abd exams. The patient was kept NPO
until return of bowel function, at which point her diet was
sequentially advanced to a regular diet which was well
tolerated. Her pain had been well controlled on a PO regimen,
and the patient ambulated independently, and discharged home on
hospital day 7.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a dPCA and then
transitioned to oral oxycodone/tylenol once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO, the diet was
advanced sequentially to a Regular diet, which was well
tolerated. Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Vicodin / MS ___ / Gabapentin / Bactrim
Attending: ___.
Chief Complaint:
Right second digit infection
Major Surgical or Invasive Procedure:
Right second digit amputation ___
History of Present Illness:
___ with diabetic neuropathy s/p right
first toe amputation ___ returns with a 12 day history of
right second toe pain, erythema and serosanginous discharge
after
stubbing his toe. He has noticed progressive redness, swelling,
erythema and drainage from the nail bed extending only to the
base of the toe. There has been no cellulitis extending up the
foot. He has not experienced any fever, chills, shortness of
breath, chest pain, nausea, vomiting or diarrhea. ROS otherwise
negative.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Type 2 Diabetes w/neuropathy, nephropathy, retinopathy chronic
- Diastolic CHF (___ Class III)
- CKD (baseline 2.4-2.8)
- OSA (Mask Choice: Swift II NV, BiPAP ___ EERS 100, 4L O2)
- Chronic restrictive ventilatory disease secondary to a bile
duct leak with pulmonary fibrosis requiring decortication
- PVD w/lower extremity claudication
- Anemia of chronic disease
- Spinal stenosis
- Severe degenerative arthritis
- BPH
- Glaucoma; on carbonic anhydrase inhibitor
- Cataracts, bilateraly, s/p surgical removal
- Depression
- Erectile dysfunction s/p penile implant ___
Past Surgical History:
- ___ Roux-en-y reconstruction after laparoscopic
cholecystectomy c/b damage to CBD
- ___ Decortication for fibrothorax complicated by respiratory
failure requiring tracheostomy
- Appendectomy
- Left knee/hip replacement
- L shoulder AC recection
- R total hip arthroplasty ___
Social History:
___
Family History:
___, h/o several strokes. Mother died in her ___ from
breast cancer. Father died at ___ from complications of
emphysema, CHF. All children in good health.
Physical Exam:
PHYSICAL EXAM
Vital Signs: Temp: 97.8 RR: 18 Pulse: 65 BP: 121/37
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound,
No hepatosplenomegally, No hernia, No AAA.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P. Ulnar: P. Brachial: P.
LUE Radial: P. Ulnar: P. Brachial: P.
RLE Femoral: P. Popiteal: P. DP: P. ___: D.
LLE Femoral: P. Popiteal: P. DP: D. ___: D.
Pertinent Results:
ADMISSION LABS
___ 07:34PM LACTATE-1.2
___ 07:22PM GLUCOSE-146* UREA N-47* CREAT-2.4*
SODIUM-147* POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-36* ANION
GAP-14
___ 07:22PM CRP-3.5
___ 07:22PM WBC-6.8 RBC-3.77* HGB-12.2* HCT-36.7* MCV-97
MCH-32.3* MCHC-33.2 RDW-14.1
___ 07:22PM NEUTS-77.6* LYMPHS-13.9* MONOS-5.2 EOS-2.3
BASOS-0.9
___ 07:22PM PLT COUNT-187
___ 07:22PM ___ PTT-30.9 ___
___ 07:22PM SED RATE-15
DISCHARGE LABS
___ 07:25AM BLOOD WBC-6.8 RBC-3.74* Hgb-12.3* Hct-36.0*
MCV-96 MCH-32.9* MCHC-34.2 RDW-14.1 Plt ___
___ 07:25AM BLOOD Glucose-149* UreaN-57* Creat-2.4* Na-141
K-4.3 Cl-97 HCO3-32 AnGap-16
___ 07:25AM BLOOD Calcium-8.6 Phos-4.6* Mg-2.1
___ 01:16AM BLOOD Vanco-16
IMAGING
Pre-op CXR ___:
FINDINGS: Again seen is mild cardiomegaly. The mediastinal and
hilar
contours are unchanged compared to prior. There continues to be
an area of volume loss on the left base and left lateral pleural
thickening/effusion. Again seen is a patchy area of infrahilar
opacity similar to prior that may represent atelectasis or
scarring.
IMPRESSION: No new infiltrate.
EKG ___
Sinus rhythm. Diffuse low voltage complexes. Cannot exclude old
inferoposterior myocardial infarction. No significant change
compared
to previous tracing of ___.
Foot x-rays ___:
IMPRESSION: Subcutaneous foci of air at the second distal
phalanx. Correlate for any signs of infection, recent
debridement or ulceration.
Findings paged to the nurse covering for Dr. ___ on ___, who was in the ___.
Non-invasive arterial studies ___:
INDICATION: ___ male with diabetic neuropathy, status
post toe
amputation, now with toe infection.
COMPARISON: ___.
TECHNIQUE: Bilateral lower extremity blood pressure
measurements, pulse
volume recordings, Doppler tracings.
FINDINGS: The apparent right ABI is 1.1. The left ABI cannot
be determined as the vessels are not compressible, likely from
calcification. Nonetheless, there are triphasic Doppler
tracings noted in bilateral femoral arteries, popliteal
arteries, posterior tibial arteries, and dorsalis pedis
arteries. The pulse volume recordings are essentially normal.
CONCLUSION: No evidence of large vessel arterial disease in the
legs. Some difficulty in obtaining ABI as above secondary to
noncompressible arteries.
MICRO
Blood cultures (___): pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.5 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
Please hold for SBP < 100 or HR < 60
7. Omeprazole 20 mg PO BID
8. Tamsulosin 0.8 mg PO DAILY
9. traZODONE 50 mg PO HS
10. Simvastatin 10 mg PO DAILY
11. Torsemide 50 mg PO DAILY
12. Diazepam 2 mg PO HS
13. Allopurinol ___ mg PO DAILY
14. Docusate Sodium 100 mg PO BID
15. pramipexole *NF* 0.125 mg Oral hs
16. LaMOTrigine 225 mg PO DAILY
17. Colchicine 0.6 mg PO DAILY
18. HYDROmorphone (Dilaudid) 2 mg PO BID
Please hold for RR < 12
19. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Calcitriol 0.5 mcg PO DAILY
5. Diazepam 2 mg PO HS
6. Finasteride 5 mg PO DAILY
7. LaMOTrigine 225 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
Please hold for SBP < 100 or HR < 60
9. Omeprazole 20 mg PO BID
10. Simvastatin 10 mg PO DAILY
11. Tamsulosin 0.8 mg PO DAILY
12. Colchicine 0.6 mg PO DAILY
13. 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
14. Ferrous Sulfate 325 mg PO DAILY
15. HYDROmorphone (Dilaudid) 2 mg PO BID
Please hold for RR < 12
16. pramipexole *NF* 0.125 mg Oral hs
17. Torsemide 50 mg PO DAILY
18. traZODONE 50 mg PO HS
19. Losartan Potassium 50 mg PO DAILY
20. Glargine 19 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
21. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
22. Senna 1 TAB PO BID
23. Metolazone 2.5 mg PO DAILY
24. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth Q ___ HOURS
Disp #*30 Tablet Refills:*0
25. Minocycline 100 mg PO BID
RX *minocycline [Dynacin] 100 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right second digit osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Right toe redness.
TECHNIQUE: Right foot, 2 views.
COMPARISON: ___.
FINDINGS:
The patient is status post amputation of the great toe at the level of the mid
proximal phalanx. No cortical destruction is identified to suggest
osteomyelitis. Extensive degenerative changes are seen involving the ___ MTP
joint with joint space narrowing, subchondral cysts, and osteophyte formation.
Degenerative changes are also seen diffusely involving the PIP and DIP joints,
as well as involving the midfoot. There are extensive vascular calcifications.
No fracture or dislocation is noted. Moderate size dorsal calcaneal spur is
visualized. Soft tissue swelling is most marked about the second toe. No
definite subcutaneous gas is present, and there are no radiopaque foreign
bodies.
IMPRESSION:
No radiographic evidence for osteomyelitis. No acute fracture or dislocation
is identified, but please note that evaluation is slightly limited as an
oblique view of the right foot was not obtained.
Radiology Report
INDICATION: ___ male with diabetic neuropathy, status post toe
amputation, now with toe infection.
COMPARISON: ___.
TECHNIQUE: Bilateral lower extremity blood pressure measurements, pulse
volume recordings, Doppler tracings.
FINDINGS: The apparent right ABI is 1.1. The left ABI cannot be determined
as the vessels are not compressible, likely from calcification. Nonetheless,
there are triphasic Doppler tracings noted in bilateral femoral arteries,
popliteal arteries, posterior tibial arteries, and dorsalis pedis arteries.
The pulse volume recordings are essentially normal.
CONCLUSION: No evidence of large vessel arterial disease in the legs. Some
difficulty in obtaining ABI as above secondary to noncompressible arteries.
Radiology Report
INDICATION: Diabetic neuropathy with question second toe infection.
COMPARISON: ___.
FINDINGS: There is soft tissue swelling and a few foci of subcutaneous air at
the level of the tuft of the second digit. No definite cortical destruction
or periosteal reaction. Status post partial amputation of first proximal
phalanx with severe degenerative changes of the first metatarsophalangeal
joint. There are heavy vascular calcifications. There are severe
degenerative changes of the tibiotalar joint.
IMPRESSION: Subcutaneous foci of air at the second distal phalanx. Correlate
for any signs of infection, recent debridement or ulceration.
Findings paged to the nurse covering for Dr. ___ on ___, who
was in the OR.
Radiology Report
CHEST ON ___
HISTORY: Infected right toe going to the OR, question effusion or
atelectasis.
REFERENCE EXAM: ___.
FINDINGS: Again seen is mild cardiomegaly. The mediastinal and hilar
contours are unchanged compared to prior. There continues to be an area of
volume loss on the left base and left lateral pleural thickening/effusion.
Again seen is a patchy area of infrahilar opacity similar to prior that may
represent atelectasis or scarring.
IMPRESSION: No new infiltrate.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RIGHT TOE INFECTION
Diagnosed with ULCER OF OTHER PART OF FOOT, CELLULITIS, TOE NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 97.6
heartrate: 75.0
resprate: 18.0
o2sat: 97.0
sbp: 131.0
dbp: 62.0
level of pain: 4
level of acuity: 3.0 | Pt was admitted for R second digit infection. IV antibiotics
(vanc/cipro/flagyl) were started on the night of admission and
pt had non-invasive vascular studies the following morning,
which showed no evidence of large vessel arterial disease in the
legs. Labs were drawn, which were essentially within normal
limits. Foot x-rays were concerning for osteomyelitis in the
distal ___ digit. On ___, pt taken to OR for digit
amputation. Pt tolerated the procedure well and was discharged
on a two-week course of minocycline. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
PO intolerance, nausea, vomiting
Major Surgical or Invasive Procedure:
___: EGD
.
___: Exchange of a gastrostomy for an 18 ___ MIC
gastrojejunostomy tube.
History of Present Illness:
We had the pleasure of seeing Mr. ___ in the ___ Pancreas
and Liver Institute today. As you know, he is a ___ year old man
with a history of longstanding iron deficiency anemia and B12
deficiency with a 2.5cm mass in D2 with poorly differentiated
adenocarcinoma. He underwent a pylorus sparing radical
pancreaticoduodenectomy with en bloc resection of the transverse
mesocolon and placement of fiducials on ___ and presents
today for follow up.
He had a protracted ___ operative course secondary to oral
intolerance and delayed gastric emptying that required a PEG
tube
placement for nausea control purposes. He was also discharged
home on total parenteral nutrition (discharged on ___.
He had an upper GI study completed yesterday which reveals very
slow and minimal passage of contrast through the pylorus with no
dilation of the stomach. They have been venting his g-tube each
night since he was discharged from the hospital and each night
it
puts out anywhere between 400-600cc of green appearing fluid. He
keeps his G tube clamped during the day but still has episodes
of
emesis.
In terms of his nutrition he was not able to get TPN on ___
or ___ night due to ___ issues. He was able to get TPN on
___. Then on ___ his PICC line was
not functioning. He feels dehydrated and reports worsening
nausea
and dry heaving afer the study was completed. He denies fevers,
chills, or shortness of breath. He denies leg swelling.
Past Medical History:
HTN/HLD, paroxysmal atrial fibrillation on Coumadin,
pre-diabetes, BPH, GERD, lower back pain with R-sided sciatica,
colonic adenomas, s/p appendectomy (___) and removal of testis
___, he says this was in ___ for a testicle that got out
of position and may have not been necessary)
Social History:
___
Family History:
Mother had CLL which transformed, she died in her ___. Father,
4 brothers, 1 sister, and 3 children all without any history of
cancer.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
VS: 98.2, 78, 110/67, 18, 95% RA
GEN: Pleasant with NAD
HEENT: NC/AT, PERRL, EOMI, no scleral icterus
CV: Irregular rhythm with normal rate.
PULM: CTAB
ABD: Subcostal incision healed well. Midline G/J-tube capped,
site with drain sponge and c/d/I.
EXTR: Warm, no c/c/e
Pertinent Results:
RECCENT LABS:
___ 09:45AM BLOOD WBC-4.9 RBC-3.03* Hgb-8.1* Hct-26.6*
MCV-88 MCH-26.7 MCHC-30.5* RDW-16.1* RDWSD-50.7* Plt ___
___ 09:45AM BLOOD Glucose-103* UreaN-14 Creat-0.9 Na-138
K-5.3 Cl-101 HCO3-26 AnGap-11
___ 05:07AM BLOOD ALT-30 AST-25 AlkPhos-193* TotBili-0.2
___ 09:45AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.2
MICRO:
___ 10:59 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (___), ___
@ 13:33.
RADIOLOGY:
___ CT ABD:
IMPRESSION:
1. Small low-density lesion in the hepatic dome seem slightly
larger measures 0.7 cm, previously 0.5 cm. This is incompletely
characterized on this exam.
2. Interval improvement of subsegmental left lower lobe
atelectasis with few areas focal hypoenhancing which could be
due to retained secretions or small areas of infection.
3. Interval resolution of small right pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Tamsulosin 0.4 mg PO QHS
3. Acetaminophen 650 mg PO TID
4. Enoxaparin Sodium 60 mg SC Q12H
5. Lidocaine 5% Patch 1 PTCH TD QPM back pain
6. Metoclopramide 5 mg PO QID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
10. Pantoprazole 40 mg PO Q12H
11. Blood Glucose Monitoring (blood-glucose meter) 1 kit
miscellaneous Q6H
12. GenStrip Test Strip (blood sugar diagnostic) 1 strip
miscellaneous Q6H
13. lancets 28 gauge miscellaneous Q6H
14. Montelukast 10 mg PO DAILY
15. Rosuvastatin Calcium 5 mg PO QPM
16. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit
oral TID W/MEALS
2. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit
oral TID W/MEALS
RX *lipase-protease-amylase [Creon] 24,000 unit-76,000
unit-120,000 unit 3 capsule(s) by mouth TID W/MEALS Disp #*300
Capsule Refills:*3
3. Sulfameth/Trimethoprim DS 2 TAB PO/NG BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
5. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Pantoprazole 40 mg PO Q24H
7. Enoxaparin Sodium 60 mg SC Q12H
RX *enoxaparin 60 mg/0.6 mL 60 mg SC every twelve (12) hours
Disp #*60 Syringe Refills:*1
8. Finasteride 5 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Montelukast 10 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Rosuvastatin Calcium 5 mg PO QPM
13. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Adenocarcinoma, intestinal type
2. Delayed gastric emptying
3. Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with malfunctioning PICC line, weakness// Please evaluate for
pneumonia or effusion, please evaluate PICC line placement
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Right PICC is seen with tip in the right atrium. If withdrawn by 2.5 cm it
would be closer to the superior cavoatrial junction. Opacity over the
posterior costophrenic angle on the lateral localizes to the left based on the
frontal view, improved since prior. The right lung is clear.
Cardiomediastinal silhouette is within normal limits. Peg tube projects over
the upper abdomen. No acute osseous abnormalities.
IMPRESSION:
Right PICC tip over the right atrium. Improving left basilar opacity.
Radiology Report
INDICATION: ___ with pancreatic adenoCA now s/p Whipple and cholecystectomy
c/b delayed gastric emptying// GJ exchange using existing PEG tube tract
COMPARISON: No relevant comparisons available.
TECHNIQUE: OPERATORS: Dr. ___ the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 50 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: 30 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 36.4 min, 210 mGy
PROCEDURE: 1. Exchange of a gastrostomy for an 18 ___ MIC
gastrojejunostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. 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.
The existing tube was injected with contrast and showed opacification of the
gastric rugae. The stay sutures were cut. A ___ wire was advanced through
the tube into the stomach. The existing tube was then removed using gentle
traction. Using a Kumpe catheter and glidewire, access was obtained into the
jejunum. A 18 ___ gastrojejunostomy tube was advanced over the wire into
the distal duodenum and the balloon was inflated using contrast diluted in
sterile water. Contrast injection confirmed appropriate position. 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. 18 ___ MIC gastrojejunostomy tube in the jejunum.
IMPRESSION:
Successful exchange of a gastrostomy tube for a new 18 ___ MIC
gastrojejunostomy tube. The tube is ready to use.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ 1 mo s/p whipple, new GJ replacement, rising WBC, eval
placement of GJ and r/o abscess. PO and IV contrast please (OK to give PO
contrast via g-tube)// evaluate GJ placement, abscess. PO and IV contrast (ok
to give PO contrast via G tube)
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 541 mGy-cm.
COMPARISON: Multiple prior CTA abdomen and pelvis examinations most recent
dated ___
FINDINGS:
LOWER CHEST: Small right pleural effusion has resolved. Moderate size left
pleural effusion has improved with a small left pleural effusion remaining.
There is interval improvement of subsegmental left lower lobe atelectasis with
few areas focal hypoenhancing noted. 4 mm right middle lobe pulmonary nodule
(series 2, image 3), unchanged.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. 1.5
cm right hepatic lobe cyst is unchanged. There is a 0.7 cm low-density lesion
in the hepatic dome (series 2, image 7) has increased in size from prior exam
which measured 0.5 cm. There is no new evidence of focal lesions. Patient is
status post hepaticojejunostomy. Postoperative fluid collections in hepatic
hilum have improved with no ring-enhancing collection is seen to suggest
abscess. There is no evidence of intrahepatic biliary dilatation. The
gallbladder is surgically absent.
PANCREAS: Patient is status post Whipple procedure. There is atrophy of the
remaining body and tail of pancreas similar to prior exam. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding. A
Fiducial marker is seen anterior to the IVC.
SPLEEN: The spleen shows normal size, without evidence of focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape. There is
nodular thickening of left adrenal gland, unchanged.
URINARY: The kidney is unremarkable except for multiple bilateral simple
cysts..
GASTROINTESTINAL: Patient is status post pylorus sparing Whipple Procedure.
There is a gastrojejunostomy tube in place. The remaining bowel is normal in
appearance with no evidence obstruction
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Small low-density lesion in the hepatic dome seem slightly larger measures
0.7 cm, previously 0.5 cm. This is incompletely characterized on this exam.
2. Interval improvement of subsegmental left lower lobe atelectasis with few
areas focal hypoenhancing which could be due to retained secretions or small
areas of infection.
3. Interval resolution of small right pleural effusion.
RECOMMENDATION(S): Recommend further evaluation with liver MR after
improvement in ___ condition, preferably in no more than 1 month.
Radiology Report
EXAMINATION: G/GJ/GI TUBE CHECK
INDICATION: ___ male please check J-tube position. Please bring
gastrografin to the bed side. Thank you
TECHNIQUE: Multiple supine abdominal radiographs were performed on the floor
prior to and status post injection of a gastrojejunostomy tube
COMPARISON: CT abdomen pelvis dated ___ and percutaneous GJ tube
check performed ___.
FINDINGS:
3 supine radiographic images of the abdomen are provided. The initial scout
image demonstrates contrast filling nondilated loops of colon, likely from
patient's recent CT abdomen pelvis from ___. Multiple surgical
clips are seen in the right upper quadrant. A gastrojejunostomy tube is
visualized overlying the left hemiabdomen, with the tip seen in the mid lower
abdomen. Evaluation of free intraperitoneal air is limited on this supine
only projection. No concerning osseous lesions are identified.
The second portable abdominal radiographs performed after the jejunostomy port
was injected at 08:55 on ___ demonstrates contrast in the left
hemiabdomen opacifying gastric rugae, with no definite intraluminal contrast
seen within small bowel loops. No evidence of extraluminal contrast.
The third portable abdominal radiograph performed after the gastrostomy port
was injected at 08:57 on ___ demonstrates contrast opacification
in the left upper quadrant within the stomach.
IMPRESSION:
Multiple serial abdominal radiograph status post injection of a
gastrojejunostomy tube demonstrate contrast only within the gastric lumen,
consistent with proximal migration of the gastrojejunostomy tube.
The findings were discussed with ___, M.D. by ___, M.D.
on the telephone on ___ at 9:32 am, 5 minutes after discovery of the
findings.
Radiology Report
INDICATION: ___ with pancreatic adenoCA now s/p Whipple and cholecystectomy
c/b persistent nausea, emesis, malnutrition with GJ placed by ___ on ___
now with tube study suggesting that the J is in the stomach.// Could we
reposition? Thanks! (overnight tube feeds were found coming out of the G tube
which was to gravity)
COMPARISON: Previous G-J exchange
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 25 mins during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: 20 ml of OPTIRAY contrast
FLUOROSCOPY TIME AND DOSE: 10 min, 105 mGy
PROCEDURE: - MIC gastrojejunostomy attempted placement
- MIC ___ G-tube placed
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
The existing tube was injected with contrast and showed opacification of the
gastric rugae. The jejunal component was flipped into the stomach. The
existing feeding tube was then removed. A sheath was placed. A C2
glidecatheter was then introduced over the wire. A glidewire combination was
utilized to navigate to the jejunum. A wire was placed distal into the
jejunum and a ___ MIC G-J tube advanced into place. However, upon removal of
the wire and fluoroscopy check, the tube had already flipped into the stomach.
Further attempts were not made given the overwhelming likelihood of repeat
migration. A ___ g-tube was then placed into the stomach. The catheters
balloon was inflated with 7 ml of contrast contrast diluted in sterile water
and locked in the stomach after confirming the position of the catheter with a
contrast injection. The catheter was then flushed, capped. Sterile dressings
were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Continual migration of G-J tube into the stomach, therefore G-tube left
IMPRESSION:
Continual migration of G-J tube back into the stomach. Unable to maintain G-J
access with the current track access into the stomach. Therefore, G tube left
in stomach currently. If a GJ tube is needed, recommend a new enteric access
for better angulation and positioning.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Back pain, Vomiting, Weakness
Diagnosed with Dehydration, Weakness
temperature: 98.3
heartrate: 111.0
resprate: 18.0
o2sat: 99.0
sbp: 106.0
dbp: 61.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ was sent to the ED from clinic on ___ with
dehydration in the setting of not being able to get his TPN due
to a nonfunctioning PICC line. Upon arrival to our ED his PICC
was able to be accessed and he was given fluids.
Gastroenterology was consulted for EGD and possible GJ tube
exchange. Per GI they would want to wait 6 weeks from PEG tube
placement so EGD was deferred to as an outpatient. ___ was
consulted on ___ for placement of a GJ tube. This was
successfully accomplished on ___ and he was transitioned off
TPN to tube feeds.
After starting tube feeds, he developed an episode of
hypotension and was febrile to 100.2. Broad spectrum antibiotics
including vancomycin, cefepime and flagyl were started. His PICC
line was discontinued. Blood cultures eventually grew sensitive
E. coli. Infectious disease was consulted and recommended a 2
week course of Bactrim from last negative blood cultures. Blood
cultures were with no growth since ___. His vitals
remained stable throughout his remainder hospitalization and he
has been afebrile.
His tube feeds were cycled on ___. Hpwever, the morning of
___, his G tube was unclamped due to nausea and 600cc of
tube feeds had come out of the G tube. A drain study verified
that the J tube had been dislodged and was no in the stomach.
Per interventional radiology, a new site would have to be used.
The patient was given a subsequent trial of PO. He was started
on fulls on ___ and advanced to a soft mechanical diet on
___ with good results. However he was not taking in enough to
nutritionally sustain himself and he eventually tube feeds was
restarted overning to provide 50% daily calories. He continued
to tolerate PO around the feeds.
He was eventually discharged home on ___ with plans for
outpatient follow up. The patient and family verbalized
understanding and were agreeable with the plan moving forward.
All questions were answered to their satisfaction. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Codeine / Lisinopril
Attending: ___
Chief Complaint:
severe progressive headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
The pt is a ___ M with history of Pancreatitis, Diabetes, HTN,
Depression, Anxiety, Chronic left hip and back pain, Migraines,
who presents with 6 days of severe headache, initially
intermittent and now constant. Patient reports that headache
started last ___. Initially pain was on left side of head and
was burning and then excrutiating, radiating to ___, lasting
about 1.5 hours at a time, and would come and go. On ___
around 3am he woke up from sleep from the pain, now on the right
side of his head. Felt like skewer from back of head out his
right eye and then from temple to temple. Headache persisted and
became more and more intense and now constant. Patient tried
Excedrin and Oxycodone at home without relief. Of note, he did
run out of home meds recently so has not had BP meds or
Gabapentin. No recent illness that he recalls. Now pain is
constant, ___, stabbing and painful and hollow, and feels like
it has a grip on him and won't let go. Patient also with severe
photophobia, unable to open eyes secondary to pain. Denies
diplopia or blurred vision. Describes burning on right side of
face but no numbness or tingling elsewhere. No weakness. No
positional component to headache. No gait instability. No speech
changes.
Of note, in ___, patient was admitted with similar headache and
required Demerol and Vistaril for control with headache
subsiding
over a couple of days.
On neuro ROS, the pt reporst headache, burning, photophobia as
above. No loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PMH:
- chronic pancreatitis
- T2DM
- Hypertension
- Left hip pain d/t ___ problem treated
conservatively
- Possible schizoaffective disorder
- Peripheral neuropathy
- Migraines
- Depression
- Anxiety
- Schizophrenia
- Chronic low back pain; degenerative disc disease
- Hypertriglyceridemia
- History of alcohol abuse
- Gout
- Recurrent left lower quadrant pain with diverticulitis
- History of unexplained chronic pancreatitis w/ acute
exacerbations
- Occasionally has flares which on CT scan appear to show
inflammation of his terminal ileum and cecum which is located in
the left lower quadrant because of congenital malrotation of his
gut
- Sleep disorder - states he has sleep apnea but doesn't like
mask
- History of chronic renal failure (in ___, when first
diagnosed w DM)
- Neck abscess drainage in ___ - neck abscess d/t seatbelt
injury.
Social History:
___
Family History:
No FH migraines or neurological problems.
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.4 P: 86 BP: 170/96 RR: 18 SaO2: 100% RA
General: In distress with ice pack over right eye
HEENT: NC/AT, eyes closed, MMM, clear oropharynx
Neck: Supple, no nuchal rigidity. No carotid bruits
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, able to name
___
backward without difficulty. Able to relate history without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. Speech was not dysarthric. Able
to follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Unable to test VF given intense
photophobia.
III, IV, VI: EOMF without nystagmus.
V: Facial sensation decreased to LT, PP, temp over V1/V2/V3,
splits midline
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 and has symmetric strengh.
-Motor: Normal bulk, tone throughout. No pronator drift. No
adventitious movements. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation
throughout. Decreased vibratory sense and proprioception at toes
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF.
-Gait: Not assessed.
Pertinent Results:
___ 01:30PM GLUCOSE-114* UREA N-15 CREAT-0.9 SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-22 ANION GAP-16
___ 01:30PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-60 TOT
BILI-0.3
___ 01:30PM CALCIUM-8.8 PHOSPHATE-4.6* MAGNESIUM-1.6
___ 01:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:30PM WBC-5.7 RBC-3.60* HGB-10.8* HCT-33.4* MCV-93
MCH-30.0 MCHC-32.3 RDW-13.6
___ 01:30PM NEUTS-83* BANDS-0 LYMPHS-17* MONOS-0 EOS-0
BASOS-0 ___ MYELOS-0
___ 01:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 01:30PM ___ PTT-33.6 ___
___ 01:30PM SED RATE-8
___ 11:16PM GLUCOSE-86 UREA N-9 CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-21* ANION GAP-19
___ 11:16PM estGFR-Using this
___ 11:16PM WBC-4.0 RBC-4.04* HGB-12.4* HCT-37.1* MCV-92
MCH-30.8 MCHC-33.5 RDW-13.8
___ 11:16PM NEUTS-27* BANDS-0 LYMPHS-61* MONOS-2 EOS-2
BASOS-2 ATYPS-6* ___ MYELOS-0
___ 11:16PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL PENCIL-OCCASIONAL TEARDROP-OCCASIONAL
___ 11:16PM PLT SMR-NORMAL PLT COUNT-152
CT head w/o contrast (___): 1. No acute intracranial
abnormality.
2. Opacification of the right mastoid air cells may represent
mastoiditis or eustachian tube dysfunction. There is no
evidence of bony remodeling.
MRI brain (___):
1. There is a vein crossing the trigeminal nerve root entry
zones on each side. Similar findings may be associated with
trigeminal neuralgia, but may also be seen in asymptomatic
patients, and clinical correlation is needed.
2. Chronic opacification of right mastoid air cells with
apparent viscous material, without evidence for osseous
destruction on the preceding CT scan, and without middle ear
cavity involvement. Please correlate clinically with any signs
of chronic infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO TID
2. Mirtazapine 45 mg PO HS
3. Aspirin 325 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Perphenazine 4 mg PO 1 (ONE) TABLET(S) BY MOUTH QAM, 2 PO QHS
6. GlipiZIDE 2.5 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
8. Allopurinol ___ mg PO DAILY
9. Gemfibrozil 600 mg PO BID
10. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atenolol 100 mg PO DAILY
RX *atenolol 50 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
5. Gemfibrozil 600 mg PO BID
6. GlipiZIDE 2.5 mg PO DAILY
7. Mirtazapine 45 mg PO HS
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
9. Omeprazole 20 mg PO DAILY
10. Perphenazine 4 mg PO 1 (ONE) TABLET(S) BY MOUTH QAM, 2 PO
QHS
11. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth TID: prn Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary headache
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with severe headaches, evaluate for intracranial
hemorrhage.
COMPARISON: ___.
TECHNIQUE: Non-contrast axial MDCT images through the head with coronal and
sagittal reformations.
DLP: 891 mGy-cm.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or infarction.
Ventricles and sulci are normal in size and configuration. Basilar cisterns
are patent. Gray-white matter differentiation is preserved.
No fracture is identified. Partially imaged paranasal sinuses demonstrate
mild mucosal thickening within the ethmoid air cells. The right mastoid air
cells are partially opacified. The left mastoid air cells and middle ear
cavities are clear. Orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Opacification of the right mastoid air cells may represent mastoiditis or
eustachian tube dysfunction. There is no evidence of bony remodeling.
NOTE ADDED IN ATTENDING REVIEW: The fluid-opacification of many of the right
mastoid air cells is not significantly changed from the non-enhanced MR study
of ___, when there was no definite corresponding slow diffusion. This is
unlikely to reflect eustachian tube dysfunction, as the ipsilateral middle ear
cavity is completely clear.
Correlate with clinical signs of mastoiditis.
Radiology Report
MRI BRAIN WITH AND WITHOUT CONTRAST, ___
INDICATION: ___ man with severe headache, question of trigeminal
neuralgia. Evaluate for compression of trigeminal nerves.
COMPARISON: Non-contrast head CT performed earlier on the same day, and ___ brain MRI.
TECHNIQUE: Sagittal T1-weighted, and axial diffusion-weighted and FLAIR
images of the brain were obtained. High-resolution axial T2-weighted gradient
echo three-dimensional images through the cranial nerves were obtained with
coronal reformations. Following intravenous gadolinium administration, axial
MP-RAGE images of the brain with multiplanar reformations, axial T1-weighted
images of the brain, and coronal high-resolution T1-weighted images through
the cranial nerves, were obtained.
FINDINGS: Artifacts at the vertex are noted on the current MRI as well as on
the ___ MRI. These are likely related to the patient's dreadlocks, which are
seen on the CT scan earlier today, and which were also noted in the MR
technologist notes in ___.
There is no evidence for a mass or abnormal contrast enhancement along the
trigeminal nerves. Trigeminal nerves appear symmetric in size and signal
intensity. There is a vein crossing the trigeminal nerve root entry zone on
each side.
There is no evidence of signal abnormalities in the brainstem or elsewhere in
the brain parenchyma on diffusion-weighted, FLAIR, or post-contrast images.
Ventricles, sulci, and basal cisterns are normal in size for age.
There is mild mucosal thickening in bilateral ethmoidal air cells. There is
opacification of right mastoid air cells with a T1 and T2 hyperintense
material, indicating viscous material rather than simple fluid. The preceding
CT demonstrates no evidence for osseous erosion. Bilateral middle ear
cavities and left mastoid air cells are clear.
IMPRESSION:
1. There is a vein crossing the trigeminal nerve root entry zones on each
side. Similar findings may be associated with trigeminal neuralgia, but may
also be seen in asymptomatic patients, and clinical correlation is needed.
2. Chronic opacification of right mastoid air cells with apparent viscous
material, without evidence for osseous destruction on the preceding CT scan,
and without middle ear cavity involvement. Please correlate clinically with
any signs of chronic infection.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Headache
Diagnosed with HEADACHE
temperature: 98.4
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: nan
dbp: nan
level of pain: 10
level of acuity: 3.0 | ___ M with history of Pancreatitis, Diabetes, HTN, Depression,
Anxiety, Chronic left hip and back pain, Migraines, who presents
with 6 days of severe headache, initially intermittent and now
constant. Progressed from intermittent burning left sided
headache to constant stabbing and intense right sided headache.
Woke from sleep once.
Differential includes migraine headache given unilateral,
throbbing, with photophobia and nausea. Also prior history of
migraines. However, burning sensation, on right side of face and
eye and jaw, is also suspicious for trigeminal neuralgia. Other
possible headaches include: primary stabbing headache, cluster
headache.
Neuro: Obtained NCHCT and MRI brain, both unremarkable.
Restarted home Gabapentin. Started Indomethacin and initially
Amitrityline, later stopped given psychiatric history. Limited
opioids given on narcotic contract. Pain team consulted and
after discussion with PMD, increased oxycodone dose by 50% for
duration of hospitalization, although this helped with back
pain, not headache. Trialed occipital nerve blocks twice and
preauricular nerve block once given positive trigger points with
some headache relief. Also trialed Toradol, Compazine and
Magnesium per pain team recommendations. Headache improved
throughout hospitalization.
CV: Increased Atenolol to 100mg po daily for BP control given
persistently hypertensive.
Endo: Started ISS for hyperglycemia. To discharge on home
Gemfibrozil and Glipizide. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
C5 fracture, admission for syncope work up
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Reliability: Patient with underlying dementia, AAOx1. Collateral
information obtained from HCP.
___ dementia, CLL, atrial fibillation that was transferred from
___ for spine fracture evaluation.
He apparently experienced an unwitnessed fall, but may have had
a syncopal episode. When he was found on the floor, he was
conscious and mentating well. The story is not clear given
underlying dementia. CT Neck revealed a cervical spine fracture.
He was hospitalized in ___ for urinary retention with a
urinary tract infection with indwelling foley catheter since
that time.
Patient lives in assisted-living, has help with ADLs/AIDLs. He
does not use any assistive devices except glasses. Patient has
fallen once in the past in setting of illness about ___ years
ago.
He states that he remembered the whole episode this morning. He
denies any associated chest pain/discomfort, shortness of
breath, "black outs," warmness, seizure activity. He states that
he was looking for something and "went to the ground." He denies
loss of consciousness and remembers the entire event. He states
that someone found him on the floor.
His main concern is right posterior shoulder pain.
In the ED, initial VS: 16:17 T 97.8 HR 80 BP 143/74 RR 18 pOx
98%
Exam was significant for non-focal neurological exam, normal
rectal tone, and t-spine tenderness.
Imaging showing CT chest and CT abdomen showed no definite acute
findings. There was trace right pleural effusion with widespread
osseous changes with expansion of medullary spaces and cystic
and sclerotic change consistent with fibrous dysplasia. Several
vertebral bodies that demonstrate these changes, have wedge
compression deformities which are age indeterminate. There are
however no retropulsion of fragments or hematoma identified.
___ hospital imaging reports were not available for review in
the chart sent to the floor.
Labs were performed showing WBC 59.6 (unknown baseline, ? from
CLL), Hgb 10 (unknown baseline) Plt 176 Diff N13,L80,Atyps4.
Chem was within normal limits except glucose 164. LFTs were
within normal limits including lipase. TropnT < 0.01.
UA was significant for SpG > 1.050, nit neg, Leuks moderate, RBC
20, WBC 99 with no bacteria, epi 1, hyaline cast 4
The neurosurgery service was consulted for the C5 lamina
fracture and bilateral pedicle fracture of C5. Impression was
perfect anatomical alignment, non-displaced. They advised a
medium aspen hard collar at all times for 6 weeks, pain control,
and muscle relaxant prn.
He was given 1 L NS and morphine 4 mg IV x 1.
Given the uncertain nature of the story, he was admitted for a
syncope work-up.
VS on transfer: 98.0, 96, 133/72, 18, 97% RA
Currently, he confirms the above story and concerns.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- atrial fibrillation
- ? prior MI based on ECG or ECHO
- benign prostatic hypertrophy with urinary retention
- CLL
Followed at ___ (Dr. ___. Uncertain
treatment history
Social History:
___
Family History:
Unable to relate.
Physical Exam:
Admission:
VS - T 96.8 PO, BP 148/77, HR 94, pOx 94 RA
GENERAL - NAD, non-toxic, in pain
HEENT - NC/AT, PERRLA, EOMI, mucous membranes were very dry with
tongue stuck to mouth
NECK - ___ J collar in place limiting exam. There is
tenderness to palpitation on C-spine.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use. Unable to assess posterior
lung fields due to patient cooperation.
HEART - Distant heart sounds, regular rate and rhythm
ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding
Some tenderness in the right lower quandrant
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox1 (to person, ___, "Room 17"), CNs
III-XII grossly intact. Patient unable to cooperate fully with
strength testing. On right and left UE, at least ___, testing on
right limited secondary to should pain.
MSK: Right shoulder with posterior pain on scapula
LABS: See below.
Discharge:
VS - 96.4-97.8, 92-140/61-81, 58-150, 95-96%RA
___
GENERAL - NAD, non-toxic.
HEENT - NC/AT, PERRLA, EOMI, mucous membranes still dry, but
improving
NECK - ___ J collar in place limiting exam. There is
tenderness to palpitation on C-spine and with movement.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use. Unable to assess posterior
lung fields due to not wanting to disrupt patient and put her in
pain.
HEART - Distant heart sounds, regular rate and rhythm
ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding
Some tenderness in the right lower quandrant
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs III-XII grossly intact. Patient unable
to cooperate fully with strength testing. On right and left UE,
at least ___, testing on right limited secondary to should pain.
MSK: Right shoulder with posterior pain on scapula
Pertinent Results:
___ 05:05PM BLOOD WBC-59.6* RBC-3.63* Hgb-10.0* Hct-29.9*
MCV-82 MCH-27.5 MCHC-33.4 RDW-15.9* Plt ___
___ 06:50AM BLOOD WBC-54.2* RBC-3.57* Hgb-9.8* Hct-30.1*
MCV-84 MCH-27.4 MCHC-32.5 RDW-16.6* Plt ___
___ 06:26AM BLOOD WBC-38.7* RBC-3.22* Hgb-8.8* Hct-27.3*
MCV-85 MCH-27.2 MCHC-32.2 RDW-15.9* Plt Ct-84*
___ 06:30AM BLOOD WBC-37.3* RBC-2.71* Hgb-7.6* Hct-23.2*
MCV-85 MCH-28.1 MCHC-32.9 RDW-16.3* Plt Ct-79*
___ 05:05PM BLOOD Neuts-13* Bands-0 Lymphs-80* Monos-3
Eos-0 Baso-0 Atyps-4* ___ Myelos-0
___ 06:50AM BLOOD Neuts-23* Bands-0 Lymphs-69* Monos-8
Eos-0 Baso-0 ___ Myelos-0
___ 02:18AM BLOOD ___ PTT-31.0 ___
___ 06:59PM BLOOD Ret Aut-1.5
___ 05:05PM BLOOD Glucose-164* UreaN-22* Creat-1.0 Na-140
K-3.7 Cl-100 HCO3-26 AnGap-18
___ 06:50AM BLOOD Glucose-117* UreaN-17 Creat-1.0 Na-141
K-4.1 Cl-105 HCO3-25 AnGap-15
___ 06:26AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-139
K-3.9 Cl-106 HCO3-26 AnGap-11
___ 05:05PM BLOOD ALT-26 AST-26 AlkPhos-69 TotBili-0.5
___ 06:59PM BLOOD LD(LDH)-117 TotBili-0.6 DirBili-0.2
IndBili-0.4
___ 05:05PM BLOOD Lipase-22
___ 05:05PM BLOOD cTropnT-<0.01
___ 06:50AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:50AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1
___ 05:50AM BLOOD Calcium-8.0* Phos-1.5*# Mg-1.9
___ 06:26AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.0
___ 06:59PM BLOOD Hapto-239*
___ 05:05PM BLOOD Digoxin-0.3*
___ 02:13PM URINE Color-Straw Appear-Hazy Sp ___
___ 02:13PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 02:13PM URINE RBC-41* WBC->182* Bacteri-FEW Yeast-NONE
Epi-3 TransE-<1
___ 09:00PM URINE CastGr-3*
___ 09:10PM URINE Color-Straw Appear-Clear Sp ___
___ 09:10PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 09:10PM URINE RBC-20* WBC-99* Bacteri-NONE Yeast-NONE
Epi-1
___ 9:00 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Blood cultures pending x2
EKG ___
The rhythm is probably sinus rhythm. Marked baseline artifact.
Left anterior fascicular block. No previous tracing available
for comparison
CT abdomen/ pelvis ___
INDICATION: Fall. Known C5 fracture. Dementia.
TECHNIQUE: Multidetector helical CT scan of the chest, abdomen,
and pelvis
was obtained after the administration of 130 cc IV Omnipaque
contrast.
Coronal and sagittal reformations were prepared.
COMPARISON: None available.
FINDINGS:
CHEST: There is a small right pleural effusion which appears
simple.
Additionally, there is mild bibasilar atelectasis. No evidence
of pulmonary contusion is seen. No pneumothorax is present. The
heart is mildly enlarged without evidence of pericardial
effusion. There are coronary artery and aortic calcifications.
The aorta is tortuous, however, not aneurysmally dilated. No
evidence of endobronchial lesion is seen. No lymphadenopathy is
identified. Note is made of fluid within the esophagus.
ABDOMEN: The liver, gallbladder, spleen, pancreas, adrenal
glands, and
kidneys appear grossly unremarkable. Loops of small and large
bowel are
normal in size and caliber with note made of fecal loading
within the large bowel. No abdominal free air, free fluid, or
lymphadenopathy is seen.
PELVIS: Distal loops of large bowel and rectum are normal in
size and caliber with note made of extensive fecal loading.
There is diverticulosis without evidence of diverticulitis. The
bladder is collapsed around a Foley catheter. There is, however,
the appearance of circumferential wall thickening of the
bladder. An oblong calcification measuring 9 x 3 mm near the
left inferior margin of the bladder (2:103) could represent a
bladder stone. The distal ureters are not dilated. The prostate
gland is enlarged measuring up to 5.2 cm in diameter. The aorta
is tortuous with ectasia of the infrarenal portion; however, no
aneurysmal dilation. Calcifications are seen throughout the
abdominal aorta extending into the iliac arteries.
There is a fat-containing left inguinal hernia. No pelvic free
air, free
fluid, or lymphadenopathy is identified.
At the inferior margin of the imaging volume, note is made of
fluid-filled
tubular structures along the perineum and extending into the
base of the
pemis, of unclear etiology (2:18).
Bone windows demonstrate Pagetoid changes with thickened
expanded cortex,
thickened disordered trabeculation of multiple bones including
the scapulae, T8, T10, T11, L1, and L4 vertebral bodies. Similar
findings are seen in the sacrum, the pelvis, and multiple
bilateral ribs. Note is made of compression deformities in the
involved vertebral bodies, greatest at the T11 level where the
is acute kyphosis. No acute fracture is identified. No
retropulsion of fragments is seen. There are multiple remote
bilateral rib fractures.
IMPRESSION:
1. No definite acute traumatic findings.
2. Pagetoid disease of bone as detailed without acute fracture.
Compression deformities in the spine appear chronic.
3. Trace right pleural effusion. Mild cardiomegaly.
4. Partially imaged fluid-filled distended corpora cavernosa of
unclear
etiology or significance. Clinical correlation and, if
indicated, correlation with ultrasound recommended.
5. Fluid within the esophagus, which could predispose to
aspiration.
___ 11:27 AM RIGHT SHOULDER STUDY
No prior shoulder radiographs for comparison. Comparison is made
to the
imaged portion of the right shoulder from a prior CT torso of
___.
FINDINGS: The patient was unable to cooperate with standard
radiographic
positioning due to pain and difficulty understanding
instructions from the
technologist. With this limitation in mind, no definite acute
fracture or
dislocation is identified. Degenerative changes are present at
the
acromioclavicular joint. Note is also made of findings
suggestive of Paget's
disease including bony expansion and coarsened trabeculation
involving
portions of the right scapula with a relatively similar
appearance
demonstrated on recent CT torso of 1 day earlier. This is most
marked in the
region of the acromion and coracoid processes as well as the
glenoid.
IMPRESSION:
1. Limited radiograph demonstrating no gross evidence of
fracture or
dislocation. If symptoms persist, repeat radiographs with
standard
positioning would be recommended when the patient's condition
permits.
2. Findings suggestive of Paget's disease.
EKG ___
Atrial fibrillation with rapid ventricular response. Since the
previous tracing atrial fibrillation is now again seen with more
marked ST-T wave abnormalities related to sinus rhythm.
Otherwise, findings are unchanged.
Medications on Admission:
- digoxin 0.25 mg PO ___
- proscar 5 mg PO qD
- folic acid 5 mg PO qD
- flomax 0.4 mg PO qHS
- KCl 10 mg PO qD
- Multivitamin PO qD
- Caltrate 600 D BID
- alendronate 70 mg PO q ___
- simvastatin 80 mg PO qHS
- buthethamide 1 mg PO qD
- tylenol prn pain
Discharge Medications:
1. digoxin 250 mcg Tablet Sig: One (1) Tablet PO ___,
___ ().
2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Caltrate 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
6. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
On ___.
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One
(1) Topical once a day as needed for pain: As needed for pain
12 hours on, 12 hours off.
9. acetaminophen 500 mg Tablet Sig: ___ Tablets PO once a day as
needed for fever or pain.
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: hold for sedation, RR<10.
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: C5 cervical fracture, paget's disease of the bone,
atrial fibrillation, advanced dementia
Secondary: Hypertension, hyperlipidemia, benign prostatic
hypertrophy, chronic lymphocytic leukemia
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: Fall. Known C5 fracture. Dementia.
TECHNIQUE: Multidetector helical CT scan of the chest, abdomen, and pelvis
was obtained after the administration of 130 cc IV Omnipaque contrast.
Coronal and sagittal reformations were prepared.
COMPARISON: None available.
FINDINGS:
CHEST: There is a small right pleural effusion which appears simple.
Additionally, there is mild bibasilar atelectasis. No evidence of pulmonary
contusion is seen. No pneumothorax is present. The heart is mildly enlarged
without evidence of pericardial effusion. There are coronary artery and
aortic calcifications. The aorta is tortuous, however, not aneurysmally
dilated. No evidence of endobronchial lesion is seen. No lymphadenopathy is
identified. Note is made of fluid within the esophagus.
ABDOMEN: The liver, gallbladder, spleen, pancreas, adrenal glands, and
kidneys appear grossly unremarkable. Loops of small and large bowel are
normal in size and caliber with note made of fecal loading within the large
bowel. No abdominal free air, free fluid, or lymphadenopathy is seen.
PELVIS: Distal loops of large bowel and rectum are normal in size and caliber
with note made of extensive fecal loading. There is diverticulosis without
evidence of diverticulitis. The bladder is collapsed around a Foley catheter.
There is, however, the appearance of circumferential wall thickening of the
bladder. An oblong calcification measuring 9 x 3 mm near the left inferior
margin of the bladder (2:103) could represent a bladder stone. The distal
ureters are not dilated. The prostate gland is enlarged measuring up to 5.2
cm in diameter. The aorta is tortuous with ectasia of the infrarenal portion;
however, no aneurysmal dilation. Calcifications are seen throughout the
abdominal aorta extending into the iliac arteries.
There is a fat-containing left inguinal hernia. No pelvic free air, free
fluid, or lymphadenopathy is identified.
At the inferior margin of the imaging volume, note is made of fluid-filled
tubular structures along the perineum and extending into the base of the
pemis, of unclear etiology (2:18).
Bone windows demonstrate Pagetoid changes with thickened expanded cortex,
thickened disordered trabeculation of multiple bones including the scapulae,
T8, T10, T11, L1, and L4 vertebral bodies. Similar findings are seen in the
sacrum, the pelvis, and multiple bilateral ribs. Note is made of compression
deformities in the involved vertebral bodies, greatest at the T11 level where
the is acute kyphosis. No acute fracture is identified. No retropulsion of
fragments is seen. There are multiple remote bilateral rib fractures.
IMPRESSION:
1. No definite acute traumatic findings.
2. Pagetoid disease of bone as detailed without acute fracture. Compression
deformities in the spine appear chronic.
3. Trace right pleural effusion. Mild cardiomegaly.
4. Partially imaged fluid-filled distended corpora cavernosa of unclear
etiology or significance. Clinical correlation and, if indicated, correlation
with ultrasound recommended.
5. Fluid within the esophagus, which could predispose to aspiration.
Radiology Report
RIGHT SHOULDER STUDY
No prior shoulder radiographs for comparison. Comparison is made to the
imaged portion of the right shoulder from a prior CT torso of ___.
FINDINGS: The patient was unable to cooperate with standard radiographic
positioning due to pain and difficulty understanding instructions from the
technologist. With this limitation in mind, no definite acute fracture or
dislocation is identified. Degenerative changes are present at the
acromioclavicular joint. Note is also made of findings suggestive of Paget's
disease including bony expansion and coarsened trabeculation involving
portions of the right scapula with a relatively similar appearance
demonstrated on recent CT torso of 1 day earlier. This is most marked in the
region of the acromion and coracoid processes as well as the glenoid.
IMPRESSION:
1. Limited radiograph demonstrating no gross evidence of fracture or
dislocation. If symptoms persist, repeat radiographs with standard
positioning would be recommended when the patient's condition permits.
2. Findings suggestive of Paget's disease.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: TRANSFER C5 FX
Diagnosed with FX C5 VERTEBRA-CLOSED, UNSPECIFIED FALL, DEHYDRATION, URIN TRACT INFECTION NOS
temperature: 97.8
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 143.0
dbp: 74.0
level of pain: unable
level of acuity: 2.0 | ___ dementia, CLL, atrial fibrillation that was transferred from
___ for spine fracture evaluation, admitted for
possible syncope work-up.
#Orthostatic hypotension and syncope. Per report, patient did
not have frank loss of consciousness, although is dry on exam.
Patient does endorse remembering entire event with no associated
symptoms. Of note, he has been on Bumex for at least 8 months
and is dry on exam. Per report, patient has been on tamsulosin
for years (according to his HCP). Cardiac history is
significant for atrial fibrillation, and ? MI based on prior
ECHO. Admission ECG showing ? LAFB, do not appreciate prior
infarct, has negative troponin. Wells score for PE low risk (1.3
%) based on HR > 100 (CLL not under treatment). Labs are
suggestive of hypovolemia (hyaline cast, mild azotemia), and
exam shows notable dehydration. Overall favor that patient fell
from dehydration. Tropoinins negative x2. Right shoulder
without evidence of fracture, with Paget's disease evidence.
Echo without WMAs and preserved EF. We volume resuscitated the
patient and he was able to walk with nursing assistance and
wearing his brace. We held Bumex and Flomax during the
hospitalization.
-Hold Bumex
-Hold Flomax but can restart in rehab when patient taking better
PO's and during the time when the Foley will be taken out.
#C5 non-displaced fractures of bilateral C5 pedicles and lamina
and right sided shoulder pain: Neuro exam non-focal. Etiology
could be from ? Paget's disease based on radiological
examination. Alk phos is normal at 69. Shoulder films negative
although limited. Patient is to continue medium aspen hard
collar at all times for 6 weeks (until early ___. Pain control
with acetaminophen standing 1000mg TID and tramadol 25mg q6h
PRN pain and Lidoderm patch. Spoke with neurosurgery again, no
possibility for taking off collar during day to eat.
-follow-up with Dr. ___ in ___ clinic in ___ervical spine (___)
#Atrial fibrillation CHADS 2 of 2 for age and HTN. Patient had
episode ___, likely secondary to pain versus hypovolemia
versus patient being on metoprolol as an outpatient for rate
control in the past, but having it stopped within the last year.
Patient back in sinus rhythm now. Outside echo reassuring (EF
55%, normal wall motion). Previous EKG is similar. We continued
digoxin .25mg M, W, F and started metoprolol which controlled
the patient when he was taking it. We discharged the patient on
25mg metoprolol succinate daily, which he was taking in the
past. Patient was not on systemic anticoagulation as outpatient
given his previous history of atrial fibrillation, and with his
fracture, we did not start anticoagulation in house. We will
have the patient follow up with cardiology as an outpatient
(patient had never seen) to determine anticoagulation.
-consideration of anticoagulation as an outpatient
#Fevers and positive UA. Patient asymptomatic and growing MRSA
from his urine, possible explanation of fevers, although also
possible is due to questionable aspiration event. Leukocytes
likely secondary to long term Foley. He recently did have
urinary tract infection in setting of urinary retention (E. coli
- resistant to fluoroquinolones). Imaging incidental showing
distended corpora cavernosa. CT Abd/pelvis also made note of
circumferential wall thickening with ? bladder stone. Initial
urine culture positive for ___ staph (likely contaminant).
Foley replaced ___
-Follow up with Dr. ___ urology
#Difficulty swallowing: patient per report able to swallow at
rehab and drink thin liquids without difficulty. In hospital
with ___ J collar on patient has intermittently had difficulty
swallowing. ___, patient failed speech and swallow study.
We discussed possibility of ___ tube with HCP and he stated
that this and a PEG tube would be inconsistent with the
patient's wishes. Will readdress when patient has done swallow
evaluation. Per repeat speech and swallow evaluation, we were
able to advance to nectar thick liquids, soft solids, 1:1
supervision, meds crushed with purees. It is likely patient was
having difficulty due to the collar in place.
#Thrombocytopenia: patient baseline platelet count between
80-200k per outpatient records. Currently within this range.
Etiologies of thrombocytopenia since admission includes
medications, dilutional, primary CLL, platelet clumping.
Digoxin, Simvastatin and Tramadol associated with
thrombocytopenia <1% of cases. Patient was stable at discharge
and within his normal range.
#Normocytic, normochromic Anemia
Etiology may be from underlying CLL among other factors. Recent
Hgb 7.9 on ___. No evidence of warm mediated autoimmune
hemolysis from underlying CLL at this juncture. Possibly anemic
due to volume resuscitation and pain/ catecholamines.
Reticulocyte count 1.5, haptoglobin elevated, LDH, total and
direct bilirubin are normal. Transfused ___ 1 Unit PRBC.
Patient had a stable HCT at discharge, with some fluctuations
from lab variation.
#Leukocytosis/CLL
WBC 59.6 on admission with abnormal differential. In ___, he started going above critical value (WBC ~ mid ___.
Since then, he has had WBC 50-70 (last measured ___. Likely reflective of CLL given smudge cells seen on
smear. We continued outpatient folate.
#BPH: Patient symptomatic with chronic Foley in place which we
did not remove given opioid treatment and holding Flomax for
orthostasis. We continued Proscar and Foley until outpatient
follow up with Dr. ___
#Dementia
Patient AAOx1 on admission. Discussed baseline mental status
with caretaker - does have some element of dementia, uncertain
of baseline mental status. Per HCP, patient at baseline
#Hyperlipidemia: We continued simvastatin; however, dose 40 mg
(instead of 80 mg) given recent FDA warning
#Imaging incidentals
-Partially imaged fluid-filled distended corpora cavernosa of
unclear etiology or significance. Clinical correlation and, if
indicated, correlation with ultrasound recommended.
-Fluid within the esophagus, possibly predisposing to
aspiration.
-will place on aspiration precautions
#Transitional:
-Hold Bumex
-Hold Flomax but can restart in rehab when patient taking better
PO and during the time when the Foley will be taken out.
-Patient is to wear neck brace at all times until neurosurgery
follow up
-follow-up with Dr. ___ in ___ clinic in ___ervical spine (___)
-consideration of anticoagulation as an outpatient for atrial
fibrillation
-Follow up with Dr. ___ urology |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Bone marrow biopsy
History of Present Illness:
Ms. ___ is a ___ woman with history of smoking, COPD,
atrial fibrillation not on anticoagulation, DMII, HTN, HLD,
gastric bypass who presented from rehab to ___ with shortness
of breath, found to be hypoxic and to have multiple hematologic
abnormalities, transferred to ___ for further management.
Per notes from ___, patient has had increase in lethargy since
yesterday, stated feeling fine but more tired. Today, lethargy
increased, resident was more difficult to rouse than usual.
Speech decreased from baseline (not as talkative). Vitals
remained stable until 1600 when resident O2 sat was found to be
84% on room air. Up to 93% on 2L via NC. At the ___, the patient
has had fluctuating platelet count between 88-150 throughout
the month of ___ of unknown etiology; normalized by ___.
The physician in the facility trialed her off PPI as this was
thought to be a possible culprit. At baseline, she is reportedly
AOx2.
On interview, the patient tells me that she has lost about 100
pounds in the last ___ years since her gastric bypass procedure.
She reports that she has had progressive shortness of breath
that has gotten worse over the past few days to week. She also
reports a diffuse anterior chest tightness. She is not able to
identify exacerbating or alleviating factors to the pain or
shortness of
breath. She denies any fevers or chills. She reports that she
feels tired. She also notes that she has had easy bruising, she
is not sure for how long. She also notes that she has back pain,
also unable to state how long.
In the ED, initial vitals: 97.4 81 141/85 18 98% 4L NC
Exam notable: Resp: Breathing comfortably on nasal cannula. No
incr WOB, CTAB
Labs notable for: WBC 4.6 Hb 10.7 plt 17, hapto 154, LDH 1630,
fibrinogen 410, INR 1.0, D-dimer 1122, uric acid 10.5; HCV Ab
pos
Imaging notable for: CT A/P pelvis with contrast
Patient given:
___ 05:08 IV Morphine Sulfate 2 mg
___ 05:57 IV CefTRIAXone 1 g
___ 09:14 PO/NG Metoprolol Tartrate 12.5 mg
___ 09:21 PO LevETIRAcetam 1000 mg
___ 09:50 IV Morphine Sulfate 2 mg
___ 14:16 IVF NS ___ Started 100 mL/hr
___ 15:07 IV Morphine Sulfate 2 mg
___ 16:26 IV Haloperidol 1 mg
___ 17:00 IV CefTRIAXone 1 gm
___ 18:53 PO/NG Allopurinol ___ mg
___ 18:53 PO/NG OxyCODONE (Immediate Release) 5 mg
___ 20:00 PO LevETIRAcetam 1000 mg
___ 20:00 PO/NG Azithromycin 500 mg
In the ED, patient was reportedly agitated for which she
received Haldol prior to coming to the floor. On arrival to the
floor, the patient report ongoing back pain. She also reports
mild shortness of breath. She otherwise has no complaints at
this time. She is aware of her likely cancer diagnosis and we
discussed next steps.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Afib
COPD
Diabetes
Hyperlipidemia
Hypertension
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission exam
VITALS: 97.4 142/88 73 18 92 2L NC
GENERAL: Alert and in no apparent distress; cachectic appearing
with temporal wasting
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.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Ecchymoses on bilateral forearms; no petechiae
NEURO: Alert, oriented x2, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: pleasant, appropriate affect
Discharge exam:
24 HR Data (last updated ___ @ 1433)
Temp: 97.8 (Tm 97.9), BP: 109/70, HR: 71, RR: 16 (___), O2
sat: 93%, O2 delivery: Ra
GENERAL: Cachectic female. Lying in bed. In no acute distress.
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx with areas of petechiae, no exudate. No cervical or
supraclavicular lymphadenopathy.
CV: Heart regular rate and rhythm, no murmur. Radial and DP
pulses 2+ bilaterally. 2+ lower extremity edema increased
through
mid-shins.
RESP: Lungs clear to auscultation with decreased air entry in
right base. Breathing is non-labored. RR 16 by my bedside
evaluation
GI: Abdomen is soft. Mildly protuberant. Moderate RUQ
tenderness,
unchanged. No rebound or guarding. No lower abdominal
tenderness.
Bowel sounds present.
GU: No suprapubic tenderness
MSK: Neck supple, moves all extremities. Clubbing of fingers.
SKIN: No rashes or ulcerations noted. Diffuse scattered
upper>lower extremity ecchymosis.
NEURO: Alert and easily arousable. Continues to be confused
today and tangential at times. Not agitated during my
evaluations. Face symmetric, gaze conjugate with EOMI, speech
fluent.
PSYCH: Confused at times per report by nursing
Pertinent Results:
Admission labs
___ 02:20AM BLOOD WBC-4.6 RBC-3.53* Hgb-10.7* Hct-34.7
MCV-98 MCH-30.3 MCHC-30.8* RDW-13.5 RDWSD-47.8* Plt Ct-17*
___ 02:20AM BLOOD Neuts-66.7 ___ Monos-10.6
Eos-0.2* Baso-0.4 NRBC-1.1* Im ___ AbsNeut-3.08
AbsLymp-0.96* AbsMono-0.49 AbsEos-0.01* AbsBaso-0.02
___ 03:07AM BLOOD ___ PTT-25.8 ___
___ 01:03PM BLOOD ___ D-Dimer-1122*
___ 02:20AM BLOOD Ret Aut-2.3* Abs Ret-0.08
___ 02:20AM BLOOD Glucose-75 UreaN-41* Creat-1.1 Na-138
K-4.7 Cl-104 HCO3-22 AnGap-12
___ 02:20AM BLOOD ALT-25 AST-56* LD(LDH)-1630* AlkPhos-257*
TotBili-0.5
___ 02:20AM BLOOD Albumin-3.2* Calcium-9.4 Phos-5.7* Mg-1.9
UricAcd-10.5* Iron-60
___ 02:20AM BLOOD calTIBC-273 VitB12-358 Folate->20
___ Ferritn-242* TRF-210
___ 01:03PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* IgM
HBc-NEG
___ 02:20AM BLOOD HCV Ab-POS*
Discharge labs:
No labs in 24 hours prior to discharge (last labs included)
___ 03:15PM BLOOD WBC-4.8 RBC-2.26* Hgb-6.9* Hct-22.5*
MCV-100* MCH-30.5 MCHC-30.7* RDW-15.3 RDWSD-54.8* Plt Ct-9*
___ 10:10PM BLOOD Plt Ct-20*
___ 03:40PM BLOOD ___
___ 01:03PM BLOOD ___ D-Dimer-1122*
___ 03:00PM BLOOD Ret Aut-2.2* Abs Ret-0.07
___ 03:15PM BLOOD Glucose-82 UreaN-30* Creat-0.7 Na-139
K-5.2 Cl-107 HCO3-21* AnGap-11
___ 03:15PM BLOOD ALT-53* AST-234* LD(LDH)-2283*
AlkPhos-326* TotBili-0.7
___ 03:40PM BLOOD Lipase-85*
___ 03:15PM BLOOD Calcium-8.6 Phos-2.3* Mg-2.0 UricAcd-4.6
___ 01:03PM BLOOD calTIBC-233* VitB12-330 Folate->20
___ Ferritn-215* TRF-179*
___ 05:50AM BLOOD Ammonia-24
___ 01:03PM BLOOD TSH-1.5
___ 01:03PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* IgM
HBc-NEG
___ 03:00PM BLOOD HIV Ab-NEG
___ 01:03PM BLOOD HCV Ab-POS*
___ 03:00PM BLOOD HCV VL-5.2*
___ 02:20AM BLOOD CHCV VL-5.5*
___ 02:34AM BLOOD Lactate-1.5
___ 01:03PM BLOOD METHYLMALONIC ACID-Test
___ 03:15PM BLOOD WBC-4.8 RBC-2.26* Hgb-6.9* Hct-22.5*
MCV-100* MCH-30.5 MCHC-30.7* RDW-15.3 RDWSD-54.8* Plt Ct-9*
___ 03:15PM BLOOD Glucose-82 UreaN-30* Creat-0.7 Na-139
K-5.2 Cl-107 HCO3-21* AnGap-11
___ 03:15PM BLOOD ALT-53* AST-234* LD(LDH)-2283*
AlkPhos-326* TotBili-0.7
___ 03:15PM BLOOD Calcium-8.6 Phos-2.3* Mg-2.0 UricAcd-4.6
Imaging
==============================
Liver/GB US ___
IMPRESSION:
1. Coarsened and nodular liver in keeping with cirrhosis. No
focal liver
lesions are identified. Main portal vein is patent.
2. Small amount of ascites.
3. Prominence of the pancreatic duct without focal lesions. In
addition,
prominent CHD on recent CT raises the possibility of ampullary
sphincter
dysfunction.
CT abd/pelvis ___
IMPRESSION:
1. Study is limited by increased noise and lack of oral contrast
limiting
evaluation of small metastases
2. Left adrenal thickening, nonspecific. Otherwise no findings
to suggest
metastatic disease in the abdomen pelvis.
3. Cirrhotic liver with portal hypertension, characterized by
splenomegaly,
upper abdominal varices and trace volume of ascites. No
suspicious liver
lesion on this single phase CT.
4. Left kidney small nonobstructive calculus measures 3 mm.
5. Partially included known right lower quadrant mass.
6. New subsegmental of right basilar atelectasis.
7. Stable left lower lobe ground-glass opacities, likely
infectious etiology
___ ___
IMPRESSION:
No evidence of an acute intracranial abnormality.
CT C spine ___
IMPRESSION:
No radiopaque foreign bodies identified. Multilevel
degenerative change.
Micro
==============================
BCx
___ 2:20 am BLOOD CULTURE Site: ARM
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
U legionella negative
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. DULoxetine 60 mg PO DAILY
2. DULoxetine 30 mg PO QHS
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 300 mg PO QHS
5. LevETIRAcetam 500 mg PO DAILY
6. LevETIRAcetam 250 mg PO QHS
7. Metoprolol Tartrate 25 mg PO BID
8. Morphine SR (MS ___ 30 mg PO Q12H
9. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain -
Moderate
10. Pantoprazole 20 mg PO Q24H
11. Alendronate Sodium 70 mg PO QTUES
12. Calcium Carbonate 500 mg PO BID
13. Mirtazapine 7.5 mg PO QHS
14. amLODIPine 10 mg PO DAILY
15. glimepiride 1 mg oral DAILY
16. Fluticasone Propionate NASAL 1 SPRY NU DAILY
17. Vitamin D 1000 UNIT PO DAILY
18. Docusate Sodium 100 mg PO BID
19. LORazepam 0.5 mg PO Q8H:PRN Anxiety
20. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
21. Salonpas (methyl salicylate-menthol) ___ % topical DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild Duration: 24
Hours
2. Benzonatate 200 mg PO TID:PRN Cough
3. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions
4. Haloperidol 0.5-2 mg PO Q4H:PRN delirium
5. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q1H:PRN moderate-severe pain or respiratory distress
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
q1 Disp ___ Milliliter Refills:*0
6. QUEtiapine Fumarate 12.5 mg PO BID:PRN Restlessness and
agitation
7. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
8. LORazepam 0.5-2 mg PO Q2H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) tablet(s) by mouth
2 hours Disp #*20 Tablet Refills:*0
9. LevETIRAcetam 500 mg PO DAILY
10. LevETIRAcetam 250 mg PO QHS
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Metastatic small cell carcinoma lung cancer
Right lower lung mass
Pancytopenia
B12 deficiency
Acute toxic-metabolic encephalopathy
Acute on chronic intermittent agitation and confusion
Cirrhosis
Hepatitis C
Severe protein-calorie malnutrition
Chronic back and pelvic pain
Depression/anxiety
Hypertension:
Paroxysmal Atrial fibrillation
Diabetes mellitus type II
Acute hypoxic respiratory failure
Acute kidney injury
Asymtomatic bacteriuria
Seizure disorder/prior traumatic brain injury with seizure.
GERD
Osteoporosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with new lung mass and mediastinal
lymphadenopathy, concern for malignancy// please eval for evidence of
metastatic disease or lymphadenopathy in the abdomen
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen without and with
IV contrast. Initially the abdomen was scanned without IV contrast.
Subsequently a single bolus of IV contrast was injected and the abdomen and
pelvis was scanned in the portal venous phase, followed by a scan of the
abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.5 s, 46.2 cm; CTDIvol = 6.1 mGy (Body) DLP = 283.3
mGy-cm.
2) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 5.7 mGy (Body) DLP = 159.8
mGy-cm.
3) Spiral Acquisition 0.8 s, 10.7 cm; CTDIvol = 5.8 mGy (Body) DLP = 61.9
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
5) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.0 mGy (Body) DLP =
20.0 mGy-cm.
Total DLP (Body) = 527 mGy-cm.
COMPARISON: CT chest dated ___. CT pelvis dated ___.
FINDINGS:
LOWER CHEST: Partially included right lower lobe lung mass measures 4.6 x 4.7
cm. Compared to prior CT chest the day before, there is a new incompletely
included subpleural opacity right lower lobe likely atelectasis. Additional
area of atelectasis seen in right lower lobe. Faint ground-glass opacities in
left lower lobe are unchanged and incompletely included on this exam.
ABDOMEN:
HEPATOBILIARY: The liver is slightly nodular and demonstrating lobular contour
with hypertrophy of the left hepatic lobe may represent underlying cirrhosis.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent. Trace
volume of perihepatic ascites is seen.
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 markedly enlarged measuring 15.3 cm, without evidence of
focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape.
URINARY: 3 mm nonobstructing calculus is seen in inter pole of the left
kidney. Punctate low-density lesion in the left lower pole is too small to
characterize. The kidneys are of normal and symmetric size with normal
nephrogram. There is no evidence of focal renal lesions or hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: Changes of post gastric bypass surgery are seen. The bowel
is normal in caliber with no left obstruction.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
trace volume of free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is fibroid uterus
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: Upper abdominal varices are seen including perisplenic and
gastrohepatic ligament varices. The portal veins and hepatic veins are
patent. There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Evidence of old healed pelvic fractures including superior and inferior pubic
rami fractures are seen. Grade 1 anterolisthesis of L4 on 5 is unchanged.
SOFT TISSUES: Diffuse infiltration of subcutaneous fat likely due to anasarca.
Multiple foci of metallic density seen in the anterior abdominal and pelvic
wall, indeterminate
IMPRESSION:
1. Study is limited by increased noise and lack of oral contrast limiting
evaluation of small metastases
2. Left adrenal thickening, nonspecific. Otherwise no findings to suggest
metastatic disease in the abdomen pelvis.
3. Cirrhotic liver with portal hypertension, characterized by splenomegaly,
upper abdominal varices and trace volume of ascites. No suspicious liver
lesion on this single phase CT.
4. Left kidney small nonobstructive calculus measures 3 mm.
5. Partially included known right lower quadrant mass.
6. New subsegmental of right basilar atelectasis.
7. Stable left lower lobe ground-glass opacities, likely infectious etiology.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with unclear medical history, here with
suspected malignancy and new diagnosis of cirrhosis// acute etiology of mental
status, patient needs MRI but family cannot recall if patient has metal
hardware given multiple falls
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.5 s, 21.6 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,125.5 mGy-cm.
Total DLP (Head) = 1,126 mGy-cm.
COMPARISON: Outside hospital noncontrast head CTs including ___ and
___
FINDINGS:
There is no evidence of large territorial infarction,hemorrhage,edema, or
mass. Periventricular and subcortical white matter hypodensities are
nonspecific but likely sequelae of chronic small vessel ischemic disease.
There is prominence of the ventricles and sulci suggestive of involutional
changes.
There is evidence of prior left frontotemporal craniotomy including underlying
dural thickening which is unchanged. There is no evidence of acute fracture.
Small, partially imaged right maxillary sinus mucous retention cyst. Large
left concha bullosa. The mastoid air cells and middle ear cavities appear
clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
No evidence of an acute intracranial abnormality.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman who presented with dyspnea/hypoxia and found to
have pancytopenia, lung mass, and cirrhosis. Screening xray prior to MRI per
radiology.// Pre-MRI screening.
TECHNIQUE: Frontal and lateral views of the cervical spine
COMPARISON: None
FINDINGS:
C1 through T1 are demonstrated on the lateral view. There is no prevertebral
swelling. Cervical lordosis is preserved. The vertebral body heights are
preserved. There is multilevel disc height loss, most pronounced at C5-C6,
C6-C7 and C7-T1. additionally, there is multilevel uncovertebral and facet
joint arthropathy as well as anterior posterior osteophytes. No fracture or
spondylolisthesis is detected. No suspicious lytic or sclerotic lesion is
identified. There are no radiopaque foreign bodies identified.
IMPRESSION:
No radiopaque foreign bodies identified. Multilevel degenerative change.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with new lung mass (? small cell cancer)
cirrhosis (?new) with ongoing abdominal pain.// Assess ascites burden. Assess
biliary tree in setting of increasing alkP.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis performed on ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass. The
main portal vein is patent with hepatopetal flow. There is small amount of
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm, 10 mm on recent CT.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas. Prominence of
the pancreatic duct measuring 4 mm is similar to recent CT.
SPLEEN: Normal echogenicity.
Spleen length: 12.5 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.Simple cyst
arises from the upper pole of the right kidney measures 6 x 7 x 11 mm.
Right kidney: 9.3 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Coarsened and nodular liver in keeping with cirrhosis. No focal liver
lesions are identified. Main portal vein is patent.
2. Small amount of ascites.
3. Prominence of the pancreatic duct without focal lesions. In addition,
prominent CHD on recent CT raises the possibility of ampullary sphincter
dysfunction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypoxia, Transfer
Diagnosed with Hypoxemia
temperature: 97.4
heartrate: 81.0
resprate: 18.0
o2sat: 98.0
sbp: 141.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with history of smoking, COPD,
atrial fibrillation not on anticoagulation, DMII, HTN, HLD,
gastric bypass who presented from rehab to BID-M with shortness
of breath, found to be hypoxic and to have multiple hematologic
abnormalities, transferred to ___ for further management. CTA
was negative for PE, but notable for RLL mass concerning for
malignancy and adjacent pneumonia. Attempts at sputum
culture/cytology were were not successful. Patient completed 5
days of ceftriaxone/azithromycin. Patient underwent a bone
marrow biopsy that revealed evidence of small cell carcinoma.
Bone marrow invasion was complicated by progressive
pancytopenia. Pancytopenia was likely due to infiltrative
malignancy, but cirrhosis and possible ITP may be contributing.
Labs also significant for elevated LDH, MMA, LFTs, INR.
Thrombocytopenia was notably low with minimal response to IVIG
and 2 packs platelets. Thoracic oncology and palliative care
guided goals of care discussion as there were limited treatment
options given her comorbidities and baseline limited functional
status. Ultimately, patient was transitioned to comfort focused
care. Goals are to maintain comfort. Family plans to visit the
patient in ___ weeks.
Patient had intermittent acute toxic-metabolic encephalopathy
complicated by delirium. This may have been exacerbated by
sedative medications. Workup included CT A/P that demonstrated
cirrhotic liver with portal hypertension, splenomegaly,
abdominal varices, and trace ascites. Cirrhosis almost
definitely alcohol related, but patient was also noted to be HCV
positive. Additionally, RUQ US showed Prominence of the
pancreatic duct without focal lesions and in relation to
prominent CHD on recent CT raises the possibility of ampullary
sphincter dysfunction. No further workup was pursued given goals
of care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
S/P Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of DM2,
HTN, HLD, recurrent UTIs (on fosfomycin), recent RLE DVT (on
apixaban), and schizophrenia who presented to the ED after a
fall. She describes tripping over her shower chair this morning
with the lights out. She fell on her left side and hit her chest
and abdomen. She denied having chest pain, palpitations,
shortness of breath, feeling lightheaded or nauseous prior to
falling down. She also says she didn't lose consciousness or hit
her head. Prior to this episode, she was feeling well although
she had been hospitalized two months ago for acute liver injury
___ polypharmacy.
In the ED,
Initial vital signs were notable for: T98.8, HR 76, BP 161/67,
RR 16, O2 98%RA
UA showed persistence of her chronic pyuria: >182WBC, few
bacteria, large leuk, trace blood, nitrite positive, 30 protein,
1 epithelial cell
Pan CT (Head, Chest, A/P, C-spine) - all largely unremarkable,
no signs of acute fracture or underlying acute pathologic
process.
Patient reportedly had episodic lightheadedness while in the ED
and was found to be in a-fib with RVR with heart rates up to
150s. BP initially slightly elevated 160s/70s, but declined to
___ in the setting of her tachyarrhythmia. Limited objective
records of this episode are available for review now that she
has left the ED (just one unconfirmed EKG, which appears to
start in sinus before going into probable a-fib).
She was given 500 cc NS, a dose of IV metoprolol, and was
admitted to medicine.
Upon arrival to the floor, she is having pain on her left chest
and upper abdomen. It's worse when she takes a deep breath but
she appears in no distress. She is adamant that she hadn't had
palpitations up until the ED. She denied recent illness or poor
PO intake. She denied fevers/chills, lightheadedness, dizziness,
chest pain, shortness of breath, nausea/vomiting, dysuria.
Past Medical History:
RLE DVT
DM
HTN
HLD
osteoarthritis
schizeophrenia
lichen sclerosis
possible bladder cyst
recurrent urinary tract infections - currently on fosfomycin
suppression
detrusor overactivity
recurrent colitis
anorexia, abnormal weight loss
anemia
bilateral ocular pseudophakia
dry eye syndrome
Social History:
___
Family History:
Mother with HTN
Physical Exam:
ADMISSION EXAM
=========
VITALS: T 98.0, BP 192/83, HR 90, RR 17, O2 sat99 Ra
GEN: In NAD.
HEENT: No scalp lacerations noted. PERRL, moist mucous
membranes, oropharynx clear without exudates.
NECK: No JVD, no cervical lymphadenopathy.
CV: RRR, no murmurs/gallops/rubs. Tenderness to palpation over
left lateral chest.
PULM: CTAB, no wheezing/crackles/rhonchi.
BACK: Kyphotic with no midline tenderness C-L spine.
ABD: Soft, tender to palpation in LUQ radiating to left flank,
no rebound or guarding, non distended.
EXTREM: Trace ___ edema bilaterally. Pulses +2 ___P, ___
bilaterally.
SKIN: No rashes.
NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly
intact.
DISCHARGE EXAM
=========
VITALS: Reviewed in OMR
GENERAL: Alert and oriented, no acute distress
ENT: NT/AC, MMM, EOMI
CV: RRR, Grade II/VI SEM most prominent at the ___.
RESP: CTAB, normal work of breathing
GI: NT/ND, BS+
EXT: Warm and well perfused, non-edematous
NEURO: CNII-XII grossly intact, no focal neurologic deficits
Pertinent Results:
ADMISSION LABS
=========
___ 09:39AM WBC-8.5 RBC-3.21* HGB-8.2* HCT-27.0* MCV-84
MCH-25.5* MCHC-30.4* RDW-17.2* RDWSD-53.0*
___ 09:39AM NEUTS-67.9 LYMPHS-17.2* MONOS-11.6 EOS-2.1
BASOS-0.7 IM ___ AbsNeut-5.78 AbsLymp-1.46 AbsMono-0.99*
AbsEos-0.18 AbsBaso-0.06
___ 09:39AM ___ PTT-30.1 ___
___ 09:39AM GLUCOSE-95 UREA N-14 CREAT-0.7 SODIUM-136
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-25 ANION GAP-14
DISCHARGE LABS
=========
___ 08:15AM BLOOD WBC-7.3 RBC-3.30* Hgb-8.3* Hct-27.6*
MCV-84 MCH-25.2* MCHC-30.1* RDW-18.2* RDWSD-55.3* Plt ___
___ 08:15AM BLOOD Glucose-113* UreaN-13 Creat-0.8 Na-139
K-4.3 Cl-103 HCO3-26 AnGap-10
IMAGING
=======
___ CXR:
Top normal heart size, mild lower lung atelectasis, chronic
compression
deformity at the thoracolumbar junction. Otherwise
unremarkable.
___ Chest/Abdomen/Pelvis:
1. No evidence of acute traumatic injury in the chest abdomen or
pelvis.
2. Chronic appearing deformities of the anterolateral left sixth
through ninth ribs are more conspicuous from prior, clinical
correlation for site of pain is recommended.
3. Subtle ground-glass opacities at the lung bases may reflect
aspiration.
Mild to moderate hiatal hernia.
4. Pulmonary nodule in the left lower lobe are stable from
prior.
5. 3 mm right thyroid nodules. No follow-up is recommended per
ACR criteria.
___ Head CT:
No acute intracranial process. Age-related involutional change.
___. No acute fractures identified.
2. No prior imaging available for comparison, however there is
no definite evidence of traumatic malalignment. There is
widening of the right facet joint at C4-C5, likely degenerative.
3. Multilevel degenerative change including uncovertebral
hypertrophy and facet arthropathy as described above.
4. 3 mm nodule in the right thyroid lobe for which no follow-up
is recommended per ACR criteria.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. OLANZapine 20 mg PO QHS
3. Metoprolol Tartrate 50 mg PO BID
4. Apixaban 5 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. Aspirin 81 mg PO DAILY
8. GlipiZIDE XL 2.5 mg PO DAILY
9. Fosfomycin Tromethamine 3 g PO PRN UTI
10. Atorvastatin 80 mg PO QPM
11. Gabapentin 100 mg PO QHS
12. ascorbic acid (vitamin C) 1,000 mg oral BID
Discharge Medications:
1. Apixaban 5 mg PO BID
2. ascorbic acid (vitamin C) 1,000 mg oral BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Fosfomycin Tromethamine 3 g PO PRN UTI
6. Gabapentin 100 mg PO QHS
7. GlipiZIDE XL 2.5 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. OLANZapine 20 mg PO QHS
11. Omeprazole 20 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
=======
Mechanical Fall
Secondary
=========
Hypertension
Hyperlipidemia
Recurrent Urinary Tract Infections
History of Deep Vein Thrombosis with Inferior Vena Cava Filter
Placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with L rib pain s/p fall// eval for fx/injury
COMPARISON: ___
FINDINGS:
AP upright and lateral views of the chest provided. Heart is top-normal in
size. There is subtle lower lung atelectasis. No convincing evidence for
pneumonia or edema. No large effusion or pneumothorax. Mediastinal contour
stable. Imaged bony structures are intact. No displaced rib fracture is
seen. A compression deformity in the thoracolumbar junction is unchanged from
___. Partially visualized in the upper abdomen is an IVC filter.
IMPRESSION:
Top normal heart size, mild lower lung atelectasis, chronic compression
deformity at the thoracolumbar junction. Otherwise unremarkable.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ s/p fall// ? injury
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
There is no evidence of acute large territorial infarction,hemorrhage,edema,or
discrete mass. Mild periventricular subcortical white matter hypodensities
are nonspecific but likely reflect the sequelae of chronic small vessel
ischemic disease. There is prominence of the ventricles and sulci suggestive
of involutional changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses and middle ear cavities are clear. There is mild opacification of the
right mastoid air cells posteriorly, similar to prior. The patient is status
post bilateral lens replacements.
IMPRESSION:
No acute intracranial process. Age-related involutional change.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ s/p fall// ? injury
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 519 mGy-cm.
COMPARISON: None.
FINDINGS:
2 mm grade 1 anterolisthesis of C3 on C4, C4 on C5 and C7 on T1 is favored to
be degenerative, although no prior exams are available for comparison. There
is 2 mm grade 1 retrolisthesis of C5 on C6. There is no prevertebral soft
tissue swelling to suggest traumatic malalignment. There is widening of the
right facet joint at C4-C5, likely degenerative.
No acute fractures are identified. Calcification of the posterior
longitudinal ligament leads to very mild canal narrowing at C5-C6. Multilevel
facet arthropathy and uncovertebral hypertrophy contribute to level moderate
neural foraminal narrowing. There is a 3 mm hypodensity in the right thyroid
lobe. The visualized lung apices are clear.
IMPRESSION:
1. No acute fractures identified.
2. No prior imaging available for comparison, however there is no definite
evidence of traumatic malalignment. There is widening of the right facet joint
at C4-C5, likely degenerative.
3. Multilevel degenerative change including uncovertebral hypertrophy and
facet arthropathy as described above.
4. 3 mm nodule in the right thyroid lobe for which no follow-up is recommended
per ACR criteria.
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 torso.
INDICATION: ___ s/p fall// ? injury
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered. Coronal and sagittal reformations were
performed and reviewed on PACS.
DOSE: Total DLP (Body) = 889 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. Heart size is top-normal. The pericardium, and
great vessels are within normal limits. No pericardial effusion is seen. Note
is made of mitral annular and aortic valve calcifications.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There are subtle bibasilar ground-glass opacities which likely
reflect atelectasis, aspiration not excluded. In addition, there is bibasilar
atelectasis. There is a 8 mm pulmonary nodule noted in the left lower lobe
(2:69). More anteriorly, loss of in the left lower lobe there is a second 6
mm nodule, stable from prior (02:75). The airways are patent to the level of
the segmental bronchi bilaterally.
BASE OF NECK: Sub 3 mm hypodensities are noted in the right thyroid lobe.
Partially visualized portions of the neck are otherwise unremarkable.
ABDOMEN:
HEPATOBILIARY: There are numerous sub-centimeter hypodensities within the
hepatic parenchyma, too small to characterize. The liver otherwise
demonstrates homogenous attenuation throughout. There is no evidence of
suspicious focal lesion or laceration. There is no evidence of intrahepatic
biliary dilatation. Prominence of the common hepatic duct likely reflects
cholecystectomy status. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is stable simple cysts bilaterally. Additional subcentimeter
hypodensities are too small to characterize but are favored to represent
simple cysts. There is no evidence of suspicious focal renal lesions or
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: There is small to moderate hiatal hernia. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
colon and rectum are within normal limits. The appendix is normal. There is
no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: Very mild hyperemia of the anterior bladder wall with associated
subtle fat stranding is improved in comparison to ___. Urinary
bladder and distal ureters are otherwise unremarkable. There is no free fluid
in the pelvis
REPRODUCTIVE ORGANS: The uterus is unremarkable. Multiple surgical clips are
noted in the pelvis. Adnexa are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Extensive atherosclerotic disease is noted. An IVC filter is again noted.
BONES: There are multilevel moderate to severe degenerative changes about the
thoracolumbar spine. There is an unchanged anterior compression deformity at
L1. There is an unchanged fracture deformity of the inferior right pubic
ramus. Chronic appearing deformities of the anterolateral left sixth through
ninth ribs are more conspicuous from prior.
SOFT TISSUES: There is a small fat containing ventral hernia. Calcification
overlying the left gluteal muscles likely reflects injection granuloma.
Visualized soft tissues are otherwise unremarkable.
IMPRESSION:
1. No evidence of acute traumatic injury in the chest abdomen or pelvis.
2. Chronic appearing deformities of the anterolateral left sixth through ninth
ribs are more conspicuous from prior, clinical correlation for site of pain is
recommended.
3. Subtle ground-glass opacities at the lung bases may reflect aspiration.
Mild to moderate hiatal hernia.
4. Pulmonary nodule in the left lower lobe are stable from prior.
5. 3 mm right thyroid nodules. No follow-up is recommended per ACR criteria.
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.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Rib pain, s/p Fall
Diagnosed with Weakness
temperature: 98.8
heartrate: 76.0
resprate: 16.0
o2sat: 98.0
sbp: 161.0
dbp: 67.0
level of pain: 10
level of acuity: 2.0 | SUMMARY
=======
Ms. ___ is a ___ year old female with a PMH of DM2, HTN,
HLD, recurrent UTIs (on fosfomycin), recent RLE DVT (on
apixaban), and schizophrenia presenting w/ mechanical fall, ED
course complicated by tachycardia which was felt to be a-fib,
but this did not recur during her admission and limited
objective records of the event are preserved. During her
admission she had a 7 second pause while on metoprolol, likely
vagal tone given atrial beat and quick return to NSR without
junctional beats. Metoprolol was discontinued as she had been on
this for hypertension only. She had some left sided abdominal
pain from her fall that was well controlled with ibuprofen.
ACUTE ISSUES
============
# Fall:
Patient fell after tripping over her shower chair in the night
without the lights on, no chest pain, SOB, palpitations, or LOC
with the fall, and no shaking or seizures. Trauma workup in the
ED negative for any fractures or acute processes. Physical
therapy evaluated the patient and deemed her stable for home
discharge without further intervention. Pain control with
ibuprofen and Tylenol (2 GM max daily) as needed.
# Narrow-complex irregular tachycardia, possibly a-fib
# Brief hypotension:
Had an episode of narrow-complex irregular tachycardia while
working with ___ in the ED. No reported history of AFib, and no
recurrence of a-fib during roughly 72 hours of inpatient
telemetry monitoring. Unfortunately, only one EKG was obtained
during her episode in the ED; on review of that EKG, clear
p-waves are present for the first half of the tracing,
suggesting a diagnosis of sinus rhythm with pACs. However, the
second half of the tracing is potentially quite consistent with
a-fib. We were nonetheless reluctant to make the diagnosis based
on only three seconds of objective data.
Will discharge with ziopatch to monitor for atrial fibrillation
vs atrial tachycardia, and possible need for rate control
initiation (possibly restarting metoprolol) and decision on
whether to continue anticoagulation past DVT treatment course
(due to end around ___.
#Pause on tele, likely vagal
Seven second pause while sleeping during her first night in the
hospital. She bradyed down rapidly over maybe 20 seconds, had
one non-conducted p-wave, then sped back up quickly to her usual
rate. She was not otherwise bradycardic and had no other
evidence of heart block. Stopped metoprolol with no further
episodes on telemetry. Plan to discontinue metoprolol on
discharge with outpatient uptitration of her lisinopril as
needed for BP control.
# Recurrent UTIs:
Had UA consistent with infection in the ED, but states that she
doesn't currently have any burning or stinging with urination
that comes with her UTIs. Mental status was at baseline and she
had no fever or systemic signs of sepsis. Urine culture showed
ecoli >100,000, and was fosfomycin sensitive. Did not treat
inpatient but discharged with her suppressive fosfomycin.
# RLE DVT:
Continued home apixaban. Has IVC filter in place from bleeding
with rivaroxaban which should be removed now that she is
tolerating AC without bleeding. Discussed with ___ about removing
it this admission versus scheduling for outpatient, and they
felt that they wouldn't be able to fit her in the inpatient
schedule. Plan to have her follow up with her scheduled visit on
___.
CHRONIC ISSUES
==============
# Recent hospitalization for acute liver failure Due to DILI and
unintentional Tylenol overdose:
LFTs normal this admission
# HTN:
Continued home lisinopril. Stopped metoprolol as above.
# DM2:
Last A1C 5.3%. Held home glipizide, restarted on discharge.
# HLD:
Continued home atorvastatin
# Schizophrenia:
Continued home olanzapine
TRANSITIONAL ISSUES
===================
Discharge Cr: 0.8
Discharge Hgb: 8.3
Discharge INR: 1.4
Discharge LFTs: normal
[ ] Has cardiology follow up with Dr. ___ NP, Ms
___, who should review the ziopatch (and the as of
yet unconfirmed EKG from ___ for Atach vs afib and decide
on rate control and/or extending her anticoagulation to
lifelong.
[ ] ID follow up scheduled for management of recurrent UTIs.
Follow up UTI symptoms. Ensure she is taking her home fosfomycin
treatment on the appropriate schedule. Urine culture this
admission with Ecoli, but fosfomycin sensitive
[ ] Atorvastatin restarted this admission, recheck LFT in ___
months to ensure that they remain stable.
[ ] Follow up blood pressures; stopped metoprolol this admission
due to sinus pause, but discharged on ziopatch as above; may
need uptitration of lisinopril if high BPs.
[ ] Consider discontinuation or reduction of her sulfonylurea.
Her A1c is low enough that she is at risk for harm from
hypoglycemia.
[ ] ___ follow up ___ for IVC filter removal!!
[ ] As per CT C/A/P: Pulmonary nodule in the left lower lobe are
stable from prior. 3 mm right thyroid nodules. No follow-up is
recommended per ACR criteria.
[ ] CT C spine with widening of the right facet joint at C4-C5,
likely degenerative, and multilevel degenerative change
including uncovertebral hypertrophy and facet arthropathy
[ ] Has blister packs with ___ pharmacy which was
updated on discharge to not include metoprolol for the follow up
packs. All changes to her medications should be made through her
existing pharmacy so they can adjust her blister packs.
[ ] Discharging with ___ services to help with medications
#CODE: Full Code
#CONTACT: HCP ___ (friend) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dehydration/ failure to thrive
Major Surgical or Invasive Procedure:
___ EGD with post pyloric feeding tube placement
History of Present Illness:
Mr. ___ is a ___ y/o male who was recently admitted to
transplant surgery for concerns of gallbladder malignancy and is
s/p subcostal incision and intraoperative cholangiogram who was
recently admitted to transplant surgery for concerns about
gallbladder malignancy and underwent subcostal incision
revealing perforated gallbladder with normal filling of biliary
ducts via intraoperative cholangiogram (___). Patient was
placed on Cipro X 1 week (GNR, no speciation). His
post-operative course was c/b ileus requiring NPO/NGT
decompression. Patient was discharged on ___. He had urinary
retention prior to his operation and had a legbag and f/u with
an urologist. Additionally his anti-HTN medications were reduced
as he was stable on low doses of metoprolol. He was seen by the
urologist and failed his voiding trial. He was also seen by his
PCP for dizziness and hypotension. There do not seem to be any
changes to his anti-HTN meds and his hypotension was treated
with IVF hydration.
He was seen in clinic on ___ and was complaining of nausea
and poor appetite. He presented with hypotension, and his SBP
was in the ___ during this encounter. He was admitted directly
from clinic to the floor for further evaluation and management.
Past Medical History:
CAD:
-___: CABG (LIMA-LAD, SVG-OM1 and OM2, SVG-rPDA)
-___: IMI, BMS to SVG-OM c/b ISR s/p 3 DES to SVG-OM
-___: MI s/p thrombectomy and BMS to SVG-OM
PAD s/p right SFA PTA/stent ___
Hypertension
Hyperlipidemia
CKD
BPH
Hx ventral hernia
Hx ampullary adenoma s/p endoscopic resection in ___
S/p partial colectomy in ___ (performed prophylactically due to
attenuated FAP)
Social History:
___
Family History:
- Multiple family members with ___ cancer
- Father ___ Disease
- Maternal Aunt ___ Cancer
- Mother ___ Cancer; ___ Cancer; Coronary Artery Disease;
Gynecologic Cancer
- Sister ___ Cancer(2)
Physical Exam:
Vitals: Temp 98.3 HR 68 BP 134/58 RR 18 SpO2 100% RA
GEN: A&O, NAD, interactive and cooperative
HEENT: No scleral icterus
CV: RRR, normal S1 and S2, no murmurs/rubs/gallops
PULM: Clear to auscultation bilaterally
ABD: Soft, nondistended, nontender, no palpable masses,
well-healed surgical scars, dressing on R abdomen
clean/dry/intact
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 07:05AM BLOOD WBC-6.5 RBC-3.80* Hgb-11.4* Hct-35.7*
MCV-94 MCH-30.0 MCHC-31.9 RDW-13.8 Plt ___
___ 11:30AM BLOOD WBC-8.5 RBC-4.42*# Hgb-13.1*# Hct-41.8#
MCV-95 MCH-29.6 MCHC-31.2 RDW-14.0 Plt ___
___ 11:30AM BLOOD Neuts-58.4 ___ Monos-7.4 Eos-2.2
Baso-0.6
___ 07:05AM BLOOD Plt ___
___ 11:30AM BLOOD Plt ___
___ 07:05AM BLOOD Glucose-105* UreaN-5* Creat-0.6 Na-140
K-4.4 Cl-107 HCO3-27 AnGap-10
___ 11:30AM BLOOD Glucose-110* UreaN-10 Creat-0.9 Na-136
K-4.9 Cl-100 HCO3-28 AnGap-13
___ 07:20PM BLOOD ALT-21 AST-19 AlkPhos-79 TotBili-0.5
___ 11:30AM BLOOD ALT-28 AST-28 AlkPhos-99 TotBili-0.7
___ 07:05AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.7
___ 11:30AM BLOOD Albumin-4.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Tamsulosin 0.4 mg PO HS
4. Atorvastatin 80 mg PO DAILY
5. Metoprolol Succinate XL 200 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO HS
7. Finasteride 5 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergy
11. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergy
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Tube Feed
Jevity 1.5 continuous at 60cc/hour via post pyloric feeding tube
Supply: 1 month
Refill: 3
7. Nystatin Oral Suspension 5 mL PO QID swish and swallow
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Disp
___ Milliliter Refills:*1
8. Nitroglycerin SL 0.3 mg SL PRN chest pain
9. Tamsulosin 0.4 mg PO HS
10. Atorvastatin 80 mg PO DAILY
11. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
12. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dehydration
Failure to thrive
Esophagitis/gastritis
Urinary retention
Incision wound s/p ccy/esophagogastroduodenostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with hypotension // eval for pneumonia
COMPARISON: ___.
FINDINGS:
AP portable upright view of the chest. Overlying EKG leads are present.
Midline sternotomy wires and mediastinal clips are noted. Lungs are clear.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
IMPRESSION:
No acute intrathoracic process
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ man with hypotension and anorexia status post ex lap
for perforated cholecystitis, evaluate for intraabdominal infection/ abscess.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after the administration of intravenous contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats. Oral contrast
was administered.
DLP: 454 mGy-cm
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
CHEST: The visualized lung bases are clear. The heart is normal in size and
there is no evidence of pericardial effusion. Coronary artery calcifications
and mitral annular calcification are noted.
ABDOMEN:
The liver enhances homogeneously and is without focal lesions. The portal
venous system is patent. There is no evidence of intrahepatic or extrahepatic
biliary dilatation.
The gallbladder is surgically absent. A 1.3 x 0.8 cm fluid collection in the
surgical bed has decreased in size from ___ (02:22). Mild stranding in the
postsurgical bed has also improved. No drainable fluid collection is
identified.
The spleen is unremarkable. The pancreas is atrophic. The adrenal glands are
unremarkable.
The kidneys display symmetric nephrograms and excretion of contrast. There are
no focal renal lesions. There is no hydronephrosis. The ureters are normal in
caliber and course to the bladder.
The patient is status post colectomy. Oral contrast extends from the small
bowel to the J pouch. The distal esophagus is normal without a hiatal hernia.
The stomach is grossly unremarkable in appearance. Small bowel loops are air
and fluid filled and have overall decreased in caliber from ___. There is
no abdominal free air.
There are dense calcification of the abdominal aorta without aneurysmal
dilation. A short stent is seen in the right common iliac artery. There is no
retroperitoneal or mesenteric lymphadenopathy by CT size criteria. There is no
free abdominal fluid or pneumoperitoneum.
PELVIS:
A Foley catheter is seen within the bladder. There is bladder wall thickening.
Air within the bladder is likely from instrumentation. There is no pelvic
side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic
fluid is identified.
OSSEOUS STRUCTURES: Mild, multifactorial degenerative changes are seen within
the visualized thoracolumbar spine. No focal lytic or sclerotic lesion
concerning for malignancy.
SOFT TISSUES: In the right upper quadrant, there are postsurgical changes
including soft tissue stranding and fluid in the anterior abdominal
musculature, which has overall improved from ___. There is no drainable
fluid collection. Surgical staples have been removed, but skin defects
persists (2:27,34,42).
IMPRESSION:
1. Nondilated loops of air/fluid small bowel with oral contrast extending to
the J-pouch, overall improved from ___.
2. Improved postsurgical changes including decreased fluid in the gallbladder
fossa and mild decrease in heterogeneity/stranding in right upper anterior
abdominal wall musculature.
3. No evidence of intra-abdominal abscess/drainable fluid collection.
4. Bladder wall thickening, recommend correlation with urinalysis.
NOTIFICATION: Changes to WET READ impression #4 were discussed with Dr. ___
by Dr. ___ on the day of the exam.
Radiology Report
INDICATION: ___ year old man with recent 50 pound weight loss, recent
washout/GB stump oversewing for perforated gallbladder c/b ileus, presenting
now w hypotension, dehydration, FTT // Assess swallow
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
COMPARISON: None
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was no gross aspiration or penetration.
IMPRESSION:
No evidence of aspiration or penetration.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old man s/p washout/GB stump oversewing for perforated
gallbladder c/b ileus, now w hypotension, dehydration, FTT 50 pound weight
loss rule out motility issues vs anatomic problem // Please perform Barium
swallow following video swallow per GI recommendations
TECHNIQUE: Barium esophagram.
COMPARISON: None
FINDINGS:
The esophagus was not dilated. There was no stricture within the esophagus.
There was no esophageal mass. The esophageal mucosa appears normal.
The primary peristaltic wave was normal, with contrast passing readily into
the stomach. The lower esophageal sphincter opened and closed normally.
There was no gastroesophageal reflux. There was no hiatal hernia.
IMPRESSION:
Normal esophagram.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p EGD // Please assess position of
post-pyloric feeding tube. Thanks Please assess position of post-pyloric
feeding tube. Thanks
IMPRESSION:
The post pyloric feeding tube extends beyond the ligament of Treitz into the
proximal jejunum. Otherwise little change from the study of ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: DEHYDRATION, Hypotension
Diagnosed with ANOREXIA
temperature: 98.0
heartrate: 68.0
resprate: 20.0
o2sat: 98.0
sbp: 80.0
dbp: 48.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ was directly admitted from clinic with systolic
blood pressures in the ___. He was admitted. He had a CT
abdomen/pelvis done which showed loops of small bowel that had
improved, less fluid in the gallbladder fossa, a thick bladder,
and no abscess. He was given Macrobid for treatment of presumed
UTI (5-day course). Blood and urine cultures eventually came
back negative. Blood pressures stabilized, and he actually
became somewhat hypertensive while all of his home blood
pressure medications were being held. He was started on
Metoprolol 12.5 mg BID. That same day, he experienced some
indigestion when drinking Ensure. He subsequently passed a
bedside speech and swallow evaluation, but speech therapy
recommended a video and barium swallow, as he was complaining of
being unable to swallow some solid foods (e.g. ___ toast).
Video swallow was negative for any evidence of aspiration, and
the barium swallow displayed normal esophageal anatomy. GI was
also consulted and recommended an EGD, which he had the
following day. Some erythematous patches were noted in the lower
esophagus, but no biopsies were done, as the patient was
continued on Aspirin and Plavix at the time of the procedure. He
was started on Nystatin swish and swallow empirically for
___ esophagitis, and his PPI dosing was increased to
Pantoprazole 40 mg IV BID in house (transitioned to 40 mg PO BID
on discharge). Due to the patient's poor PO intake, he also had
a post-pyloric Dobhoff tube placed at the time of the EGD. He
was started on tube feeds with Gevity 1.5 at 20 cc/hr, increased
to a goal of 60 cc/hr. Macrobid was d/c'ed on the ___ day of the
course. Patient was monitored in house for 2 more days, and
discharged home with the Dobhoff tube in place and ___ services
secured for help at home with the tube and tube feeds. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F pharmacy student with recent diagnosis of sickle cell
disease who presents with back pain since ___. The pain is
in her mid-upper back and worse with flexion. It started out as
mild pain, and she did not present for medical evaluation
initially since it had coincided with the onset of menses, and
she felt it could be menstrual pain. However, her pain worsened
and persisted, which was inconsistent with her typical menstrual
cramps, and she became concerned for a sickle cell crisis, so
she came in to be evaluated.
Of note, she has not had any fever, chills, dyspnea, chest pain,
N/V/D, rash, bleeding (other than menses), vision changes,
numbness, tingling, weakness.
In the ED initial vitals were: 97.8 95 107/56 16 100%
- Labs were significant for WBC 11, HCt 23.5, LDH 774
- Patient was given 3mg IV dilaudid, 30mg MS ___, 1 U pRBC
Vitals prior to transfer were: 98 72 104/71 16 100%
On the floor she reports feeling well, but thinks her pain is
worsening since she received pain medications several hours ago.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
- Sickle cell disease: HbA 45%, HbS 55%, HbC 0%
* ___: Index admission with diffuse arthralgias, low back
pain, chest pain, fever. Found to have hemolysis and
elecrophoresis confirmed HbS.
* ___: Started on hydroxyurea
* ___: Admitted with acute chest syndrome
* ___: Arm pain
- Overactive bladder
- Sensorineural hearing loss
Social History:
___
Family History:
- Sister: ___. Healthy
- Mother: Healthy
- Father: ___ from father but reports he is healthy.
Father has a daughter with a different mother who ___ has
sickle cell disease.
- No family history of heart disease, cancer, or
hemoglobinopathy
Physical Exam:
ON ADMISSION:
===============================
Vitals - T 99.5 BP 126/74 HR 88 RR 20 SpO2 98% on RA
Weight (bed): 55.8 kg
GENERAL: Well appearing young female in no apparent distress
HEENT: EOMI, MMM
CARDIAC: RRR, no m/r/g
LUNG: CTAB
BACK: No tenderness to palpation of spinous processes or
paraspinal muscles. Minimal tenderness to percussion of lower
thoracic spine.
ABDOMEN: Soft, nontender. Unable to palpate spleen
EXTREMITIES: WWP, nonedematous
NEURO: A&OX3. Moving all four extremities. Follows commands
SKIN: No rashes.
ON DISCHARGE:
==================================
Vitals: T99.5 BP126/74 P88 RR20 98%
General: Alert, pleasant, no acute distress.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear.
Neck: Supple, no lymphadenopathy.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
Chest: Area under breasts nontender to palpation.
Back: Spinous processes nontender to palpation, paraspinal
muscles nontender to palpation. CV: Regular rate and rhythm,
normal S1 + S2, no murmurs, rubs, gallops.
Abdomen: +BS, soft, nondistended, nontender to palpation. No
hepatosplenomegaly.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes.
Neuro: Grossly intact.
Pertinent Results:
ON ADMISSION:
==========================================
___ 05:45PM BLOOD WBC-11.2* RBC-2.29* Hgb-7.7* Hct-23.5*
MCV-103* MCH-33.8* MCHC-32.9 RDW-20.5* Plt ___
___ 05:45PM BLOOD Neuts-57 Bands-0 ___ Monos-6 Eos-3
Baso-0 Atyps-1* ___ Myelos-0 NRBC-4*
___ 05:45PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-3+
Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-2+ Target-2+ Sickle-3+
___ 05:45PM BLOOD ___ PTT-28.3 ___
___ 05:45PM BLOOD Ret Man-18.1*
___ 05:45PM BLOOD Glucose-83 UreaN-6 Creat-0.5 Na-137 K-5.1
Cl-102 HCO3-25 AnGap-15
___ 05:45PM BLOOD LD(LDH)-774*
___ 05:45PM BLOOD Calcium-9.3 Phos-4.7* Mg-2.0
___ 05:45PM BLOOD Hapto-<5*
ON DISCHARGE:
==========================================
___ 06:10AM BLOOD WBC-10.2 RBC-2.53* Hgb-8.2* Hct-25.9*
MCV-102* MCH-32.6* MCHC-31.8 RDW-19.8* Plt ___
___ 06:10AM BLOOD Glucose-76 UreaN-6 Creat-0.4 Na-136 K-4.3
Cl-102 HCO3-25 AnGap-13
___ 06:10AM BLOOD LD(LDH)-532*
___ 06:10AM BLOOD Calcium-8.2* Phos-4.8* Mg-1.9
___ 06:10AM BLOOD Hapto-<5*
STUDIES:
==========================================
CXR (___)
No acute findings in the chest.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Morphine SR (MS ___ 30 mg PO Q12H
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 5 mg PO DAILY
4. Hydroxyurea 1000 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. Cyanocobalamin ___ mcg PO DAILY
7. Magnesium Oxide 400 mg PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Medications:
1. Cyanocobalamin ___ mcg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 5 mg PO DAILY
4. Hydroxyurea 1000 mg PO DAILY
5. Magnesium Oxide 400 mg PO DAILY
6. Morphine SR (MS ___ 30 mg PO Q12H
7. Senna 8.6 mg PO BID:PRN constipation
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Sickle cell disease, acute pain episode
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Sickle cell disease with back pain, question pneumonia.
FINDINGS: PA and lateral views of the chest provided demonstrate no focal
consolidation, effusion or pneumothorax. Cardiomediastinal silhouette appears
normal and stable. Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION: No acute findings in the chest.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: SICKLE CELL
Diagnosed with HB-SS DISEASE W/CRISIS
temperature: 97.8
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 107.0
dbp: 56.0
level of pain: 9
level of acuity: 3.0 | ___ with PMH significant for sickle cell disease presents with
back pain.
# Acute pain episode/Sickle cell disease:
Back pain secondary to sickle cell disease. Trigger for this
pain episode likely multifactorial: menses, dehydration (patient
reports drinking ___ per day instead of the recommended 4L),
and stress. Infection was ruled out as the patient did not have
any infectious symptoms, is up-to-date with vaccinations,
negative CXR, and unremakable UA. The patient was treated with
IV fluids and dilaudid IV PRN. When the pain was adequately
controlled, she was transitioned to oxycodone 10mg. We continued
her home MS ___. We talked briefly about birth control to
decrease the acute pain episodes triggered by menses. We would
recommend the Mirena IUD as it does not have an increase risk of
thrombosis and may decrease the amount of blood loss during
menses. We recommended the patient continue this discussion with
her primary care phyisician and hematologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cervical hardware failure s/p c3-t9 fusion with wound
dehiscence.
Major Surgical or Invasive Procedure:
___ - Wound revision
History of Present Illness:
___ with hx of ankylosing spondylitis s/p C3-T9 fusion for
C7-T5-T6 fracture after fall down stairs on ___.
Postoperatively he remained in TLSO brace until ___. He was
seen in follow-up on ___ at that time he had a small
opening in his incision with no signs of infection. The patient
at that visit was noted to be cachectic and instrumentation was
palpable through the skin, but there was no breakdown. He was
referred for x-ray which showed hardware failure.
Patient is currently demonstrating improvement- PEG is still in
place but began taking medication by mouth and slowly advancing
diet. Patient currently walks ___ FT with a walker. Patient
reports slight tingling to his hands and feet. Foley catheter
still in place. Denies any pain.
Past Medical History:
HTN
HLD
Prior epidural hematoma and T9-S1 spinal fusion
spinal fusion T9-S1, prostetic hip, hernia repair
Social History:
___
Family History:
Non-contributory
Physical Exam:
9On Admission: ___
============================
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 4 5 4 5 5 4 4 4 5 3 5
L 4 5 4 5 5 4 4 4 5 5 5
Bilater finger intrinsics ___ Bilateral grip ___
No ___, no clonus
ON DISCHARGE: ___
=========================
General:
___ ___ Temp: 97.8 PO BP: 105/67 R Lying HR: 90 RR: 30 O2
sat: 95% O2 delivery: 1.5L
Bowel Regimen: [x]Yes [ ]No Last BM: ___
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
Right54-4+4+4+
Left54+554+
IPQuadHamATEHLGast
Right4+ 4 4+ 5 5 5
Left4+ 4+ 4+ 5 5 5
[no]Clonus ___
[x]Sensation intact to light touch
Wound:
- Palpable hardware in cervical spine, no pain to palpation, no
skin tenting or breakdown.
- Revised wound:
[x]Clean, dry, intact, no active drainage noted. Small
portion
of superior aspect of incision with separation.
[x]Sutures in place
Pertinent Results:
See OMR for pertinent results
Medications on Admission:
Atropine prn secretions
Pantoprazole 40mg qday
Levalbuterol TID
Melaotonin 9mg qhs
Mirtazapine 15mg Qday
Sevelamer Carbonate 0.8g oral powder TID
Tamsulosin 0.4mg qday
trazodone 25mgqhs
albuterol sulfate nebs Q4hr prn
Zofran 4mg PRN
Oxycodone 5mg PRN
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Do not exceed 4G per day.
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/SOB
3. Atropine Sulfate 1% 1 DROP SL DAILY:PRN excessive secretions
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC BID
7. Lidocaine 5% Patch 1 PTCH TD QPM
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth Q6hrs Disp #*20
Tablet Refills:*0
9. Ramelteon 8 mg PO QPM:PRN insomnia
10. Senna 17.2 mg PO QHS
11. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
Start date ___
end date ___
12. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
13. Mirtazapine 15 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Tamsulosin 0.4 mg PO QHS
17. TraZODone 25 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C3-t9 fusion with interval cervical spine hardware failure
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: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE.
INDICATION: ___ year old man with ankylosing spondylitis, prior c3-T9 fusion
presents from ___ with interval hardware failure// preoperative planning for
___ OR hardware revision. preoperative planning for ___ OR hardware
revision.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed.
COMPARISON: CT whole spine ___.
FINDINGS:
CERVICAL:
The moderate to severe C7 vertebral body compression fracture is unchanged.
There is no retropulsion, however disc protrusion remains unchanged causing
anterior thecal sac deformity, there is no evidence of lesion or abnormal
signal within the spinal cord at this level.
C2-C3: Posterior disc bulge and ligamentum flavum thickening causing mild
spinal canal narrowing. No neural foraminal stenosis.
C3-C4: Posterior disc bulge and ligamentum flavum thickening causing mild
spinal canal narrowing. Mild right neural foraminal narrowing.
C4-C5: Posterior disc bulge and ligamentum flavum thickening causing moderate
spinal canal narrowing. Mild right neural foraminal narrowing.
C5-6: Posterior disc bulge and ligamentum with thickening within mild spinal
canal narrowing and moderate right neural foraminal narrowing.
C6-C7: Posterior disc bulge not causing spinal canal or neural foraminal
stenosis.
C7-T1: Posterior disc bulge indenting the thecal sac, not causing significant
spinal canal or neural foraminal narrowing.
Alignment is normal. There is mild loss of intervertebral disc height at
C5-C6. Vertebral body and intervertebral disc signal intensity otherwise
appear normal.The spinal cord appears normal in caliber and configuration.
There is a fluid collection posterior to the posterior elements of C4 and C5,
in the left side of the neck, measuring 23 mm (SI) x 6.7 mm (AP) x 23 mm (TV).
This may be postoperative in nature and may represent a seroma. Does the
patient have any symptoms or signs of infection?
THORACIC:
Chronic T6 and T12 vertebral body fractures with retropulsion and associated
retrolisthesis T5 on T6 and T11 on T12, appear unchanged. The spinal cord is
deviated at the level of retropulsion at T6, but there is no spinal cord
compression. No definite T2 hyperintensity is identified within the
cord.Vertebral body and intervertebral disc signal intensity appear normal.
There is no evidence of infection or neoplasm. Note is made of a loculated
right pleural effusion, which is chronic.
LUMBAR:
Chronic L2, L3 and L4 vertebral fractures. Vertebroplasty at L3 and L4.
Appearances are unchanged. The spinal cord appears normal in caliber and
configuration, on terminates at L1-L2 level.There is no evidence of infection
or neoplasm.
L1-L2: Diffuse disc bulge causing mild spinal canal narrowing. No neural
foraminal narrowing.
L2-L3: Diffuse disc bulge causing mild spinal canal narrowing. No neural
foraminal narrowing.
L3-L4: Central disc/posterior osteophyte causing mild-to-moderate spinal canal
narrowing. Bilateral facet joint arthropathy causing moderate bilateral
neural foraminal narrowing.
L4-L5: Posterior osteophyte and ligamentum flavum thickening causing moderate
spinal canal narrowing. In association with bilateral facet joint arthropathy
there is bilateral neural foraminal narrowing, moderate on the right and mild
on the left.
L5-S1: Diffuse disc bulge causing mild spinal canal narrowing. There is no
significant neural foraminal narrowing.
OTHER: There is a 1.8 cm right adrenal mass, which is not fully characterized
on this MRI and may represent an adrenal adenoma. Note is made of bilateral
simple renal cysts.
IMPRESSION:
1. Chronic T6 vertebral body fracture with retropulsion associated
retrolisthesis of T5 and T6, with deviation of the cord at this level but no
frank evidence of cord compression, there is persistent CSF fluid surrounding
the cord at the level of the retropulsion.
2. No change compared with previous, post spinal fusion.
3. Fluid collection noted in the left posterior neck posterior to C4 and C5.
This may represent a postoperative seroma. Does the patient have any symptoms
or signs of infection?
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with c3-t9 fusion, ankylosing spondylitis, HTN,
HLD, now failure of cervical hardware.// Preop for cervical hardware removal,
exploration of wound. Surg: ___ (cervical removal of hardware, wound
exploration)
IMPRESSION:
In comparison with the study of ___, there is little overall change and
no evidence of acute pneumonia. In extensive cervical, thoracic, and lumbar
hardware remain in place.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with tachycardia and new cough// Rule out
pneumonia
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
Low lung volumes are noted. There are small bilateral pleural effusions. No
focal consolidation or pneumothorax is identified. The cardiomediastinal
silhouette is stable in appearance. There is no pulmonary edema. Spinal
hardware and osseous structures are unchanged in appearance.
Radiology Report
EXAMINATION: CTA CHEST ___
INDICATION: ___ year old man hx of prior C3-T9 fusion, T6 laminectomy presents
with hardware failure. patient with persistent tachycardia, chest pain, and
desaturation, concern for PE// Evaluate for PE
TECHNIQUE:
Axial multidetector CT images were obtained through the thorax after the
uneventful administration of intravenous contrast. Reformatted coronal,
sagittal, thin slice axial images, and oblique maximal intensity projection
images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 33.2 cm; CTDIvol = 13.4 mGy (Body) DLP = 443.2
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
4) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 23.2 mGy (Body) DLP =
11.6 mGy-cm.
Total DLP (Body) = 458 mGy-cm.
COMPARISON:
Chest CTA ___
FINDINGS:
CHEST PERIMETER: No incidental thyroid findings. No supraclavicular or left
axillary adenopathy. There may be a new 13 mm right subpectoral lymph node.
301:107. No other soft tissue abnormalities in the chest wall. This study is
not appropriate for subdiaphragmatic diagnosis but shows no subphrenic
collection or adrenal mass.
CARDIO-MEDIASTINUM: Esophagus is unremarkable. Atherosclerotic calcification
mild in head and neck vessels, is heavy in at least left anterior descending
coronary artery. Minimally calcified ascending thoracic aorta normal caliber.
Pericardium is physiologic.
PULMONARY ARTERIES:
Pulmonary arteries are enlarged, main 35 mm, right 29 mm, previously 34 mm and
31 mm. No pulmonary emboli to the segmental level.
THORACIC LYMPH NODES: No lymph nodes in the chest are pathologically enlarged
or growing.
LUNGS, AIRWAYS, PLEURAE: Moderate, right and small left, generally dependent
nonhemorrhagic pleural effusions, including the right fissural component are
comparable in volume to that on ___. No pleural mass or hematoma.
Moderate atelectasis, posterior segment right upper lobe and severe
atelectasis right basal lower lobe segments unchanged. No bronchial
obstruction.
CHEST CAGE: No interval change except for slight progression of callus
formation in multiple healing fractures of the chest cage. No new fractures
or evidence of chest wall infection. No migration of stabilized thoracic
spine trauma or hardware.
IMPRESSION:
No pulmonary embolism. Chronic pulmonary hypertension.
Moderate right and small left pleural effusions stable or recurrent.
Stable atelectasis, moderate, right upper and severe, right lower lobes.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Neck pain
Diagnosed with Cervicalgia
temperature: 97.4
heartrate: 90.0
resprate: 18.0
o2sat: 97.0
sbp: 100.0
dbp: 54.0
level of pain: 0
level of acuity: 3.0 | # Hardware failure
Mr. ___ presented to ___ on ___ after c-spine xray on
___ demonstrated hardware loosening. At clinic hardware was
palpable in the cervical spine, no threatened skin, no pain with
palpation. Patient admitted to floor in stable condition, CT and
MRI c/t/L spine were ordered for preoperative planning. Plan for
OR on ___ with Dr. ___ cervical hardware removal
and wound exploration. Patient restarted on tube feeds with oral
supplementation per SNF regimen and nutrition consult. Patient
restarted on home medication, preoperative cxr wnl, patient went
to OR on ___ for planned removal of cervical instrumentation
and wound exploration. During the case, when the patient was
flipped into the prone position he became acutely hypotensive
requiring epinephrine and IVF boluses and to be returned to
___ position. TEE done in OR demonstrated hyperdynamic left
ventricle, concerning for hypertrophic obstructive
cardiomyopathy. Patient was unable to tolerate prone position
and the case was aborted. Distal end of incision was revised
with patient in lateral position in the OR. Please read Dr.
___ report for further details of case. Patient was
brought out to the PACU intubated and was managed by the TSICU
overnight. He was started on IV fluids. He was weaned off
sedation, phenylephrine drip, and extubated. He remained
hemodynamically and neurologically stable so patient was
transferred back to the floor. Patient's surgical dressing was
removed on POD #2 and his surgical incision appeared intact with
sutures in place, no active drainage noted. On POD #3 patients
surgical incision with slight opening at the superior portion of
the incision but no active drainage. Patient remained
neurologically stable.
# Chest pain
Overnight on ___, patient complained of sternal chest pain
which was worse with inspiration. EKG was done, reviewed by the
Medicine team, and felt to be grossly stable from EKGs on prior
admission. Troponins were elevated at 0.04 x4. Chest pain
resolved with pain management. Patient continued to complain of
chest pain on ___ worsening with deep breaths and cough. A
repeat EKG was obtained on ___ which was stable compared to
prior EKGs. Pain was thought to be musculoskeletal in nature s/p
OR positioning. On ___ patient stated that his chest pain has
improved.
#Hypoxia
Overnight on ___ into ___ patient with tachypnea and hypoxia
to the 80's. Patient was placed on supplemental O2 via NC with
some improvement in O2 sat. CXR on ___ revealed low lung
volumes, small bilateral pleural effusions with no
consolidation. Patient also underwent a CTPE which was negative
for an acute PE.
# Dysphagia
Patient presented from SNF with PEG tube on tube feeds.
Nutrition was consulted for recommendations regarding tube
feeds. Post-op, patient was restarted on tube feeds and puree
diet per nutrition recommendations. SLP was consulted who
recommended upgrading diet to soft food, thin liquids, meds
whole or crushed in puree, 1:1 supervision with meals and to
slowly decrease TF after 24 hour supervision of tolerating new
diet.
# Urinary retention
Patient presented from ___ with foley catheter in place. Void
trial was attempted on ___, but patient was unable to void and
coude catheter was replaced. Urology was contacted and it was
recommended that patient follow up 2 weeks from time of
discharge for a void trial. Patient was found to have a UTI on
___ when the urine culture resulted as enterobacter. Patient
was given 1Gm of ceftriaxone on ___ and sent to rehab with
Bactrim BID for a ___nd the nursing facility can
extend course to 14 days if needed.
# Dispo
___ and OT evaluated the patient on ___ and ___ and recommended
discharge to rehab. Patient was discharged back to his ___ on
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Central venous line placement (IJ) ___
Bone marrow biopsy ___
Skin biopsy over dorsum of right foot ___
History of Present Illness:
Ms. ___ is a ___ with no PMH who was recently seen in ED ___
for c/o fever who was discharged with diagnosis of viral illness
and monospot was negative. She returns to the ED today with
reported fever of 103.1. Patient reports 2 weeks of fever,
chills, arthralgias, night sweats and sore throat associated
with general myalgia and mild abdominal pain. Patient has been
taking Tylenol and Ibuprofen with temporary resolution of most
of her symptoms.
Patient was seen 4 times at ___ in addition to
ED on ___. Also notes chest pain and SOB when having fever.
Patient also notes chest pain during fever and night sweats as
well as an itchy rash on her extremities that comes and goes.
Patient also says she has some positional dizziness,
conjunctivitis, joint pain in hands, and nonbloody diarrhea.
Patient not certain if she has weight loss. Patient reports that
vaccines are up to date, and is not sure she had TB testing.
In the ED, her initial vitals were: 99.4 ___ 20 97%. Her
initial labs were significant for a normal WBC, H/H 11.3/33.6,
PLT 138, normal Chem7, transaminitis with ALT/AST 86/139 (nl AP,
last TB 0.3 on ___, LDH 656, Ca 8.3, CRP 101.4. bHCG negative.
Lactate 1.4. While in the ED, she had a negative monospot and a
preliminary ID work-up with initiated. She was started on
empiric doxycycline given the report that she was recently in
___ and that she was spending time at a farm. She denies
any sick contacts, no hx of infectious mono. No new foods or
medication. She reports having a diffuse maculopapular rash that
appears when she has high fevers or a hot shower, itchy, self
resolves in an hour. No other complaints reported.
She was initially admitted to the Medicine floor for further
workup of FUO, including CT of her neck, chest, abdomen, and
pelvis. Her vitals on arrival to the floor were T: 101.5 BP:
113/77 HR: 98 RR: 26 02 sat: 100%RA. Shortly after admission,
she became hypotensive with SBPs in the ___ and was
transferred to the MICU for septic shock. She had received
roughly 7L IVF upon arrival to the ICU. Of note, she was briefly
treated with peripheral Neo and Levo during transport.
Past Medical History:
None
Social History:
___
Family History:
No family history of autoimmune illness, cancers, heart or
respiratory conditions. Parents are alive and healthy in ___.
___ grandparents are alive and well; patient unsure what the ___
died from.
Physical Exam:
Admission physical exam
Vitals: T 101.5 BP 113/77 HR 98 RR 26 02 sat 100%RA
GENERAL: rigoring in bed, worse when blankets pulled back or
with movement, better with relaxation, anxious affect though
pleasant and cooperative, NAD
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, clear OP without ulcers or lesions, good dentition
NECK: markedly tender on palpation of her tonsils allowing only
limited exam, remainder of neck with small tender adenopathy, no
thyromegaly
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, slightly tachypneic,
better with reassurance
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, no stigmata of endocarditis
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength ___ though this seems
effort-dependent
SKIN: warm and well perfused, no excoriations or lesions, no
rashes at this time.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5F 98/50 60 18 100%RA
General: well-appearing, NAD
HEENT: PERRL, sclera clear
Neck: no LAD
Lungs: CTAB, no crackles or wheezes. no cough with deep
insiration
CV: RRR, nl S1,S2, no murmurs, rubs, or gallops
Abdomen: soft, non-tender, non-distended, no rebound or guarding
Neuro: CN II-XII intact, passive and active ROM of the wrists,
MCP joints intact, strength ___ UE bilaterally
Pertinent Results:
On admission:
___ 07:01PM BLOOD WBC-11.8* RBC-3.64* Hgb-11.3* Hct-32.5*
MCV-89 MCH-31.1 MCHC-34.8 RDW-12.6 Plt ___
___ 11:59PM BLOOD Neuts-81* Bands-11* Lymphs-5* Monos-1*
Eos-0 Baso-0 ___ Metas-2* Myelos-0
___ 11:59PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Burr-OCCASIONAL Tear Dr-OCCASIONAL
___ 11:59PM BLOOD ___ PTT-76.1* ___
___ 07:09PM BLOOD Lactate-3.2*
___ 06:02AM BLOOD CRP-101.4*
___ 06:02AM BLOOD ___ * Titer-1:40 ___
___ 08:00AM BLOOD ___ Echo:
Normal global and regional biventricular systolic function. Mild
mitral regurgitation. Borderline pulmonary hypertension.
___. Prominent cervical lymph nodes bilaterally. These may be
reactive in nature however exact etiology is difficult to
determine. 2. The right sternocleidomastoid muscle is enlarged
and there is some stranding posteriorly, likely due to central
line placement
___ CT A/P
1. Prominent cervical lymph nodes bilaterally. These may be
reactive in nature however exact etiology is difficult to
determine.
2. The right sternocleidomastoid muscle is enlarged and there is
some
stranding posteriorly, likely due to central line placement
___ CT chest
1. Moderate nonhemorrhagic, bilateral pleural effusions with
adjacent
atelectasis. 2. Significant consolidations within the left and
right lower lobes. Findings may represent lobar atelectasis,
however, superimposed infection cannot be excluded. 3.
Non-obstructing, right hilar lymphadenopathy. 4. Enlarged
thymus, probably reactive.
Significant Labs:
___ 01:41AM BLOOD IgG-746 IgA-164 IgM-59
___ 08:00AM BLOOD RheuFac-12
___ 06:02AM BLOOD ___ * Titer-1:40 ___
___ 06:02AM BLOOD CRP-101.4*
___ 10:00AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___ 05:50AM BLOOD Cortsol-2.4
___ 05:50AM BLOOD TSH-1.2
___ 06:00AM BLOOD Ferritn-1506*
Discharge labs:
___ 07:30AM BLOOD WBC-15.1* RBC-3.36* Hgb-10.2* Hct-30.6*
MCV-91 MCH-30.4 MCHC-33.4 RDW-16.3* Plt ___
___ 07:30AM BLOOD Plt ___
___ 06:00AM BLOOD ___
___ 07:30AM BLOOD Glucose-96 UreaN-11 Creat-0.3* Na-138
K-4.1 Cl-101 HCO3-28 AnGap-13
___ 06:00AM BLOOD ALT-134* AST-67* LD(LDH)-447* AlkPhos-104
TotBili-0.5
___ 07:30AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q4-6H:PRN fever, discomfort
Discharge Medications:
1. anakinra 100 mg SC DAILY
RX *anakinra [Kineret] 100 mg/0.67 mL 1 syringe daily Disp #*30
Syringe Refills:*2
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*2
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
4. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. Acetaminophen 325-650 mg PO Q4-6H:PRN fever, discomfort
6. Calcium Carbonate 500 mg PO DAILY
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
7. PredniSONE 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Hemophagocytic Lymphohistiocytosis, Adult
Onset Still's Disease
Secondary Diagnosis: Shock, Acute Kidney Injury, Disseminated
Intravascular Coagulation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ yo woman with persistent fevers of unclear etiology x 2 weeks.
// pneumonia?
TECHNIQUE: PA and lateral images of the chest.
COMPARISON: None.
FINDINGS:
The lungs are well expanded and clear. There is no pleural effusion or
pneumothorax. The cardiomediastinal silhouette is unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: Q22
INDICATION: ___ year old woman with FUO now having hypotensive episodes // ?
Lemierre's or intra-abdominal or intra-thoracic infection or malignancy
TECHNIQUE: MD CT axial imaging of the neck were obtained following the
administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
DOSE: DLP: 378.9mGy-cm; CTDI: 10.2 mGy
COMPARISON: None.
FINDINGS:
There are prominent level 2B, 5A and 5B lymph nodes bilaterally. There is no
abscess or drainable fluid collection within the neck. The neck vessels
enhance normally and are patent. The parotid and submandibular glands are
unremarkable. The visualized intracranial structures are unremarkable. The
paranasal sinuses and mastoid air cells are clear. The right
sternocleidomastoid muscle is enlarged and there is some stranding
posteriorly, likely due to central line placement.
Please see the dedicated chest CT report for further details regarding
intrathoracic findings.
IMPRESSION:
1. Prominent cervical lymph nodes bilaterally. These may be reactive in nature
however exact etiology is difficult to determine.
2. The right sternocleidomastoid muscle is enlarged and there is some
stranding posteriorly, likely due to central line placement.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with septic shock // Evaluate IJ CVL placement
Contact name: ___: ___
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the patient has received a right-sided
internal jugular vein catheter. The course of the catheter is unremarkable,
the tip of the catheter projects over the cavoatrial junction. The stomach is
overinflated.
Obviously reflecting the known septic shock, the patient shows bilateral
parenchymal opacities, with perihilar and lower lung predominance. Given the
simultaneous 0 current 's of a wide and right-sided mediastinum, the changes
most likely reflect hydrostatic pulmonary edema. A coexisting right pneumonia
or aspiration can not be excluded. Mild cardiomegaly. No larger pleural
effusions.
Radiology Report
INDICATION: Fever of unknown origin now hypotensive. Evaluate for
intra-abdominal infection, lymphadenopathy or malignancy.
TECHNIQUE: MDCT axial images were acquired through the torso after the
uneventful administration of 130 mL Omnipaque. Oral contrast was not
administered. Coronal and sagittal reformations were provided and reviewed.
Findings in the chest are reported separately from this study.
DOSE: DLP: 830.91 mGy-cm
COMPARISON: None.
FINDINGS:
The bilateral pleural effusions and intrathoracic findings are reported
separately.
The liver enhances homogeneously without focal lesions. There is substantial
gallbladder wall edema without additional evidence for acute cholecystitis.
The spleen, pancreas and adrenal glands are unremarkable. The kidneys enhance
symmetrically and excrete contrast without hydronephrosis
The stomach, small and large bowel. There is no bowel wall thickening or
obstruction. The appendix is air-filled (601B: 27). There is a cluster of
enlarged lymph nodes centered near the cecum, which measure up to 12 mm
(2:87). There is minimal fat stranding in this area as well, with thickening
of the lateral conal fascia. Retroperitoneal lymph nodes are not enlarged by
CT criteria but are prominent and numerous (2:78). There is no free air. The
aorta is normal caliber. The portal vein, splenic vein and superior mesenteric
vein are patent.
There is a small amount of free pelvic fluid. The rectum is unremarkable. Air
and a Foley catheter noted within the bladder. Multiple follicular cysts are
seen in the both ovaries and range in size up to 11 mm. The uterus is
unremarkable. There is no inguinal or pelvic sidewall lymphadenopathy.
There are no lytic or blastic osseous lesions within the abdomen or pelvis.
IMPRESSION:
1. Nonspecific right lower quadrant lymphadenopathy and prominent
retroperitoneal lymph nodes, not amenable to biopsy. The differential is
broad and includes a reactive process, lymphoma or granulomatous disease.
2. Substantial gallbladder wall edema is presumably related to volume status
and hepatic dysfunction. There are no findings to suggest acute cholecystitis.
3. Bilateral pleural effusions and intrathoracic findings are reported
separately.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
telephone on ___ at 11:20 AM, 30 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CT Chest
INDICATION: Fever of unknown origin, hypotension. Evaluate for infectious
etiology.
TECHNIQUE: MDCT images were obtained from the thoracic inlet to the upper
abdomen. IV Omnipaque contrast was administered. Axial images were
interpreted in conjunction with sagittal and coronal reformats.
COMPARISON: Comparison is made to chest radiographs dated ___.
FINDINGS:
The thyroid is normal. There is mild-moderate right hilar lymphadenopathy
which is nonobstructing. Axillary, supraclavicular, and mediastinal lymph
nodes are not pathologically enlarged. Increased soft tissue density seen
within the anterior mediastinum, likely representing an enlarged thymus.
The great vessels are normal caliber. The heart size is normal. No
pericardial effusion. A right internal jugular venous catheter terminates at
the cavoatrial junction.
There are moderate-sized, bilateral, pleural effusions with adjacent
atelectasis. Significant bilateral lower lobe consolidations are noted, left
greater than right, and may represent lobar atelectasis although concurrent
infection is not excluded. Septal thickening is most pronounced within the
right upper lobe, likely secondary to interstitial edema.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
The examination is not tailored for evaluation of the subdiaphragmatic
structures. For further details, please see the concomitant dedicated CT
abdomen and pelvis.
IMPRESSION:
1. Moderate nonhemorrhagic, bilateral pleural effusions with adjacent
atelectasis.
2. Significant consolidations within the left and right lower lobes. Findings
may represent lobar atelectasis, however, superimposed infection cannot be
excluded.
3. Non-obstructing, right hilar lymphadenopathy.
4. Enlarged thymus, probably reactive.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED, NONSPECIF SKIN ERUPT NEC, JOINT PAIN-MULT JTS
temperature: 99.4
heartrate: 112.0
resprate: 20.0
o2sat: 97.0
sbp: 98.0
dbp: 65.0
level of pain: 5
level of acuity: 3.0 | This is a ___ no significant PMHx recently seen in ED ___
for c/o fever, who re-presents for fever to 103.1, with multiple
physical complaints, as well as elevated CRP, transaminitis,
elevated ferritin and new leukocytosis.
MICU COURSE
# Septic shock / FUO: Met ___ SIRS criteria at admission and
required pressors briefly until ___. Received about 11L fluids.
Initial differential included infectious, autoimmune,
malignancy. Her hemophagocytic process (elevated LDH, ferritin)
was concerning for hemophagocytic lymphohistiocytosis (HLH).
Patient was seen by ID, heme/onc, and rheumatology. Bone marrow
biopsy was performed, which showed hemophagocytosis.
Presentation was felt to be most likely due to HLH vs macrophage
activation syndrome secondary to Still's disease. CT
neck/abdomen/pelvis was performed given tender lymphadenopathy
and to rule out occult malignancy or abscess. CT showed
nonspecific lymphadenophathy and gallbladder wall edema (likely
secondary to volume overload). Echo for vegetations was
negative. Infectious workup to date has been unrevealing. Beta
glucan was elevated, but was felt to be a false positive given
no clinical signs of fungal infection and improvement on
steroids. Patient was started on broad spectrum antibiotics of
___ per ID recommendations on ___ which was
d/c on ___. Patient was given 1g solumedrol daily for 3
days, followed by 60mg prednisone. She was started on Anakinra
on ___. Meropenem was continued because of immunosuppression on
high dose steroids. Patient was also started on bactrim for PCP
prophylaxis on ___.
# Coagulopathy: Patient presented to ICU with low platelets,
elevated FDP, elevated ___ concerning for DIC. Labs were
trended and patient did not require transfution of FFP or
pRRBCs. Labs improved during MICU course and while on floor.
#Transaminitis / ___: Likely multifactorial, related to
inflammation from underlying process and shock. LFTs were
followed and downtrended appropriately.
# ___: Cr 1.3 in setting of septic shock and volume depletion.
UA with bland sediment. Cr returned to baseline during MICU
course and stayed at normal levels while on floor
# Hypoxia: Patient had new O2 requirement in the setting of
aggressive volume resuscitation. Unlikely to be PNA as she did
not have any previous localizing symptoms except a sore throat.
Was initially started on broad spectrum antibiotics as above,
but O2 requirement decreased as patient self-diuresed and was
weaned to room air on ___.
GENERAL MEDICINE FLOOR COURSE
1. HLH/MACROPHAGE ACTIVATION SYNDROME: As discussed, Ms. ___ was
admitted with fever without localizing signs requiring a MICU
admission for hypotension, pressors and broad spectrum
antibiotics. She also was found to have a transaminitis,
elevated LDH, and rapid ferritin elevation to ___ concerning
for hemophagocytic lymphohistiocytosis with unclear precipitant.
Given the clinical suspicion for HLH, a bone marrow biopsy was
performed. Aspirate smear was reviewed with heme pathology and
was significant for hemophagocytosis, consistent with a
diagnosis of HLH. Given the patient's clinical status with
worsening ferritin and LFTs, prompt steroids were initiated. We
believe that she has a form of HLH known as Macrophage
activation syndrome (MAS) which is associated with juvenile
idiopathic arthritis and other rheumatologic conditions. MAS is
a subset of HLH in which successful therapy of the underlying
condition may produce a good response and allow the patient to
avoid HLH-specific therapy. Therefore, pulse dose steroids as
recommended by rheumatology were continued, to which indefinite
anakinra was added.
2. Fevers/Adult Stills: Ms. ___ had fevers with evanescent rash,
pharyngitis, very high ferritin and questionable LAD that best
fit a diagnosis of Adult Stills Disease. She responded to
Stills treatment including pulse-dose steroids. It is possible
that that was triggered by a viral infection, but if so, that
virus had resolved by the time of her hospitalization.
Infectious work-up did not reveal any infectious causes of the
fevers. A quantiferon gold was indeterminate, EBV serology
consistent with prior infection, CMV with no prior infection and
no evidence of Parvo B19, RSF, Erlichia, Anaplama, Lyme
infection. She was started on Bactrim prophylaxis and high dose
IV steroids were started on ___. On ___ Anakinra ___ was
initiated and she was switched to PO Pred 60mg with a plan to
taper by 5mg weekly.
3. ___: As above, her Cr had initially increased to 1.2, but
then restored to 0.5 with fluids as clinical symptoms improved.
She was mildly dizzy without orthostatic vital signs during the
several days before she was discharged and received small
amounts of fluids with good effect.
4. Hypoxemia: As discussed above, Ms. ___ received large amounts
of IV Fluids so this oxygen requirement was most likely related
to fluid overload. No crackles or decreased breath sounds on
exam, but non-productive cough present. This gradually resolved
on its own and she was without an oxygen requirement and with
good oxygen saturation on discharge.
5. DIC: Her fibrinogen was monitored for possible continued low
grade DIC. These lab values steadily improved and did not
require intervention on the floor.
TRANSITIONAL ISSUES
- Ms. ___ is being discharged on both steroids (Prednisone 50mg
per day X 1 week with a planned 5mg per week taper thereafter)
and self-administered injections of Anakinra
- Ms. ___ will ___ with Rheumatology within 1 week
following her discharge
- Ms. ___ will also ___ with a new Primary Care doctor at
___ for management of her other medical
issues
- Please ___ result of IL-2 receptor test |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___: Small bowel resection and repair of incarcerated
umbilical hernia.
History of Present Illness:
Patient is a ___ year old male with PMH significant for NICM with
EF 15% now recovered to >55%,HTN, COPD, AICD, CKD, and a known
umbilical hernia, who is presenting today to the ED with one day
of pain and swelling at the hernia site. He states that he has
vomited three times this morning last one of which have been
bilious.
The patient underwent a CT in the ED which showed incarcerated
bowel, with SBO and TP in the hernia sac.
His Cr is 2.3. lactate 1.9, bicarb 24.
he denies SOB, CP, fever, chills, dysuria, frequency.
Past Medical History:
- non-ischemic/hypertrophic cardiomyopathy with EF of 15%
___
thought to be less likely amyloidosis
- severe aortic regurgitation s/p bioprosthetic aortic valve
replacement
- ICD placement ___ for primary prevention of sudden cardiac
death
- HTN
- CKD (baseline Cr 1.5-2)
- sellar/parasellar meningioma s/p radiation therapy (done at
Mass Eye and Ear per patient, unclear dates)
Social History:
___
Family History:
Mother and brother with heart disease.
Physical Exam:
Admission Physical Exam:
Vitals: 97 55 ___ 99% RA
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, nontender, midline umbilical hernia
noted, irreducible, firm and TTP, with overlying skin changes
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical exam:
VS: 97.4 PO ___ 16 99 1L
GEN: awake, alert, interactive.
HEENT: PERRL, EOMI.
CV: RRR
PULM: Rhonchorus and crackles in bases.
ABD: Soft, non-tender, non-distended. Surgical incision CDI with
staples.
EXT: Warm and dry. no edema.
NERUO: A&O. follows commands and moves all extremities equal and
strong. Speech is delayed, but clear.
Pertinent Results:
___ 04:54AM BLOOD WBC-4.2 RBC-3.45* Hgb-10.2* Hct-33.1*
MCV-96 MCH-29.6 MCHC-30.8* RDW-14.4 RDWSD-50.4* Plt ___
___ 04:21AM BLOOD WBC-6.3 RBC-3.34* Hgb-10.2* Hct-31.7*
MCV-95 MCH-30.5 MCHC-32.2 RDW-14.6 RDWSD-51.0* Plt ___
___ 04:44AM BLOOD WBC-8.0 RBC-3.44* Hgb-10.6* Hct-32.4*
MCV-94 MCH-30.8 MCHC-32.7 RDW-14.6 RDWSD-49.9* Plt ___
___ 06:09AM BLOOD WBC-8.7 RBC-4.12* Hgb-12.6* Hct-37.7*
MCV-92 MCH-30.6 MCHC-33.4 RDW-14.4 RDWSD-48.0* Plt ___
___ 04:51AM BLOOD WBC-13.4* RBC-4.45* Hgb-13.4* Hct-42.0
MCV-94 MCH-30.1 MCHC-31.9* RDW-14.4 RDWSD-49.7* Plt ___
___ 12:57PM BLOOD WBC-5.7 RBC-4.72 Hgb-14.5 Hct-43.7 MCV-93
MCH-30.7 MCHC-33.2 RDW-14.2 RDWSD-47.9* Plt ___
___ 06:09AM BLOOD ___ PTT-28.7 ___
___ 04:54AM BLOOD Glucose-108* UreaN-74* Creat-2.1* Na-153*
K-3.8 Cl-110* HCO3-30 AnGap-13
___ 06:06PM BLOOD Glucose-147* UreaN-81* Creat-2.3* Na-150*
K-3.7 Cl-110* HCO3-28 AnGap-12
___ 04:21AM BLOOD Glucose-126* UreaN-87* Creat-2.6* Na-151*
K-3.9 Cl-110* HCO3-28 AnGap-13
___ 04:44AM BLOOD Glucose-82 UreaN-95* Creat-2.8* Na-148*
K-4.3 Cl-108 HCO3-26 AnGap-14
___ 06:09AM BLOOD Glucose-125* UreaN-74* Creat-3.1* Na-145
K-4.2 Cl-102 HCO3-25 AnGap-18
___ 04:39AM BLOOD Glucose-121* UreaN-72* Creat-3.2* Na-148*
K-4.5 Cl-100 HCO3-28 AnGap-20*
___ 04:51AM BLOOD Glucose-91 UreaN-32* Creat-2.3* Na-146
K-3.5 Cl-103 HCO3-28 AnGap-15
___ 12:57PM BLOOD Glucose-103* UreaN-30* Creat-2.3* Na-142
K-4.1 Cl-100 HCO3-24 AnGap-18
___ 12:57PM BLOOD ALT-18 AST-28 AlkPhos-58 TotBili-0.9
___ 04:54AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.3
___ 06:06PM BLOOD Calcium-8.2* Phos-2.9 Mg-2.4
___ 04:21AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.8*
___ 04:44AM BLOOD Calcium-8.1* Phos-5.0* Mg-2.9*
___ 06:09AM BLOOD Calcium-8.6 Phos-6.4* Mg-2.8*
___ 04:39AM BLOOD Calcium-8.7 Phos-6.5* Mg-2.9*
___ 04:51AM BLOOD Calcium-8.5 Phos-5.7* Mg-1.4*
___ 01:03PM BLOOD Lactate-1.9
___ 03:09AM URINE Blood-MOD* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG*
___ 03:09AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 03:09AM URINE Hours-RANDOM Creat-122 Na-<20 Cl-<20
Calcium-<0.8
___ R Heel Xray:
Mild irregularity of a small plantar calcaneal enthesophyte may
relate to
prior trauma. If there is concern for acute on chronic injury
MRI can be
performed.
___ CXR:
Comparison to ___. The extent and severity of the
pre-existing
multifocal parenchymal opacities is stable. Stable moderate
cardiomegaly. No new opacities. No pleural effusions. The
left pectoral pacemaker is in stable correct position
___ CXR:
1. Multifocal bilateral opacities, worse on the right lung,
concerning for
moderate pulmonary edema. Small right pleural effusion.
2. Moderate cardiomegaly and widened mediastinum the
mediastinum, likely
exaggerated in current study due to positioning.
___ Xray abd:
The entire abdomen is not demonstrated on plain abdominal
radiographs.
Partially visualized large bowel measures up to 6.6 cm which may
represent
ileus.
The small bowel is not well delineated suggesting fluid within
the
intraluminal cavity better characterized on CT abdomen and
pelvis dated ___.
___ CT A/P:
1. Supraumbilical ventral hernia containing small bowel loops
with associated small bowel obstruction. Small amount of fluid
in the hernia sac. Please correlate for incarceration.
2. Severe cardiomegaly with mild interstitial pulmonary edema.
___ 04:49AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0 UricAcd-13.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Bumetanide 2 mg PO BID
3. CARVedilol 25 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Polyethylene Glycol 17 g PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bumetanide 2 mg PO BID
5. CARVedilol 25 mg PO BID
6. Pantoprazole 40 mg PO Q12H
7. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do
not restart Lisinopril until follow up with PCP.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Incarcerated umbilical hernia, with bowel ischemia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old man with umbilical hernia, CKD, and NICM presenting
with abdominal pain// evaluate for bowel obstruction
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.Coronal and sagittal reformations were
performed and reviewed on PACS.
DOSE: Total DLP (Body) = 628 mGy-cm.
COMPARISON: CT ___
FINDINGS:
LOWER CHEST: Mild pulmonary edema is noted in the lower lungs with septal
thickening and engorged vasculature. There is severe cardiomegaly which
appears worsened compared to the prior study. No pleural or pericardial
effusion. A intraventricular pacing lead is partially visualized.
ABDOMEN:
HEPATOBILIARY: The unenhanced appearance of the liver is normal. The
gallbladder is unremarkable.
PANCREAS: The pancreas is grossly unremarkable.
SPLEEN: The spleen is normal in size.
ADRENALS: No adrenal lesions.
URINARY: No kidney stone or hydronephrosis. No definite worrisome renal
lesion on this unenhanced exam.
GASTROINTESTINAL: There is a small hiatal hernia. Multiple small bowel loops
are dilated and fluid-filled. The proximal small bowel is decompressed.
There is progressive small bowel dilation which can be traced to a ventral
supraumbilical hernia which contains a small bowel loop. Distal to this
hernia, small bowel is decompressed. A small amount of fluid is also seen
within the hernia sac. The hernia neck is small measuring 14 x 17 mm,
correlate for incarceration. A small amount of free fluid within the right
lower quadrant (series 2, image 49). The colon and rectum are within normal
limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
trace free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: A ventral abdominal wall defect measures 1.4 x 1.7 cm. The soft
tissue adjacent to the hernia demonstrates moderate stranding.
IMPRESSION:
1. Supraumbilical ventral hernia containing small bowel loops with associated
small bowel obstruction. Small amount of fluid in the hernia sac. Please
correlate for incarceration.
2. Severe cardiomegaly with mild interstitial pulmonary edema.
Radiology Report
INDICATION: ___ h.o NICM, AICD, CKD with incarcerated umbilical hernia s/p
SBR and hernia repair // ? ileus or obstruction
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: Abdominal x-ray dated ___. CT abdomen and pelvis
dated ___
FINDINGS:
The entire abdomen is not included on the plain abdominal radiographs. The
demonstrated large bowel is mildly dilated up to 6.6 cm. The small bowel is
not well delineated suggesting fluid within the intraluminal cavity.
There is no free intraperitoneal air.
Osseous structures are unchanged. There are staples overlying the left
paraspinal region. An AICD lead and inferior-most sternotomy wire is
demonstrated at the inferior chest. Chronic interstitial changes are
demonstrated at the lower lung fields, most pronounced on the left.
IMPRESSION:
The entire abdomen is not demonstrated on plain abdominal radiographs.
Partially visualized large bowel measures up to 6.6 cm which may represent
ileus.
The small bowel is not well delineated suggesting fluid within the
intraluminal cavity better characterized on CT abdomen and pelvis dated ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p SBR, hernia repair, now with decreased
BS left ant chest, crackles bases// evaluate for consolidation/interval change
TECHNIQUE: Portable AP
COMPARISON: Chest radiograph ___
FINDINGS:
Single lead pacemaker and defibrillator projects over the right ventricle,
unchanged from prior. Median sternotomy wires and round hyperdensities
projecting over the mediastinum are unchanged.
Multifocal patchy airspace opacities, worse on the right. No pneumothorax.
Persistent widening of the vascular mediastinum, likely worsened by position.
The right hemidiaphragm interface is not well seen, could be secondary to
small pleural effusion cardiac size is moderately enlarged.
IMPRESSION:
1. Multifocal bilateral opacities, worse on the right lung, concerning for
moderate pulmonary edema. Small right pleural effusion.
2. Moderate cardiomegaly and widened mediastinum the mediastinum, likely
exaggerated in current study due to positioning.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ h.o NICM, AICD, CKD with incarcerated umbilical hernia s/p
SBR and hernia repair// hypoxia, evaluate heart failure vs atelectasis
hypoxia, evaluate heart failure vs atelectasis
IMPRESSION:
Comparison to ___. The extent and severity of the pre-existing
multifocal parenchymal opacities is stable. Stable moderate cardiomegaly. No
new opacities. No pleural effusions. The left pectoral pacemaker is in
stable correct position.
Radiology Report
EXAMINATION: HEEL (AXIAL AND LATERAL) RIGHT
INDICATION: ___ year old man with right heel pain worse with weight bearing.//
? fracture
TECHNIQUE: Two views of the right calcaneus.
COMPARISON: None.
FINDINGS:
There is mild irregularity of a small plantar calcaneal enthesophyte. Dorsal
calcaneal enthesophyte appears intact.There are mild degenerative changes of
the tibiotalar, subtalar and talonavicular joints.Bone mineralization is age
appropriate.
IMPRESSION:
Mild irregularity of a small plantar calcaneal enthesophyte may relate to
prior trauma. If there is concern for acute on chronic injury MRI can be
performed.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with desat in POP// Interval change
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
Median sternotomy wires are noted. There is a left chest wall AICD with a
single lead terminating in the regions of the right ventricle.
There are multifocal parenchymal opacities, which are not significantly
changed compared to prior study. There is no pleural effusion or
pneumothorax. The cardiomediastinal silhouette stable in appearance. There
are no acute osseous abnormalities.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Periumbilical pain, Athscl heart disease of native coronary artery w/o ang pctrs
temperature: 97.0
heartrate: 55.0
resprate: 17.0
o2sat: 99.0
sbp: 108.0
dbp: 77.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ yo M with history of non-ischemic
cardiomyopathy, AICD, CKD who presented to the emergency
department on ___ with abdominal pain. He underwent CT scan
that was consistent with an incarcerated umbilical hernia. White
blood cell count normal at 5.7 and lactate normal at 1.9. The
indication and possible complications of this procedure were
explained to him preoperatively and appropriate informed signed
consent was obtained. On ___ the patient underwent small
bowel resection and repair of incarcerated umbilical hernia.
Please see operative report for details.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV Tylenol
and then transitioned to oral Tylenol once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint. Initially post operatively he had increased work of
breathing and a new supplemental oxygen requirement. He was
given diuresis and was able to be weaned off oxygen. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO after surgery. He
was given clears on POD3-4 and on POD5 he had return of bowel
function and therefore was advanced to a regular diet which was
well tolerated. Patient's intake and output were closely
monitored. Foley catheter was removed on POD3 and he was able to
void without difficulty. He was hypernatremic to 151 on POD4
with a resolving acute kidney injury. Nephrology was consulted
and he was given D5W and sodium levels improved. IV fluids were
stopped after 1 day with resolution of hypernatremia. After
stopping fluids, sodium level then increased to 153 on POD8.
Acute kidney injury was judiciously managed given comorbidity of
heart failure with an EF of 15%. His creatinine normalized to
baseline of 1.8 at time of discharge. Given his stable clinical
exam and previous response to fluids, increased oral fluids were
encouraged.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
The patient reported foot pain. Xrays negative for acute injury.
Uric acid level elevated at 13. Recommend increased hydration
and further work up for gout as needed.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. The patient was discharged to
rehab to continue his recovery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
postoperative abdominal pain
Major Surgical or Invasive Procedure:
___ ERCP with CBD stent placement
History of Present Illness:
This patient is a ___ year old female status post lap
cholecystectomy, POD#6 who presents to the ED with abdominal
pain.
The patient states the pain has been present and has persisted
since the operation. The pain is diffuse in her abdomen but
predominantly localized to her left sided rib cage. It radiates
to both of her shoulders. She describes the pain as stabbing in
nature. It is triggered by being lying on her back or positional
changes. It is not meal related. She denies fever, chills,
nausea, emesis, choluria, acholia. She endorses dysuria. Denies
hematuria. She says that she's been more irregular with bowel
movements, yet, she is passing flatus and last bm was two days
ago.
Upon arrival to the ED. VS: 97.8, 107 132/81, 16, 100% RA. She
is
no acute distress. There is not jaundice on exam. Oral mucosa is
dry. Abdomen is slight obese, soft, non-distended. I could not
appreciate any tenderness in the abdomen or over the rib cages.
She has + CVA tenderness to the right side.
ROS:
(+) per HPI
(-) Denies pain, fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
Past Medical History: Acne, obesity with weight loss.
Past Surgical History: Per HPI. Dental implants
Social History:
___
Family History:
Family history is negative for gallstones.
Physical Exam:
VS: 98.1
___
GEN: A&Ox3, NAD, resting comfortably
HEENT: NCAT, EOMI, sclera anicteric
CV: RRR
PULM: no respiratory distress
ABD: soft, NT ND, no rebound or guarding
EXT: warm, well-perfused, no edema
PSYCH: normal insight, memory, and mood
WOUND(S): Incision c/d/i
Pertinent Results:
___ 07:20AM BLOOD WBC-6.5 RBC-3.21* Hgb-9.8* Hct-28.6*
MCV-89 MCH-30.5 MCHC-34.3 RDW-11.5 RDWSD-36.9 Plt ___
___ 04:00AM BLOOD WBC-9.3 RBC-3.51* Hgb-10.6* Hct-31.5*
MCV-90 MCH-30.2 MCHC-33.7 RDW-11.8 RDWSD-38.2 Plt ___
___ 10:30AM BLOOD WBC-9.8 RBC-3.49* Hgb-10.7* Hct-31.6*
MCV-91 MCH-30.7 MCHC-33.9 RDW-11.9 RDWSD-38.6 Plt ___
___ 10:30AM BLOOD Neuts-84.1* Lymphs-10.1* Monos-5.1
Eos-0.0* Baso-0.3 Im ___ AbsNeut-8.24* AbsLymp-0.99*
AbsMono-0.50 AbsEos-0.00* AbsBaso-0.03
___ 04:00AM BLOOD ___ PTT-32.0 ___
___ 07:20AM BLOOD Glucose-61* UreaN-5* Creat-0.4 Na-141
K-3.8 Cl-101 HCO3-25 AnGap-15
___ 04:00AM BLOOD Glucose-93 UreaN-6 Creat-0.4 Na-141 K-4.2
Cl-102 HCO3-26 AnGap-13
___ 07:20AM BLOOD ALT-33 AST-19 AlkPhos-122* TotBili-0.8
___ 04:00AM BLOOD ALT-36 AST-15 AlkPhos-100 TotBili-0.8
___ 10:30AM BLOOD ALT-47* AST-15 AlkPhos-102 TotBili-0.6
___ 07:20AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7
___ 04:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8
Medications on Admission:
Medications - OTC
IBUPROFEN - ibuprofen 200 mg tablet. 3 tablet(s) by mouth as
needed for pain last dose ___ - (Prescribed by Other
Provider)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary leak s/p lap chole
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with recent lap chole p/w epigastric pain and back pain//
Please assess for evidence of cholangitis, retained stones
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Comparison is made to ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
The distal common bile duct is not well visualized. No evidence of distal
obstructing stones.
GALLBLADDER: The patient is status post cholecystectomy. Small fluid
collection visualized in the postop bed.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 15.1 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. Patient is status post cholecystectomy. Small fluid collection in the
postop bed may represent a postoperative seroma or biloma however,
superimposed infection cannot be excluded. The common bile duct measures 5 mm.
The distal common bile duct is not well visualized, however there is no
evidence of distal obstructing stones.
2. Mild splenomegaly measuring up to 15.1 cm, was not well demonstrated on
prior exam however this is likely secondary to differences in technique.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with recent lap chole p/w abdominal pain and shoulder pain.
Evaluate for subphrenic hematoma or other pathology to explain abdominal pain.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 7.0 s, 55.1 cm; CTDIvol = 20.2 mGy (Body) DLP =
1,112.2 mGy-cm.
Total DLP (Body) = 1,119 mGy-cm.
COMPARISON: Abdominal ultrasound from earlier on the same date.
FINDINGS:
LOWER CHEST: There is trace right pleural effusion with adjacent compressive
atelectasis. Mild left basilar atelectasis. No pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is mild intrahepatic biliary
dilatation in the setting of prior cholecystectomy. Notably, a smaller 6 mm
rounded density adjacent to the surgical clips in the gallbladder fossa may
represent the remnant cystic duct. There is moderate perihepatic and
perisplenic fluid, of simple internal attenuation, tracking down the bilateral
paracolic gutters, into the pelvis.
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: The urinary bladder and distal ureters are unremarkable. There is a
small to moderate amount of free pelvic fluid.
REPRODUCTIVE ORGANS: The uterus is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No significant
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Post cholecystectomy, with mild intrahepatic biliary dilatation and a
moderate amount of gallbladder fossa, perihepatic, and perisplenic fluid
tracking down the bilateral gutters and into the pelvis. In the setting of
prior surgery, biliary leak is not excluded on the basis of this CT.
2. Trace right pleural effusion.
NOTIFICATION: The above findings were communicated in person by Dr. ___
to Dr. ___ at 15:45 on ___, 2 minutes after discovery.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman ___ s/p cholecystectomy, with abdominal pain
and free fluid on CT, concern for biliary leak. Needs MRCP WITH EOVIST to
further evaluate for bile leak.// ___ year old woman ___ s/p cholecystectomy,
with abdominal pain and free fluid on CT, concern for biliary leak. Needs MRCP
WITH EOVIST to further evaluate for bile leak.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Eovist.
Oral contrast: None was administered
COMPARISON: ___ abdomen and pelvis CT
FINDINGS:
Redemonstrated is large volume ascites. The patient is post cholecystectomy.
Mild prominence of the intra and extrahepatic bile duct is unchanged compared
prior imaging. The common bile duct tapers normally to the ampulla without
filling defect to suggest choledocholithiasis. There is a prominent fluid
collection at the porta hepatis which extends to the region of the cystic duct
stump, also seen on the prior CT. Post Eovist 20 minute delayed images
demonstrate appropriate opacification of the intrahepatic bile ducts and left
and right hepatic ducts to their confluence/very proximal portion of the
common bile duct (series 20, image 30). The remainder of the common bile duct
is not opacified. However, there is extraluminal pooling of excreted biliary
contrast in the gallbladder fossa where a prominent fluid collection was
present previously, consistent with biliary leakage (20:25). Although the
exact site of biliary leakage is not identified, it is likely somewhere
between confluence of the right and left hepatic ducts and the region of the
cystic duct stump.
There are no focal liver lesions. The spleen, pancreas, adrenal glands,
bilateral kidneys are within normal limits. The stomach and visualized loops
of bowel are unremarkable. There are vascular abnormalities. There is no
lymphadenopathy. A small right pleural effusion is noted.
IMPRESSION:
1. Biliary leakage status post cholecystectomy as evidenced by pooling of
biliary excreted contrast within the gallbladder fossa. The exact site of
leakage is not identified but likely lies between the confluence of the right
and left hepatic ducts and the cystic duct insertion.
2. Large volume ascites in the setting of active biliary leakage, overall
similar to most recent prior CT scan of the abdomen and pelvis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:50 pm, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: US INTERVENTIONAL PROCEDURE
INDICATION: ___ s/p laparoscopic cholecystectomy ___ with persistent
abdominal pain, imaging showing bile leak with biloma: please drain biloma,
send for fluid cultures and please leave drain// please drain biloma, send for
fluid cultures and please leave drain
TECHNIQUE: Limited gray scale ultrasound images were obtained of the liver.
COMPARISON: Ultrasound dated ___
FINDINGS:
Limited preprocedure evaluation of the gallbladder fossa demonstrated a small
residual fluid pocket measuring 6 mm in short axis. This has significantly
decreased in size compared to ultrasound from 1 day prior where it measured
2.5 cm in short axis.
IMPRESSION:
Decrease in size of the fluid collection in the gallbladder fossa. No
drainable collection identified on today's examination. If clinically
warranted, interval follow-up ultrasound or CT may be considered if clinically
warranted to assess for fluid reaccumulation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, Epigastric pain, Shoulder pain
Diagnosed with Unspecified abdominal pain
temperature: 97.8
heartrate: 107.0
resprate: 16.0
o2sat: 100.0
sbp: 132.0
dbp: 81.0
level of pain: 10
level of acuity: 3.0 | Patient presented to the ED with abdominal pain
post-cholecystectomy, and MRI and CT scans were positive for
bile leakage. She underwent ERCP with stent placement in CBD.
Patient then experienced significant improvement in abdominal
pain. Subsequent imaging by ___ showed decrease in size of fluid
collection in the gallbladder fossa with no drainable collection
identified. She received IV-ampicillin sulbactam during her
hospital stay and transition to PO amoxicillan-clavulanic acid
prior to discharge.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV dilaudid and
then transitioned to oral tylenol once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO, then post ERCP,
the diet was advanced sequentially to a Regular diet, which was
well tolerated. Patient's intake and output were closely
monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Patient will need a Repeat ERCP with GI in 4 weeks for stent
pull and re-evaluation. She was discharged on 5 day course of
amoxicillan-clavulanic acid and tylenol for pain control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Vioxx / Penicillins / CellCept / Ceftriaxone /
Ferrlecit / Sulfa (Sulfonamide Antibiotics)
Attending: ___
___ Complaint:
HEMOPTYSIS
Major Surgical or Invasive Procedure:
LEFT BRONCHIAL ARTERY EMBOLIZATION UNDER FLUOROSCOPY
RIGHT INTERNAL JUGULAR LINE PLACEMENT, REPOSITIONING, AND
REMOVAL
IVC FILTER PLACEMENT
INTUBATION AND MECHANICAL VENTILATION
History of Present Illness:
___ with history of lupus, lupus nephritis with ESRD on
peritoneal dialysis on transplant list, hx of PE/Antiphopholipid
antibody on coumadin, mitral regurg, presents with ___ month
history of cough, worse in the morning, one week of trace blood,
now producing bright red blood over last couple days. Patient
states that the amount of blood she has been coughing has been
increasing and is now almost hourly, aprroximately 1 teaspoon
bright red blood. Patient states that the cough produced
primarily yellow sputum until it turned to blood. Patient denies
any other symptoms such as dizziness or lightheadedness. She
denies any changes in her BMs, including consistency, frequency,
and color. Patient visited PCP on ___, and a CXR was
negative. Her was also noted to be subtherapeutic and she took
an extra day of 10 mg warfarin as instructed.
.
Initial vitals in the ED were: 108 138/95 18 100% RA. Her HCT
was 29.6, her baseline is unclear but appears to be low ___. INR
was 4.4. A CTA was done for concern of PE which showed: 1. Left
lower lobe consolidation with large amount of secretions/fluid
within the left lower lobe segmental bronchi. 2. Centrilobular
nodules and ground glass opacities throughout both lungs,
compatible with chronic collagen vascular disease, progressed
since ___. Ground glass opacities could also represent
hemorrhage. 3. Chronic left lower segmental pulmonary arterial
PE, unchanged since ___. No new acute PE detected to the
subsegmental levels. She was initially admitted to medicine but
then transferred to the ICU.
.
On arrival to the MICU initial vitals were: 110 163/96 20 95%RA.
She is breathing comfortably but complains of pain in her chest.
Her EKG was reviewed which did not show changes from her prior.
She also complains of a HA that she says she occasionally
recieves toradol. She has had emesis in the ED that looked
dark/possibly coffee ground but currently denies nausea.
Past Medical History:
# Lupus rash
# Herpes Simplex I - ___, white lesions on the tongue and
buccal mucosa
# Axillary Adenopathy - ___, biopsied -> reactive lymph node
# Osteopenia - ___, L spine Tscore -2.40, Fem neck -1.91, Tot
Hip -1.41
# Hypercholesterolemia - ___
# Lung abscess - ___
# Pulmonary emboli (PE) - ___
# Angioedema vs Anasarca - ___, associated with 2 grand mal
seizures, required intubation for massive facial/laryngeal
swelling
# Pleural Effusions - s/p pleurodesis in ___ nephrotic
syndrome
# Lupus nephritis / Nephrotic syndrome - ___, renal bx showed
focal proliferative class III
# GERD / Gastric ulcer - ___, seen on barium swallow
# Recurrent pneumonia - ___, possibly from aspirations, most
recent ___
# Antiphospholipid antibody syndrome (APS) - ___, requiring
anticoagulation to INR of 2 to 3
# Breast Masses - ___, bilateral, largest right upper outer
quadrant ___ cm
# Thrombotic thrombocytopenic purpura (TTP) - ___, s/p
plasmapheresis
# Inflammatory eye mass - ___, s/p excision of mass, ___ lupus
# Gonorrhea - ___, disseminated gonococcus
# Abnormal pap smear - ___, subsequent paps x 2 normal
# Systemic lupus erythematosus (SLE) - ___, followed by Dr.
___
# Raynaud's syndrome
# Stroke - hemiparalysis
# Asthma - no problems for several years
Social History:
___
Family History:
Mother with MS
___ with sarcoid
___ discoid lupus
Physical Exam:
ADMISSION EXAM
Vital signs: 110 163/96 20 95%RA.
Gen: Uncomfortable appearing but no acute distress.
HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP
clear.
Neck: Supple.
Resp: Absent breath sounds entire L Lung fields, R lung firels
CTA
CV: Tachycardic, regular rhythym. Normal s1 and s2. ___ SM at
apexNo M/G/R.
Abd: +BS. Soft. NT/ND. No rebound or guarding. No
hepatosplenomegaly.
Ext: Warm and well-perfused. Radial and DP pulses 2+
bilaterally.
Neuro: A+Ox3. PERRL. EOMI, with no nystagmus. Face symmetric.
.
DISCHARGE EXAM
VS T 98.0 HR 128 (regular) BP 102/76 RR 22 O2 100/RA
GEN thin young woman resting in bed, somnolence but easily
roused, NAD
NCAT MMM EOMI OP clear
Lungs CTAB, prominent breath sounds, no wheeze no L dullness
CV tachycardic at regular rate, nl S1 S2 no mumur Abd full but
nondistended and nontender, soft
Ext no edema, warm and dry
Pertinent Results:
ADMISSION LABS
___ 07:30AM WBC-7.9# RBC-3.19* HGB-9.2* HCT-29.6* MCV-93
MCH-28.8 MCHC-31.0 RDW-16.9*
___ 07:30AM NEUTS-64.1 ___ MONOS-4.4 EOS-6.4*
BASOS-0.8
___ 07:30AM PLT COUNT-376#
___ 07:30AM GLUCOSE-96 UREA N-58* CREAT-13.0*# SODIUM-142
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-24 ANION GAP-23*
___ 07:30AM ___ PTT-46.9* ___
.
OTHER PERTINENT LABS
___ 05:04PM BLOOD ___ * Titer-1:160 dsDNA-POSITIVE
*
___ 04:57AM BLOOD dsDNA-NEGATIVE
___ 11:44AM BLOOD SM ANTIBODY-3.6 POS (<1.0 NEG AI)
___ 05:04PM BLOOD ANCA-NEGATIVE B
___ 04:57AM BLOOD dsDNA-NEGATIVE
___ 07:00PM BLOOD Lupus ANTICOAGULANT-POS
___ 05:13AM ANTICARDIOLIPIN IgG-5.5(NEG) ANTICARDIOLIPIN
IgM-5.6(NEG)
___ 05:04PM BLOOD ___ * Titer-1:160 dsDNA-POSITIVE
(1:10)
___ 05:13AM BLOOD Beta-2-Glycoprotein 1 Antibodies IgG-PND
___ 07:30AM BLOOD C3-109 C4-44*
___ 04:57AM BLOOD C3-87* C4-29
___ 03:36AM BLOOD C3-104 C4-30
.
DISCHARGE LABS
___ 03:12AM BLOOD WBC-14.2* RBC-3.89* Hgb-11.5* Hct-35.9*
MCV-92 MCH-29.5 MCHC-31.9 RDW-15.9* Plt ___
___ 03:12AM BLOOD ___ PTT-31.8 ___
___ 03:12AM BLOOD Glucose-90 UreaN-77* Creat-12.1* Na-136
K-4.1 Cl-94* HCO3-25 AnGap-21*
___ 03:12AM BLOOD Calcium-10.1 Phos-6.4* Mg-2.4
.
MICRO
___ BLOOD CULTURE -PENDING
___ BLOOD CULTURE -PENDING
___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; POTASSIUM
HYDROXIDE PREPARATION-FINAL
___ URINE CULTURE-FINAL
___ BLOOD CULTURE -PENDING
___ BLOOD CULTURE -PENDING
___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
___ DIALYSIS FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL
___ STOOL C. difficile DNA amplification assay-FINAL
___ BLOOD CULTURE -FINAL
___ BLOOD CULTURE -FINAL
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; POTASSIUM
HYDROXIDE PREPARATION-FINAL
.
___ CTA CHEST
The lung apices are excluded from this examination, which was
optimized for assessment of the pulmonary vasculature.
Coarse calcifications within the breasts are new on the left
(2:33), and
slightly increased in size on the right (2:24), in comparison to
the ___ examination. No distinct mass is seen,
although the breast tissue is diffusely dense.
There is no axillary or mediastinal lymphadenopathy. The heart
size is top
normal. There is no pericardial effusion. The aorta is normal in
caliber and patent. There is no dissection.
The main pulmonary arteries are normal in caliber. There is a
chronic
pulmonary embolus within the left lower segmental pulmonary
artery (3:57),
which is present since the ___ CT examination. No superimposed
acute
pulmonary embolus is detected to the subsegmental levels.
Endobronchial secretions are seen within the left lower lobe
segmental
bronchus (3:54), extending into the left lower lobe, where there
is a
moderate-sized consolidation (3:86) filling a previously-seen
large air
collection from ___. There are neighboring areas of
___
and ground-glass opacities (3:72). Ground-glass and ___
opacities are also seen throughout both lungs, slightly worse at
the lower zones (right lower lobe 3:104, right middle lobe
3:109, right upper lobe 3:49, lingula 3:95), distributed along a
centrilobular pattern, with associated mild bronchiectasis, all
progressed since ___. There is no pleural effusion. Mild
pleural thickening along the left lower lobe (3:78) has slightly
progressed since ___.
Moderate intraabdominal ascites is present.
OSSEOUS STRUCTURES: There is no bony lesion concerning for
infection or
neoplasm.
IMPRESSION:
1. Left lower lobe consolidation with large amount of
secretions/fluid within the left lower lobe segmental bronchi. A
small air-filled space within the left lower lobe seen on the
___ CT examination is now filled with fluid and/or blood.
Findings could represent hemorrhage secondary to collagen
vascular disease. Infection and abscess also have the same
appearance on CT.
2. Centrilobular nodules and ground glass opacities throughout
both lungs,
with a basilar predominance, with associated mild
bronchiectasis, compatible with chronic collagen vascular
disease, progressed since ___. There is no advanced fibrosis.
Superimposed infection cannot be excluded by imaging alone.
Ground glass opacities could also represent hemorrhage.
3. Chronic left lower segmental pulmonary arterial PE, unchanged
since ___. No new acute PE detected to the subsegmental levels.
.
___ CXR
CHEST, SINGLE AP PORTABLE VIEW
Suspect background hyperinflation. Superimposed on this, the
heart is not
enlarged. The left hemidiaphragm is elevated.
There is patchy dense opacity at the left base, increased
compared with
___. Blunting of the left costophrenic angle suggests a
small effusion.
Smudgy densities scattered in the right and ? left upper lung
are compatible with ground glass oapcities seen on chest CTA
obtained earlier the same day.
There is minimal biapical pleural scarring. Note is made of
calcification
along the bronchial walls, an unusual finding in an individual
of this age.
A large (13 mm) coarse calcification overlying the right lung
lies within the right breast.
Minimal superior endplate scalloping is noted in several
mid/upper thoracic vertebral bodies.
IMPRESSION: Irregular dense opacity at left base, increased
compared with ___, associated with an elevated left
hemidiaphragm. Differential diagnosis includes alveolar
processes such as infection and hemorrhage.
.
___ CT ABD/PELVIS
ABDOMEN: There is atelectasis at the left base with a small left
pleural
effusion. Centrilobular nodules and ground-glass opacities at
the right base remain unchanged from CTA chest performed
yesterday.
Lack of intravenous contrast limits evaluation of the solid
abdominal viscera.
The liver, spleen, adrenal glands and pancreas demonstrate a
grossly
unremarkable unenhanced appearance. The kidneys are small in
size. There is vicarious excretion of contrast within the
gallbladder from contrast CT
performed yesterday. Nonenlarged retroperitoneal lymph nodes are
visualized.
There is no adenopathy. The abdominal aorta is normal in caliber
with
atherosclerotic calcifications noted predominantly infrarenally.
A peritoneal dialysis catheter is present, looped in the right
mid abdomen
entering from the left. There is a moderate amount of ascites,
which measures higher than simple fluid in ___ units.
There is no evidence of retroperitoneal hematoma.
PELVIS: The bladder, uterus and rectum are within normal limits.
Ascites is redemonstrated within the pelvis. There are no
dilated or thick-walled loops of bowEl. There is no inguinal or
pelvic adenopathy.
OSSEOUS STRUCTURES: Mild degenerative changes are present in the
right hip
and sacroiliac joints. A sclerotic 9-mm lesion in the left iliac
bone appears nonaggressive and is essentially unchanged from
___ suggesting a benign lesion.
IMPRESSION:
1. Moderate ascites. Given the fluid withdrawn from the
peritoneal dialysis catheter is nonhemorrhagic, and the patient
underwent a contrast-enhanced CT yesterday, this is likely
increased in density from the contrast administration. No
evidence of retroperitoneal hematoma.
2. Vicarious excretion of contrast in the gallbladder consistent
with stated history of chronic kidney disease.
3. Left basilar disease is poorly evaluated on this examination.
Centrilobular nodules and ground-glass opacities are
redemonstrated consistent with known chronic collagen vascular
disease. Again, superimposed infection cannot be excluded by
imaging.
.
___ FLUOROSCOPIC-GUIDED EMBOLIZATION L BRONCHIAL ARTERY
FINDINGS:
1. Existing right IJ temporary triple-lumen catheter was seen
with the tip in the axillary vein. This was successfully
repositioned/replaced with the new catheter tip positioned in
the distal SVC.
2. Angiography demonstrated dilated tortuous left bronchial
artery, supplying the left lung and specifically, the left lower
lobe. Some filling of an adjacent pulmonary artery was seen at
the end of the angiography suggesting microvascular shunting.
3. No contributor was identified from the left bronchial artery
anywhere in its course to an anterior spinal artery.
4. During selective microcatheterization of the left bronchial
artery, a
small amount of contrast extravasation was noted in the
mediastinum from the proximal portion of the artery. Subsequent
aortic angiography demonstrated no contrast extravasation from
the aorta or evidence of aortic dissection.
5. Following this, 5 ___ was again used to select
the ostium of the left bronchial artery. From this location,
particle embolization with 300-500 micron Embospheres was
performed to good slowing of flow and
angiographic result.
IMPRESSION:
1. Successful particle embolization in the left bronchial
artery, as
described above.
2. Successful replacement and repositioning of non-tunneled
right internal
jugular vein triple lumen catheter, with the tip now in distal
SVC. The line is ready to use.
.
___ CT CHEST
FINDINGS:
AIRWAYS AND LUNGS: Since ___, high-density
consolidation in the
left lower lobe sparing only a portion of the superior segment
has increased and new in posterior basal segment of the right
lower lobe. Preexisting left lower lobe cavity is obscured by
this large consolidation. In addition,
diffuse ground-glass opacities without septal thickening in both
lungs (left side more than right), are also new since ___. Keeping with clinical history, these are highly suggestive
of multifocal pulmonary hemorrhage, most pronounced in the left
lower lobe. Thin rim of hyperdensity along the
posterior pleural space in the left lower lobe is probably due
to the
dissection of the blood from the consolidation.
MEDIASTINUM: Thyroid gland is normal. Endotracheal tube tip lies
3 cm above the carina. There are no pathologically enlarged,
mediastinal,
supraclavicular or axillary lymph nodes. Heart is normal size,
and thin rim of pericardial fluid is likely reactive. Coronary
artery calcification is minimal.
ABDOMEN: The study is not designed for assessment of
subdiaphragmatic
pathology; however, limited views were remarkable for moderate
ascites with an attenuation value ranging between 19 to 35,
suggesting complex fluid, unchanged since ___.
BONES: There is no bone lesion concerning for malignancy or
infection.
IMPRESSION:
1. CT featuRes are concerning for progressive multifocal
pulmonary hemorrhage, most pronounced in left lower lobe.
2. Left lower lobe bronchial tree occlusion is likely from
aspirated blood.
3. Moderate ascites with attenuation ranging between 19 to 35 is
probably
complex fluid, unchanged since ___.
.
___ CXR
FINDINGS: As compared to the previous radiograph, there is
substantial
improvement with substantially improved ventilation of the left
lung. Only at the left lung base, areas of atelectasis with
subsequent elevation of the left hemidiaphragm persists.
Two new tubular structures project over the left hemithorax.
There is no
evidence of pneumothorax. The monitoring and support devices are
overall
constant. Constant appearance of the right lung.
.
___ LENIS
FINDINGS: There is normal phasicity within the common femoral
veins
bilaterally. The visualized vessels are patent and compressible
with normal waveforms and augmentation. No thrombus identified.
IMPRESSION: No evidence of DVT within the lower extremities
bilaterally.
.
___ TTE
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size is normal. with normal free wall contractility. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are elongated. There is
no mitral valve prolapse. An eccentric, posteriorly directed jet
of Moderate (2+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Poor image quality (patient difficult to position
and unable to cooperate). Preserved regional and global left
ventricular systolic function. Based on limited views, right
ventricular cavity size and function are probably normal.
Pulmonary pressures were undetermined.
Compared with the prior study dated ___ (images reviewed),
left ventricular function is more vigorous. Other findings are
probably similar although current suboptimal image quality
precludes definite comparison.
Medications on Admission:
AMITRIPTYLINE - 25 mg Tablet QHS
B COMPLEX-VITAMIN C-FOLIC ACID
CALCITRIOL 0.25 mcg Capsule six times weekly
CODEINE-GUAIFENESIN ___ tsp(s) prn cough
DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] -
60 mcg/0.3 mL Syringe -Q2weeks
GENTAMICIN - 0.1 % Cream - apply to exit site as directed
HYDROXYCHLOROQUINE [PLAQUENIL] - 200 mg Tablet - 1 Tablet(s) by
mouth ONE BY MOUTH EVERY DAY, TWO BY MOUTH EVERY OTHER DAY
LISINOPRIL - 40 mg Tablet - one Tablet(s) by mouth once a day
-recently stopped for concern of contributing to chroninc cough
RANITIDINE HCL - 150 mg Tablet - BID
SEVELAMER CARBONATE [RENVELA] 800 mg Tablet - 3 Tablet TID
VALACYCLOVIR - 500 mg Tablet - one Tablet(s) by mouth x 1 dose
as
needed for cold sore outbreak as soon as ___ have symptoms
WARFARIN - Alternating 7.5 mg and 10 mg
Discharge Medications:
1. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 6x/week.
4. Aranesp (polysorbate) 60 mcg/0.3 mL Syringe Sig: One (1)
injection Injection q2weeks.
5. gentamicin 0.1 % Cream Sig: One (1) Topical once a day:
apply to exit site as directed.
6. hydroxychloroquine 200 mg Tablet Sig: AS DIRECTED Tablet PO
once a day: 200 MG (1 TAB) AND 400 MG (2 TABS) ON ALTERNATING
DAYS.
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
9. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO x1: take 1
tablet immediately as needed for cold sore outbreak as soon as
___ have symptoms.
10. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q6H (every 6 hours) as needed for throat pain.
Disp:*QS * Refills:*0*
11. prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: take 4 tabs (40 mg) ___ morning, then 3 tabs (30 mg)
every morning until further instructions from your
rheumatologist.
Disp:*50 Tablet(s)* Refills:*1*
12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for anxiety or nausea for 30 doses.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
LEFT BRONCHIAL ARTERY BLEED
VENTILATOR-ASSOCIATED PNEUMONIA
END-STAGE RENAL DISEASE, PERITONEAL DIALYSIS-DEPENDENT
HISTORY OF PULMONARY EMBOLISM
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 history of PE, on Coumadin, history of
lupus nephritis, with coughing and hemoptysis.
COMPARISON: Chest CT available from ___ and chest radiographs from
___ through ___.
TECHNIQUE: MDCT-acquired 3.5 mm axial images of the chest were obtained
following the uneventful administration of 100 cc of Omnipaque intravenous
contrast. Coronal and sagittal reformations were performed at 5-mm slice
thickness. Additional right and left oblique reconstructions were obtained
for further evaluation of the pulmonary vasculature.
CT OF THE CHEST WITH IV CONTRAST:
The lung apices are excluded from this examination, which was optimized for
assessment of the pulmonary vasculature.
Coarse calcifications within the breasts are new on the left (2:33), and
slightly increased in size on the right (2:24), in comparison to the ___ examination. No distinct mass is seen, although the breast tissue is
diffusely dense.
There is no axillary or mediastinal lymphadenopathy. The heart size is top
normal. There is no pericardial effusion. The aorta is normal in caliber and
patent. There is no dissection.
The main pulmonary arteries are normal in caliber. There is a chronic
pulmonary embolus within the left lower segmental pulmonary artery (3:57),
which is present since the ___ CT examination. No superimposed acute
pulmonary embolus is detected to the subsegmental levels.
Endobronchial secretions are seen within the left lower lobe segmental
bronchus (3:54), extending into the left lower lobe, where there is a
moderate-sized consolidation (3:86) filling a previously-seen large air
collection from ___. There are neighboring areas of ___
and ground-glass opacities (3:72). Ground-glass and ___ opacities are
also seen throughout both lungs, slightly worse at the lower zones (right
lower lobe 3:104, right middle lobe 3:109, right upper lobe 3:49, lingula
3:95), distributed along a centrilobular pattern, with associated mild
bronchiectasis, all progressed since ___. There is no pleural effusion. Mild
pleural thickening along the left lower lobe (3:78) has slightly progressed
since ___.
Moderate intraabdominal ascites is present.
OSSEOUS STRUCTURES: There is no bony lesion concerning for infection or
neoplasm.
IMPRESSION:
1. Left lower lobe consolidation with large amount of secretions/fluid within
the left lower lobe segmental bronchi. A small air-filled space within the
left lower lobe seen on the ___ CT examination is now filled with fluid
and/or blood. Findings could represent hemorrhage secondary to collagen
vascular disease. Infection and abscess also have the same appearance on CT.
2. Centrilobular nodules and ground glass opacities throughout both lungs,
with a basilar predominance, with associated mild bronchiectasis, compatible
with chronic collagen vascular disease, progressed since ___. There is no
advanced fibrosis. Superimposed infection cannot be excluded by imaging alone.
Ground glass opacities could also represent hemorrhage.
3. Chronic left lower segmental pulmonary arterial PE, unchanged since ___.
No new acute PE detected to the subsegmental levels.
Radiology Report
HISTORY: Hemoptysis, limited air movement. Question interval change.
CHEST, SINGLE AP PORTABLE VIEW
Suspect background hyperinflation. Superimposed on this, the heart is not
enlarged. The left hemidiaphragm is elevated.
There is patchy dense opacity at the left base, increased compared with
___. Blunting of the left costophrenic angle suggests a small effusion.
Smudgy densities scattered in the right and ? left upper lung are compatible
with ground glass oapcities seen on chest CTA obtained earlier the same day.
There is minimal biapical pleural scarring. Note is made of calcification
along the bronchial walls, an unusual finding in an individual of this age.
A large (13 mm) coarse calcification overlying the right lung lies within the
right breast.
Minimal superior endplate scalloping is noted in several mid/upper thoracic
vertebral bodies.
IMPRESSION: I
Irregular dense opacity at left base, increased compared with ___,
associated with an elevated left hemidiaphragm. Differential diagnosis
includes alveolar processes such as infection and hemorrhage.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Line placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, a right internal jugular
vein catheter has been placed. The catheter is malpositioned in the right
axillary vein. Repositioning is required. The observation was made at the
time of dictation, 8:36 a.m. on ___, and Dr. ___ was contacted by
telephone.
Radiology Report
CHEST RADIOGRAPH
INDICATION: ___ woman with line placement, to look for the position.
TECHNIQUE: Semi-erect portable chest view was read in comparison with
multiple prior radiographs with the most recent from ___ acquired two to
three hours apart.
FINDINGS:
Right-sided internal jugular line courses along lower neck till medial portion
of the clavicle and then laterally upto the upper and lateral chest wall,
suggesting persistant malpositioned line into the right subclavian vein.
There is no pneumothorax. A dense opacity in the left lung disease and mild
haziness in the left upper lung is unchanged since prior radiograph acquired
three to four hours apart, but worsened since yesterday suggesting left lower
lung collapse with effusion. Right cardiac margin is indistinct owing to left
lower lung volume loss. Mild right lung base atelectasis and the presumed
small effusion is unchanged since prior study.
IMPRESSION:
1. Internal jugular line malpositioned with its tip positioned in the right
internal jugular line, persisting since prior radiograph acquired ___ hours
apart.
2. Lower lung collapse and mild-to-moderate left effusion is unchanged since
___ but worsened since yesterday. Minimal right lung base
atelectasis and presumed small right effusion is similar.
___ discussed findings with Dr. ___ by phone on ___,
___ at 8.46AM
Radiology Report
CT ABDOMEN AND PELVIS WITHOUT CONTRAST
COMPARISON: CTA chest ___, renal ultrasound ___, CT
abdomen and pelvis ___.
CLINICAL INDICATION: ___ woman with lupus and chronic kidney disease
on peritoneal dialysis who presents with falling hematocrit, with concern for
intraperitoneal and retroperitoneal bleed.
TECHNIQUE: Unenhanced axial images of the abdomen and pelvis were obtained.
Coronal and sagittal reformatted images were constructed.
TOTAL EXAM DLP: 391.36 mGy-cm.
FINDINGS:
ABDOMEN: There is atelectasis at the left base with a small left pleural
effusion. Centrilobular nodules and ground-glass opacities at the right base
remain unchanged from CTA chest performed yesterday.
Lack of intravenous contrast limits evaluation of the solid abdominal viscera.
The liver, spleen, adrenal glands and pancreas demonstrate a grossly
unremarkable unenhanced appearance. The kidneys are small in size. There is
vicarious excretion of contrast within the gallbladder from contrast CT
performed yesterday. Nonenlarged retroperitoneal lymph nodes are visualized.
There is no adenopathy. The abdominal aorta is normal in caliber with
atherosclerotic calcifications noted predominantly infrarenally.
A peritoneal dialysis catheter is present, looped in the right mid abdomen
entering from the left. There is a moderate amount of ascites, which measures
higher than simple fluid in ___ units. There is no evidence of
retroperitoneal hematoma.
PELVIS: The bladder, uterus and rectum are within normal limits. Ascites is
redemonstrated within the pelvis. There are no dilated or thick-walled loops
of bowel. There is no inguinal or pelvic adenopathy.
OSSEOUS STRUCTURES: Mild degenerative changes are present in the right hip
and sacroiliac joints. A sclerotic 9-mm lesion in the left iliac bone appears
nonaggressive and is essentially unchanged from ___ suggesting a benign
lesion.
IMPRESSION:
1. Moderate ascites. Given the fluid withdrawn from the peritoneal dialysis
catheter is nonhemorrhagic, and the patient underwent a contrast-enhanced CT
yesterday, this is likely increased in density from the contrast
administration. No evidence of retroperitoneal hematoma.
2. Vicarious excretion of contrast in the gallbladder consistent with stated
history of chronic kidney disease.
3. Left basilar disease is poorly evaluated on this examination.
Centrilobular nodules and ground-glass opacities are redemonstrated consistent
with known chronic collagen vascular disease. Again, superimposed infection
cannot be excluded by imaging.
Radiology Report
INDICATION: ___ woman with history of lupus and end-stage renal
disease with hemoptysis, and worsening opacities of the left suggestive of
left bronchial artery source. Additionally, she had a temporary right IJ line
placed which is malpositioned with tip in the axillary vein.
PHYSICIAN: Dr. ___, the attending radiologist, was present and
performed the procedure. Dr. ___, fellow.
PROCEDURE:
1. Fluoroscopic guided repositioning/replacement of non-tunneled right IJ
triple-lumen central venous catheter.
2. Fluoroscopic-guided right common femoral artery access.
3. Aortogram and selective left bronchial angiogram.
4. Embolization of left bronchial artery (300-500 micron Embospheres).
5. Post-embolization angiogram.
MEDICATIONS: The procedure was performed with general anesthesia. 135 cc
Optiray was used.
PROCEDURE: Prior to initiation of procedure, written informed consent was
obtained and a preprocedure timeout was performed. Patient was brought to the
angiographic suite and placed supine on the angiographic table. Patient
underwent endotracheal intubation. Following this, the right groin and right
neck were prepped and draped in sterile manner.
Initially, a fluoroscopic image demonstrated the tip of the central venous
catheter was positioned in the axillary vein. A ___ wire was advanced
through this catheter which was removed, and a new catheter was placed via the
existing right internal jugular vein access such that the tip was in the
distal SVC. All three ports were flushed and aspirated and the catheter was
secured to the skin with suture and dressed in the requisite manner.
Next, under fluoroscopic and manual palpation, right common femoral artery
access was obtained using a micropuncture set, followed by placement of a 5
___ sheath. ___ catheter was formed over ___ wire
over the arch, this was used to look for the left brachial artery origin.
This was identified in the upper aorta, and contrast injection was performed
in multiple projections demonstrating this. Next, attempts to access this
with a STC microcatheter and a Headliner and Double-Ended guidewire were made.
During these attempts, the microcatheter was advanced over the wire and
contrast injection demonstrated some contrast extravasation out of the
proximal portion of the left bronchial artery, into the mediastinum. The
microcatheter was removed and the ___ was changed for a 5 ___ pigtail
catheter. An angiogram was performed in multiple projections, and
demonstrating no aortic extravasation or dissection.
Next, the ___ was replaced and used to re-select the left bronchial
artery origin. Brisk forward flow was seen so particle embolization was
performed with 300-500 micron Embospheres to slow flow. Post-embolization
contrast injection demonstrated good angiographic result. The ___
catheter was removed over ___ wire, the 5 ___ sheath was removed and
manual pressure was applied to hemostasis. The patient tolerated the
procedure well, and was returned to the ICU.
FINDINGS:
1. Existing right IJ temporary triple-lumen catheter was seen with the tip in
the axillary vein. This was successfully repositioned/replaced with the new
catheter tip positioned in the distal SVC.
2. Angiography demonstrated dilated tortuous left bronchial artery, supplying
the left lung and specifically, the left lower lobe. Some filling of an
adjacent pulmonary artery was seen at the end of the angiography suggesting
microvascular shunting.
3. No contributor was identified from the left bronchial artery anywhere in
its course to an anterior spinal artery.
4. During selective microcatheterization of the left bronchial artery, a
small amount of contrast extravasation was noted in the mediastinum from the
proximal portion of the artery. Subsequent aortic angiography demonstrated no
contrast extravasation from the aorta or evidence of aortic dissection.
5. Following this, 5 ___ ___ was again used to select the ostium of
the left bronchial artery. From this location, particle embolization with
300-500 micron Embospheres was performed to good slowing of flow and
angiographic result.
IMPRESSION:
1. Successful particle embolization in the left bronchial artery, as
described above.
2. Successful replacement and repositioning of non-tunneled right internal
jugular vein triple lumen catheter, with the tip now in distal SVC. The line
is ready to use.
Radiology Report
CLINICAL HISTORY: ___ woman with hemoptysis. Change in clips and
change in pulmonary hemorrhage.
COMPARISON: ___.
FINDINGS: Left lung has progressed to complete complete opacification
consistent with collapse. Trachea is deviated to the left consistent with
volume loss. The left bronchus also appears to have secretions within it,
likely clot causing this atelectasis. ET tube is approximately 5 cm from the
carina. Right IJ terminates likely in the low SVC. The right lung is
essentially clear.
IMPRESSION: Collpase of the left lung probably from bronchial plugging/clot.
Size of the hemorrhage is difficult to evaluate.
These findings were discussed with Dr ___ by Dr ___ telephone at 11 AM.
Radiology Report
HISTORY: For ET tube placement.
FINDINGS: In comparison with study of ___, there is little change. Again
there is a complete collapse of the left lung presumably from bronchial
plugging with mucus impaction or clot. Shift of the mediastinum to the left
as well as the trachea is consistent with the volume loss. The right lung is
essentially clear.
Radiology Report
INDICATION: History of lupus anticoagulant, prior PEs, with current pulmonary
hemorrhage, IVC filter placement was requested.
OPERATORS: Dr. ___ (fellow), Dr. ___ (resident), and
Dr. ___, (attending physician). Dr. ___ was present and
supervised throughout the procedure.
ANESTHESIA: Moderate sedation was provided via divided doses of fentanyl 75
mcg and Versed 1.5 mg administered throughout the total intraservice time of
40 minutes during which the patient's hemodynamic parameters were continuously
monitored.
PROCEDURE AND FINDINGS: After explaining the risks, benefits and alternatives
to the patient's designated proxy (husband), informed consent was obtained.
The patient was brought to the angiographic suite and placed supine on the
table. The right groin was prepped and draped in the usual sterile fashion.
A timeout and huddle were performed per ___ protocol.
Under ultrasound guidance, the right femoral vein was accessed at the level of
the mid femoral head with a 19-gauge micropuncture needle through which a
___ wire was advanced. The needle was removed and a ___ Omniflush
catheter was placed and positioned to the contralateral common iliac vein. A
venogram was performed from the left common iliac vein demonstrating no
evidence of duplication, patent single IVC without evidence of thrombus and
IVC diameter of 20 mm. The level of the renal veins was noted at
approximately the L2 level, with left renal vein slightly inferior to the
right.
Based on these diagnostic findings, a retrievable Option IVC filter was placed
via the right femoral vein just below the level of the inferior margin of the
left renal vein via the 6.5 ___ provided sheath. The sheath was then
removed and pressure applied for 5 minutes to achieve hemostasis. A sterile
dressing was applied. There were no immediate complications.
IMPRESSION:
1. Diagnostic venogram demonstrating single patent IVC.
2. Successful placement of infra-renal potentially retrievable Option IVC
filter.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Woman with lupus, endotracheal tube placement.
COMPARISON: ___, 2:05 a.m.
FINDINGS: As compared to the previous radiograph, the tip of the endotracheal
tube has been minimally advanced. The tip of the tube is within 5 cm of the
carina. The left lung apex shows minimally ventilation. However, the entire
left hemithorax is still subtotally opacified. The course of the right
internal jugular vein catheter is unchanged. Unchanged appearance of the
right lung without evidence of pneumonia or pulmonary edema. No right pleural
effusion.
Radiology Report
INDICATION: ___ woman with lupus, history of PE on Coumadin and
presents with hemoptysis, to look for blood collection.
TECHNIQUE: Unenhanced multidetector CT of thorax was performed using a
standard department protocol. Contiguous axial images at 5-mm and 1.25-mm
slice thickness were reviewed concurrently with coronal and sagittal
reformats. The study was reviewed in comparison with prior chest CTs through
___ with the most recent from ___.
FINDINGS:
AIRWAYS AND LUNGS: Since ___, high-density consolidation in the
left lower lobe sparing only a portion of the superior segment has increased
and new in posterior basal segment of the right lower lobe. Preexisting left
lower lobe cavity is obscured by this large consolidation. In addition,
diffuse ground-glass opacities without septal thickening in both lungs (left
side more than right), are also new since ___. Keeping with clinical
history, these are highly suggestive of multifocal pulmonary hemorrhage, most
pronounced in the left lower lobe. Thin rim of hyperdensity along the
posterior pleural space in the left lower lobe is probably due to the
dissection of the blood from the consolidation.
MEDIASTINUM: Thyroid gland is normal. Endotracheal tube tip lies 3 cm above
the carina. There are no pathologically enlarged, mediastinal,
supraclavicular or axillary lymph nodes. Heart is normal size, and thin rim
of pericardial fluid is likely reactive. Coronary artery calcification is
minimal.
ABDOMEN: The study is not designed for assessment of subdiaphragmatic
pathology; however, limited views were remarkable for moderate ascites with an
attenuation value ranging between 19 to 35, suggesting complex fluid,
unchanged since ___.
BONES: There is no bone lesion concerning for malignancy or infection.
IMPRESSION:
1. CT features are concerning for progressive multifocal pulmonary hemorrhage,
most pronounced in left lower lobe.
2. Left lower lobe bronchial tree occlusion is likely from aspirated blood.
3. Moderate ascites with attenuation ranging between 19 to 35 is probably
complex fluid, unchanged since ___.
Radiology Report
REASON FOR EXAMINATION: Lupus and recent hemoptysis.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is 4.7 cm above the carina. The right internal jugular line
tip is at the level of low SVC. There is interval improvement of the left
lung aeration with still substantial collapse and left mediastinal shift.
Calcifications in the right lower lobe are redemonstrated. No appreciable
pneumothorax is seen.
Radiology Report
INDICATION: ___ woman, intubated with new OG tube, assess OG tube
placement.
COMPARISON: Portable AP chest radiograph from ___.
FINDINGS: There has been placement of an OG tube which is coiled within the
stomach. ET tube is in appropriate positioning. Since the prior radiograph,
there has been no significant change. Again seen is complete opacification of
the left hemithorax with volume loss in the left upper and left lower lobes.
There is leftward mediastinal shift, consistent with volume loss. There is no
pneumothorax. Right IJ central line is in appropriate position within the
right atrium.
IMPRESSION: Appropriate placement of OG tube. No significant interval
change.
Radiology Report
PORTABLE AP CHEST FILM, ___ AT 3:04 AM
CLINICAL INDICATION: ___ with left lung bleed, intubated, assess for
interval change.
Comparison is made to the patient's previous study dated ___ at 13:08.
A single portable supine chest film ___ at 3:04 a.m. is submitted.
IMPRESSION:
1. There is persistent opacification of the left hemithorax with some
residual aeration at the left lower lobe associated with volume loss and
mediastinal and cardiac shift to the left. Overall, the appearance does not
appear to be significantly changed. The endotracheal tube continues to have
its tip 4 cm above the carina. A right internal jugular central line has its
tip in the distal SVC. Nasogastric tube is seen coursing below the diaphragm
with the tip within the stomach. A portion of an inferior vena caval filter
is also visualized at the edge of the film within the abdomen. The right lung
is well inflated without evidence of focal airspace consolidation, pulmonary
edema, or pleural effusion. There is a stable calcified nodule measuring 1.3
cm in the seventh interspace. This most likely represents a calcified
granuloma. No acute bony abnormality is appreciated.
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: ___ woman with SLE, hemoptysis. She is ventilated
and sedated.
FINDINGS: Comparison is made to the prior study performed one and a half
hours earlier.
Endotracheal tube, feeding tube, right IJ central venous lines are unchanged
in position. There remains extensive volume loss and increased density within
the right and left lung, stable. The right lung field is clear. A calcified
granuloma is seen adjacent to the sixth rib interspace, stable.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Lupus, hemoptysis, intubation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. Volume loss in the left lung with subsequent mediastinal and cardiac
shift. Moderate atelectasis at the left lung base with evidence of a
coexisting left pleural opacity. The size of the cardiac silhouette cannot be
determined. The normal appearance of the right lung is unchanged. Unchanged
monitoring and support devices.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Lupus, hemoptysis, current intubation, new fever, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged position
of the monitoring and support devices. The appearance of the normal right
lung is unchanged. Unchanged volume reduction of the left lung, with rather
extensive both pleural and parenchymal opacities and signs of leftward
mediastinal shift. No newly appeared opacities. The more central aspect of
the ventilated left lung shows unchanged ___.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Lupus, bronchial artery bleed, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is substantial
improvement with substantially improved ventilation of the left lung. Only at
the left lung base, areas of atelectasis with subsequent elevation of the left
hemidiaphragm persists.
Two new tubular structures project over the left hemithorax. There is no
evidence of pneumothorax. The monitoring and support devices are overall
constant. Constant appearance of the right lung.
Radiology Report
INDICATION: ___ woman with hemoptysis, assess for interval change.
COMPARISONS: Multiple prior radiographs, most recently AP radiograph from ___.
FINDINGS: The left upper lobe is well aerated but left lower lobe atelectasis
persists, with associated elevation of the left hemidiaphragm due to volume
loss. The right lung is clear. A right IJ central line terminates in the
lower SVC. There is no pneumothorax or pleural effusion. The
cardiomediastinal silhouette is normal.
IMPRESSION: Persistent left lower lobe atelectasis with associated elevation
of the left hemidiaphragm.
Radiology Report
ULTRASOUND BILATERAL LOWER EXTREMITY DOPPLER DATED ___
INDICATION: ___ woman with lupus, persistent tachycardia, and
dyspnea. Assess for DVT.
COMPARISON: No relevant ultrasounds available for comparison.
TECHNIQUE: Grayscale and color Doppler images performed of bilateral common
femoral veins, superficial femoral veins, popliteal veins, posterior tibial
veins, and peroneal veins.
FINDINGS: There is normal phasicity within the common femoral veins
bilaterally. The visualized vessels are patent and compressible with normal
waveforms and augmentation. No thrombus identified.
IMPRESSION: No evidence of DVT within the lower extremities bilaterally.
Radiology Report
STUDY: CHEST RADIOGRAPH.
INDICATION: Hemoptysis, status post extubation. Assess for interval change.
TECHNIQUE: Portable AP radiograph was obtained.
COMPARISON: ___
REPORT: Right-sided central line appears at the lower SVC or the cavoatrial
junction. This is unchanged. There is unchanged patchy opacification
slightly elevated left hemidiaphragm reflects an atelectasis. Unchanged
right-sided granuloma.
Reasonably heavy tracheobronchial calcifications noted. Nonspecifically
mildly increased lung markings are noted. There is no acute cardiopulmonary
finding noted. A right caval temporary filter is noted.
CONCLUSION:
No Significant change from prior study. No acute findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: COUGHING BLOOD
Diagnosed with HEMOPTYSIS, UNSPECIFIED, ABNORMAL COAGULATION PROFILE
temperature: 98.2
heartrate: 108.0
resprate: 18.0
o2sat: 100.0
sbp: 138.0
dbp: 95.0
level of pain: 0
level of acuity: 2.0 | ___ with SLE c/b lupus nephritis, w/ESRD on PD & bilateral PE on
chronic coumadin p/w hemoptysis & hypoxic respiratory failure,
found to have L bronchial artery bleed.
# HEMOPTYSIS
On admission pt was HD stable, not hypoxia, and without airway
compromise. She did have significant Hct drop, from 29.6 to 20.8
within 24h of admission. Pt is on chonic coumadin for hx
bilateral PE ___ ago; INR was elevated to 4.4 on admission.
Explanation for acute bleed not entirely clear - initial ddx
included infection (PNA vs abscess) in setting of elevated INR
most likely; diffuse alveolar hemorrhage also possible, &
rheumatology consult also suggested possible pulmonary
vasculitis. No new PE seen on CTA. She initially received
antibiotics for possible pulmonary infection (vanc/levo/flagyl,
subsequently narrowed to levo/flagyl). On HD3, underwent
CT-guided pulmonary angiography for question source of bleed and
possible bleeding into mediastinum. Bleed localized to L
bronchial artery, which was embolized. Solumedrol started for
possible vasculitis. Hct stabilized and uptrended thereafter.
There was discussion of possible pulmonary wedge biopsy for
purpose of solidifying a tissue diagnosis to guide possible
immunosuppression but this was decided against after
risk/benefit analysis. Discharge Hct 35.9. Sent home w/steroid
taper to be further managed in rheumatology follow-up next week.
.
# HYPOXIC RESPIRATORY FAILURE
Pt developed respiratory failure while in the ICU, w/increasing
O2 requirement. CXR showed significant left-sided infiltrate,
most likely from L bronchial arterial bleed (as discussed
above). Pt developed progressive respiratory distress requiring
supplemental O2. She was intubated on HD4 for rigid bronchoscopy
and was difficult to extubate, first because of persistent
L-sided infiltrate (blood) and volume overload (retained >5L
over ___ from PD), then because she developed ventilator
associated pneumonia (VAP). She was already on levo/flagyl at
the time (coverage for possible pulmonary infection as
precipitant for hemoptysis, discussed above);
aztreonam/vancomycin added briefly for VAP coverage. On repeat
bronchoscopy on HD9, large mucous plug removed from LUL
bronchus. Pt's respiratory status improved quickly thereafter,
and she was successfully extubated the following morning. Weaned
to RA within several hours, O2 sat in high ___ for >48h
thereafter.
.
#CHRONIC PE/ANTICOAGULATION
Hx indication for anticoagulation was revisited during this
admission given hemoptysis and supratherapeutic INR on
admission. No acute PE on CTA. Heme was consulted and agreed
w/continuing to hold anticoagulation. IVC filter placed. Review
of OMR records revealed that anticoagulation was started in
___ during hospitalization for lung abscess; large bilateral
PEs were revealed on CTA done for unexplained persistent sinus
tachycardia. She has been on anticoagulation since. OMR also
include diagnosis of antiphospholipid antibody syndrome in
OB/GYN notes (based upon 3 miscarriages and hx CVA age ___ but
rheumatology notes/records show autoantibody panel not c/w this
diagnosis ___ positive 1:320, anti-Ro/La positive, lupus
anticoagulant negative x2, *anticardiolipin negative*.
Rheumatology and hematology were consulted here for assistance
with re-evaluation of pt's indication for chronic
anticoagulation and plan to resume anticoagulation. Repeat
serologies sent - lupus anticoagulation now *positive*,
anticardiolipin again negative, b2glycoprotein Ab pending at
time of discharge. Discharge anticoagulation plan as follows:
- IVC filter to be removed in ~1 week ___ aware, procedure
scheduled for ___
- Resume warfarin after IVC filter removed, with f/u INR checks
at ___ clinic overseen by PCP ___. ___ require
re-hospitalization to restart warfarin, TBD by PCP and heme/pulm
in outpatient follow-up
- PCP, ___ and Pulmonary follow-up appointments arranged
- situation discussed with ___ Dr. ___
will review paper records for any OSH coagulopathy studies sent
prior to initiation of coumadin in ___ and share info w/Dr. ___
.
# SINUS TACHYCARDIA
Pt's HR was 100 on admission and trended 100-140 during her
hospital status. Always sinus tachycardia on EKG and telemetry.
Given hx PE, she had bilateral LENIs and a TTE to evaluate any
right heart strain. Both were wnl. No CTA was obtained because
a) pt had an IVC filter placed on admission so low-likelihood
and b) no anticoagulation would have been restarted as an
inpatient given recent life-threatening bleed.
# Hx ESRD on PD
Renal failure chronic, lupus nephritis. Underwent PD throughout
hospital stay. Initially there was some difficulty evacuating
entire content of PD dwells, and pt became volume overloaded.
Renal consult service followed closely and guided modifications
to PD solution. Pt was euvolemic on PD for 4 days prior to
discharge.
.
# Hx SLE
Diagnosed in ___ and followed by Dr. ___. Complicated by
nephritis, & recurrent pleural effusions, w/additional ocular
and skin manifestations. Plaquenil was continued while pt able
to take POs; held while intubated & restarted thereafter.
Rheumatology consult service followed, suggested possibility
that lupus vasculitis or other vasculitis might have contributed
to her hemoptysis (see above) and recommended initiation of IV
steroids. Steroid taper to be further managed by rheumatologist
in follow-up.
.
# Hx HTN
Recently stopped lisinopril for concern of exacerbation of her
cough. BP meds held on admission given concern for bleeding.
Used PRN IV labetolol to control BPs while intubated. After
extubation, pt's BP ran
.
# Hx MIGRAINE HEADACHES
Takes amitriptyline at home at night. Amitriptyline + PRN
tylenol while here.
.
# Hx GERD
Continued ranitidine. Pt did have some nausea and PO intolerance
but was able to take small-volume POs prior to discharge.
.
TRANSITIONAL ISSUES
1. ANTICOAGULATION |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nifedipine
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
===============
___ 12:14AM BLOOD WBC-18.1* RBC-5.59 Hgb-16.7 Hct-48.9
MCV-88 MCH-29.9 MCHC-34.2 RDW-13.1 RDWSD-41.8 Plt ___
___ 12:14AM BLOOD Neuts-88.3* Lymphs-6.6* Monos-4.5*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-16.01* AbsLymp-1.20
AbsMono-0.81* AbsEos-0.02* AbsBaso-0.02
___ 12:14AM BLOOD ___ PTT-31.1 ___
___ 12:14AM BLOOD Glucose-165* UreaN-34* Creat-1.8* Na-138
K-4.1 Cl-80* HCO3-23 AnGap-35*
___ 12:14AM BLOOD Albumin-5.7* Calcium-10.9* Phos-5.2*
Mg-2.4
___ 12:14AM BLOOD ALT-16 AST-30 AlkPhos-163* TotBili-0.6
___ 12:14AM BLOOD Lipase-20
___ 12:14AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 12:20AM BLOOD Lactate-4.9*
___ 03:22AM BLOOD Lactate-1.9
___ 05:52AM URINE Blood-TR* Nitrite-NEG Protein-70*
Glucose-NEG Ketone->150* Bilirub-NEG Urobiln-NORMAL pH-6.5
Leuks-NEG
___ 05:52AM URINE RBC-2 WBC-1 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 05:52AM URINE CastHy-10*
DISCHARGE LABS
===============
___ 07:22AM BLOOD WBC-11.5* RBC-4.51* Hgb-13.3* Hct-41.3
MCV-92 MCH-29.5 MCHC-32.2 RDW-13.1 RDWSD-44.3 Plt ___
___ 07:22AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-143
K-3.8 Cl-96 HCO3-32 AnGap-15
___ 07:22AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.3
STUDIES/IMAGING
================
___ CXR
No acute cardiopulmonary abnormality.
___ CT ABD/PELVIS W/ CONTRAST
No acute intra-abdominal or intrapelvic pathology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. Gabapentin 600 mg PO TID
3. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY
4. Morphine SR (MS ___ 45 mg PO Q12H
5. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain
- Moderate
6. Senna 17.2 mg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
2. Gabapentin 600 mg PO TID
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY
5. Morphine SR (MS ___ 45 mg PO Q12H
6. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain
- Moderate
7. Senna 17.2 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
========
Hematemesis
SECONDARY
==========
Hypertension
Phantom limb pain
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 hematemesis // Evaluate for pneumomediastinum,
widened mediastinum, pneumonia, or other acute abnormalities
TECHNIQUE: Chest AP upright and lateral
COMPARISON: Multiple prior chest radiographs dating back to ___,
most recently ___.
Chest CT dated ___.
FINDINGS:
Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes
are normal. As before, there is a trace pleural thickening in the right lung
base. Spinal fusion hardware is in unchanged position.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: +PO contrast; History: ___ with hematemesis+PO contrast //
Evaluate for perforated ulcer, SBO, appendicitis or other acute abnormalities
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 13.9 mGy (Body) DLP = 682.8
mGy-cm.
Total DLP (Body) = 696 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Aside from 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. A
1.5 x 1.0 cm left hepatic hemangioma (2:18) is unchanged. Focal fat adjacent
to the falciform ligament (2:15) is also stable. 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. There is an 8 mm splenule located posteriorly.
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.
Subcentimeter hypodensities bilaterally are too small to characterize, but
statistically likely represent simple cysts. There is no evidence of solid
renal lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
colon and rectum are within normal limits. The appendix is normal. There is
no free intraperitoneal air. Oral contrast is seen passing into the proximal
large bowel.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Redemonstrated is a homogeneously hyperdense linear
structure lying between the corpora cavernosa, which remains indeterminate
(series 2, image 82).
LYMPH NODES: Subcentimeter mesenteric lymph nodes are likely reactive. 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. A
healed fracture in the posterior left ninth rib is again noted. There marked
degenerative changes in the lower lumbar spine, most severe at L4-5 and L5-S1
as evidenced by loss of intervertebral disc space height, vacuum phenomena,
endplate sclerosis, facet hypertrophy, subcortical cystic change and anterior
posterior osteophyte formation.
SOFT TISSUES: There is a small left fat containing inguinal hernia.
IMPRESSION:
No acute intra-abdominal or intrapelvic pathology.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Hematemesis, N/V
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 98.2
heartrate: 164.0
resprate: 22.0
o2sat: 99.0
sbp: 151.0
dbp: 115.0
level of pain: 10
level of acuity: 1.0 | TRANSITIONAL ISSUES
===================
[] Patient should follow up with GI as an outpatient within 1
week for further evaluation of his hematemesis
[] Patient discharged on 1 month course of omeprazole for acute
GI bleed. Continue or stop as clinically indicated.
[] Discharge hgb 13.3
[] Should have Hgb checked within 1 week of discharge by primary
care physician
[] Patient counseled on alarming symptoms that would prompt
urgent ED evaluation
BRIEF SUMMARY
==============
___ HTN, polysubstance abuse, and left AKA d/t osteo, who
presented with epigastric abdominal pain and vomiting 4 days
prior to admission, which progressed to hematemesis concerning
for upper GIB. Trigger unclear as patient denies EtOH use and
has no lab abnormalities concerning for cirrhosis, no recent
NSAID use, or other historical triggers for GI bleed. He was
fluid resuscitated in the ED with 3L IVF, and had CT A/P which
was unremarkable. Labs notable for mild anemia s/p IVF. He has a
history of GIB d/t gastritis, which was the leading diagnosis.
He received IV pantoprazole BID. He was scheduled for EGD,
however felt better and elected to leave the hospital prior to
further evaluation. As he was hemodynamically stable and with
stable H/H, GI and the medicine team felt outpatient follow-up
was acceptable (though not ideal), however counseled the patient
about the benefits of EGD, particularly around identifying a
source of bleed or identifying ongoing bleed which would require
further fluid resuscitation, possible transfusions, and/or
endoscopic intervention with ablation. He was instructed to
schedule his own follow-up with PCP and GI for further
evaluation of his upper GIB. He was discharged on omeprazole 40
BID. Discharge Hgb 13.3.
ACUTE ISSUES:
=============
#Hematemesis
#Concern for upper GI bleed
#Acute blood loss anemia
Given hematemesis with dark stools, presentation is most
concerning for upper GI bleed. Unclear trigger, as patient
denies EtOH, no NSAIDs, no hx cirrhosis and w/o labs concerning
for cirrhosis. Given his 4 days of vomiting that progressed to
hematemesis, concerning for ___ tear. One prior
admission in ___ for the same issue w/ gastritis on EGD; given
the similarity in presentation, he may have repeat gastritis.
Mild anemia likely secondary to blood loss. Treated with IV BID
pantoprazole while inpatient. He was kept NPO starting ___
midnight and supposed to go for EGD. Patient vehemently declined
EGD as he felt much improved and wanted to leave the hospital.
As he was hemodynamically stable and with stable H/H, GI and the
medicine team felt outpatient follow-up was appropriate, however
counseled the patient about the benefits of EGD, particularly
around identifying a source of bleed or identifying ongoing
bleed which would require further fluid resuscitation, possible
transfusions, and/or endoscopic intervention with ablation. He
is to schedule his own follow-up with PCP and GI for further
evaluation of his upper GIB.
CHRONIC ISSUES:
===============
#HTN
Continued home losartan-HCTZ
#s/p AKA
#Phantom limb pain
Narcotic agreement in place, most recent ___ with PCP ___
___. Continued home pain regimen: Percocet, MS contin,
gabapentin.
Pt seen on the day of discharge ___, hemodynamically
stable, denied any further n/v/hematemesis. He preferred not to
stay in-house for EGD and was intent on leaving under a specific
timeframe, not able to secure him an actual appointment time for
GI clinic but we did provide the number and recommended followup
>30 min spent on d/c activities |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / atenolol /
naproxen / aspirin
Attending: ___.
Chief Complaint:
Seizure, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a history of polysubstance use disorder,
alcoholic/HCV cirrhosis, and COPD and alcohol withdrawal
seizures
who presented with altered mental status and hypoxia s/p a
presumed seizure. According to EMS, this morning around 10am,
Mr.
___ had a presumed seizure. He called his ___, who then
alerted
EMS. On arrival, EMS found him awake and alert. However, in
transit to the hospital, Mr. ___ acutely worsened, becoming
progressively somnolent and hypoxic.
In the ED, he endorsed R sided chest wall pain s/p reported rib
fractures ___ a seizure and fall. He reports taking Keppra
1500mg
daily, differing from his 1000 BID Rx. He denies taking
Zonisamide, one of his other Rx, and he endorses having a drink
today. It was difficult to obtain a clear history given his
current mental status, though it continues to improve.
In the ED:
- Initial vital signs were notable for: T 97.6, HR 81, BP
107/78,
RR 14, 88% RA
- Exam notable for:
General: Somnolent but arousable
HEENT: Normal oropharynx, no exudates/erythema, atraumatic head,
EOMI, PERRL
MSK: No deformities or signs of trauma, no focal deficits noted
Neuro: Alert and oriented x1, slurred speech, right leg weakness
which is pain limited. The rest of his exam is non-focal.
- Labs were notable for:
BLOOD
WBC: 3.5*
RBC: 3.83*
Hgb: 11.4*
Hct: 35.7*
Plt Ct: 51*
Monos: 14.0*
AbsNeut: 1.56*
___: 15.0*
___: 1.4*
Glucose: 115*
Cl: 110*
HCO3: 21*
ALT: 30
AST: 91*
AlkPhos: 220*
TotBili: 1.5
Ethanol: ___
Lactate: 1.3
URINE
cocaine: POS*
- Studies performed include:
CT Head
1. No acute intracranial abnormality.
2. Sinus disease.
CXR
Mild-to-moderate pulmonary edema.
- Patient was given:
IV LevETIRAcetam (1000 mg ordered)
PO/NG Thiamine 500 mg
PO Multivitamins 1 TAB
- Consults: Neuro
Vitals on transfer: Temp: 97.4 PO BP: 113/78 HR: 77 RR: 18 O2
sat: 95% O2 delivery: 4L
Upon arrival to the floor, the patient confirmed much of the
previous history. He explained that his seizures began roughly
six months ago, when he was struck in the back of the head with
a
lead pipe. Since that accident, he has experienced seizures
roughly every other day. He reports that they are triggered by
stress and that he experiences a metallic taste in his mouth
before the onset of each seizure. He attempts to lower himself
to
the floor before the onset to prevent a fall, but he is not
always aware of the onset and able to do so in time. He reports
rib fractures due to a seizure roughly one week ago during which
he fell off of his bed onto his nightstand. He is followed by a
neurologist at ___. He reports being more stressed over the last
year due to the passing of both his parents and his sibling in
quick succession.
When asked about his alcohol consumption, Mr. ___ reports
drinking ___ beers about 4 times per week. He reports having his
last drink at 10am today. He denied additional substance use,
noting that someone had slipped cocaine into his beverage to
trigger the positive cocaine screen.
He endorsed fevers, chills, and feeling incredibly cold.
Past Medical History:
PAST MEDICAL HISTORY:
R 8 and 9 Rib Fractures
HCV
Alcoholic Cirrhosis
Portal Vein Thromboses
Esophageal Varices s/p Banding
OA
pseudoseizures vs. seizures
COPD
panctyopenia
Social History:
___
Family History:
N/a
Physical Exam:
GENERAL: AOx3, engaging in conversation appropriately
EYES: NCAT. EOMI. Dilated pupils b/l, reactive to light. Sclera
anicteric and without injection.
ENT: MMM. No cervical lymphadenopathy. Unable to appreciate JVD
given body position.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Poor air movement. Diffusely ronchorus with expiratory
wheeze.
ABDOMEN: Hypoactive bowels sounds, mildly distended, TTP along
the R.
EXTREM: Clubbing of the fingers. Pulses Radial 2+ bilaterally,
___ 2. +1 pitting edema. Extremities warm and well-perfused
NEUROLOGIC: AOx3. Dilated pupils. Otherwise, CN2-7 evaluated
and
intact. Moving extremities appropriately. Normal sensation. Mild
tremor
PSYCH: appropriate
Pertinent Results:
___ 01:00PM URINE HOURS-RANDOM
___ 01:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 01:00PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 01:00PM URINE RBC-1 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 01:00PM URINE MUCOUS-RARE*
___ 12:50PM GLUCOSE-115* UREA N-6 CREAT-0.5 SODIUM-146
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-21* ANION GAP-15
___ 12:50PM estGFR-Using this
___ 12:50PM ALT(SGPT)-30 AST(SGOT)-91* ALK PHOS-220* TOT
BILI-1.5
___ 12:50PM LIPASE-57
___ 12:50PM LIPASE-57
___ 12:50PM ALBUMIN-3.5
___ 12:50PM ASA-NEG ___ ACETMNPHN-NEG
tricyclic-NEG
___ 12:50PM LACTATE-1.3
___ 12:50PM WBC-3.5* RBC-3.83* HGB-11.4* HCT-35.7* MCV-93
MCH-29.8 MCHC-31.9* RDW-16.3* RDWSD-55.2*
___ 12:50PM NEUTS-44.7 ___ MONOS-14.0* EOS-4.0
BASOS-0.3 IM ___ AbsNeut-1.56* AbsLymp-1.28 AbsMono-0.49
AbsEos-0.14 AbsBaso-0.01
___ 12:50PM PLT SMR-VERY LOW* PLT COUNT-51*
___ 12:50PM ___ PTT-35.7 ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Tiotropium Bromide 1 CAP IH DAILY
2. LevETIRAcetam 1000 mg PO BID
3. Ciprofloxacin HCl 500 mg PO Q24H
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. FoLIC Acid 0.8 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Lactulose 15 mL PO BID
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/wheeze
10. Magnesium Oxide 400 mg PO BID
11. Melatin (melatonin) 5 mg oral QHS:PRN sleep aid
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Spironolactone 100 mg PO DAILY
15. tadalafil 40 mg oral DAILY
16. Thiamine 100 mg PO DAILY
17. rifAXIMin 550 mg PO BID
18. ergocalciferol (vitamin D2) 50,000 unit oral 1X/WEEK
19. Prazosin 1 mg PO DAILY
20. QUEtiapine Fumarate 100 mg PO QHS
21. Venlafaxine XR 75 mg PO TID
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/wheeze
3. Ciprofloxacin HCl 500 mg PO DAILY
4. ergocalciferol (vitamin D2) 50,000 unit oral 1X/WEEK
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Furosemide 40 mg PO DAILY
8. Lactulose 15 mL PO BID
9. LevETIRAcetam 1000 mg PO BID
10. Magnesium Oxide 400 mg PO BID
11. Melatin (melatonin) 5 mg oral QHS:PRN sleep aid
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Prazosin 1 mg PO DAILY
15. QUEtiapine Fumarate 100 mg PO QHS
16. rifAXIMin 550 mg PO BID
17. Spironolactone 100 mg PO DAILY
18. tadalafil 40 mg oral DAILY
19. Thiamine 100 mg PO DAILY
20. Tiotropium Bromide 1 CAP IH DAILY
21. Venlafaxine XR 75 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Final diagnoses:
- Acute Toxic/Metabolic/Postictal/Hepatic encephalopathy
- Seizure
- Acute pulmonary edema c/b acute hypoxic respiratory failure
- Polysubstance use disorder
- ETOH intoxication/use disorder/withdrawal
- ETOH cirrhosis c/b portal hypertension and coagulopathy
- Pancytopenia d/t ETOH and splenomegaly
- PTSD/Depression/Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ with altered mental status and hypoxia // Hypoxia
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. Overlying EKG leads are present.
There is ground-glass opacity concerning for edema which is mild to moderate
in extent. No large effusion is seen though the right CP angle is excluded.
No pneumothorax. No gross signs for pneumonia. Cardiomediastinal silhouette
appears normal. Bony structures are intact
IMPRESSION:
Mild-to-moderate pulmonary edema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with AMS, seizure, // eval for bleed
DOSE:
Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of fracture, acute major infarction,hemorrhage,edema,or
definite mass. There is prominence of the ventricles and sulci suggestive of
involutional changes.
There is near complete opacification of the right maxillary sinus and adjacent
ethmoid air cells. Otherwise, the visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are normal.
IMPRESSION:
1. No acute intracranial abnormality.
2. Sinus disease.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: Mr. ___ is a ___ with a history of EtOH use
disorder,alcoholic/HCV cirrhosis, and COPD and alcohol withdrawal seizures.
// ___ screen
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. Evaluation for
focal liver masses is limited. The main portal vein is patent with
hepatofugal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 8 mm
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 20.3 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 13.4 cm
Left kidney: 13.9 cm
RETROPERITONEUM: Although not well visualized, the visualized portions of
aorta and IVC are within normal limits.
OTHER: Incidental note is made of midline varicosity.
IMPRESSION:
Cirrhotic liver morphology with sequelae of portal hypertension including
hepatofugal portal flow, midline varices, and splenomegaly. Evaluation for
focal liver lesions is limited on this study given heterogeneity of the liver.
Liver MRI or multiphasic liver CT is recommended for further screening.
RECOMMENDATION(S): Liver MRI or multiphasic liver CT is recommended for
further screening.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypoxia, Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 97.6
heartrate: 81.0
resprate: 14.0
o2sat: 88.0
sbp: 107.0
dbp: 78.0
level of pain: 0
level of acuity: 1.0 | SUMMARY
========
Mr. ___ is a ___ with a history of EtOH use disorder,
alcoholic/HCV cirrhosis, and COPD and alcohol withdrawal
seizures who presented with altered mental status and hypoxia
s/p a presumed seizure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old male with a history of asthma
presenting with SOB at rest and with exertion. For the past few
weeks, he has had some rhinitis, congestion with a productive
cough and a mild sore throat. He notes that for the past week he
has developed increasing SOB with exertion, and more recently at
rest as well. He has also had associated nasal congestion and
cough. He denies fevers, chills, nausea, vomiting, abd pain,
dysuria, diarrhea.
He reports that he has had asthma exacerbations in the past, but
has never been hospitalized before. Typically his asthma
exacerbations are managed as an outpatient occasionally
requiring PO steroids. He also takes Flovent, but only when he
has an exacerbation. His only routine asthma medication is
albuterol rescue inhaler. He says that when he is feeling at his
baseline he usually uses his rescue inhaler ___ per day. He
does not have night time awakenings with shortness of breath or
cough. He also has seasonal allergies and will take fluticasone
nasal spray when needed.
In the ED, the patient was noted to be tachycardic with a HR of
113, but was satting 96% on room air. He was noted to be
diffusely wheezing in all lung fields, and was given albuterol
and ipratropium nebs, as well as IV solumedrol 125mg, and IV
magnesium sulfate 2g. The patient was then placed on BiPAP. Labs
were drawn which were only notable to a lactate of 3.1. The
patient was satting well on room air following multiple nebs and
IV steroids and was normotensive, however a repeat lactate was
6.0, and the patient was admitted to the ICU.
Past Medical History:
Asthma
Social History:
___
Family History:
Notable for DM, HTN in multiple family members
Physical ___ Physical Exam
VITALS: Tm 98.6, HR 110s, BP 120s-140s/60s-80s, RR 19, > 95%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. Peak flow 220
CV: Tachycardic, regular rhythm, no murmurs, rubs or gallops
ABD: NABS, soft, NT, ND, no rebound or guarding
EXT: Warm, well perfused, no edema
NEURO: CN II-XII grossly intact, moving all 4 extremities
spontaneously and purposefully, gait normal, speech fluent
Discharge Physical Exam
VITALS: reviewed in Metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. Peak flow 220
CV: Tachycardic, regular rhythm, no murmurs, rubs or gallops
ABD: NABS, soft, NT, ND, no rebound or guarding
EXT: Warm, well perfused, no edema
NEURO: CN II-XII grossly intact, moving all 4 extremities
spontaneously and purposefully, gait normal, speech fluent
Pertinent Results:
Admission Labs
___ 07:03PM LACTATE-6.0*
___ 05:03PM ___ PO2-28* PCO2-45 PH-7.36 TOTAL CO2-26
BASE XS--1
___ 01:44PM ___ PO2-43* PCO2-46* PH-7.37 TOTAL
CO2-28 BASE XS-0
___ 01:44PM O2 SAT-76
___ 01:17PM LACTATE-3.1*
___ 01:00PM GLUCOSE-118* UREA N-11 CREAT-0.8 SODIUM-143
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18
___ 01:00PM WBC-7.2 RBC-5.93 HGB-14.2 HCT-44.8 MCV-76*
MCH-23.9* MCHC-31.7* RDW-16.4* RDWSD-42.1
___ 01:00PM NEUTS-67.3 ___ MONOS-7.8 EOS-2.4
BASOS-0.6 IM ___ AbsNeut-4.84 AbsLymp-1.55 AbsMono-0.56
AbsEos-0.17 AbsBaso-0.04
___ 01:00PM PLT COUNT-222
___ 01:00PM ___ PTT-30.1 ___
DISCHARGE LABS
___ 02:03AM BLOOD WBC-9.1 RBC-5.43 Hgb-12.9* Hct-40.7
MCV-75* MCH-23.8* MCHC-31.7* RDW-15.4 RDWSD-41.1 Plt ___
___ 02:03AM BLOOD Glucose-211* UreaN-12 Creat-0.9 Na-138
K-4.7 Cl-102 HCO3-24 AnGap-12
___ 02:03AM BLOOD Calcium-8.9 Phos-1.2* Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Cialis (tadalafil) 10 mg oral PRN
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth DAILY Disp #*6 Tablet
Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
3. Cialis (tadalafil) 10 mg oral PRN
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
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 asthma exacerbation// PNA?
TECHNIQUE: Portable frontal views of the chest.
COMPARISON: None.
FINDINGS:
Heart size is normal. Cardiomediastinal silhouette and hilar contours are
preserved. Lungs are clear. Pleural surfaces are clear without effusion or
pneumothorax. There is no acute osseous abnormality.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Cough, Dyspnea
Diagnosed with Unspecified asthma with (acute) exacerbation
temperature: 98.1
heartrate: 113.0
resprate: 18.0
o2sat: 96.0
sbp: 143.0
dbp: 45.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES
========================
- None
MICU COURSE
=========================
___ with a history of asthma presenting with an acute asthma
exacerbation likely triggered by a viral upper respiratory
infection.
#Asthma exacerbation: Most likely asthma exacerbation given
history, wheezing on exam and great improvement with
bronchodilator therapy. No history of heart failure, no volume
overload on exam and history inconsistent with CHF. Low concern
for bacterial infection given no fevers, normal CXR, no
leukocytosis. Asthma exacerbation likely triggered by viral URI.
Patient was treated with albuterol nebs Q4h, albuterol nebs Q2h
PRN SOB, ipratropium Q6h, prednisone 40mg PO on discharge with
taper based on symptoms. Flu shot was offered prior to
discharge. The patient's respiration improved with these
interventions and without need of supplemental oxygen.
#Lactic acidosis: No documented hypotensive episodes with very
low concern for end organ and tissue hypoperfusion. Lactic
acidosis likely secondary to beta agonist therapy with stacked
albuterol nebs in the ED. No need to trend lactate. Vital signs
per ICU protocol and can trend lactate if patient develops any
signs of systemic infection or hypotension. Patient did not
develop these signs and no further lactate measurements were
indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abnormal imaging
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of recurrent GI bleeds, CVAs, UTIs, Grave's
disease, DMII, atrial fibrillation on apixaban, and asthma who
presents with dyspnea and a CT scan from an outside facility
suggestive of right lower lobe pneumonitis.
Since earlier this week, her family has noticed she has had a
productive cough with yellow phlegm and vomited ___. She also
had a fever to ___ on ___ and ___. Her family was giving
her cool towels and treating her at home and overall felt she
was
feeling better with that treatment. She had a CT scan on ___
which was ordered for evaluation of a lung nodule at ___
that revealed evidence of RLL pneumonitis. She was unable to
provide a history in the ED and history was obtained from her
niece. There is possible chest pain associated with her cough.
No
history of significant shortness of breath. Denied sick contacts
at home.
At baseline, she is wheelchair bound after multiple
cardioembolic
strokes with fluctuating alertness. Last had a stroke ___ months
ago and was admitted with a stroke. Since then, she has been
wheelchair bound and has had R sided hemiparesis. The niece
notes
she has also had dysphagia and has been on pureed foods and
thickened liquids. Minimally conversant at baseline. She has a
PCA at home and requires dependence in all ADLs including
transfers and feeding.
In the ED, initial vitals:
T ___ HR 85 BP 167/78 RR 20 O2 98% RA
Labs notable for:
WBC 8.1 Hgb 11.3 Plt 401
Cr 0.6 BUN 9 Na 144 Bicarb 25 Cl 106
Lactate 3.9, 3.7, 4.4
VBGx2 unremarkable
Flu negative
Imaging notable for:
Comparison to ___. On today's examination, there is
stable mild bilateral apical scarring and elevation of the right
hemidiaphragm. Moreover, the heart is slightly enlarged and
there
is elongation of the descending aorta. However, there is no
evidence of pneumonia, pulmonary edema or pleural effusions. No
pneumothorax. Severe scoliosis with secondary degenerative
vertebral changes.
- Patient was given:
IV Ampicillin-Sulbactam 3 g
2L IV LR
On arrival to the floor, patient is minimally conversant and
unable to provide a history.
Past Medical History:
- Atrial fibrillation, paroxysmal
- Hypertension
- Diabetes mellitus II
- Asthma
- Obesity
- Graves Disease
- Right knee DJD
- Mild esophagitis seen on EGD ___
- history of UTI
- Colitis thought to be ischemic colitis
- Microcytic anemia
- Total abdominal hysterectomy (for uterine prolapse)
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ Temp: 98.2 PO BP: 161/87 HR: 76 RR: 17 O2 sat:
96% O2 delivery: Ra
GENERAL: Patient comfortable but non-verbal, lying in bed
HEENT: atraumatic, PERRL. Preferetial rightward eye gaze but
tracks to voice.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, Expiratory rhonchi
throughout. Decreased breath sounds at RL base.
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: Not verbalizing so unable to assess orientation. PERRL,
Preferential R eye gaze but tracks to all directions. Face
symmetric at rest and with activation. Motor exam notable for at
least ___ strength in left arm and leg but ___ strength in right
arm. Increased tone in left upper arm with 1+ reflexes
throughout. Unable to assess sensory function. Plantar reflexes
bilaterally.
SKIN: No significant rashes
Discharge Exam
==================
___ ___ Temp: 98.0 PO BP: 164/84 L Lying HR: 69 RR: 18
O2 sat: 94% O2 delivery: Ra FSBG: 225
GENERAL: Patient comfortable, smiling, minimally-verbal
HEENT: atraumatic, PERRL. Preferetial rightward eye gaze but
tracks to voice.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, Expiratory rhonchi
throughout. Decreased breath sounds at RL base.
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: AOx1.5 (self, knows in hospital but not which one) PERRL,
Preferential R eye gaze but tracks to all directions. Face
symmetric at rest and with activation. Motor exam notable for at
least ___ strength in left arm and leg but ___ strength in right
arm. Increased tone in left upper arm with 1+ reflexes
throughout. Unable to assess sensory function. Plantar reflexes
bilaterally.
SKIN: No significant rashes
Pertinent Results:
Admission Labs
==================
___ 10:40AM BLOOD WBC-8.1 RBC-4.63 Hgb-11.3 Hct-37.1
MCV-80* MCH-24.4* MCHC-30.5* RDW-22.2* RDWSD-63.6* Plt ___
___ 10:40AM BLOOD Neuts-78.0* Lymphs-15.3* Monos-5.5
Eos-0.6* Baso-0.1 Im ___ AbsNeut-6.33* AbsLymp-1.24
AbsMono-0.45 AbsEos-0.05 AbsBaso-0.01
___ 06:23AM BLOOD ___ PTT-150* ___ 10:40AM BLOOD Plt ___
___ 10:40AM BLOOD Glucose-272* UreaN-9 Creat-0.6 Na-144
K-5.5* Cl-106 HCO3-25 AnGap-13
___ 10:40AM BLOOD ALT-22 AST-26 AlkPhos-83 TotBili-0.3
___ 10:40AM BLOOD cTropnT-<0.01 proBNP-378
___ 10:40AM BLOOD Albumin-3.1* Calcium-10.8* Mg-1.6
___ 06:23AM BLOOD PTH-169*
___ 05:14AM BLOOD 25VitD-39
___ 10:46AM BLOOD Lactate-3.9*
Pertinent Labs
-============
___ 06:23AM BLOOD PTH-169*
___ 05:14AM BLOOD 25VitD-39
___ 10:40AM BLOOD Albumin-3.1* Calcium-10.8* Mg-1.6
Imaging
===========
CT CHEST W/O CONTRASTStudy Date of ___ 2:52 ___
IMPRESSION:
Severe broncho centric and bronchiolar infection right lung,
probably viral.
Moderate, chronic generalized bronchial inflammation is more
severe due to
acute infection.
Chronic mild to moderate thyromegaly.
Possible anasarca.
Reccs:
Conventional chest radiograph now, repeated in 6 weeks, at
which time any need for repeat chest CT scanning will be
determined.
Discharge Labs
===================
___ 05:14AM BLOOD WBC-6.2 RBC-4.67 Hgb-11.4 Hct-37.2
MCV-80* MCH-24.4* MCHC-30.6* RDW-22.4* RDWSD-63.3* Plt ___
___ 05:14AM BLOOD Plt ___
___ 05:14AM BLOOD Glucose-207* UreaN-8 Creat-0.4 Na-144
K-4.0 Cl-103 HCO3-29 AnGap-12
___ 06:23AM BLOOD ALT-19 AST-16 LD(LDH)-241 AlkPhos-72
TotBili-0.4
___ 05:14AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate
2. Apixaban 5 mg PO BID
3. Benzonatate 100 mg PO TID
4. Bisacodyl ___AILY:PRN constipation
5. Ferrous GLUCONATE 324 mg PO DAILY
6. FLUoxetine 20 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Methimazole 5 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Senna 17.2 mg PO QHS
11. Diltiazem Extended-Release 90 mg PO DAILY
12. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheezing
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Vesicare (solifenacin) 10 mg oral daily
15. Atorvastatin 80 mg PO QPM
16. Amantadine 100 mg PO BID
17. Pantoprazole 40 mg PO Q24H
18. Carbidopa-Levodopa (___) 0.5 TAB PO TID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
twice a day Disp #*9 Tablet Refills:*0
2. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate
4. Amantadine 100 mg PO BID
5. Apixaban 5 mg PO BID
6. Atorvastatin 80 mg PO QPM
7. Benzonatate 100 mg PO TID
8. Bisacodyl ___AILY:PRN constipation
9. Carbidopa-Levodopa (___) 0.5 TAB PO TID
10. Diltiazem Extended-Release 90 mg PO DAILY
11. Ferrous GLUCONATE 324 mg PO DAILY
12. FLUoxetine 20 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheezing
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Methimazole 5 mg PO DAILY
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Pantoprazole 40 mg PO Q24H
19. Senna 17.2 mg PO QHS
20. Vesicare (solifenacin) 10 mg oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Viral Bronchitis
Aspiration pneumonia
Urinary Tract Infection
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with history of cough, phlegm, fever at home// PNA?
PNA?
IMPRESSION:
Comparison to ___. On today's examination, there is stable mild
bilateral apical scarring and elevation of the right hemidiaphragm. Moreover,
the heart is slightly enlarged and there is elongation of the descending
aorta. However, there is no evidence of pneumonia, pulmonary edema or pleural
effusions. No pneumothorax. Severe scoliosis with secondary degenerative
vertebral changes.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Pneumonia, unspecified organism
temperature: 98.0
heartrate: 85.0
resprate: 20.0
o2sat: 98.0
sbp: 167.0
dbp: 78.0
level of pain: 3
level of acuity: 2.0 | Summary
___ with history of recurrent GI bleeds, CVAs, UTIs, Grave's
disease, DMII, atrial fibrillation on apixaban, and asthma who
presented with dyspnea and a CT scan from an outside facility
suggestive of right lower lobe pneumonitis vs PNA iso probable
aspiration. Read of CT scan here was more concerning for viral
bronchitis. She was also found w/ pyuria. Discharged to complete
a 7 day course of augmentin/azithromycin for CAP/UTI.
Transitional Issues
===================
[] found w/ hypercalcemia (mild) with elevated PTH, normal vit
D.
[] Patient is being followed by neurology and likely does not
have parkinsons disease. She is being weaned off her parkinsons
medications, ensure patient has adequate neurology follow up.
[] Augmentin ___, azithromycin ___
[] Recommend repeating CXR in 6 weeks to eval for resolution of
bronchiolar inflammation, consider CT scan at that time
Acute Issues
============
# Dysphagia, Aspiration Risk
# Aspiration Pneumonia
# Bronchitis, viral
Outside imaging with RLL pneumonitis per report. Patient is at
aspiration risk given CVA history with fluctuating mental
status.
CXR on presentation was without focal consolidation. BNP wnl.
Started on IV unasyn and azithro. CT chest here was concerning
for acute infection, likely viral bronchitis. Given the clinical
setting, w/ neurologic deficits and aspiration risk, we elected
to treat for CAP, unasyn transitioned to Augmentin ___ -
___, and continued azithromycin. Speech and swallow evaluated,
recommended continuing nectar thick liq/pureed solids, no e/o
aspiration at time of d/c.
# UTI: UA w/ positive nitrites, WBCs, urine cx contaminated. As
above, on IV unasyn initially, transitioned to PO augmentin at
time of d/c to treat PNA and UTI concurrently.
# Atrial fibrillation
Continued apixaban, briefly on a heparin gtt while NPO.
# Hypercalcemia
Corrected calcium 11.5 on admission. PTH notably elevated. ___
be
primary parathyroidism +/- some component of bone resorption due
to patient's immobility. Currently asymptomatic w/o GI symptoms,
nephrolithiasis, appears at neurologic baseline. Vitamin D wnl.
CHRONIC ISSUES:
===============
# Tremor
# Concern for ___ Disease
Per last neuro note, was started on amantadine and
carbidopa-levodopa at rehab due to concern for ___
disease. However, per neurology, do not think patient has
underlying parkinsons and think her symptoms are likely related
to stroke. Per family medications have not improved symptoms
much
and neuro is weaning off meds currently. Continued
carbidopa-levodopa ___ 0.5 tab TID, and amantadine 100mg
daily for now, will continue wean w/ neuro as OP.
# DMII
-Discharged on metformin
# History of CVA
- Continued atorvastatin 80 mg PO QHS
# History of GI bleeds (esophagitis and ischemic colitis)
- Continued PPI
# Grave's disease
- Continued methimazole |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tramadol / Abacavir
Attending: ___.
Chief Complaint:
Positive blood culture.
Major Surgical or Invasive Procedure:
hemodialysis session on ___
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of HIV, HCV,
end-stage renal disease on HD, and hypertension, who was found
to have a positive gram positive blood culture taken during HD
yesterday.
.
According to Ms. ___, she began to feel unwell yesterday
during HD which prompted her to ask for a blood culture. After
the HD session she had up to 30 episodes of non-bloody vomiting
which was followed by severe, ___, epigastric abdominal pain
that felt like a gnawing dullness. "It felt like pancreatitis."
This morning, her primary care physician informed her by
telephone that her blood culture had come back positive and
advised her to go to the emergency department.
.
Her vital signs on presentation to the emergency department
were: T 99.6, P 90, BP 192/114, RR 18, O2 Sat 100%.
She was given 1 gram of IV Vancomycin for the positive blood
culture, Zofran for nausea, and morphine for pain, and
acetaminophen for a new onset headache while in the ED. Her
labs were significant for a BUN 55, Cr 8.5, and a lactate that
was initially 3.3 but then dropped to 2.1. She also received 1L
of NS. Her vital signs on transfer to the floor were T 98.0, P
89, RR 14, BP 116/70, O2 Sat 100%.
.
Currently, she does not complain of pain or nausea. She had no
sick contacts. She attributes the nausea and vomiting to having
eaten at a restaurant where she previously developed a gi
illness. She endorses having had developed a headache while in
the emergency department that still persists. She denies
shortness of breath, cough, diarrhea and constipation, urinary
changes, fevers, night sweats, and chills.
Past Medical History:
End Stage Renal Disease on HD. (Dr. ___ is her
nephrologist)
Hepatitis C (has never had treatment for HCV)
HIV (Diagnosed ___ years ago. CD4 299, Viral Load 55 per ___
labs)
Hypertension
ITP
Right Subclavian Thrombosis
Anxiety
Depression
Social History:
___
Family History:
non-contributory.
Physical Exam:
On Admission:
VS - Temp 98.8F, BP 116/70, HR 89, R 14, O2-sat 100% RA
GENERAL - NAD, comfortable, appropriate
HEENT - No head trauma. Extraocular movements are intact.
Pupils are equal, round, and reactive to light and
accommodation. Moist mucous membranes.
NECK - supple, no thyromegaly, no carotid bruits, non-tender
lymphadenopathy appreciated, no JVD.
LUNGS - Clear to auscultation bilaterally.
HEART - RRR, nl s1 and s2, no murmurs appreciated
ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - Failed fistulas in her right and left upper
extremity. Left sided tunneled drain with no purulous drainage
or pus surrounding the site.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, sensation
grossly intact throughout
At Discharge:
AF, no abdominal pain, line appears clean without purulence or
erythema
Pertinent Results:
Images:
IMPRESSION: No evidence of acute cardiopulmonary disease.
Labs on admission:
.
___ 11:10AM BLOOD WBC-4.7 RBC-4.46 Hgb-13.7 Hct-43.0 MCV-96
MCH-30.7 MCHC-31.9 RDW-16.0* Plt ___
___ 11:10AM BLOOD Neuts-72.8* ___ Monos-3.8 Eos-0.2
Baso-0.4
___ 11:10AM BLOOD Plt ___
___ 11:10AM BLOOD Glucose-100 UreaN-57* Creat-8.2* Na-133
K-GREATER TH Cl-87* HCO3-27
___ 11:10AM BLOOD ALT-33 AST-76* AlkPhos-457* TotBili-0.7
___ 11:10AM BLOOD Lipase-41
___ 12:30PM BLOOD CK-MB-1 cTropnT-0.02*
___ 11:10AM BLOOD HoldBLu-HOLD
___ 11:17AM BLOOD Lactate-3.3*
Microbiology:
___ CULTUREBlood Culture, Routine-FINAL
{STAPHYLOCOCCUS EPIDERMIDIS}; Aerobic Bottle Gram Stain-FINAL;
Anaerobic Bottle Gram Stain-FINAL
.
___ CULTUREBlood Culture, Routine-FINAL
{STAPHYLOCOCCUS EPIDERMIDIS}; Aerobic Bottle Gram Stain-FINAL;
Anaerobic Bottle Gram Stain-FINAL
.
Labs on Discharge:
___ 06:45AM BLOOD WBC-5.8 RBC-3.89* Hgb-12.0 Hct-37.8
MCV-97 MCH-30.9 MCHC-31.8 RDW-16.1* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-75 UreaN-73* Creat-10.2*# Na-133
K-5.5* Cl-87* HCO3-31 AnGap-21*
___ 12:00AM BLOOD CK(CPK)-36
___ 12:00AM BLOOD CK-MB-1 cTropnT-0.02*
___ 06:45AM BLOOD Calcium-11.2* Phos-7.2*# Mg-2.0
___ 06:45AM BLOOD PTH-3381*
___ 06:45AM BLOOD Vanco-23.2*
Medications on Admission:
Atazanavir 300mg po daily
Ritonavir 400mg po BID
Raltegravir 400mg po BID
Emtricitabine 200mg q96hr (has not yet filled ___ prescription)
Sulfamethoxazole-Trimethoprim 1 tab every other day.
Lisinopril 40mg po daily
Metoprolol Tartrate 100mg po BID
Aspirin 81mg po daily
Sevelamer 800mg with meals
Nephrocaps 1mg capsule daily
Lactulose 10 gram/15ml once daily as needed
Acetaminophen 325mg q6h as needed
Oxycodone 2mg per day for right shoulder pain per patient.
Polyethylene glycol as needed per patient.
Docusate as needed per patient.
Senna as needed per patient.
Discharge Medications:
1. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q96H
(every 96 hours).
5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO EVERY OTHER DAY (Every Other Day).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
10. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
11. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
12. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO once a day as
needed for pain.
14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 0.5 to 1 gram
Intravenous HD PROTOCOL (HD Protochol) for 2 weeks: If Vanc
level < 15, give 1 gram
If Vanc level ___, give 500 mg
If Vanc level > 25, hold dose.
Last dose to be given on ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Gram positive, coagulase negative staph bacteremia.
Secondary Diagnosis:
End Stage Renal Disease on Hemodialysis
HIV
HCV
Hypertension
ITP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Confirm bacteremia. Question pneumonia.
COMPARISONS: Radiographs from ___.
TECHNIQUE: Chest, AP upright and lateral views.
FINDINGS: There is a dual-lumen dialysis catheter terminating in the
uppermost part of the atrium, in an unchanged position. The heart is normal
in size. The aortic arch is partly calcified. There is no pleural effusion
or pneumothorax. The lungs appear clear aside from patchy right infrahilar
opacity that appears unchanged and may be associated with minor chronic
scarring or atelectasis. The appearance includes mildly dilated descending
airways noting an element of slight bronchiectasis. There are similar
degenerative changes which are incompletely characterized along the right
shoulder. The bones appear sclerotic compatible with known renal
osteodystrophy.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: EPISATRIC, N/V
Diagnosed with BACTEREMIA NOS, END STAGE RENAL DISEASE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
temperature: 99.6
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 192.0
dbp: 114.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ year old woman who came to the ___ because
of a positive blood culture, received hemodialysis, and
receieved antibiotics for line infection.
.
#Bacteremia: A blood culture was performed during a hemodialysis
session on ___ that grew staph epi in ___ bottles of 1 set. She
was then referred to the ED the next day where she received 1g
of Vancomycin; 2 sets of blood cultures were taken. She
remained afebrile. Her WBC was 4.7. She received a second dose
of vancomycin during hemodialysis on ___. Cultures from the ED
on ___ grew staph epi in 1 of 2 sets - ___ bottles. Nephrology
recommended treating through the infection with vancomycin for 2
weeks per HD protocol and this was communicated to her outpt HD
center - ___. Her line was not replaced.
.
#Abdominal Pain, Nausea, and Vomiting: Ms. ___ developed
abdominal pain soon after her hemodialysis session on ___ ended.
This pain was followed by nausea and emesis. She mentioned
that she had eaten at a restaurant at which she formerly
developed a gi illness. She received morphine and ondansetron
while in the emergency department. After she was transferred to
the internal medicine floor, she no longer complained of
abdominal pain, nausea, and vomiting.
.
#Abnormal EKG/CAD: An EKG done on the internal medicine floor
showed inverted T waves in leads I, II, III, and V3-V5 that were
new compared to an EKG from ___. CK-MB and troponins were
sent which were negative for ischemia. Continued her home
medications of Lisinopril 40mg po daily and metoprolol tartrate
100mg po bid.
.
#Chronic Kidney Disease: Ms. ___ has stage V chronic kidney
disease on hemodialysis. She received hemodialysis on ___. She
had an elevated Ca level of 11.2 and an elevated PTH of 3381.
Her PTH in ___ was 2913. Continude her home medications of
Sevelamer 800mg with meals, Nephrocaps 1mg capsule daily, and
Epoetin Alpha.
.
#HIV: Ms. ___ was diagnosed with HIV ___ years ago. She is
followed by the infectious disease specialist, Dr. ___
___. Continued HAART: Atazanavir 300mg po daily, Ritonavir
100mg po BID, Raltegravir 400mg po BID, Emtricitabine 200mg
q96hr (has not yet filled ___ prescription).
.
#Hypertension: Ms. ___ was markedly hypertensive, to a
systolic pressure of 198, while she was in the emergency
department. Despite not having received any anti-hypertensive
medications, her blood pressure fell to 116 upon admission to
the floor. Her systolic pressure then rose to 170 by nighttime.
She received a dose of metoprolol at that time, after which her
blood pressure remained normal throughout the remainder of the
hospitalization.
.
#Transitional issues:
Follow up appointments: She will be following up with her
nephrologist, Dr. ___.
- management of hypertension
- management of hypercalcemia and secondary hyperparathyroidism
Code Status: Full (Confirmed)
Contacts: Son, ___ is healthcare proxy (she does
not have his phone number). Can contact other son, ___,
in case of emergencies, (___). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / niacin
Attending: ___.
Chief Complaint:
worsening leg edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of AVR s/p redo, CAD s/p CABG, CHB s/p pacer
placement, CKD baseline cre 1.3, HTN p/w complaints of b/l ___
edema x 2 wks in the setting of now resolved upper respiratory
symptoms (nonproductive cough, congestion). She wears stockings
that she is now unable to pullup her thigh (only able to get up
to mid calf now). However, she reports stable wt of 130. She
states that she has minimal nocturia now despite taking
nighttime lasix. She has been drinking less since noticing the
swelling. She denies orthopnea, pnd. Does complain of some DOE.
Feels that her legs are heavy and gets fatigued with walking
short distances. No BRBPR, melena. No f/c/n/v/d/chest
pain/baseline sob/flank pain.
In the ED, initial VS were 98.6 59 132/44 16 99% ra.
Exam was significant for 1+ pitting edema to mid shin. There was
no stool present on rectal exam.
Labs significant for Cr of 1.7 from baseline of 1.3 and HCT of
24 from normal baseline (although last value in our system from
___. BNP was in the 900s (no prior in our system). LDH
elevated but normal tbili. Iron studies were suggestive of iron
deficiency anemia. INR of 4.1. She had a CTAP which showed no
evidence of bleed and a CXR. She was given no medications.
Transfer VS were 98.5 64 104/38 16 96%
On arrival to the floor, patient reports no pain, no change in
bowel habits, a colonoscopy done by Dr. ___ in ___ which
was "normal", a remote history of anemia that she takes
folate/B12 for, no easy brusing, neuropahties or pain. She does
note that for the last 2 months she has been chewing on ice
which is not normal for her.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-ALLERGIC URTICARIA
-ANEMIA, ACQUIRED HEMOLYTIC NOS
-ANGINA PECTORIS
-ATRIAL FIBRILLATION
-ATRIOVENTRICULAR BLOCK s/p pacer
-AVR
-COUMADIN THERAPY
-DISORDER, AORTIC VALVE
-DIVERTICULOSIS
-GERD
-HOMOCYSTEINE ELEVATION
-HYPERCHOLESTEROLEMIA
-HYPERTENSION
-PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
-SHOULDER PAIN
-WRIST FX
-GOUT
-H/O AORTIC VALVE REPLACEMENT
-H/O CLOSED HUMERUS, UPPER END, LEFT
-H/O NQWMI
-H/O OPHTHALMIC MIGRAINES
Social History:
___
Family History:
Father: MI at age ___,
Paternal uncle: MI
___: MI at age ___ and ___
Mother: ___ cancer- in her ___, died in her ___.
Sister: CVA in ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.4, 122/84, 70, 18, 98RA
GEN - Alert, oriented, no acute distress
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - RRR, mechancial S1S2 with ___ early systolic murmur at the
RSB
ABD - obese soft, NT/ND, normoactive bowel sounds, no guarding
or rebound
EXT - WWP, trace ankle edema bilaterally, 2+ pulses palpable
bilaterally
NEURO - CN ___ intact, motor function grossly normal
SKIN - no ulcers or lesions
DISCHARGE PHYSICAL EXAM:
VS - 98.4 ___ 16 97%RA ___ pain
GEN - Alert, oriented, no acute distress
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD however difficult to assess given body
habitus, no LAD
PULM - CTAB, no w/r/r
CV - RRR, mechancial S1, S2 with ___ early systolic murmur at
the RSB
ABD - obese, soft, NT/ND, normoactive bowel sounds, no guarding
or rebound
EXT - WWP, 1+ pitting edema to upper shins stable in comparison
to yesterday, 2+ pulses palpable bilaterally
NEURO - CN ___ intact, motor function grossly normal
SKIN - no ulcers or lesions
Pertinent Results:
Admission Labs:
___ 04:25PM BLOOD ___
___ Plt ___
___ 04:25PM BLOOD ___
___
___ 04:25PM BLOOD ___
___
___ Tear ___
___ 04:25PM BLOOD ___ ___
___ 04:25PM BLOOD ___
___
___ 04:25PM BLOOD ___ LD(LDH)-347* ___
___
___ 04:25PM BLOOD ___
___ 04:25PM BLOOD ___
___ 04:25PM BLOOD ___
___ 04:25PM BLOOD ___
.
___ 08:00PM URINE ___ Sp ___
___ 08:00PM URINE ___
___
___ 08:00PM URINE ___
___
.
Discharge Labs:
___ 06:45AM BLOOD ___
___ Plt ___
___ 04:00PM BLOOD ___
___ 06:45AM BLOOD ___ ___
___ 06:45AM BLOOD ___
___
.
Imaging:
ECG ___: Sinus bradycardia with marked first degree ___
delay. Left ___ block. Compared to the previous
tracing of ___ the ___ interval is more prolonged and the
sinus rate is slower.
.
CXR ___: No evidence of acute disease.
.
CT ABD/PELVIS ___: 1. No evidence of retroperitoneal
hematoma.
2. Indeterminant renal cysts. Evaluation with ultrasound is
recommended when clinically appropriate. 3. Moderate to large
hiatal hernia.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
hold for SBP<100
2. Allopurinol ___ mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Colchicine 0.6 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
hold for HR<60
6. Ezetimibe 10 mg PO DAILY
7. Warfarin 4 mg PO 5X/WEEK (MO,WE,TH,SA)
8. Warfarin 3 mg PO 2X/WEEK (___)
9. Ranitidine 150 mg PO BID
10. Simvastatin 80 mg PO DAILY
11. Furosemide 40 mg PO BID
hold for SBP<100
12. Clopidogrel 75 mg PO DAILY
13. potassium chloride *NF* 10 mEq Oral daily
14. Folic ___ B12 (Ca) *NF* ___
___ Oral daily
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Furosemide 40 mg PO BID
5. Metoprolol Tartrate 12.5 mg PO BID
6. Warfarin 3 mg PO 2X/WEEK (___)
7. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
9. Ferrous Sulfate 325 mg PO TID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Capsule Refills:*0
11. Colchicine 0.6 mg PO DAILY
12. potassium chloride *NF* 10 mEq Oral daily
13. Ranitidine 150 mg PO BID
14. Warfarin 4 mg PO 5X/WEEK (MO,WE,TH,SA)
15. Lisinopril 5 mg PO DAILY
16. Folic ___ B12 (Ca) *NF* ___
___ 0 tab ORAL DAILY
17. Outpatient Lab Work
Mechanical aortic valve
Please measure INR week of ___ and fax results to
Dr. ___ of ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Iron deficiency anemia
Secondary: Chronic kidney disease, hypertension, coronary artery
disease s/p stent placement, pacemaker, aortic valve repair x2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Bilateral lower extremity edema.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The patient is status post aortic valve replacement and probably
coronary artery bypass graft surgery. A dual-lead pacemaker/ICD device
appears unchanged. The heart is moderately enlarged. The mediastinal and
hilar contours appear unchanged. There is no pleural effusion or
pneumothorax. The lungs appear clear. The bones are probably demineralized.
Mild degenerative changes along the lower thoracic spine appear similar.
IMPRESSION: No evidence of acute disease.
Radiology Report
CT OF THE ABDOMEN AND PELVIS
HISTORY: Anemia and supratherapeutic INR. Question retroperitoneal hematoma.
COMPARISONS: Chest CT is available from ___, but no prior
dedicated CT imaging of the abdomen and pelvis.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
without oral or intravenous contrast. Sagittal and coronal reformations were
also performed.
FINDINGS:
The patient is status post sternotomy. A dual-lead pacemaker/ICD device is in
place. The heart is somewhat enlarged. Patchy basilar opacities suggest
minor atelectasis.
Along the lower pole of the left kidney there is a small moderately hyperdense
focus measuring 8 mm in diameter, indeterminant although likely a hemorrhagic
cyst). A small hypodense focus in the interpolar region of the right kidney
of 8 mm in diameter is too small to characterize. A simple cyst along the
left mid to lower pole measures 22 mm in diameter. The spleen is normal in
size and appearance. The liver, pancreas and adrenal glands appear within
normal limits.
There is a moderate to large hiatal hernia with an air-fluid level.
The stomach is otherwise unremarkable. There is moderate sigmoid
diverticulosis.
CT PELVIS: The uterus and adnexal regions appear within normal limits. There
are no enlarged lymph nodes or ascites.
The common iliac arteries are relatively small and substantial vascular
disease is suspected, but not fully characterized. Patchy vascular
calcifications are present. There is no aneurysm.
No hematoma is identified. Dependent fluid in posterior subcutaneous tissues
could be seen with some degree of fluid overload. A surgical clip is present
in the left inguinal region.
BONE WINDOWS: There are no suspicious lytic or blastic lesions. Moderate
degenerative changes are present along lower lumbar facets. The bones appear
demineralized.
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Indeterminant renal cysts. Evaluation with ultrasound is recommended when
clinically appropriate.
3. Moderate to large hiatal hernia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LOWER EXTREMITY SWELLING
Diagnosed with ANEMIA NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, CARDIAC PACEMAKER STATUS
temperature: 98.6
heartrate: 59.0
resprate: 16.0
o2sat: 99.0
sbp: 132.0
dbp: 44.0
level of pain: 0
level of acuity: 3.0 | ___ with significant cardiac history including PPM placement,
CABG, AVR x2 and CKD p/w worsening ___ edema and increasing
dyspnea on exertion found to have significant hematocrit drop
from 31 to 24 over the past several days.
.
# Anemia - Unclear etiology of acute worsening of anemia but
found to be severely iron deficient, guaiac negative, and
without systemic signs of active bleeding. Imaging was also
reassuring- without occult hematoma. Hematocrit increased almost
appropriately to 2 u PRBCs and remained stable. INR was slightly
supratherapeutic but corrected and remained therapeutic
thereafter. She will need close follow up for management of
anemia, given that she probably has persistent low grade
intravascular hemlysis from her mechanical valve which has been
documented in the past. She was started on iron supplementation
and given instructions to relieve constipation as needed. She
may require outpatient IV iron repletion and should discuss this
with her PCP and nephrologist.
.
.
# Acute on chronic kidney injury: Chronic stage IV CKD followed
by Dr. ___ felt to be from hypertensive disease which
has been well controlled. Acute injury due to hypoperfusion and
resolved ___. Ace inhibitor was held on admission
and restarted upon discharge. Patient was encouraged to drink
water as she had been restricting ALL fluid intake prior to
admission. Follow up with PCP and nephrology as outpatient.
.
.
# CAD and CHB s/p PPM, AVR x2: Stable during this admission.
Continued home clopidogrel and furosemide. Initially held
warfarin for elevated INR and restarted on normal dosing
schedule prior to discharge. Changed ezetimibe and simvastatin
to atovastatin.
.
.
# Gout: Stable and inactive during this admission, held
colchicine during admission for ___ and restarted upon
discharge. Allopurinol continued throughout admission.
.
.
# Leg Swelling: continue home lasix for now and monitor
.
.
Transitional Issues:
- Full code
- ___ with PCP
- ___ with nephrology
- ___ with cardiology and device clinic |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right cerebellar mass
Major Surgical or Invasive Procedure:
___ Right occipital craniotomy for tumor resection
History of Present Illness:
This is a ___ year old male who presents with outpatient MRI
revealing
a 3cm R cerebellar mass with mass effect on the ___ ventricle.
Patient reports about a year ago he began to feel very fatigued
and had difficult with short term memory as well as word finding
difficulty. He was referred by his PCP at that time to a
neurologist. He was started on CPAP machine with no improvement
of symptoms. Subsequently he was trialed on a number of
antidepressants with no improvement in symptoms. He was sent for
an outpatient MRI with and without contrast of the brain by his
PCP. Patient denies headache, weakness, numbness or tingling. He
does report word finding difficulty and intermittent double
vision.
Past Medical History:
Rosacea
"eye condition that requires injection to eye Q6-8 wks"
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
O: T:97.7 BP: 154/72 HR:95 R 16 O2Sats 100% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Patient has trouble getting out some words with slowing and
slurring until he arrives on the correct word.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
on the day of discharge:
intact, no dysmetria
Pertinent Results:
MRI head at outside hospital:
3cm R cerebellar mass with mass effect on ___ ventricle
Cardiovascular Report ECG Study Date of ___
Sinus rhythm. Findings are within normal limits. Compared to the
previous
tracing of ___ there is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 142 82 366/381 51 4 15
Pathology Report Tissue: BRAIN/MENINGES FOR TUMOR Procedure Date
of ___
Report not finalized.
Logged in only.
PATHOLOGY # ___
BRAIN/MENINGES FOR TUMOR
Radiology Report CHEST (PRE-OP PA & LAT) Study Date of
___
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report MR HEAD W/ CONTRAST Study Date of ___
IMPRESSION:
No significant interval change in enhancing right cerebellar
lesion. No new enhancing lesions.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
IMPRESSION:
Postoperative changes from right cerebellar lesion resection,
within expected limits. No acute findings.
Medications on Admission:
___ (pt does not know the name)
Discharge Medications:
1. Minocycline 50 mg PO Q24H
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Bisacodyl 10 mg PO DAILY constipation
4. Dexamethasone 4 mg PO Q6H Duration: 48 Hours
RX *dexamethasone 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*2 Tablet Refills:*0
5. Dexamethasone 3 mg PO Q6H Duration: 72 Hours
RX *dexamethasone 1.5 mg 2 tablet(s) by mouth every six (6)
hours Disp #*24 Tablet Refills:*0
6. Dexamethasone 2 mg PO Q6H Duration: 72 Hours
RX *dexamethasone 2 mg 1 tablet(s) by mouth every six (6) hours
Disp #*12 Tablet Refills:*0
7. Dexamethasone 2 mg PO Q8H Duration: 48 Hours
RX *dexamethasone 2 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*6 Tablet Refills:*0
8. Dexamethasone 2 mg PO Q12H Duration: 48 Hours
RX *dexamethasone 2 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*4 Tablet Refills:*0
9. Dexamethasone 2 mg PO DAILY Duration: 48 Hours
Tapered dose - DOWN
RX *dexamethasone 2 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID
11. Methocarbamol 500 mg PO TID
RX *methocarbamol 500 mg 1 tablet(s) by mouth tid prn Disp #*40
Tablet Refills:*0
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*40
Tablet Refills:*0
13. Senna 8.6 mg PO BID constipation
14. Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right cerebellar mass
Discharge Condition:
Improved AO3. WBAT BLE. Outpatient ___. ___, home OT, assistance
w/IADLs.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/ CONTRAST
INDICATION: ___ year old man with new right cerebellar lesion. //
Pre-operative planning. Pt to OR with Dr. ___ on ___. Please perform in
early AM ___.
TECHNIQUE: After administration of Gadavist intravenous contrast, axial
imaging was performed with MPRAGE and T1 technique. MPRAGE images were
re-formatted in sagittal and coronal orientations.
COMPARISON: Prior MRI of the brain dated ___.
FINDINGS:
There has been no significant interval change in solitary enhancing right
cerebellar lesion. Effacement of the fourth ventricle appears similar to prior
study. The lateral and third ventricles are stable in size and configuration.
There is no shift of midline. No new enhancing lesions are identified. There
is no extra-axial collection.
IMPRESSION:
No significant interval change in enhancing right cerebellar lesion. No new
enhancing lesions.
Radiology Report
INDICATION:
___ year old man with preop craniotomy .
COMPARISON: None Available.
TECHNIQUE
Frontal and lateral view of the chest.
FINDINGS:
The cardiomediastinal silhouette is normal. There is no pleural effusion or
pneumothorax. There is no focal lung consolidation. Degenerative changes are
noted in the mid thoracic spine with anterior osteophytes.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with R tentorial lesion s/p resection //
evaluate for post-operative change
TECHNIQUE: MRI of the head without and with IV contrast
COMPARISON: MRA of the head ___
FINDINGS:
Status post resection of the previously noted right tentorial dural-based mass
lesion.
Postsurgical changes are noted adjacent with small amount of gas and fluid and
blood products.
Small foci of negative susceptibility are noted in the in the right cerebellar
hemisphere, related to blood products.
Increased DWI signal intensity medially in the right cerebellar hemisphere,
can relate to blood products or ischemic/infarction changes. Limited
assessment on diffusion sequences for ischemic changes due to the confounding
effects of blood products.
There is surrounding edema and mass effect on the right side of the fourth
ventricle, similar to the prior CT study.
Linear, slightly irregular enhancement in the right cerebellar hemisphere and
tentorium, can relate to postoperative changes. No obvious nodular component
of enhancement to suggest obvious residual tumor. Assessment can be limited
due to the postoperative changes.
Postsurgical changes are noted in the overlying soft tissues of the right
occipital and upper cervical regions.
Increased signal intensity in the left more than right parietal and temporal
subcutaneous soft tissues of the scalp with swelling with a focal area of
heterogeneous enhancement, can be correlated clinically. (se 11, im 14; se 13,
im 16). This can relate to edema or inflammation with focal
contusion/hematoma.
The lateral and third ventricles and the extra-axial CSF spaces in the
cerebral sulci are unremarkable, without significant change compared to the
preoperative study.
A few small FLAIR hyperintense foci are noted in the cerebral white matter,
nonspecific in appearance.
No abnormal enhancement is noted in these foci.
The major intracranial arterial flow voids are noted on the T2 sequence, left
vertebral artery is diminutive.
The venous sinuses are unremarkable on the routine study.
Near total empty sella.
Tiny cystis focus in the pineal gland.
The craniocervical junction region is otherwise unremarkable.
Mild ethmoidal mucosal thickening.
Small amount of fluid in the mastoid air cells on both sides.
Sphenoid sinus major septation inserts on the left carotid groove.
IMPRESSION:
1. Postsurgical changes, with interval resection of the previously noted
right tentorial dural-based lesion.
Foci of negative susceptibility in the right cerebellar hemisphere can relate
to blood products.
Surrounding edema and mass effect on the fourth ventricle, as before.
Foci of increased DWI signal intensity in the medial aspect of the right
cerebellar hemisphere can relate to blood products or ischemic/infarction
related changes. Limited assessment on diffusion sequences for ischemic
changes due to the confounding effects of blood products. Attention on close
followup
2. Linear, slightly irregular enhancement in the right cerebellar hemisphere
and tentorium, can relate to postoperative changes. No obvious nodular
component of enhancement to suggest obvious residual tumor. Assessment can be
limited due to the postoperative changes.
3. Postsurgical changes are noted in the overlying soft tissues of the right
occipital and upper cervical regions.
Increased signal intensity in the left more than right parietal and temporal
subcutaneous soft tissues of the scalp with swelling with a focal area of
heterogeneous enhancement, can be correlated clinically. (se 11, im 14; se 13,
im 16). This can relate to edema or inflammation with focal
contusion/hematoma.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Right tentorial lesion resection. Evaluate for interval change.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows.
DOSE: DLP: 897.12 mGy-cm
CTDI: 55.04 mGy
COMPARISON: MRI ___, outside hospital MR head ___.
FINDINGS:
Status post right suboccipital craniotomy with resection of previously noted
right tentorial mass. Expected trace fluid and small pneumocephalus, within
expected limits. Trace edema around the resection cavity. Mild effacement of
the fourth ventricle appears similar to preoperative scan.
There is otherwise no intracranial hemorrhage, acute infarction, large mass or
midline shift.
There is no hydrocephalus.
The ventricles and sulci are stable in size and configuration. The basal
cisterns are patent and there is preservation of gray-white matter
differentiation.
The orbits are unremarkable.
The visualized paranasal sinuses, middle ear cavities and mastoid air cells
are clear.
IMPRESSION:
Postoperative changes from right tentorial mass lesion resection, within
expected limits.
No acute findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: NEURO EVAL
Diagnosed with BRAIN CONDITION NOS
temperature: 97.7
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 154.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to ___ Neurosurgery service on
___ for further work-up of his word-finding difficulties and
new right cerebellar lesion. He was started on Decadron due to
noted vasogenic edema noted on his outside hospital MRI.
The patient was admitted to the inpatient ward for close
neurologic monitoring. Neurology was asked to see the patient
due to his word-finding difficulties.
Mr. ___ was consented for surgical resection of his brain
mass on ___. A chest x-ray and pre-operative labs were
ordered, in addition to a MRI wand study.
On ___, The patient went to the operating room for a R
suboccipital craniotomy for tumor resection by Dr ___. The
procedure was tolerated well. The patient was recovered in the
PACU and stayed there overnight. A post operative head Ct was
performed which was consistent with expected post operative
change.
On ___, The patient was in the PACU in the morning. He was
found to be neurologically intact. The patient denies headache
however stated that he had ___ neck pain. The patient was
started on a low dose of muscle relaxant ROBAXIN. Given the
patients excellent neurological exam, the patient was
transferred to the floor. The patient had his post operative
MRI which was consistent with post op changes, and small foci of
blood and edema. In the morning the patient complained of
objects in his vision field moving downward- this occurred ___
days prior to his surgery but went away, the patient's
peripheral vision was intact and the patient remained
neurologically intact on exam. The patient Foley catheter was
discontinued.
On ___, the patient remained neurologically and hemodynamically
intact. He voided without difficulty. He was mobilizing with
nursing and was evaluated by physical therapy who recommended
outpatient ___. His dressing was removed and his incision was
clean dry and intact with sutures. His pain was well managed on
his current pain regimen.
___: cleared by ___, OT says home with direct supervision for
IADLs, dispo planning, re-eval, home OT and outpatient ___ with
___.
___: neuro intact, no dysmetria. d/c home ___, home OT, outpt
___, dex taper. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Malaise, SOB, myalgia, chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ yoM with PMH of CAD s/p CABG, biventricular
pacer, COPD on 2L at home (at night), CKD, asbestosis with known
pleural plaques, AAA s/p repair who presented to the ED with a 4
day history of myalgia, SOB, and dull chest pain. He was in his
usual state of health until ___ day, when he started to
feel tired and achy all over. Per daughter, he began to sleep a
lot and lost his appetite. He states that his cough worsened as
well. He described the cough as productive of white phlegm,
about a tablespoon a day. He says that he was around "a lot of
people" during ___ and might have sat across from someone
who had a cold. Denies nausea, vomiting, diarrhea.
His daughter, ___, states that they went to a ___
clinic on either ___ or ___, where patient was started on
erythromycin. They tried to call his PCP at the ___, but his
previous PCP retired and his new PCP was on vacation.
Patient states that over the past several weeks, he has been
trying to lose weight by eating healthier food. He lives with
his daughter ___, who is his caretaker. A few months ago,
he presented to ___ with dark stools. An EGD was
done, which reportedly showed no bleeding. Per patient's
daughter, they did not do a colonoscopy because of his age and
other medical issues. Neither the patient nor his daughter
remembers whether he got the flu vaccine this year, as he
receives his primary care at the ___.
In the ED, he received 1x dose of azithromycin 500mg iv and
ceftriaxone 1g iv. He also received 500cc of NS bolus. CXR
showed a retrocardiac opacity that may be either atelectasis or
pneumonia.
Labs were notable for Hgb of 9.9, Cr 1.4, and proBNP of 4507.
Upon arrival to the floor, the patient was breathing comfortably
on 2L NC. He states that his appetite has improved since
arriving in the ED. He also thinks that his cough is improving
and his throat is not as sore anymore. He states that at home,
he only uses his oxygen at night. However, he sometimes gets SOB
and light-headed during the day, and this is his baseline.
Past Medical History:
CARDIAC HISTORY
-CAD s/p CABG in ___ SVG -> R-PDA, SVG -> OM1 with skip to D1,
SVG to LAD known to be occluded
- Moderate-Severe AS
- Infarct related cardiomyopathy s/p BiV ICD
- Nonsustained VT
OTHER PAST MEDICAL HISTORY
- Diabetes
- Hypertension
- Dyslipidemia
- Abdominal aortic aneurysm s/p repair
- Asbestos exposure w/ pleural plaques known
- Gout
- GERD
- CKD Stage III
- Bilateral corneal transplant
- Umbilical hernia repair
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission Physical exam:
General: elderly man sitting up, NAD
HEENT: ATNC
CV: harsh systolic murmur with radiation to clavicles
Resp: faint wheezing bilaterally, breathing comfortably on 2L NC
GI: +BS, nontender
Extr: Trace edema bilaterally
Neuro: Alert, oriented, able to answer all questions
appropriately
Pertinent Results:
ADMISSION LABS:
============
___ 02:35PM BLOOD WBC-7.8# RBC-3.20* Hgb-9.9* Hct-32.3*
MCV-101* MCH-30.9 MCHC-30.7* RDW-15.9* RDWSD-58.4* Plt ___
___ 02:35PM BLOOD Neuts-73.3* Lymphs-14.4* Monos-7.6
Eos-4.1 Baso-0.3 Im ___ AbsNeut-5.72# AbsLymp-1.12*
AbsMono-0.59 AbsEos-0.32 AbsBaso-0.02
___ 02:35PM BLOOD Glucose-104* UreaN-51* Creat-1.4* Na-145
K-4.1 Cl-102 HCO3-30 AnGap-13
___ 02:35PM BLOOD CK(CPK)-34*
___ 02:35PM BLOOD CK-MB-2 proBNP-4507*
___ 02:35PM BLOOD cTropnT-<0.01
___ 06:41AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.9
___ 06:41AM BLOOD VitB12-789
___ 02:39PM BLOOD Lactate-1.0
___ 06:41AM BLOOD ___ PTT-26.4 ___
DISCHARGE LABS:
============
___ 06:10AM BLOOD WBC-6.7 RBC-3.21* Hgb-9.6* Hct-31.2*
MCV-97 MCH-29.9 MCHC-30.8* RDW-15.3 RDWSD-54.4* Plt ___
___ 06:10AM BLOOD Glucose-108* UreaN-55* Creat-1.6* Na-145
K-4.3 Cl-106 HCO3-29 AnGap-10
___ 06:10AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.0
MICRO:
=====
___ GRAM STAIN, CULTURE: CONTAMINATED
___ Culture, Routine-PENDING
IMAGES:
=======
CXR ___
1. Interval increased retrocardiac opacity could be left lower
lobe focal pneumonia in the appropriate clinical situation
versus atelectasis.
2. Increased peribronchial wall thickening can be seen with
small airways disease and chronic inflammation.
3. Extensive bilateral pleural plaques.
4. Cardiomegaly without edema or pleural effusion. No evidence
of pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Carvedilol 6.25 mg PO BID
7. Furosemide 60 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lisinopril 10 mg PO DAILY
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QHS
11. Benzonatate 100 mg PO TID
12. Ipratropium Bromide MDI 1 PUFF IH TID
13. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Benzonatate 100 mg PO TID
8. Carvedilol 6.25 mg PO BID
9. Ipratropium Bromide MDI 1 PUFF IH TID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QHS
12. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH BID
13. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until speaking with your primary care
doctor and having your kidney function tested
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Pneumonia
COPD exacerbation
Claudication
Aortic Stenosis
Secondary:
CKD
Chronic diastolic HF
CAD
Angina
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 chest pain. Evaluate for pneumonia or
pneumothorax.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___. Reference is made with a
chest CT dated ___.
FINDINGS:
Left retrocardiac parenchymal opacity is new or more conspicuous since ___ and could be atelectasis and/or pneumonia in the appropriate clinical
setting. Bilateral peribronchovascular thickening, particularly in the
perihilar region and bilateral lower lobes is slightly more pronounced can be
seen with bronchiolar inflammation and small airways disease. Extensive
bilateral calcified pleural plaques are similar to the prior chest CT. No
pleural effusion or pneumothorax.
The patient has a left ACID in place. Median sternotomy wires and mediastinal
clips are unchanged. The heart remains moderate to severely enlarged.
Mediastinal contours are unchanged. Aortic knob calcifications are mild,
unchanged.
Degenerative changes in the bilateral AC joints are severe. Widening of the
right AC joint is similar to the prior exam. Degenerative changes in the
glenohumeral joints are moderate. Coarse calcification of the anterior
longitudinal ligament.
IMPRESSION:
1. Interval increased retrocardiac opacity could be left lower lobe focal
pneumonia in the appropriate clinical situation versus atelectasis.
2. Increased peribronchial wall thickening can be seen with small airways
disease and chronic inflammation.
3. Extensive bilateral pleural plaques.
4. Cardiomegaly without edema or pleural effusion. No evidence of
pneumothorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Cough, ILI
Diagnosed with Pneumonia, unspecified organism
temperature: 97.6
heartrate: 73.0
resprate: 18.0
o2sat: 99.0
sbp: 110.0
dbp: 56.0
level of pain: 6
level of acuity: 3.0 | Mr ___ is a ___ yoM with PMH of CAD s/p CABG, biventricular
pacer, COPD on 2L at home, CKD, asbestosis with known pleural
plaques, AAA s/p repair who presented to the ED with a 4 day
history of myalgia, SOB, and cough. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
low back, left leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with h/o hypertension and herniated lumbar disc with
sciatica x 6 months presents with worsening low back pain
radiating down left leg similar to previous sciatica. Pt
reports overnight was turning in bed and felt "pop" and sudden
onset pain left low back/buttock radiating down lateral leg.
Has had intermittent numbness in left toe but otherwise no
paresthesias or loss of bowel or bladder. Worse with movement.
Has difficulty weight bearing but doesn't feel he has focal
weakness. No fevers or chills. No difficulty urinating,
subjective perianla anesthsia. No trauma. Oxycodone at home gave
minimal relief. Has gotten cortisol injections x2, last one 3
weeks ago. Has trialed NSAIDs, flexiril, and oxycodone at home.
Has not see a specialist yet.
In the ED, he had the following vitals: pain 8, 98.6F, HR68,
BP180/90, RR16, O2 100%RA. EXAM: no TTP along spinous processes,
TTP mid-left buttock musculature, reflexes symmetric, downgoing
babinski's bl,, sensation grossly intact to soft touch, motor-
4+/5 strenght LLE plantar flexion (?limited by pain), normal
perianal sensation and rectal tone. Patient was given 5mg IV
morphine, 5mg morphine sc, oxycodone 10mg PO, and diazepam 5mg.
Plain film L spine done with arthrosis in lumbar and sacral
areas, no subluxation.
Currently, resting in bed in NAD. Family at bedside.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
HTN
Sciatica
Alcohol use
Social History:
___
Family History:
No significant family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.3F, BP 170/83, HR 64, R 18, O2-sat 98% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, slightly dry MM,
OP clear
NECK - supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, unable to
elicit DTRs in bilateral LEs. Toes downgoing. Straight leg raise
mildly positive in left leg. No saddle anesthesia
DISCHARGE PHYSICAL EXAM:
unchanged
Pertinent Results:
LABS:
On admission:
___ 03:05PM BLOOD WBC-8.1 RBC-4.50* Hgb-14.9 Hct-42.8
MCV-95 MCH-33.1* MCHC-34.7 RDW-12.8 Plt ___
___ 03:05PM BLOOD Neuts-79.1* Lymphs-13.1* Monos-4.8
Eos-2.4 Baso-0.6
___ 03:05PM BLOOD Glucose-115* UreaN-26* Creat-0.8 Na-140
K-4.5 Cl-104 HCO3-23 AnGap-18
MICRO:
none
IMAGING:
___ Lumbo-sacral xray:
FINDINGS: Frontal and lateral views of the lumbar spine were
obtained. Five non-rib-bearing vertebral bodies are identified.
No fracture is present and vertebral body heights are
preserved. Multilevel lumbar spine degenerative changes are
present, most severe at L4-5 and L5-S1, with moderate-to-severe
facet arthrosis. No alignment abnormality. No focal lytic or
sclerotic lesion. Chain sutures are present in the right lower
quadrant.
IMPRESSION: Multilevel degenerative change, worst in lower
lumbar spine.
___ MRI Lumbar Spine:
IMPRESSION: Underlying dextroscoliosis with associated
alignment
abnormalities, as well as congenitally abnormal spinal canal
geometry and
prominent epidural lipomatosis, result in:
1. L4-L5: Most severe spinal canal and left more than right
subarticular
zone stenosis with traversing L5 neural impingement; bilateral
neural
foraminal stenosis with exiting L4 neural impingement.
2. L3-L4: Multifactorial moderate canal stenosis with central
crowding of
the traversing nerve roots; right more than left neural
foraminal stenosis
with possible impingement upon the exiting right L3 nerve root.
3. L5-S1: Grade 1 anterolisthesis, likely spondylolytic, with
bilateral
neural foraminal narrowing and possible exiting L5 neural
impingement, left
more than right.
4. T11-T12: Disc degeneration with right paracentral/proximal
foraminal
protrusion which may impinge upon the exiting right T11 nerve
root,
incompletely imaged.
COMMENT: Given the numerous findings, close correlation should
be made with the nature, level and side of the patient's
symptoms. In addition, comparison with any previous (outside)
MR imaging study would be helpful.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Ibuprofen 800 mg PO Q8H
2. Lisinopril 10 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
4. Indomethacin 50 mg PO TID
Discharge Medications:
1. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
2. Lisinopril 20 mg PO DAILY
Hold for SBP <110
RX *lisinopril 10 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
Hold for RR <12 or sedation
RX *oxycodone 5 mg 2 tablet(s) by mouth every 6 hours Disp #*30
Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*120 Tablet Refills:*0
5. Outpatient Physical Therapy
722.1 Displacement of thoracic or lumbar intervertebral disc
without myelopathy
Evaluate and treat for lumbar radiculopathy from degenerative
disc disease with disc herniation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
L5 lumbar radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with lower back pain and radiculopathy.
Evaluate for compression fracture.
COMPARISONS: None.
FINDINGS: Frontal and lateral views of the lumbar spine were obtained. Five
non-rib-bearing vertebral bodies are identified. No fracture is present and
vertebral body heights are preserved. Multilevel lumbar spine degenerative
changes are present, most severe at L4-5 and L5-S1, with moderate-to-severe
facet arthrosis. No alignment abnormality. No focal lytic or sclerotic
lesion. Chain sutures are present in the right lower quadrant.
IMPRESSION: Multilevel degenerative change, worst in lower lumbar spine.
Radiology Report
MR EXAMINATION OF LUMBAR SPINE WITHOUT CONTRAST, ___
HISTORY: ___ male with severe left back pain and radicular symptoms
"down the left leg," and "MRI (six months ago) with herniated discs and
stenosis, of unknown degree"; now with acute worsening (symptoms).
TECHNIQUE: Routine ___ non-enhanced MR examination with supplemental
sagittal STIR FSE sequence.
FINDINGS: The reported OSH MR examination has not been obtained and uploaded
to ___ for comparison.
The sagittal STIR sequence is essentially unremarkable, with no finding to
suggest acute vertebral compression injury. Other than a small right
parapelvic cyst, the included paraspinal soft tissues are grossly
unremarkable. Note that there is no significant fatty atrophy of the
paraspinal musculature. The distal spinal cord is normal in caliber and
intrinsic signal intensity, as is the conus medullaris, which is normal in
morphology and terminates at the mid-S1 level.
As on the recent radiographs of ___, there is a slight lumbar dextroscoliosis
with associated minimal retrolisthesis of L3 on L4 and L4 on L5. The lumbar
vertebrae are normal in height and demonstrate somewhat heterogeneous T1- and
T2-hypointensity.
There is multilevel degenerative disc, endplate and facet joint disease, as
follows:
There is degeneration of the T11-T12 disc, with a small right
paracentral/proximal foraminal protrusion which may impinge upon the exiting
right T11 nerve root; this is incompletely imaged, only in the sagittal plane.
The T12-L1 and L1-L2 discs are preserved in height and signal intensity with
normal intranuclear clefts and no significant bulge or focal herniation.
The L2-L3 disc is also preserved in height and signal intensity with mild
bulging, but no significant canal or foraminal compromise.
There is more marked degeneration of the L3-L4 disc with vacuum phenomenon and
mild-moderate bulging, eccentric to the right. There is a superimposed anular
tear with accompanying protrusion. In combination with facet arthropathy and
prominent dorsal epidural fat, and superimposed on congenitally short
pedicles, this results in relative central crowding of the traversing nerve
roots with loss of the normal CSF-signal within the thecal sac (2:11, 5:12).
There is also caudal narrowing of the neural foramina, right more than left,
with likely impingement upon the exiting right L3 nerve root.
There is marked degeneration of the L4-L5 disc with ___ type 2 change in the
adjacent vertebral endplates. There is moderately severe bulging with a
superimposed broad-based central/left paracentral disc protrusion measuring
roughly 11 mm (AP). In combination with the above factors, as well as
congenitally narrow intralaminal angle, this again results in relatively
severe canal stenosis and impingement upon the traversing L5 nerve roots in
the subarticular zones. There is also severe bilateral neural foraminal
narrowing with likely impingement upon the exiting L4 nerve roots.
There is grade 1 anterolisthesis of L5 on S1, which appears related to
bilateral spondylolysis, with expected relative widening of the AP dimension
of the spinal canal. However, the redundant anulus and "rolled disc," in
addition to L5 inferior endplate spondylosis, produces expected narrowing of
both neural foramina with possible impingement upon the exiting L5 nerve
roots, left more than right. There is also contact with the traversing S1
nerve roots in the subarticular zones.
IMPRESSION: Underlying dextroscoliosis with associated alignment
abnormalities, as well as congenitally abnormal spinal canal geometry and
prominent epidural lipomatosis, result in:
1. L4-L5: Most severe spinal canal and left more than right subarticular
zone stenosis with traversing L5 neural impingement; bilateral neural
foraminal stenosis with exiting L4 neural impingement.
2. L3-L4: Multifactorial moderate canal stenosis with central crowding of
the traversing nerve roots; right more than left neural foraminal stenosis
with possible impingement upon the exiting right L3 nerve root.
3. L5-S1: Grade 1 anterolisthesis, likely spondylolytic, with bilateral
neural foraminal narrowing and possible exiting L5 neural impingement, left
more than right.
4. T11-T12: Disc degeneration with right paracentral/proximal foraminal
protrusion which may impinge upon the exiting right T11 nerve root,
incompletely imaged.
COMMENT: Given the numerous findings, close correlation should be made with
the nature, level and side of the patient's symptoms. In addition, comparison
with any previous (outside) MR imaging study would be helpful.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BACK PAIN
Diagnosed with SCIATICA
temperature: 98.6
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 180.0
dbp: 90.0
level of pain: 8
level of acuity: 3.0 | ___ yo M with h/o hypertension and herniated lumbar disc with
sciatica x 6 months presents with worsening low back pain
radiating down left leg similar to previous sciatica.
# Lumbar radiculopathy: History and exam consistent with
exacerbation of known herniated disc leading to worsening
radicular pain down left leg. No evidence of cord compression
or cauda equina on exam. Xray did not show any bony
deformities. MRI confirmed severe degenerative disc disease with
lumbar disc herniation resulting in multilevel moderate to
severe spinal stenosis and nerve impingement, worst at left L5
(consistent with symptoms). His pain was fairly well-controlled
with standing tylenol and ibuprofen with PRN oxycodone, so he
was discharged on this regimen for pain control. He was
encouraged to continue physical therapy and establish care with
an orthopedic spine specialist for further evaluation and care.
# Hypertension: increased lisinopril to 20mg daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
amino acids
Attending: ___.
Chief Complaint:
admission for expedited stroke workup
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ right-handed man with past medical
history significant for Hodgkin's lymphoma diagnosed in ___
with
recurrences later that year in ___ and ___. He is status post
full body radiation in ___ and a bone marrow transplant in ___
followed by another round of radiation. He then developed
squamous cell carcinoma of the left mandible requiring modified
radical neck dissection with resection of the left posterior
mandible followed by a third radiation treatment. He presented
to neurology clinic last week after CT earlier this year showed
evidence of a frontal stroke.
Earlier today, Mr ___ called the clinic to report several
concerning episodes over the weekend. On ___, around noon
he
had 30- 60min of right hand numbness. He has had this sensation
before (maybe ~6x in his life). Occasionally, it has been
associated with weakness where he is unable to keep the hand
lifted up. This time, it was associated with numbness of all the
fingers as well as the palm but no weakness. He also reports a
frontal headache around this time that he treated with Tylenol.
At 3pm, he developed dysarthric speech. He knew what he wanted
to
say but the words coming out did not sound like the words he was
trying to say. His wife was unable to understand what he was
trying to say until he repeated it several times. This
completely
resolved within an hour. It was not associated with any other
weakness, numbness, visual problems, or vertigo. Yesterday, he
had a additional episode of right hand numbness (no weakness)
lasting ___ minutes. He reports that he is currently back to
his baseline. He denies any recent illnesses, infections,
intoxications that could explain his symptoms. He had a full
stoke workup ordered as an outpatient (scheduled to get MRI/MRA
head and neck, carotid ultrasounds next ___, a week from
today) but because of these recent episodes, he was instructed
to
come to the ED for admission and expedited workup.
The patient had a long and complicated medical history since his
diagnosis of Hodgkin's when he was ___ most significant for bone
marrow transplant and whole body radiation x 3. mmediately
after the bone marrow transplant, secondary to immunosuppression
medications, he developed chronic kidney disease. This
progressed
into fulminant renal failure earlier this year (the exact cause
unknown) requiring the placement of a peritoneal dialysis
catheter in ___. During the time of his kidney
failure, he developed severe generalized sharp headaches focused
behind his eyes that would last approximately four hours a day
but were relatively well treated with Tylenol and Percocet.
Those
headaches have since resolved as his metabolic and electrolyte
disturbances have normalized with the use of the PD catheter.
Earlier this year, in order to workup the severe headaches, he
underwent a CT scan which showed a hypodensity in the left
frontal region. On further questioning, he remembers having a
facial droop in ___ that lasted about a month. In addition, he
and his wife describe an episode of an abnormal heart rhythm
during his hospitalization in ___ as SVT) which was
associated with negative CE and unchanged EKG. During that
hospitalization, he had CT Head which did not show the lesion
leading us to believe that it occurred some time in the last
___ years although we are unable to determine a more exact
date. He comes to clinic today for recommendations for further
workup of this finding as well as secondary prevention
recommendations.
Review of Systems: Positive for headaches earlier this year
which have almost entirely resolved, generalized numbness and
weakness which has since resolved; chronic muscle cramps; easy
fatigability; vertigo/nausea with any abrupt changes in his PD
catheter which has since resolved; chronic speaking and
swallowing difficulties related to his radical neck dissection;
chronic insomnia; difficulty with maintaining his weight since
his initial diagnosis. He denies loss of vision, blurred
vision,
diplopia, hearing difficulty. He reports difficulty of gait
secondary to his gout.
On general review of systems, he denies recent fever or chills.
No night sweats. Denies cough, shortness of breath, chest pain,
tightness, palpitations. Had intermittent nausea and vomiting
with his headaches and when his PD catheter malfunctions, but
otherwise this seems to have resolved. Chronic myalgias since
his bone marrow transplant.
Past Medical History:
Past Medical History:
- Hodgkin's lymphoma dx ___
- status post allogenic bone marrow transplant ___
- asplenic
- basal cell carcinoma
- squamous cell carcinoma
- hyperlipidemia
- history of orthostatic hypotension especially for several
months following the radical neck dissection (___)
- chronic renal failure now requiring peritoneal dialysis
- chronic graft-versus-host disease
Past Surgical History:
- squamous cell carcinoma status post radical neck dissection
(___)
- bilateral hip replacement due to chronic osteonecrosis
secondary to long-term prednisone use
- splenectomy in ___
- numerous skin biopsies and resections for basal cell carcinoma
- the placement of peritoneal dialysis catheter in ___.
Social History:
___
Family History:
His mother passed away at ___ from cervical
cancer. His father is alive at ___ with dementia and prostate
cancer. He has three sisters at ___, ___, ___ with ovarian cancer,
arthritis, COPD. He has two brothers at ___ and ___ with
hypertension and heart disease. He has three adopted children.
A ___ daughter who is healthy, a ___ son with
mental health issues and a son who passed away ___ from an
overdose.
Physical Exam:
ADMISSION EXAM:
T 97.8; HR 80; BP 137/118; RR 18 SpO2 100% RA
General: Cachechtic, pleasant man sitting up in NAD.
HEENT: Normocephalic. Post-surgical changes over left jaw,
post-surgical tongue with minimal range of movement.
Neck: Supple.
Pulmonary: Normal work of breathing on room air. Vesicular
breath
sounds bilaterally, no wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, RRR, no M/R/G.
Abdomen: Surgical scars and peritoneal dialysis catheter noted.
Soft, nontender, nondistended.
Extremities: No lower extremity edema
Skin: Wound over left great toe.
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive to ___ backwards.
Able to relate history without difficulty. Recalls what he had
for breakfast. Language is fluent, intact to repetition,
comprehension, naming high and low frequency objects. There was
mild dysarthria, ligual and labial most prominent. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation. Could not appreciate fundi.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch and temperature in all
distributions.
VII: R nasolabial fold flattening, but activation is symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. (the structure of the
palatal arch appears somewhat altered ?postsurgical? but
excursion is full and symmetric)
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes minimally due to post-surgical changes.
-Motor: Normal bulk, increased tone throughout. R pronation
without drift. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ 4+ ___ 5 5 5 5
R ___ ___ 4+ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
- Plantar response was withdrawal on the left, extensor on the
right.
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, or proprioception in upper extremities. Vibration sense
decreased at the great toes bilaterally (6s), temperature
decreased below the ankle. Proprioception intact. No extinction
to DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Antalgic, favoring left knee and ankle.
Gait is slightly wide-based, normal stride and arm swing.
Romberg
absent.
DISCHARGE EXAM:
MS: alert and oriented x3, intact fluency and comprehension
CN: pupils reactive bilaterally, eomi, intact light touch and
facial strength bilaterally, vfftc, no visual extinction
Motor: ___ strength of all four ext.
Sensory: intact light touch and pp of all four ext.
Reflexes: left toe down, right toe up
Coord: intact fnf bilaterally
Pertinent Results:
ADMISSION LABS:
___ 08:52PM BLOOD WBC-7.0 RBC-3.43* Hgb-9.8* Hct-31.5*
MCV-92 MCH-28.6 MCHC-31.1* RDW-15.8* RDWSD-52.2* Plt ___
___ 08:52PM BLOOD Neuts-65.1 ___ Monos-8.0 Eos-1.7
Baso-0.4 Im ___ AbsNeut-4.53 AbsLymp-1.71 AbsMono-0.56
AbsEos-0.12 AbsBaso-0.03
___ 08:52PM BLOOD ___ PTT-30.3 ___
___ 08:52PM BLOOD Glucose-79 UreaN-50* Creat-8.1* Na-139
K-5.4* Cl-98 HCO3-29 AnGap-17
___ 08:52PM BLOOD ALT-10 AST-17 AlkPhos-120 TotBili-0.1
___ 07:00AM BLOOD Calcium-7.6* Phos-5.6* Mg-1.5*
Stroke Risk Factors:
Cholest-182 Triglyc-100 HDL-45 CHOL/HD-4.0 LDLcalc-117
T4-5.0
%HbA1c-5.3 eAG-105
Imaging:
MRI Brain w/wo
IMPRESSION:
1. Small cortical acute to early subacute infarction in the
inferior left
parietal lobe extending to the parieto-occipital sulcus.
2. Confluent elevated T2 signal in the deep and periventricular
white matter of the cerebral hemispheres is compatible with
sequela of chronic small vessel ischemic disease, prior
medication toxicity, or prior brain radiation.
3. Linear foci of mildly high signal on the diffusion tracer
sequence in the posterior frontal centrum semiovale, more
conspicuous on the right than left, without associated signal
abnormality on the ADC map, most likely represent T2 shine
through, and less likely subacute infarcts.
4. Small area of encephalomalacia and gliosis in the superior
left frontal lobe at the site of a prior hematoma, with several
prominent adjacent superficial veins. Diagnostic considerations
include prior hemorrhage which may be secondary to amyloid
angiopathy or an underlying vascular malformation. No clear
evidence for an underlying cavernous malformation is seen. This
area is not included in the field of view of the MRA.
5. Left greater than right internal carotid artery origin
atherosclerosis
without evidence for flow-limiting stenosis by NASCET criteria.
6. No evidence for occlusion or flow-limiting stenosis of the
major
intracranial arteries.
7. 7 mm fusiform dilatation of the cavernous right internal
carotid artery. No evidence for a saccular aneurysm.
CTA Head/Neck ___:
IMPRESSION:
1. No acute intracranial pathology.
2. 8 mm fusiform aneurysm of the right ICA cavernous segment. 6
mm fusiform aneurysm of the left ICA cavernous segment. No
saccular aneurysms.
3. No significant stenosis of the extracranial circulation.
4. Post radiation changes the right lung with small bilateral
pleural
effusions. Multiple biapical lung nodules, better visualized on
the prior dedicated CT chest.
5. A 1 cm left thyroid nodule for which a dedicated thyroid
ultrasound can be performed.
Carotid ultrasound ___:
IMPRESSION:
Bilateral mild heterogeneous atherosclerotic plaque in the ICAs
resulting in less than 40% stenosis on both sides.
Echocardiogram ___
Conclusions:
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. There is mild global
left ventricular hypokinesis (LVEF = 45-50 %). No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. Right ventricular chamber size is normal. with
borderline normal free wall function. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. No masses or vegetations are
seen on the aortic valve. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild to moderate (___) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___, the
LVEF has decreased.
MRI Cervical Spine ___:
IMPRESSION:
Mild cervical degenerative disease. Mild to moderate left C2-3
neural foraminal narrowing. No spinal canal narrowing. Normal
appearance of the spinal cord.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Nystatin 100,000 UNIT PO Q8H
4. Lanthanum 1000 mg PO TID W/MEALS
5. Calcitriol 0.25 mcg PO 3X/WEEK (___)
6. Fluconazole 200 mg PO 2X/WEEK (MO,TH)
Discharge Medications:
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Calcitriol 0.25 mcg PO 3X/WEEK (___)
3. Lanthanum 1000 mg PO TID W/MEALS
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
7. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
8. Fluconazole 200 mg PO 2X/WEEK (MO,TH)
9. Nystatin 100,000 UNIT PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE ISCHEMIC STROKE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with history of Hodgkins lymphoma diagnosed in
___ with recurrence in ___, status post fall body radiation in ___ and bone
marrow transplant with additional radiation in ___. Also history of squamous
cell carcinoma of the left mandible status post modified radical neck
dissection in ___ and radiation. Now the patient demonstrates a left frontal
hypodensity on head CT and TIA-like events, including slurred speech and right
arm numbness which brought the patient to the emergency department on ___. Please evaluate for vessel stenosis or cutoff. Please evaluate
for infarct.
TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo,
and diffusion-weighted images of the brain were obtained. 3D time-of-flight
MRA of the brain was obtained with multiplanar maximum intensity projection
angiographic reformatted images. 2D time-of-flight MRA of the neck was
obtained with multiplanar maximal intensity projection angiographic
reformatted images. This report is based on interpretation of all of the
above images.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
BRAIN MRI: There is a small cortical focus of slow diffusion in the inferior
left parietal lobe extending to the parieto-occipital sulcus, images 13 and 14
of series 404 and 402. There is corresponding high signal on FLAIR images.
There is no evidence for associated blood products on gradient echo images.
In the centrum semiovale of bilateral posterior frontal lobes, there are
linear foci of mildly high signal on the diffusion tracer sequence, more
conspicuous on the right than left, without corresponding signal abnormality
on the ADC map. FLAIR and T2 weighted images demonstrate confluent high
signal in the centrum semiovale, corona radiata, other deep white matter, and
periventricular white matter of the cerebral hemispheres, nonspecific but
compatible with sequela of chronic small vessel ischemic disease, prior
medication toxicity or prior brain radiation. In the setting, the mild signal
abnormalities in the centrum semiovale on the diffusion tracer sequence are
most likely related to T2 shine through, and less likely subacute infarcts.
In the left middle frontal gyrus bordering the superior frontal gyrus, there
is a small area of encephalomalacia with adjacent gliosis, which demonstrates
extensive low signal on gradient echo images. There are several adjacent
prominent superficial veins with preserved flow voids. Diagnostic
considerations include prior hemorrhage which may be secondary to amyloid
angiopathy or an underlying vascular malformation. No clear evidence for an
underlying cavernous malformation is seen. Prior ischemic infarction with
hemorrhagic transformation is less likely.
There is mild parenchymal volume loss with associated prominence of the
ventricles and sulci.
There is mild partial bilateral mastoid air cell opacification.
There is evidence of left lens replacement.
NECK MRA: The aortic arch is not included on the 2D time-of-flight images.
2D time-of-flight technique limits evaluation of minimal stenoses due to
stepping artifact. There are filling defects at the origins of bilateral
internal carotid arteries, left greater than right, without evidence for
flow-limiting stenosis by NASCET criteria. Visualized portions of bilateral
vertebral arteries appear patent. Left vertebral artery is dominant.
BRAIN MRA: There is ___ termination of the non dominant right vertebral
artery without evidence for flow-limiting stenosis. Left vertebral artery,
basilar artery, internal carotid arteries, and their major branches appear
patent without evidence for flow-limiting stenosis. Cavernous right internal
carotid artery demonstrates fusiform dilatation measuring 7 mm. There is no
evidence for a saccular aneurysm.
The area of prior hematoma in the superior left frontal lobe is not included
in the field of view of the MRA.
IMPRESSION:
1. Small cortical acute to early subacute infarction in the inferior left
parietal lobe extending to the parieto-occipital sulcus.
2. Confluent elevated T2 signal in the deep and periventricular white matter
of the cerebral hemispheres is compatible with sequela of chronic small vessel
ischemic disease, prior medication toxicity, or prior brain radiation.
3. Linear foci of mildly high signal on the diffusion tracer sequence in the
posterior frontal centrum semiovale, more conspicuous on the right than left,
without associated signal abnormality on the ADC map, most likely represent T2
shine through, and less likely subacute infarcts.
4. Small area of encephalomalacia and gliosis in the superior left frontal
lobe at the site of a prior hematoma, with several prominent adjacent
superficial veins. Diagnostic considerations include prior hemorrhage which
may be secondary to amyloid angiopathy or an underlying vascular malformation.
No clear evidence for an underlying cavernous malformation is seen. This area
is not included in the field of view of the MRA.
5. Left greater than right internal carotid artery origin atherosclerosis
without evidence for flow-limiting stenosis by NASCET criteria.
6. No evidence for occlusion or flow-limiting stenosis of the major
intracranial arteries.
7. 7 mm fusiform dilatation of the cavernous right internal carotid artery.
No evidence for a saccular aneurysm.
RECOMMENDATION(S): Recommend CTA of the head to exclude an arteriovenous
malformation in the superior left frontal lobe.
NOTIFICATION: The findings and recommendations were discussed by Dr. ___
with Dr. ___ on the telephone on ___ at 10:21.
Radiology Report
EXAMINATION: MRI CERVICAL SPINE WITHOUT CONTRAST
INDICATION: ___ year old man with history of Hodgkins lymphoma diagnosed in
___ with recurrence in ___, status post fall body radiation in ___ and bone
marrow transplant with additional radiation in ___. Also history of squamous
cell carcinoma of the left mandible status post modified radical neck
dissection in ___ and radiation. Now the patient demonstrates a left frontal
hypodensity on head CT obtained for evaluation of TIA-like events, including
slurred speech and right arm numbness which brought the patient to the
emergency department on ___. Please evaluate for for myelopathy.
TECHNIQUE: Sagittal T1 weighted, T2 weighted, and fat suppressed T2 weighted
images of the cervical spine with axial gradient echo and T2 weighted images.
COMPARISON: Concurrent brain MRI/ MRA and neck MRA from ___ is
reported separately. Neck CT without contrast from ___ is
available for correlation.
FINDINGS:
No concerning bone marrow signal abnormalities are seen. Vertebral body
heights are preserved. Alignment is normal.
The cerebellar tonsils are normally positioned. Concurrent brain MRI is
reported separately.
The cervical and included upper thoracic spinal cord demonstrates normal
morphology and signal intensity.
C2-3: Mild to moderate left neural foraminal narrowing by uncovertebral
osteophytes. No spinal canal narrowing.
C3-4: Small bilateral uncovertebral osteophytes. Minimal left neural
foraminal narrowing. No spinal canal narrowing.
C4-5: No spinal canal or neural foraminal narrowing.
C5-6: Shallow broad-based central disc protrusion without spinal canal or
neural foraminal narrowing.
C6-7: A shallow left paracentral disc protrusion. Tiny bilateral
uncovertebral osteophytes. No spinal canal or neural foraminal narrowing.
C7-T1: No spinal canal or neural foraminal narrowing.
This exam is not tailored for evaluation of the partially included soft
tissues of the neck. There are changes related to prior left neck dissection
in radiation. Plaque is seen at the common carotid arterial bifurcations,
left greater than right. Concurrent neck MRA is reported separately.
IMPRESSION:
Mild cervical degenerative disease. Mild to moderate left C2-3 neural
foraminal narrowing. No spinal canal narrowing. Normal appearance of the
spinal cord.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with history of head/neck radiation presenting
with multpiple TIAs and CT scan concerning for L frontal infarct. Please
evaluate carotids.
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
The right carotid vasculature has mild heterogeneous atherosclerotic plaque in
the ICA and the CCA.
The peak systolic velocity in the right common carotid artery is 75 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 56, 81, and 57 cm/sec, respectively. The peak end diastolic
velocity in the right internal carotid artery is 30 cm/sec.
The ICA/CCA ratio is 1.0.
The external carotid artery has peak systolic velocity of 105 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild heterogeneous atherosclerotic plaque in
the ICA and the ECA.
The peak systolic velocity in the left common carotid artery is 78 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 96, 88, and 84 cm/sec, respectively. The peak end diastolic
velocity in the left internal carotid artery is 38 cm/sec.
The ICA/CCA ratio is 1.2.
The external carotid artery has peak systolic velocity of 62 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Bilateral mild heterogeneous atherosclerotic plaque in the ICAs resulting in
less than 40% stenosis on both sides.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ year old male status post radiation with episodes of hand
numbness concerning stroke. Evaluate for infarct.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque350 intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
5) Spiral Acquisition 5.2 s, 41.2 cm; CTDIvol = 32.1 mGy (Head) DLP =
1,321.7 mGy-cm.
Total DLP (Head) = 2,249 mGy-cm.
COMPARISON: CT head from ___ and CT chest from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
No intra or extra-axial hemorrhage, mass effect, or shift of normally midline
structures. Small the moderate chronic infarct in the left frontal lobe.
Small focus of low attenuation beneath the left basal ganglia likely
represents a prominent perivascular space versus chronic lacunar infarct.
Mild low attenuation in the periventricular white matter is nonspecific, but
likely relates to chronic microangiopathic ischemia. No CT evidence for
acute, major vascular territorial infarction. Mild prominence of the
ventricles, sulci, and cisterns appears proportional.
Left lens replacement. Dental implants with partial erosion of the mandibular
condyles. \
CTA HEAD: Fusiform aneurysm arise involving the right ICA cavernous segment,
measuring up to 8 mm, compared with 5 mm in the proximal petrous segment.
Mild fusiform dilatation of the left ICA cavernous segment measuring up to 6
mm, compared with 5 mm more proximally. Otherwise, bilateral intracranial
internal carotid arteries, middle cerebral arteries, and anterior cerebral
arteries enhance normally. The anterior communicating artery is patent.
Small right posterior communicating artery. Left posterior communicating
artery is either absent or hypoplastic.
Left vertebral artery is dominant. Right vertebral artery largely terminates
as the right posterior inferior cerebellar artery. Basilar artery, visualized
cerebellar arteries, and posterior cerebral arteries enhance normally.
CTA NECK: Mild to moderate calcified atherosclerotic plaque surrounds the
right carotid bifurcation. The right common, internal, and external carotid
arteries otherwise enhance normally.
Moderate calcified atherosclerotic plaque surrounds the left carotid
bifurcation. Mild narrowing of the left ICA origin. The left common,
internal, and external carotid arteries otherwise enhance normally.
The vertebral arteries enhance normally. The left vertebral artery is
dominant.
3 vessel arch configuration.
OTHER: There are small partially visualized bilateral pleural effusions.
There is a stable right upper lobe lung nodule measuring 6 x 5 mm, series 5,
image 29. An additional 1 cm right upper lobe nodule with central
hypoattenuation is seen, slightly more prominent in comparison to the prior
CT. There is a right upper lobe pleural parenchymal scarring with associated
bronchiectasis. Debris is seen within the trachea. A stable 0.5 cm left
upper lobe lung nodule is seen, series 5, image 33. A 1 cm left thyroid
nodule is seen.
IMPRESSION:
1. No acute intracranial pathology.
2. 8 mm fusiform aneurysm of the right ICA cavernous segment. 6 mm fusiform
aneurysm of the left ICA cavernous segment. No saccular aneurysms.
3. No significant stenosis of the extracranial circulation.
4. Post radiation changes the right lung with small bilateral pleural
effusions. Multiple biapical lung nodules, better visualized on the prior
dedicated CT chest.
5. A 1 cm left thyroid nodule for which a dedicated thyroid ultrasound can be
performed.
RECOMMENDATION(S): Nonurgent thyroid ultrasound.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Arm numbness, Slurred speech
Diagnosed with TRANS CEREB ISCHEMIA NOS
temperature: 97.8
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 118.0
level of pain: 0
level of acuity: 2.0 | He was admitted for dysarthria and Right hand numbness. His MRI
notable for a punctate infarct in L parietal lobe, small vessel
ischemic changes. CTA and US notable for atherosclerosis, <40%
stenosis. His stroke risk factors were evaluated and notable for
history of radiation, A1c (5.3%)/LDL (117)/ Echo: no PFO/ASD,
normal EF. He was started on ASA 81, Atorvastatin and Norvasc
for BP control. Renal following for PD. ___ cleared for home
no services. He was set up with a holter to monitor for pAFIb.
He was discharged home.
Transitional issues:
- ___ of ___ Holter
========================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 117) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine / Restoril / Demerol / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o dementia on asa 81, no other anticoagulation,
transferred with questionable traumatic SAH s/p unwitnessed fall
today. Pt is delirious and cannot provide history. Per ___ note,
pt lives with family, found down. Initial eval showed normal
EKG, troponins negative. Vitals benign exam non focal Labs
notable for cr 2.0 (unk baseline), negative troponin. CT head
with bilateral frontal intraparenchymal calcifications but
negative for hemorrhage.
___ RN NOTE and corroborated by HCP:
Pt was discharged from ___ on ___ after admission
for AMS. Pt had wandered to neighbors house who called police
and per daughter w/u was negative. Followed at home by ___
___ last home visit was ___ and has declined at home over this
weekend with generalized weakness and c/o of her back/neck/knee
pain which is chronic. Fell at home and was estimated to be on
the floor for appx 30 min. Pt was ambulatory up until ___
and has been having decreased PO's for several days.
In the ___, initial vitals were: 98.4 80 125/72 16 97% 2L NC.
Initial Labs were largely unremarkable and showed WBC 10.9,
Hgb/Hct 11.2/35.1, Plt 245, U/A negative leuks/negative
nitrites, few bacteria, BUN/Cr 47/1.9. A CK was eelvated to 632
and downtrended to ___ s/p 2L NS bolus. Lactate was WNL at 1.6
and trop < 0.01. Pt given IV Haloperidol 1 mg for delirium.
Imaging CT head w/o contrast: Stable bifrontal intraparenchymal
hemorrhage without appreciable mass effect. No fracture is
identified.; CXR was negative for acute cardiopulmonary process.
Left knee xray was negative for fracture or dislocation.
On the floor, pt is NAD but AOx0. Pt's HCP daughter is present
and corroborates ___ story. Pt is purported to be off her
baseline in terms of mental status. Pt denies any fevers,
chills, chest pain, dyspnea, abd pain, nausea, vomiting,
diarrhea, dysuria.
Past Medical History:
1. HTN - poorly controlled
2. Depression
3. Hyperlipidemia
4. Frequent falls
5. Arthritis - needs knee replacements but hold due to poor BP
control
6. s/p hysterectomy
7. GERD
8. Vertigo
9. Essential tremor
10. s/p L cataract repair - awaiting R side to be repaired as
well.
11. Insomnia
12. Anxiety
Social History:
___
Family History:
Daughter died of likely metastatic breast cancer in her ___.
Physical Exam:
ADMISSION:
Vital Signs: 98.3 138/68 84 18 98% RA
General: Alert, AOx0, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
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:
98.6 160/67-191/76 ___ 18 95% RA
GEN: AOx1, sad, in tears, poor eye contact
HEENT: atruamatic, conjunctiva pink, sclera anicteric, MMM
NECK: supple, FROM, no LAD, JVP<10
CV: RRR, no m/r/g
LUNG: CTAP b/l
ABD: benign
EXT: wwp, no c/c/e
NEURO: grossly intact, cognition impaired, insight poor
Pertinent Results:
ADMISSION:
___ 11:41PM BLOOD WBC-10.8 RBC-3.81* Hgb-11.2* Hct-35.1*
MCV-92 MCH-29.5 MCHC-32.0 RDW-12.5 Plt ___
___ 11:41PM BLOOD Neuts-79.8* Lymphs-11.7* Monos-7.4
Eos-0.9 Baso-0.3
___ 11:41PM BLOOD Plt ___
___ 11:41PM BLOOD Glucose-170* UreaN-47* Creat-1.9* Na-145
K-4.4 Cl-104 HCO3-21* AnGap-24*
___ 11:41PM BLOOD CK(CPK)-632*
___ 11:41PM BLOOD cTropnT-<0.01
___ 07:45AM BLOOD cTropnT-<0.01
___ 11:54PM BLOOD Lactate-1.6
DISCHARGE:
___ 07:23AM BLOOD WBC-5.5 RBC-3.51* Hgb-10.6* Hct-31.4*
MCV-90 MCH-30.2 MCHC-33.7 RDW-12.7 Plt ___
___ 07:23AM BLOOD Plt ___
___ 07:23AM BLOOD Glucose-120* UreaN-24* Creat-1.1 Na-143
K-4.0 Cl-112* HCO3-21* AnGap-14
___ 07:23AM BLOOD ALT-103* AST-73* CK(CPK)-207*
AlkPhos-140* TotBili-0.3
___ 07:23AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.8
___ 06:30AM BLOOD calTIBC-185* Ferritn-209* TRF-142*
___ 06:30AM BLOOD TSH-0.67
CT HEAD W/O CONTRAST:
IMPRESSION:
Stable bifrontal subcortical calcification. No fracture is
identified. Note that there is no evidence of hemorrhage.
NOTIFICATION: A revised report indicating with the frontal lobe
hyperintensities are calcification rather than acute hemorrhage
for was
discussed by telephone by Dr. ___ with the attending
covering the ___ at 09:40 on ___
CXR: no acute cardiopulmonary process
KNEE PLAIN FILM:
IMPRESSION:
No acute fracture or dislocation. Moderate tricompartmental
osteoarthritis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Lorazepam 1 mg PO TID
4. Venlafaxine XR 75 mg PO BID
5. Losartan Potassium 100 mg PO DAILY
6. HydrALAzine 25 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Simvastatin 40 mg PO QPM
9. Zolpidem Tartrate 10 mg PO QHS
10. Omeprazole 20 mg PO BID
11. OxycoDONE (Immediate Release) 10 mg PO Q6H
12. Gabapentin 100 mg PO TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 100 mg PO BID
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. HydrALAzine 25 mg PO BID
4. Lorazepam 0.5 mg PO TID
RX *lorazepam 0.5 mg 1 by mouth three times a day Disp #*90
Tablet Refills:*0
5. Losartan Potassium 100 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. OxycoDONE (Immediate Release) 5 mg PO Q6H
RX *oxycodone 5 mg 1 tablet(s) by mouth q6 Disp #*30 Tablet
Refills:*0
9. Simvastatin 40 mg PO QPM
10. Venlafaxine XR 37.5 mg PO BID
RX *venlafaxine 37.5 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. Vitamin D 1000 UNIT PO DAILY
12. Citalopram 10 mg PO DAILY
RX *citalopram 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Toxic-metabolic encephalopathy
- Acute renal failure
- Recurrent falls
- Elevated LFTs NOS
Secondary:
- Dementia NOS
- Bifrontal subcortical calcifications secondary to traumatic
frontal ICH (___)
- Hypertension
- Anxiety and Depression
- Osteoarthritis w/ chronic pain
- GERD
- Vertigo
- S/P hysterectomy
- S/P L cataract repair
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: History: ___ with IPH s/p fall and L knee pain // evidence of
fracture or worsening bleed
TECHNIQUE: 3 views of the left knee.
COMPARISON: None available.
FINDINGS:
There is no fracture or dislocation. Moderate tricompartmental degenerative
changes are noted, most severe in the patellofemoral compartment with joint
space narrowing and subchondral sclerosis. A well ossified fragment along the
superior aspect of the patella likely represents a loose body or prior trauma.
No focal lytic or sclerotic lesion is identified. No gross joint effusion.
No soft tissue calcification or radio-opaque foreign body is seen.
IMPRESSION:
No acute fracture or dislocation. Moderate tricompartmental osteoarthritis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with hypoxia
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest. There is no focal consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged
osseous structures are intact. Degenerative changes of the AC joint again
noted.
IMPRESSION:
No acute intrathoracic process
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with ALTERED MENTAL STATUS , FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.4
heartrate: 80.0
resprate: 16.0
o2sat: 97.0
sbp: 125.0
dbp: 72.0
level of pain: 13
level of acuity: 2.0 | ___ w/ h/o dementia, poorly controlled HTN, on ASA 81 presents
s/p fall in the setting of declining mental status of unknown
etiology with CT showing no acute intracranial hemorrhage but
labs concerning for ___. Cuase of the fall thought to be 2'/2
orthostatic hypotension in the setting of decreased PO intake.
Although her mental status improved with holding of delirium
inducing medications and hydration to treat her pre-renal
azotemia, she was seen by geriatrics who thought her
presentation was most likely related to worsening dementia. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Amiodarone
Attending: ___.
Chief Complaint:
Generalized weakness
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Overall patient is an ___ yo man with h/o ESRD on HD, Afib on
coumadin, HTN, CHF with EF 48% p/w generalized weakness. Patient
reports 3 days of generalized fatigue and weakness on morning of
admission esp in LEs with inability to get out of bed to walk
short distence. Some concern for left sided weakness initially,
although patient now states that at baseline uses LUE less due
to old injury and LLE w/ heel ulcer, thus less concern for left
sided weakness. Patient recently admitted with UTI for which
completed course of ceftaz on ___ and he continues to get
neomycin bladder flush and dwell q2 days. Denies any change in
quality of urine. Patient denies chest pain, palpiations,
orthostasis, cough, fever, chills, abdominal pain, nausea,
vomiting, diarrhea, shortness of breath, orhopnea, PND, leg
swelling, parestesias, dysathria, dysphagia.
Overnight noted to have peaked TW on EKG w/ elevated K. He was
given one dose of kayelxelate and transfered to HD this morning
as he missed HD session on ___.
At the time of my exam, patient states feeling back to baseline
and is eager to go home. Has no complaints.
Past Medical History:
T2DM - now resolved s/p weight loss, A1c<5% in ___, not on
treatment
ESRD- most likely multifactorial from hypertensive and
obstructive nephropathy. On dialysis since ___.
Atrial fibrillation- Pt is anticoagulated on coumadin.
Hypertension
CHF outpatient TTE ___ with LVEF ___ and subsequent
recovery with EF 48% on office study ___.
Obesity
Gout
PVD
Anemia of chronic disease- Secondary to renal dysfunction.
Sleep apnea
Autonomic dysfunction, remitted (no longer on midodrine and
fludrocort); persistent volume-sensitive BP regulation
Social History:
___
Family History:
His grandparents and father have hypertension and diabetes.
Physical Exam:
ADMISSION EXAM
Vitals: 97.4, 125/78, 72, 20, 96% RA
General: elderly male, NAD, AAOx3
HEENT: MM dry, EOMI,
Neck: no JVD
Lungs: CTAB
CV: RRR no m/r/g
Abdomen: soft, NT, ND NABS
Ext: 2+ pulses, no edema
Skin: no rashes; pressure ulcer under left heel with fibrinous
exudate, not infected-appearing
Neuro: CN2-12 intact. stength ___ in UE bilaterally except for
4+/5 with left triceps and 4+/5 with right biceps. biceps
appears to be limited by pain from IV in wrist. unable to make
strong grip, worse on left, due to bilateral baseline extension
of fingers which patient says is chronic. ___ strength ___ bilat.
LTSI.
DISCHARGE EXAM
Vitals: 97.0 139/88 87 20 97% RA 97.4kg
General: AAOx3, sitting in bed eating in NAD
HEENT: MMM, EOMI
Neck: no JVD
Lungs: CTABL
CV: irreg irreg, no mrg
Abdomen: soft, NT, ND NABS
Ext: no edema
Skin: left heel ulcer not examined
Neuro: CN2-12 intact. strength 4+ to ___ bil upper and lower
extremities. sensation to soft touch grossly intact.
Pertinent Results:
ADMISSION LABS
___ 02:15PM BLOOD WBC-7.8 RBC-3.60* Hgb-10.8* Hct-34.8*#
MCV-97 MCH-29.9 MCHC-31.0 RDW-16.7* Plt ___
___ 02:15PM BLOOD ___ PTT-42.5* ___
___ 02:15PM BLOOD Glucose-107* UreaN-70* Creat-7.1*# Na-138
K-5.7* Cl-101 HCO3-19* AnGap-24*
___ 02:15PM BLOOD ALT-11 AST-21 CK(CPK)-37* AlkPhos-215*
TotBili-0.3
___ 02:15PM BLOOD Lipase-132*
___ 02:15PM BLOOD CK-MB-2 cTropnT-0.07*
___ 02:15PM BLOOD Albumin-3.9 Calcium-8.3* Phos-3.8 Mg-2.3
INTERVAL LABS
___ 07:00AM BLOOD TSH-6.0*
___ 07:25AM BLOOD T4-6.1 Free T4-1.3
DISCHARGE LABS
___ 07:25AM BLOOD WBC-6.4 RBC-3.51* Hgb-10.4* Hct-33.2*
MCV-95 MCH-29.7 MCHC-31.4 RDW-16.9* Plt ___
___ 07:25AM BLOOD ___ PTT-42.2* ___
___ 07:25AM BLOOD Glucose-89 UreaN-39* Creat-5.6*# Na-139
K-4.3 Cl-101 HCO3-27 AnGap-15
IMGAING
CXR ___
IMPRESSION:
1. Moderate size right pleural effusion, similar compared to the
prior exam,
with trace left pleural effusion.
2. Bibasilar airspace opacities could reflect compressive
atelectasis but
infection is not excluded.
3. Interval improvement in mild pulmonary edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Cinacalcet 30 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Furosemide 80 mg PO 4X/WEEK (___)
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Metoprolol Succinate XL 150 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Paricalcitol 6 mcg IV QHD
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Sucralfate 1 gm PO TID
13. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
14. Allopurinol ___ mg PO DAILY
15. Warfarin 2 mg PO EVERY OTHER DAY
16. Warfarin 3 mg PO EVERY OTHER DAY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Neomycin-Polymyxin B GU 1 mL / 1000 ml SW ___ Q48H
Each 1000mL bottle contains 1mL of Neosporin GU Irrigant. please
leave 25 cc of neosporin in bladder dwell between flushes
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Cinacalcet 30 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Furosemide 80 mg PO 4X/WEEK (___)
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Metoprolol Succinate XL 150 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Sucralfate 1 gm PO TID
13. Warfarin 2 mg PO EVERY OTHER DAY
14. Warfarin 3 mg PO EVERY OTHER DAY
15. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
16. Paricalcitol 6 mcg IV QHD
17. Allopurinol ___ mg PO DAILY
18. Neomycin-Polymyxin B GU 1 mL / 1000 ml SW ___ Q48H
please leave 10 cc of neosporin in bladder dwell between
flushes
19. Collagenase Ointment 1 Appl TP DAILY
RX *collagenase clostridium hist. [Santyl] 250 unit/gram As
directed once a day Disp #*1 Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Generalized weakness
Volume depletion
Hypothyroidism
ESRD
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: Weakness.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Heart size is difficult to determine given the presence of a moderate size
right pleural effusion, which appears relatively unchanged compared to the
prior exam. There is mild pulmonary edema, slightly improved compared to the
previous exam. Streaky left basilar opacity may reflect atelectasis, with a
right basilar opacity also likely reflective of compressive atelectasis. A
small left pleural effusion appears to be present. There is no pneumothorax.
Assessment of the lung apices is somewhat obscured due to the patient's chin
projecting over this region. No acute osseous abnormalities are present.
IMPRESSION:
1. Moderate size right pleural effusion, similar compared to the prior exam,
with trace left pleural effusion.
2. Bibasilar airspace opacities could reflect compressive atelectasis but
infection is not excluded.
3. Interval improvement in mild pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: WEAKNESS
Diagnosed with OTHER MALAISE AND FATIGUE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, HYPOTHYROIDISM NOS
temperature: 96.8
heartrate: 83.0
resprate: 18.0
o2sat: 94.0
sbp: 122.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with PMH ESRD on HD, afib on coumadin, HTN, CHF with EF
48% p/w generalized weakness.
ACTIVE ISSUES
# Weakness
Unclear etiology at presentation. One possibility included a UTI
so initially started on antibioitics, however U/A was not
convincing and no leukocytosis so antibiotics were discontinued.
No cardiac symptoms suggesting ACS or focal symptoms to suggest
infection. No neuro findings to suggest CVA or neuropathic. He
had signs of volume depletion so he was given IVF with some
improvement in weakness. Also the possibility that neomycin
bladder dwells could have been causing the weakness so the
volume of neomycin was decreased. At discharge patient felt
back to his baseline strength and was safe for discharge.
# Hyperkalemia
Patient presented with K of 7.1 and EKG showed peaked T waves.
He was given one dose of kayexelate and had two rounds of HD.
On discharge his K normalized and his EKG was at baseline.
# ESRD:
On HD ___, Th, Sa. Missed Th HD so got HD ___ and had a repeat
HD on ___ for ___ schedule. Continued cinacalcet, nephrocaps,
and sevelemer.
CHRONIC ISSUES
# Anemia
This is a chronic, but at presentation he is above baseline and
most likely hemoconcentrated. There was no concern for active
bleeding at this time. His hematocrit was stable throughout the
hospitalization.
# Atrial fibrillation
Continued his home dose of coumadin and metoprolol XL. No
issues during hospitalization and he was discharged
hemodynamically stable.
# Hypertension
Continued home dose of metoprolol.
# CHF
Continued lasix and metoprolol per home regimen.
# Gout
Continue home dose allopurinol.
# Hypothyroidism:
Contine home dose Levothyroxine.
TRANSITIONAL ISSUES
- Please follow-up at your regularly scheduled Dialysis center
- Please follow-up Free T4 and T4
- Follow up blood cultures, urine culture.
- Please follow-up with your primary care physician, ___. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Compazine / Gluten / Reglan
Attending: ___
Chief Complaint:
Nausea
Concern for Dobhoff tube migration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with history of anorexia nervosa presenting
from Radius LTS with nausea. ___ staff concerned that pt pt's
J-tube had migrated into stomach, and that pt needs higher level
of care so transferred her back to ___ with all of her
belongings. Of note, pt was recently discharged on ___ from
___ to ___. Last hospital course was notable for prolonged
stay secondary to anorexia nervosa.
Initial VS in the ED:97.8 74 113/75 15 100%. Labs notable for
unremarkable lytes accept slightly elevated phos. CBC shows crit
of 34.9 at baseline
Imaging notable for KUB dobhoff is clearly still in the right
place.
VS prior to transfer: 97.8 74 113/75 15 100%
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, Denies sinus tenderness,
rhinorrhea or congestion. Denied cough, shortness of breath.
Denied chest pain or tightness, palpitations. No recent change
in bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
Past Medical History:
1. Celiac Sprue - Diagnosed via biopsy several years ago.
Managed with diet, but with frequent complaints abdominal pain.
2. History of laxative, diet pill, and diuretic abuse
3. Osteoporosis - complicated by ankle fracture from
stressrrelated to overexercising, and rib fracture s/p fall from
blackout. On calcium and Vit D supplements
4. Chronic anemia - patient pancytopenic in past
5. Migraines
6. Chronic Arthritis in L Knee with a h/o 7 operations on L knee
for torn meniscus - injury related to running. Last operation in
___.
Past psychiatric history:
1. Anorexia Nervosa - per patient, diagnosed ~ ___ years ago.
Lowest weight was "around 80 lbs" on her 5'2" frame (thinks she
has lost ~ 0.5 inches of height). Amenorrheic in the past. AN
c/b severe osteoporosis & h/o fractures and and h/o leukopenia
in the past. Patient has been hospitalized > 10 times for her
eating disorder, including past treatment at ___, most
recently in the ___ and prior to that a nearly 3
month hospitalization there in the ___. Has h/o
requiring tube feeds. Patient has also had treatment at a
facility in ___ and at ___ in the past. Eating
disorder behavior is primarily restricting, although patient has
a h/o abuse of laxative, diuretics and diet pills and a h/o
over-exercising. She denied any h/o binging behavior.
2. Unipolar Depression - Has a h/o previous inpatient
psychiatric admissions, including a stay at ___ in
___ during which she was treated with ECT, which pt
says was not helpful. Was discharged from ___ to the
eating disorders program at ___, where she stayed for three
months.
3. Self-injurious behavior and suicide attempts - Patient has a
h/o one suicide attempt by attempted self-electrocution (use of
a hair dryer while standing at a sink with water--nothing
happened, later told her therapist), but the circumstances
around this episode remain hazy (although the report of the
attempt has been consistent over the years). She estimated that
this attempt was approximately ___ years ago. Also has a h/o
cutting, used to cut arms to "relieve pain," has req'd stitches
in the past. Reported that she last cut over ___ years ago.
Psychiatrist- Referred to new psychiatrist on discharge from
___ but pt and PCP have not heard back from new psychiatrist
after multiple outreach attempts and pt feels she will likely
need a new referral.
Therapist- ___, ___ ___ (pastoral counselor, ___. Pt reports both are
'great' and that she's been seeing ___ since ___,
though pt notes that she hasn't seen her very frequently ___ to
frequent hospitalizations.
Medication trials: Med trials have included sertraline,
fluoxetine, amitriptyline, mirtazepine, duloxetine, olanzapine,
aripiprazole and quetiapine.
Social History:
Guardian- Temporary court-appointed ___,
___. Court date for permanent guardianship pending.
Sisters were guardians previously.
B/R- ___
Family/Support- Primary supports include best friend ___,
friend/boyfriend of ___ years, his mother, and church community.
Mother is deceased. Father, 3 sisters live in the area. Patient
is able to drive, but has transportation assistance through DMH.
Housing- Lives w/ sister and brother-in-law, feels this is a
supportive environment, feels safe.
Employment- SSDI for psychiatric illness. No work since ___.
Reports she is hoping to get back to work soon. Previously
worked
as ___ and in ___ and a ___ lab.
Education- HS
Spiritual- Identifies as ___. Reads bible regularly. Feels
supported by church community.
Trauma/Abuse- Endorses h/o sexual/physical/emotional abuse in
teens/___.
Firearms- Denies access.
Family History:
Mother - deceased age ___ from ___
Father - alive and well; history of depression.
Physical Exam:
PHYSICAL EXAMINATION:
VITALS: 5'2", 41 kg, 98.3, 104/70, 64, 24, 97RA
GENERAL: cachectic appearing, comfortable aox3
HEENT: PERRL, EOMI
NECK: no carotid bruits, JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, slightly tender in LUQ, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
Pertinent Results:
Admission Labs:
___ 11:45PM BLOOD WBC-4.5# RBC-3.60* Hgb-11.6* Hct-34.9*
MCV-97 MCH-32.2* MCHC-33.3 RDW-13.7 Plt ___
___ 11:45PM BLOOD Neuts-66.1 ___ Monos-5.8 Eos-2.8
Baso-0.8
___ 11:45PM BLOOD ___ PTT-26.4 ___
___ 11:45PM BLOOD Glucose-91 UreaN-9 Creat-0.6 Na-137 K-4.3
Cl-99 HCO3-30 AnGap-12
___ 11:45PM BLOOD Calcium-9.6 Phos-5.6*# Mg-1.9
Discharge Labs:
Microbiology: none
Imaging:
KUB ___:
FINDINGS: Dobbhoff tube ends beyond the ligament of Treitz in
the proximal jejunum, in appropriate position. Nonspecific
bowel gas pattern, no evidence of obstruction. No free air.
Medications on Admission:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Dulcolax Stool Softener] 100 mg 1
capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. HydrOXYzine 25 mg PO Q6H:PRN anxiety
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q12H
before breakfast and dinner
7. Psyllium 1 PKT PO TID
8. Ranitidine 300 mg PO HS
9. traZODONE 100 mg PO HS:PRN insomnia
10. Vitamin D 400 UNIT PO DAILY
11. Venlafaxine XR 225 mg PO DAILY
12. Sumatriptan Succinate 50 mg PO QID:PRN headache
do not exceed 200mg/24hours
13. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [Senna Laxative] 8.6 mg 1 tablet by mouth twice a
day Disp #*60 Tablet Refills:*1
14. Ondansetron 4 mg PO Q6H:PRN nausea
15. Lorazepam 0.5 mg PO BID:PRN anxiety
16. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily
Disp #*30 Capsule Refills:*1
17. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth / rectum daily Disp #*60
Tablet Refills:*1
18. Calcium Carbonate 500 mg PO TID
19. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*1
20. DiCYCLOmine 20 mg PO QID
RX *dicyclomine 20 mg 1 tablet(s) by mouth four times a day Disp
#*40 Tablet Refills:*1
21. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN GI
discomfort
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 5 mL by
mouth four times a day Disp #*5 Bottle Refills:*1
22. Lorazepam 0.5 mg PO Q8H:PRN nausea, anxiety
RX *lorazepam 0.5 mg one tablet by mouth three times per day
Disp #*60 Tablet Refills:*1
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indegestion
4. Docusate Sodium 100 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. HydrOXYzine 25 mg PO Q6H:PRN anxiety
7. Lorazepam 0.5-1 mg PO TID
hold for sedation
8. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN GI
discomfort
9. Multivitamins 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q12H
before breakfast and dinner
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Psyllium 1 PKT PO TID
13. Ranitidine 300 mg PO HS
14. Sumatriptan Succinate 50 mg PO QID:PRN headache
do not exceed 200mg/24hours
15. Vitamin D 400 UNIT PO DAILY
16. Venlafaxine XR 225 mg PO DAILY
17. Senna 1 TAB PO BID:PRN constipation
18. Ondansetron 4 mg PO Q6H:PRN nausea
19. Lubiprostone 24 mcg PO BID
RX *lubiprostone [___] 24 mcg 1 capsule(s) by mouth twice a
day Disp #*40 Capsule Refills:*2
20. OLANZapine 2.5 mg PO HS
RX *olanzapine 2.5 mg 1 tablet(s) by mouth bedtime Disp #*30
Tablet Refills:*1
21. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*30
Tablet Refills:*2
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- anorexia
Secondary:
- Anxiety
- Chronic abdominal pain
- Orthostatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___. Please assess Dobhoff position.
TECHNIQUE: Supine and upright radiographs of the abdomen.
COMPARISON: KUB from ___.
FINDINGS: Dobbhoff tube ends beyond the ligament of Treitz in the proximal
jejunum, in appropriate position. Nonspecific bowel gas pattern, no evidence
of obstruction. No free air.
Radiology Report
HISTORY: Dobbhoff tube.
FINDINGS: Tip of the Dobbhoff tube lies in the jejunum.
Radiology Report
HISTORY: Dobbhoff tube.
FINDINGS: In comparison with earlier study of this date, the Dobbhoff tube
now lies within the third portion of the duodenum.
Radiology Report
HISTORY: Dobbhoff placement.
FINDINGS: The Dobbhoff tube is now in the upper stomach. Little change in
the appearance of the heart and lungs.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: NAUSEA
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, ANOREXIA NERVOSA
temperature: 97.8
heartrate: 74.0
resprate: 15.0
o2sat: 100.0
sbp: 113.0
dbp: 75.0
level of pain: 13
level of acuity: 3.0 | ___ female with pmhx of anorexia, osteoporosis, chronic anemia
and migraines presenting from ___ with nausea and concern for
migration of Dobhoff.
# r/o Dobhoff migration - Dobhoff has not migrated, it is in
proper place. However a new Dobhoff was placed in the stomach on
___, as ___ (where she is being discharged to) does not
take post-pyloric tubes. This was verified by chest-xray on the
day of discharge.
# Nausea - pt complains of nausea with emesis, and abdominal
pain. Nausea is a chronic problem, perhaps secondary to
gastroparesis from life long anorexia, could also be secondary
to celiac sprue or somatization. She was treated with Zofran and
ativan PRN. We discontinued her bentyl and started amitiza for
possible irritable bowel syndrome and bloating. At the time of
discharge her abdominal pain and nausea was moderately improved.
We increased her ativan from 0.5mg to 1mg TID as needed for
anxiety and nausea.
# Anorexia: The patient had normal electrolytes with exception
of slightly elevated phos. Eating disorder was not initiated as
patient was tolerating tube feeds. She was allowed to order and
eat food for pleasure. Her weight was recorded daily, and at the
time of discharge she weighed 93.2 lbs or 42.3 kg from 41kg on
admission.
# GERD: continued Ranitidine, Maalox.
# CELIAC DISEASE: Maintained gluten-free diet.
# DEPRESSION, ANXIETY: continued Venlafaxine, Abilify,
Clonazepam. She was started on olanzapine 2.5mg QHS on ___,
which she tolerated well. QTc was not elevated. We increased her
ativan from 0.5mg to 1mg TID as needed for anxiety and nausea.
# MIGRAINES: continued sumatriptan and Fiorocet as needed for
headache.
# OSTEOPOROSIS: we continued Calcium, Vitamin D.
# CODE STATUS: Full Code
# EMERGENCY CONTACT: ___, sister ___
___, sister, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
antihistamines / decongestants / Amitriptyline / Adhesive
Bandage / IV Dye, Iodine Containing Contrast Media / ACE
Inhibitors
Attending: ___.
Chief Complaint:
spinal abscess
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with PMH of MRSA infections (notably left
knee
PJI, T6-T7 discitis requiring T4-T9 fusion in ___, also hx of
L3-L5 fusion laminectomy in ___ who is referred to ED for after
abnormal MRI (available through ATRIUS) with right L2-L3
paracentral fluid collection concerning for abscess. Per PMD,
patient has had longstanding back pain, which is currently
unchanged. She is being referred for admission for biopsy, spine
surgery and ID consults.
- In the ED, initial vitals were:
T 97.5 HR 97 BP 168/67 RR 17 O2 97% RA 320
- Exam was notable for:
Neuro intact
Diffuse midline lower back tenderness
Rectal tone
- Labs were notable for:
137 103 92 AGap=15
------------<235
4.2 19 1.7
13.4
18.1>---<168
42.1
CRP: 217.8
- The patient was given:
___ 22:55 IVF LR
___ 00:59 PO/NG Gabapentin 600 mg
___ 00:59 PO/NG HYDROmorphone (Dilaudid) 2 mg
___ 00:59 PO/NG Methadone 5 mg
___ 02:00 IVF LR 1000 mL
___ 02:18 SC Insulin
- Ortho was consulted, who recommended medicine admission and ID
consult for IV antibiotics.
On arrival to the floor, the patient confirms the history as
above. Feels that her back pain is at baseline. Does have
occasional shooting left leg pain, which is persistent. Does
also
note some significant left shoulder pain after having a
cortisone
injection on ___.
Past Medical History:
Prior hx of spinal osteomyelitis and discitis as above, h/o foot
osteomyelitis s/p amputation
CKD Stage III
Insulin dependent type 2 diabetes
Hypertension
Obesity
Ischemic colitis
Hypertlipidemia
Hypothyroidism
Migraines
GERD
Social History:
___
Family History:
No history of immunodeficiency.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.3 PO 149 / 75 L Lying 79 20 93 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection. MMM.
NECK: No appreciable JVD
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: TTP in lower
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Left shoulder TTP
at joint line, limited ROM due to pain.
SKIN: No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: ___ 0734 Temp: 98.0 PO BP: 149/69 HR: 71 RR: 20 O2
sat: 100% O2 delivery: Ra FSBG: 110
HEENT: MMM.
NECK: No appreciable JVD
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: TTP in lumbar spine.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Left shoulder no significant tenderness. Improved
ROM, able to reach across body, abduct past 90 degrees. L hallux
s/p amputation.
SKIN: Warm.
NEUROLOGIC: AOx3. ___ strength in L foot dorsiflexion, remainder
___ throughout. Reports tingling to light touch on LLE to
mid-calf.
Pertinent Results:
ADMISSION LABS
===============
___ 08:30PM BLOOD WBC-18.1* RBC-4.39 Hgb-13.4 Hct-42.1
MCV-96 MCH-30.5 MCHC-31.8* RDW-14.1 RDWSD-49.8* Plt ___
___ 08:30PM BLOOD Glucose-308* UreaN-95* Creat-1.9* Na-135
K-4.5 Cl-99 HCO3-20* AnGap-16
___ 04:39AM BLOOD ALT-29 AST-49* AlkPhos-119* TotBili-0.3
___ 04:39AM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.1 Mg-1.9
___ 11:03PM BLOOD CRP-217.8*
___ 08:47PM BLOOD ___ pO2-42* pCO2-56* pH-7.19*
calTCO2-22 Base XS--8
DISCHARGE LABS
===============
___ 06:36AM BLOOD WBC-9.0 RBC-3.85* Hgb-11.7 Hct-36.1
MCV-94 MCH-30.4 MCHC-32.4 RDW-14.2 RDWSD-48.1* Plt ___
___ 06:36AM BLOOD Glucose-79 UreaN-38* Creat-0.8 Na-141
K-4.2 Cl-107 HCO3-22 AnGap-12
___ 06:36AM BLOOD ALT-29 AST-37 AlkPhos-104 TotBili-0.4
___ 06:36AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.6
___ 06:36AM BLOOD CRP-87.9*
___ 03:18AM BLOOD ___ pO2-56* pCO2-33* pH-7.30*
calTCO2-17* Base XS--8
MICRO
======
___ 11:09 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Susceptibility testing requested per ___ ___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___ MD (___)
ON ___
AT 20:35.
IMAGING
========
L SHOULDER XRAY ___
Moderate left glenohumeral joint degenerative changes and joint
space
narrowing. Mild AC joint degenerative changes.
L SHOULDER US ___
No evidence of fluid collection within the left shoulder.
SECOND OPINION MRI L-SPINE W & W/O CONTRAST ___. Study is degraded by motion and spinal fusion hardware
artifact.
2. Postsurgical changes from L3-5 laminectomy and posterior
fusion.
3. Approximately 5 mm T2 hyperintense, rim enhancing lesion in
the right
lateral recess at L2. While findings suggestive of suggestive
of a discal
cyst, differential considerations of infectious or inflammatory
etiologies are not excluded on the basis examination. Recommend
follow-up imaging to
resolution.
4. Nonspecific paraspinal soft tissue edema centered at L4-5
persists, though is decreased from prior.
5. Multilevel lumbar spondylosis as described, most pronounced
at L2-3, where there is moderate vertebral canal, mild left and
moderate right neural foraminal narrowing.
6. Limited imaging of the kidneys demonstrate right at least
partially cystic structures, incompletely characterized.
RECOMMENDATION(S): Approximately 5 mm T2 hyperintense, rim
enhancing lesion in the right lateral recess at L2. While
findings suggestive of suggestive of a discal cyst, differential
considerations of infectious or inflammatory etiologies are not
excluded on the basis examination. Recommend follow-up
imaging to resolution.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Methadone 5 mg PO TID
5. Minocycline 50 mg PO Q12H
6. Omeprazole 20 mg PO DAILY
7. Pregabalin 50 mg PO TID
8. Rosuvastatin Calcium 5 mg PO QPM
9. Sertraline 125 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. irbesartan 75 mg oral Q24H
13. Furosemide 20 mg PO DAILY
14. Tresiba FlexTouch U-100 (insulin degludec) 46 units
subcutaneous QAM
Discharge Medications:
1. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate
2. Minocycline 100 mg PO Q12H
3. Aspirin 81 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Methadone 5 mg PO TID
8. Omeprazole 20 mg PO DAILY
9. Pregabalin 50 mg PO TID
10. Rosuvastatin Calcium 5 mg PO QPM
11. Sertraline 125 mg PO DAILY
12. Tresiba FlexTouch U-100 (insulin degludec) 46 units
subcutaneous QAM
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- irbesartan 75 mg oral Q24H This medication was held.
Do not restart irbesartan until instructed by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
=================
Suspected spinal abscess
Acute kidney injury
Secondary diagnosis
===================
Osteoarthritis
Diabetes
Hypertension
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA LEFT
INDICATION: ___ year old woman with significant left shoulder pain// ?fraction
TECHNIQUE: Three views of the left shoulder
COMPARISON: No priors for comparison
FINDINGS:
The bones are demineralized. There is no acute displaced fracture or
dislocation involving the glenohumeral or AC joint. Moderate degenerative
changes are noted within the glenohumeral joint. There is moderate joint
space narrowing of the glenohumeral joint. Mild AC joint degenerative
changes. No suspicious lytic or sclerotic lesions are identified. No
periarticular calcification or radio-opaque foreign body is seen.
Thoracic posterior fusion hardware is partially visualized.
IMPRESSION:
Moderate left glenohumeral joint degenerative changes and joint space
narrowing. Mild AC joint degenerative changes.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE LEFT
INDICATION: ___ year old woman with spinal abscess, now with severe shoulder
pain// evaluate for effusion
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left shoulder.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left shoulder. There is no evidence of fluid collection or joint effusion.
IMPRESSION:
No evidence of fluid collection within the left shoulder.
Radiology Report
EXAMINATION: SECOND OPINION MR NEURO PSO4 MR
INDICATION: ___ year old woman ___ year old female with PMH of MRSA infections
(notably left knee PJI, T6-T7 discitis requiring T4-T9 fusion in ___, also
hx of L3-L5 fusion laminectomy in ___, IDDM, HTN, CKD, hypothyroidism who is
coming in for evaluation and treatment of suspected spinal abscess.// second
opinion on back abscess second opinion on back abscess
TECHNIQUE: Second opinion read on MRI ___ with and without contrast
performed at outside institution.
COMPARISON: MR ___ dated ___.
FINDINGS:
Study is degraded by motion and spinal fusion hardware artifact.
For the purposes of numbering, the lowest rib bearing vertebral body was
designated the T12 level.
There is minimal anterolisthesis of L4 on L5, unchanged, as well as
levoscoliosis of the lumbar spine.
The patient is status post L3-5 laminectomy and posterior transpedicular
fusion, with disc spacers noted at L3-4 and L4-5.
T1 and T2 hypointensity along the inferior endplate of L2 and the superior
endplate of L3 is also similar to prior, suggestive of degenerative sclerosis.
Question STIR hyperintensity of the vertebral bodies of L2 and L3 versus
hardware artifact.
The visualized portion of the spinal cord is grossly preserved in signal and
caliber, with the conus medullaris terminating at L1-2.
There is loss of intervertebral disc space and loss of disc signal intensity
at T12-L1 and L5-S1. STIR hyperintensity within the L2-3 and L3-4 disc spaces
is similar to slightly decreased from most recent prior.
Within the right lateral recess at L2, there is a 5 mm T2 hyperintense, rim
enhancing focus (08:13, 2:9, 9:7) with questioned extension from the L2-3
intervertebral disc. Posterior disc bulge at L2-3 and uncovertebral
hypertrophy contribute to moderate spinal canal narrowing and moderate right
and mild left neural foraminal narrowing.
Multilevel facet joint hypertrophy is noted throughout the lumbar spine.
There is no definite vertebral canal narrowing or neural foraminal narrowing
at T12-L1 or L1-L2.
Evaluation of the neural foramen at L3-4, L4-5 and L5-S1 is limited due to
hardware artifact.
OTHER:
Nonspecific L3 through sacrum paraspinal soft tissue probable edema is again
seen, minimally decreased from prior exam.
Nonspecific probable dependent edema is noted in the dorsal lumbar soft
tissues.
The partially imaged abdomen is notable for a right renal lesion which is at
least partially cystic, though incompletely imaged, measuring at least 1.0 cm.
IMPRESSION:
1. Study is degraded by motion and spinal fusion hardware artifact.
2. Postsurgical changes from L3-5 laminectomy and posterior fusion.
3. Approximately 5 mm T2 hyperintense, rim enhancing lesion in the right
lateral recess at L2. While findings suggestive of suggestive of a discal
cyst, differential considerations of infectious or inflammatory etiologies are
not excluded on the basis examination. Recommend follow-up imaging to
resolution.
4. Nonspecific paraspinal soft tissue edema centered at L4-5 persists, though
is decreased from prior.
5. Multilevel lumbar spondylosis as described, most pronounced at L2-3, where
there is moderate vertebral canal, mild left and moderate right neural
foraminal narrowing.
6. Limited imaging of the kidneys demonstrate right at least partially cystic
structures, incompletely characterized.
RECOMMENDATION(S): Approximately 5 mm T2 hyperintense, rim enhancing lesion
in the right lateral recess at L2. While findings suggestive of suggestive of
a discal cyst, differential considerations of infectious or inflammatory
etiologies are not excluded on the basis examination. Recommend follow-up
imaging to resolution.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain
Diagnosed with Intraspinal abscess and granuloma
temperature: 97.5
heartrate: 97.0
resprate: 17.0
o2sat: 97.0
sbp: 168.0
dbp: 67.0
level of pain: 8
level of acuity: 3.0 | TRANSITIONAL ISSUES
===================
[] Minocycline dose increased to 100mg q12h, she should continue
on this dose after completing antibiotics for her current
infection
[] Blood cultures from ___ with coag negative Staph
(preliminary), follow up final culture results
[] Discussed with patient risks of leaving the hospital prior to
speciation of cultures and prior to set up of antibiotics for
home infusions. Attempted to coordinate home antibiotics but
were unable to coordinate this on a ___ with her insurance.
She understood the risks (death, septic shock, recurrent
bacteremia) and chose to leave the hospital against medical
advice. She will have an appointment with ID at 10 am on ___
and is agreeable to this and we will email them about the need
to set up PICC placement and home infusions of Vancomycin 1250
mg IV Q 12H pending follow-up with ID regarding course.
[] Held home irbesartan at time of discharge. Follow up BPs and
consider restarting as outpatient.
BRIEF SUMMARY
=============
Ms ___ is a ___ year old woman with history of MRSA
infections (notably left knee PJI, T6-T7 discitis requiring
T4-T9 fusion in ___, hx of L3-L5 fusion laminectomy in ___,
IDDM, HTN, CKD, hypothyroidism who was admitted for evaluation
and treatment of suspected spinal abscess on MRI. This was
evaluated by ID and ___ and determined that it was not accessible
for biopsy or drainage. She was started on IV vancomycin with
final antibiotic course pending blood culture speciation. She
left against medical advice prior to determination of final
antibiotic course.
ACUTE ISSUES
============
#Suspect spinal abscess
#GPCs in blood
#Recurrent discitis
Found to have rim-enhancing fluid collection near L2 on recent
outpatient MRI, along with increasing CRP, concerning for
abscess and potential discitis despite chronic minocycline. ___
BCx from ___ grew coag negative Staph (preliminary). ID was
consulted and recommended IV vancomycin with final antibiotics
pending speciation; however, the patient left against medical
advice prior to determination of final antibiotic course. She
was discharged on her home minocycline 100mg q12h (she had
previously been on 50mg q12h but clarified dose should be 100mg
q12h).
#Left shoulder pain
History of OA of shoulder, s/p cortisone injection ___. She had
pain on moving her L shoulder this admission. She was evaluated
by orthopedics who recommended ___ guided aspiration to rule out
infection (low suspicion), which she declined. Shoulder pain
improved the following day.
#Diabetes, insulin dependent
On Tresiba 46 units in AM at home, treated with insulin glargine
and ISS while inpatient.
___
Baseline renal function with Cr of 1.0, elevated to 1.9 on
admission, suspected pre-renal I/s/o worsening infection and
dehydration. Cr downtrended after IVF and was 0.8 at time of
discharge.
#Hypertension
Held home irbesartan in setting ___ and normotensive at time
of discharge. Initially held furosemide in setting of ___,
restarted after Cr improved.
#Depression
Continued sertraline
#Peripheral vascular disease
Continued rosuvastatin and aspirin
#Chronic pain
On methadone and hydromorphone as an outpatient which were
continued. She reported her home dose of hydromorphone 4mg q4h
prn despite Atrius records stating hydromorphone 2mg q4h prn so
was continued on hydromorphone 4mg q4h prn this admission.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Remicade
Attending: ___
Chief Complaint:
lower extremity weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ M with a h/o multiple spinal surgeries
following spinal cord accident in early ___, s/p cervical
spine
fusion, lumbar spinal fusion, cauda equine syndrome s/p
decompression/fusion (___) with chronic lumbar spinal pain (on
fentanyl and hydrocodone), h/o multiple MRSA infection incl.
bacteremia, chronic diverticulitis, Crohn's and RA (on
immunosuppression), and CVL who p/w acute on chronic back pain
with b/l lateral lower extremity pain, saddle paranesthesias,
inability to void, and bilateral lower extremity weakness
following a minor fall at 14:30 on ___.
The patient reports that he was in usual state of health until
14:30 on ___ when he stopped a gasstation on his way to visit
family in the ___ area, tripped and fall on his back and
head.
Minor head strike to occiput. No LOC. He was able to stand and
walk but noticed an intense pain shooting down his lateral legs
b/l to the level of knees and on the left down to his lateral
foot. This was followed by numbness and tingling sensations in
the same location (L>R). He was able to walk back to his car.
His
symptoms felt similar to the symptoms he had when he had cauda
equine syndrome and he noted that he was unable to void so he
drove himself to the local ED at ___. At
___ he had a Foley catheter placed yielding about 900cc of
urine. He was transferred to ___ for further care. A code cord
was activated and he had several imaging studies done as
summarized below.
Of note the patient reports having being hospitalized at ___ in ___ 3 weeks ago for transient neurological
symptoms, possibly a stroke. He seems to remember receiving TPA
and was admitted to the hospital for 2 days. He is not on
aspirin
or AC.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. He denies difficulties
producing or comprehending speech.
On ___ review of systems, the pt reports having several days
of diarrhea with lower abdominal pain (c/w CD flare vs
diverticulitis). No fevers or chills. No blood in stool or
urine.
He acknowledges an about 10 lbs unintentional weight loss over
the last 4 weeks. He has chronic arthralgias.
Past Medical History:
RA
IBD (Crohn's)
HTN
Spinal surgeries (2 cervical, 3 lumbar) - most recent ___
GERD
Chronic lower back pain
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM
=============
Vitals: Temp: 96.9 HR: 89 BP: 145/89 Resp: 16 O2 Sat: 97 room
air
Normal
___: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, tender in RLQ and supra
Extremities: No cyanosis, clubbing or edema bilaterally.
Tenderness over mid thoracic and lumbar spine.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive.
Language is fluent with intact repetition and comprehension.
There were no paraphasic errors. Pt was able to name both high
and low frequency objects. Speech was not dysarthric. Able to
follow both midline and appendicular commands. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3->2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: No adventitious movements, such as tremor, noted. No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4* 4* 4* 4* 4* 4* 4* 4* 0 0 0 0 0
R 5 ___ 5 ___ 5 5 5 5 5
*unclear if giving away weakness
-Sensory: Sensation to light touch, pain, proprioception intact
in both upper extremities. Sensory deficit with no sensation in
LLE below the level of L1. Perianal sensation decreased.
Sphincter tonus decreased per ED team.
-DTRs:
Bi Tri ___ Pat Ach
L 4+* 4+ 4+* 4+ 1+ 1+
R 3+ 3+ 3+ 4+ 1+ 2+
*several beats of clonus
Plantar response was flexor on the right. No movement
appreciated
on the left.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF. Unable to perform heel to shin.
-Gait: deferred
Pertinent Results:
ADMISSION LABS
===============
___ 09:20PM BLOOD WBC-5.9 RBC-3.73* Hgb-9.7* Hct-31.1*
MCV-83 MCH-26.0 MCHC-31.2* RDW-16.0* RDWSD-48.2* Plt ___
___ 09:20PM BLOOD Neuts-74.7* Lymphs-12.8* Monos-9.7
Eos-1.4 Baso-0.7 Im ___ AbsNeut-4.37 AbsLymp-0.75*
AbsMono-0.57 AbsEos-0.08 AbsBaso-0.04
___ 09:20PM BLOOD Plt ___
___ 09:20PM BLOOD ___ PTT-29.4 ___
___ 09:20PM BLOOD Glucose-98 UreaN-9 Creat-0.8 Na-147 K-4.3
Cl-109* HCO3-23 AnGap-15
___ 09:20PM BLOOD Calcium-9.0 Phos-3.6 Mg-2.2
IMAGING
=======
CT C-SPINE W/O CONTRAST
IMPRESSION:
1. Postoperative changes spine.
2. No fractures.
3. Degenerative changes.
CT ABD & PELVIS WITH CO
IMPRESSION:
1. No acute CT findings in the abdomen or pelvis to correlate
with patient's reported symptoms. Specifically, no evidence of
fracture in the lumbosacral spine.
2. Hepatic steatosis.
CT HEAD W/O CONTRAST
IMPRESSION:
1. No acute intracranial abnormalities.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Fentanyl Patch 25 mcg/h TD Q72H
2. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Frequency is
Unknown
3. Metoprolol Tartrate 25 mg PO BID
4. Pravastatin 20 mg PO QPM
Discharge Medications:
1. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain
- Severe
DOSE FREQUENCY UNKNOWN, NOT VERIFIED BY HOME PHARMACY
2. Fentanyl Patch 25 mcg/h TD Q72H
NOT VERIFIED BY HOME PHARMACY
3. Metoprolol Tartrate 25 mg PO BID
4. Pravastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
left lower extremity weakness
urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: *** CODE CORD *** History: ___ with fall injury// fractures
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.5 cm; CTDIvol = 48.9 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: CT head without contrast from ___
FINDINGS:
There is no evidence of acute major vascular territorial
infarction,hemorrhage,edema,or mass. Mild brain parenchymal atrophy.. No
evidence of midline shift. The basilar cisterns are patent.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. Patient is
status post lens resections
IMPRESSION:
1. No acute intracranial abnormalities.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: *** CODE CORD *** History: ___ with fall injury// fractures
fractures
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.5 s, 21.8 cm; CTDIvol = 22.7 mGy (Body) DLP = 493.9
mGy-cm.
Total DLP (Body) = 494 mGy-cm.
COMPARISON: CT C-spine without contrast from ___
FINDINGS:
Please note that the exam is limited due to streak artifact from fusion
hardware which limits assessment of adjacent structures. No evidence of
prevertebral soft tissue swelling. Normal alignment. No acute fractures are
identified.
Anterior C4-C6 vertebral levels with interbody spaces, screws, solid fusion
across vertebral bodies.. C4-C6 laminoplasty.
Mild degenerative changes cervical spine. Probably mild central canal
narrowing C3-C4 level. Multilevel foraminal narrowing.
There is no evidence of infection or neoplasm. The visualized lung apices
appear unremarkable. The thyroid gland is normal. Port-A-Cath in place.
IMPRESSION:
1. Postoperative changes spine.
2. No fractures.
3. Degenerative changes.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ year old man with sx concerning for cauda equina // r/o
fracture; please include sacral spine.
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 6.8 s, 53.8 cm; CTDIvol = 23.7 mGy (Body) DLP =
1,276.0 mGy-cm.
Total DLP (Body) = 1,276 mGy-cm.
COMPARISON: CT abdomen pelvis with contrast from ___
FINDINGS:
LOWER CHEST: Mild atelectasis is seen in the lung bases. There is no evidence
of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous low attenuation throughout,
compatible with hepatic steatosis. There is no evidence of focal lesions.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A 1.4 hypodense lesion is seen in the interpolar region of the right kidney,
compatible with simple cyst. A subcentimeter hypodense lesion is seen in the
left lower renal pole, too small to characterize. No hydronephrosis
bilaterally. 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 not seen.
PELVIS: The urinary bladder is decompressed by a Foley catheter there is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is near complete fusion of the L4-L5 vertebral level. There is
evidence of prior laminectomies. Mild retrolisthesis is seen at the L4-5 to S1
vertebral level. No definite fracture is identified.
SOFT TISSUES: Note is made of a right fat containing inguinal hernia. There
is evidence of prior anterior hernia mesh repair. Otherwise, the abdominal
and pelvic wall is within normal limits.
IMPRESSION:
1. No acute CT findings in the abdomen or pelvis to correlate with patient's
reported symptoms. Specifically, no evidence of fracture in the lumbosacral
spine.
2. Hepatic steatosis.
Gender: M
Race: WHITE
Arrive by HELICOPTER
Chief complaint: Back pain, L Leg numbness
Diagnosed with Low back pain, Fall on same level, unspecified, initial encounter, Crohn's disease, unspecified, without complications
temperature: 96.9
heartrate: 89.0
resprate: 16.0
o2sat: 97.0
sbp: 145.0
dbp: 89.0
level of pain: 8
level of acuity: 2.0 | Mr ___ is a ___ M with a h/o multiple spinal surgeries
following spinal cord accident in early ___, s/p cervical
spine fusion, lumbar spinal fusion, cauda equine syndrome s/p
decompression/fusion (___) with chronic lumbar spinal pain (on
fentanyl and hydrocodone), h/o multiple MRSA infection incl.
bacteremia, chronic diverticulitis, Crohn's and RA (on
immunosuppression), and CVL who p/w acute on chronic back pain
with b/l lateral lower extremity pain, saddle paranesthesias,
inability to void, and bilateral lower extremity weakness
following a minor fall at 14:30 on ___. CT head, abdomen/pelvis,
C-spine were unremarkable. He chose to leave AMA shortly after
his admission prior to completion of Neurologic workup, despite
counseling regarding dangers of leaving. He was offered his home
medications and additional nonnarcotic neuropathic pain
medications in-house. Final radiologic reads of MRI lumbar and
thoracic spine were pending at time of discharge. MRI brain and
C spine were scheduled but not yet performed; ESR and CRP
pending. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Latex / Levaquin
Attending: ___.
Chief Complaint:
palpitations, fever
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
The patient is a ___ year old male with a PMHx of metastatic RCC
(papillary vs clear cell) to lungs & L pleural effusions s/p
multiple chemo regimens (most recently cycle 10 of bevacizumab +
erlotinib on ___, presents after a recent admission to
___ for PNA now with fevers, hypotension.
The patient was recently admitted from ___ to ___ for
similar symptoms. He was started on a 14-day course of unasyn &
doxycycline but was ultimately discharged on augmentin. He did
not, however, complete a 14-day course; opting to stop
antibiotics on ___ in hopes of being considered for a clinical
trial. He was screened for a clinical trial for a novel
anti-PDL1 antibody that required him to hold his tarceva for 3
weeks. During this time, he appears to have clinically
deteriorated.
Most recently, he was admitted from ___ - ___ for
respiratory failure due to post obstructive pneumonia and
progressive metastatic disease to the lungs, as well as the
pleural effusion. He was given vanc/cefepime switched to
Levofloxacin for a total of ___T scan showed mild
colitis affecting the distal descending and sigmoid colon. Stool
studies were negative for C. Diff, he was empirically treated
with Flagyl and completed a 2 week course of treatment.
In the ED inital vitals were, 98.5 168 126/66 25 100% RA. He was
triggered on arrival to ED for HR in 160s, SBP 125 initially
then 88/69, got 2L IVF. CXR which shows large effusion ? similar
to prior, difficult to tell if new/old PNA, treated with
levofloxacin and vanc. He had a questionable allergic rxn to
levo (hives on arms, got benadryl) so planned to give vanco /
cefepime / gent / azithro, but only got cefepime and
levofloxacin. His BP was down in ___ for approximately 40
min and he was admitted to the ICU for close monitoring.
Patient did not want CVL or pressors in ED, lactate 3.3, had 2
18G PIVs (but pt requested one be d/c'd), HR down to 110s, not
febrile in ED, EKG showed sinus tach.
In the ICU, he remained stable not requiring pressors. On
___ he no longer required IVF boluses to maintain his BP.
His other VS also remained stable.
On the floor, he reports no problems.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Past Oncologic History:
- Renal Cell Carcinoma
---> ___: Microscoping hematuria
---> CT A/P: 4.5 cm L adrean & periadrenal mass
---> MRI: L periaortic mass 4.6 cm
---> PET CT: lingular nodule, RP lesion adjacent to L adrenal
- ___: underwent resection of mass & L adrenal nodule
---> Pathology revealved metastatic adenocarcinoma of unknown
origin
---> Prominent papillary architecture w abundant eosinophilic or
clear cytoplasm & high-grade nuclear features
- PET ___: interval increase in size & update of pulmonary
nodules
- ___: 6 cycles carboplatin & Taxotere
---> PET CT: improvement in L lung lesions
- ___: Enrolled in phase 1 trial of MET/ALK inhibitor
---> PET CT: Progression of disease in L adrenalectomy bed &
lungs
---> Taken off trial
- THEROS CancerType ID molecular classification test revealed
90.9% probability that cancer is of kidney origin based on 92
gene expression profile
- ___: Sunitinib
---> Post-CT: Partial regression of adrenal bed lesion &
stability in pulmonary nodules.
---> Progressed after 6 cycles of sunitinib
- ___: Everolimus
- ___: Taken off everolimus for disease progression
- ___: Cyberknife radiation for mass invading psoas muscle
---> Recovery c/b severe pain ___ inflammation
---> Fevers to 100-102, SOB, R-sided CP.
- ___: Bronch revealed malignant cell
---> No ABPA
- ___: Started pazopanib
- ___: Disease progression; taken off pazopanib
- ___: s/p 10 cycles bevacizumab & erlotinib
.
Past Medical History:
- Nephrolithiasis (bilateral)
- Mitral valve prolapse
- Colon polyp
- Dysplastic nevus x3
- Necrotic LN in left neck (never biopsied/cultured)
Social History:
___
Family History:
- Father: Died in his ___ from brain aneurysm. Hypoplastic
kidney
- Mother: Alive in her ___.
- All 3 sisters healthy.
Physical Exam:
On Admission:
VS: 98.6 128/62 92 16 97% RA; ___ pain
GEN: No apparent distress, resting comfortably in bed
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-tender, non-distended; no guarding/rebound
EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, ___ motor function globally
DERM: no lesions appreciated
On Discharge:
VS: 98.1 128/80 102 17 98% on RA
GEN: No apparent distress, resting comfortably in bed
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-tender, non-distended; no guarding/rebound
EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, ___ motor function globally
DERM: no lesions appreciated
Pertinent Results:
ADMISSION
___ 10:05AM BLOOD WBC-10.4 RBC-4.14* Hgb-10.2* Hct-34.5*
MCV-83 MCH-24.6* MCHC-29.5* RDW-18.3* Plt ___
___ 10:05AM BLOOD Neuts-88.4* Lymphs-8.1* Monos-3.0 Eos-0.1
Baso-0.4
___ 10:05AM BLOOD ___ PTT-35.2 ___
___ 10:05AM BLOOD Glucose-121* UreaN-11 Creat-0.9 Na-130*
K-4.7 Cl-93* HCO3-25 AnGap-17
___ 10:05AM BLOOD ALT-271* AST-252* AlkPhos-439*
TotBili-0.7
___ 10:05AM BLOOD Albumin-2.9* Calcium-9.3 Phos-2.6* Mg-1.6
___ 10:12AM BLOOD Lactate-3.3*
PERTINENT
___ 10:05AM BLOOD ALT-271* AST-252* AlkPhos-439*
TotBili-0.7
___ 08:00PM BLOOD ALT-271* AST-296* LD(___)-319*
AlkPhos-398* TotBili-0.6
___ 02:47AM BLOOD ALT-227* AST-216* LD(LDH)-256*
AlkPhos-339* TotBili-0.6
___ 02:47AM BLOOD Cortsol-11.6
___ 10:12AM BLOOD Lactate-3.3*
CXR
FINDINGS: A persistent patchy opacification in the left mid and
lower lung fields, unchanged from the prior exam. The right
lower lung aeration has improved from the prior exam with
resolution of the previously seen opacity.
On discharge:
Multiple small nodules are seen bilaterally, consistent with the
patient's known history of metastatic renal cell carcinoma. No
new opacifications are present. There is no pleural effusion or
pneumothorax. The cardiomediastinal silhouette is normal.
IMPRESSION:
1. Improvement in right lower lobe aeration with resolution of
previously
seen opacity.
1. Persistent left mid and lower lung opacification.
2. Multiple pulmonary nodules, consistent with known history of
metastatic renal cell carcinoma.
ABD U/S ___
FINDINGS: The liver shows no focal or textual abnormalities. The
gallbladder is normal, without evidence of stones. No intra- or
extra-hepatic biliary duct dilatation. The CBD measures 0.4 cm.
Normal appearance of the pancreas.
Note is made to multiple lymph nodes around the celiac axis.
Both right and left kidneys are normal without hydronephrosis or
stones. The right kidney measures 13.2 cm and the left kidney
measures 14.5 cm. Spleen is unremarkable measuring 12.2 cm. The
aorta is of normal caliber throughout.
The visualized portion of the inferior vena cava appears normal.
No ascites is detected.
COLOR DOPPLER AND SPECTRAL WAVEFORM ANALYSIS: The RHV, MHV, and
LHV are
patent, showing normal flow direction.
The MPV, RPV, and LPV are patent, showing normal flow direction
and normal
spectral waveform.
The hepatic artery is patent, showing normal spectral waveforms
with RI of
0.7. Normal flow is seen in the splenic vein.
IMPRESSION:
1. Normal appearance of the liver with no focal or textural
abnormalities.
2. The bile ducts are not dilated.
3. Normal liver vasculature.
3. Enlarged lymph nodes around the celiac axis consistent with
the patient's known lymphadenopathy.
Discharge:
___ 06:50AM BLOOD WBC-4.8 RBC-3.91* Hgb-9.7* Hct-32.2*
MCV-82 MCH-24.8* MCHC-30.1* RDW-18.9* Plt ___
___ 06:50AM BLOOD ___ PTT-29.9 ___
___ 06:50AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-138
K-4.6 Cl-97 HCO3-27 AnGap-19
___ 06:50AM BLOOD ALT-121* AST-85* LD(LDH)-262*
AlkPhos-221* TotBili-0.4
___ 06:50AM BLOOD Albumin-2.6* Calcium-9.8 Phos-3.4 Mg-1.8
___ 06:45AM BLOOD Cortsol-24.3*
___ 06:50AM BLOOD WBC-4.8 RBC-3.91* Hgb-9.7* Hct-32.2*
MCV-82 MCH-24.8* MCHC-30.1* RDW-18.9* Plt ___
___ 06:50AM BLOOD ___ PTT-29.9 ___
___ 06:50AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-138
K-4.6 Cl-97 HCO3-27 AnGap-19
___ 06:50AM BLOOD Albumin-2.6* Calcium-9.8 Phos-3.4 Mg-1.8
___ 06:45AM BLOOD Cortsol-24.3*
Medications on Admission:
axitinib [Inlyta] 5 mg one Tablet by mouth twice daily
erlotinib [Tarceva] 150 mg 1 Tablet by mouth once a day
lorazepam 1 mg 1 Tablet by mouth every four hours as needed for
nausea oxycodone 5 mg ___ Tablets by mouth ___ hours as needed
for pain
zinc oxide-cod liver oil [Diaper Rash] 40% Ointment apply to
affected area prn
Discharge Medications:
1. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0*
2. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Inlyta 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. oxycodone 5 mg Tablet Sig: ___ Tablets PO every four (4)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Metastatic renal cell carcinoma
Fevers
Hypotension
Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Tachycardia. History of renal cell carcinoma.
COMPARISONS: Chest radiograph ___. CTA chest ___.
FINDINGS: A persistent patchy opacification in the left mid and lower lung
fields, unchanged from the prior exam. The right lower lung aeration has
improved from the prior exam with resolution of the previously seen opacity.
Multiple small nodules are seen bilaterally, consistent with the patient's
known history of metastatic renal cell carcinoma. No new opacifications are
present. There is no pleural effusion or pneumothorax. The cardiomediastinal
silhouette is normal.
IMPRESSION:
1. Improvement in right lower lobe aeration with resolution of previously
seen opacity.
1. Persistent left mid and lower lung opacification.
2. Multiple pulmonary nodules, consistent with known history of metastatic
renal cell carcinoma.
Radiology Report
REASON FOR THE EXAMINATION: This is a ___ man with metastatic RCC
with elevated liver enzymes and epigastric pain; the request is to perform
right upper quadrant examination with Dopplers to evaluate for source of
elevated liver enzymes.
COMPARISON: CT torso from ___.
FINDINGS: The liver shows no focal or textual abnormalities. The gallbladder
is normal, without evidence of stones. No intra- or extra-hepatic biliary
duct dilatation. The CBD measures 0.4 cm. Normal appearance of the pancreas.
Note is made to multiple lymph nodes around the celiac axis. Both right and
left kidneys are normal without hydronephrosis or stones. The right kidney
measures 13.2 cm and the left kidney measures 14.5 cm. Spleen is unremarkable
measuring 12.2 cm. The aorta is of normal caliber throughout.
The visualized portion of the inferior vena cava appears normal.
No ascites is detected.
COLOR DOPPLER AND SPECTRAL WAVEFORM ANALYSIS: The RHV, MHV, and LHV are
patent, showing normal flow direction.
The MPV, RPV, and LPV are patent, showing normal flow direction and normal
spectral waveform.
The hepatic artery is patent, showing normal spectral waveforms with RI of
0.7. Normal flow is seen in the splenic vein.
IMPRESSION:
1. Normal appearance of the liver with no focal or textural abnormalities.
2. The bile ducts are not dilated.
3. Normal liver vasculature.
3. Enlarged lymph nodes around the celiac axis consistent with the patient's
known lymphadenopathy.
Gender: M
Race: OTHER
Arrive by UNKNOWN
Chief complaint: PALPATATIONS
Diagnosed with PALPITATIONS, HYPOTENSION NOS, VERTIGO/DIZZINESS, SEPTICEMIA NOS, SEPTIC SHOCK, SEVERE SEPSIS , ACCIDENT NOS
temperature: 98.5
heartrate: 168.0
resprate: 25.0
o2sat: 100.0
sbp: 126.0
dbp: 66.0
level of pain: 13
level of acuity: 1.0 | ___ M w metastatic RCC (papillary vs clear cell) to lungs & L
pleural effusions s/p multiple chemo regimens (most recently
cycle 10 of bevacizumab + erlotinib on ___, presents after
a recent admission to ___ for PNA, presented with fevers and
hypotension, which was managed with IVFs and antibiotics in the
FICU, but managed with steroids (stopped antibiotics) on the
floor, given that the fever and hypotension were likley related
to his underlying progressing malignancy and adrenal
insuffiency.
# Hypotension: The patient presented with hypotenstion that
resolved with IVF. The hypotension was likely due to
dehydration; the patient reported poor PO intake of fluid for a
few days prior to presenting to the hospital, partly due to
abdominal pain. The patient also reported a fever prior
admission. He was initially started on vanco/zosyn/azithromycin
out of concern for possible sepsis (given patient has recent
pneumonia requiring intubation). These antibiotics were stopped
due to 1)CXR demonstrating radiographic improvement of his
pneumonia, 2) recent completion of adequate antibiotics for that
pneumonia, and 3) rapid improvement of his hypotension and
fever. The patient's hypotension/fever was felt to be related
to underlying RCC and immulogical response by his primary
outpatient oncologist. The patient was started on Prednisone
40mg daily on HD#2, which was continued through discharge. The
patient will continue steroids, until his f/u with his medical
oncologist. The patient remained afebrile and normotensive
while on steroid (and off antibiotics) for the remained of his
hospital stay.
.
# Abdominal Pain: Intermittent sharp epigastric pain may
represent gas or gastritis, as symptoms improved with
simethicone. Given transaminitis, also concern for pain from
capsular swelling or obstruction. Given the persistent pain, GI
was consulted. He was taken for EGD which demonstrated normal
mucosa in the whole stomach (biopsy) and otherwise normal EGD to
third part of the duodenum. A gastric mucosal biopsies was taken
was within normal limits per histopathological examination. He
was continued on his home dose of omeprazole 20 mg daily. He
was also started on gabapentin 300mg TID given that he had
enlarge ___ lymph that could be potentially cause
neuropathic pain. He was started on oxycodone 10mg Extended
Release with oxycodone 5mg for breakthrough pain.
# Transaminitis: Possibly a sign of progressive disease.
However, may also consider iatrogenic, as patient started
erlotinib last week - listed common side effects of
transaminitis and abdominal pain. A RUQ ultrasound was negative.
# Renal Cell CA: metastatic disease. S/P cycle 10 erlotinib and
bevacizumab on ___. He was continued on erlotinib and
axitinib while inpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ man with CAD s/p PCI with chronic
anginal symptoms, symptomatic bradycardia status post pacer
placement at ___ several months prior, malignant
melanoma and other skin cancers s/p multiple resections and CLL
here for evaluation of atraumatic lower back pain. Patient
reports he awoke 2 days prior with mid back pain that has been
worsening in severity and is now radiating to his right flank.
The pain is exacerbated with movement. He does report
intermittent anginal symptoms over this time however he does
have
these at baseline, and was recently started on isosorbide
dinitrate (he also uses SL nitro occasionally in the evening).
He
denies dysuria, leg weakness/numbness/tingling, urinary fecal
incontinence, fevers, chills, night sweats, abdominal pain,
nausea, vomiting, diarrhea. He uses a cane at baseline, and is
independent in his ADLs except for the past few days as he was
limited by pain. Denies any skin rash or history of zoster.
Past Medical History:
--CLL: He is RAI stage I on the basis of his lymphadenopathy,
without hepatosplenomegaly. His Binet staging is unclear given
the unknown extent of lymphadenopathy. His WBC is overall
stable. His hemoglobin, platelet count are stable and his
symptoms remain unchanged during ___ ___ onc evaluation
--numerous, nonmelanoma skin cancers, as well as a melanoma
on the right shin, 0.4 mm, no mitoses and nonulcerated (___)
s/p multiple surgeries for removal of skin cancers
PMH/PSH:
1. Coronary artery disease status post stent in ___.
2. Hypertension.
3. Basal and squamous cell skin cancers.
4. Prostate cancer, previously on Lupron, managed by urology.
5. Osteoporosis.
6. History of blepharitis.
- Malignant melanoma
- CLL as above
- TMJ left-sided mass (likely benign salivary tumor, previously
followed at ___
- Bilateral cataract repair
- ? stroke vs TIA (head MRI ___ without any e/o acute
infarct)
Social History:
___
Family History:
No known family history of cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.2, 125/53, 61, 18, 95%RA
GEN: NAD
HEENT: PER and minimally reactive (2mm b/l), EOMI, MMM,
oropharynx clear, no cervical ___. L jaw nodular mass not TTP
Resp: slight bibasilar crackles, no wheezes or rhonchi
CV: RRR without m/r/g, nl S1 S2. JVP<7cm
Chest: left upper chest wall with well healed incision from PPM
placement.
ABD: normal bowel sounds, non-tender, not distended
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: alert and orientedx3, CN ___ grossly intact, ___ motor
grossly intact. Downgoing babinski's bilaterally. patellar
reflexes 1+ equal b/l.
Back: +TTP of thoracic/ upper lumbar spine. No paraspinal
tenderness. No CVA tenderness.
DISCHARGE PHYSICAL EXAM:
VS: 98 97.7 113-132/53-70 60-66 ___ 95/RA
GEN: NAD, sleeping in bed
HEENT: L jaw nodular mass not TTP and mobile, no JVD
Resp: CTAB, no wheezes or rhonchi
CV: RRR with ___ SEM throughout pericordium, no r/g, nl S1 S2.
Chest: left upper chest wall with well healed incision from PPM
placement.
ABD: normal bowel sounds, non-tender, not distended
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: ___ and ___ motor grossly intact.
Back: Dark red papules diffuse across his back with underlying
erythema. pain with palpation at T11 region. No paraspinal
tenderness. No CVA tenderness.
Pertinent Results:
ADMISSION LABS:
___ 03:48PM BLOOD WBC-21.5* RBC-3.82* Hgb-11.5* Hct-35.5*
MCV-93 MCH-30.1 MCHC-32.4 RDW-14.0 Plt ___
___ 03:48PM BLOOD Neuts-33* Bands-0 Lymphs-63* Monos-3
Eos-0 Baso-1 ___ Myelos-0
___ 03:48PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:25AM BLOOD ___ PTT-28.8 ___
___ 03:48PM BLOOD Glucose-108* UreaN-24* Creat-1.0 Na-135
K-4.1 Cl-102 HCO3-25 AnGap-12
___ 07:25AM BLOOD ALT-13 AST-57* LD(LDH)-216 CK(CPK)-604*
AlkPhos-47 TotBili-0.5
TROPONINS:
___ 04:48AM BLOOD CK-MB-6 cTropnT-2.19*
___ 03:37AM BLOOD CK-MB-30* MB Indx-7.2* cTropnT-1.04*
___ 01:20PM BLOOD CK-MB-56* MB Indx-9.3* cTropnT-1.06*
___ 05:50PM BLOOD cTropnT-0.18*
___ 03:48PM BLOOD cTropnT-0.18*
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-18.5* RBC-3.40* Hgb-10.4* Hct-30.8*
MCV-91 MCH-30.7 MCHC-33.8 RDW-13.8 Plt ___
___ 07:00AM BLOOD ___ PTT-59.6* ___
___ 05:25AM BLOOD Glucose-97 UreaN-17 Creat-0.7 Na-135
K-3.8 Cl-100 HCO3-24 AnGap-15
BONE SCAN Study Date of ___
INTERPRETATION: Whole body images of the skeleton obtained in
anterior and posterior projections show intense, linear tracer
uptake at the T11 vertebral body compatible with compression
fracture. Incidental note is made of focal tracer uptake at the
left 3rd rib end anteriorly compatible with prior trauma. There
is residual tracer in the bowel from a sestamibi cardiac
perfusion study the day before.
The kidneys and urinary bladder are visualized, the normal route
of tracer excretion.
IMPRESSION: Intense linear tracer uptake at T11 vertebral body
compatible with compression fracture.
CARDIAC PERFUSION PHARM Study Date of ___
INTERPRETATION:
The image quality is adequate but limited due to soft tissue and
left arm
attenuation.
Left ventricular cavity size is increased.
Rest and stress perfusion images reveal a fixed, moderate
reduction in photon counts involving the distal anterior wall,
distal septum, distal inferior wall and the apex. There is also
a fixed, severe reduction in photon counts involving the distal
lateral wall and the mid and distal inferior and inferolateral
walls.
Gated images reveal akinesis of the apex, distal lateral wall
and the mid
inferior and inferolateral walls. There is hypokinesis of the
distal anterior wall, distal septum, distal inferior wall, and
the basal inferior and inferolateral walls The calculated left
ventricular ejection fraction is 38% with an EDV of 147 ml.
IMPRESSION:
1. Fixed, medium sized, moderate severity perfusion defect
involving the LAD territory.
2. Fixed, large, severe perfusion defect involving the LCx
territory.
3. Increased left ventricular cavity size. Moderate systolic
dysfunction with multiple wall motion abnormalities as described
above.
Stress Study Date of ___
INTERPRETATION: This ___ year old man with h/o HTN, HLD, sCHF,
AS,
and stable angina; s/p MI ___, PPM in ___, and possible
PCI in
___ was referred to the lab for CAD evaluation. The patient was
admininstered 0.142 mg/kg/min of Persantine over four minutes.
The
patient presented with low/mid back discomfort constant over the
last
week. No other chest, neck, back, or arm discomforts were
reported by
the patient throughout the study. In the presence of baseline
ventricular pacing, the ST segments are uninterpretable for
ischemia.
The rhythm was intermittent A-V paced and sinus with ventricular
pacing.
Several, isolated APBs, one VPB, and an 11 beat run of atrial
tachycardia was noted after aminophylline. Appropriate
hemodynamic
response to the infusion. Post-MIBI, the Persantine was reversed
with 125 mg of Aminophylline IV. IMPRESSION: Non-anginal type
symptoms. Uninterpretable ST segments for ischemic in the
presence of ventricular pacing. Rhythm as noted. Nuclear report
sent separately.
ECG Study Date of ___ 4:56:32 ___
Atrial and ventricular sequential pacing. Compared to the
previous tracing of ___ there is no significant change.
Portable TTE (Complete) Done ___ at 3:50:06 ___
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with infero-lateral, apical and distal septal
hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the LVEF has decreased and regional LV systolic dysfunction is
much more extensive
ECG Study Date of ___ 10:41:08 AM
Probable A-V sequentially paced rhythm. Atrial spikes are
difficult to
discern. Compared to the previous tracing of ___ pacemaker
rhythm is
unchanged. However, T waves are now inverted in the
anterolateral precordial leads, although difficult to interpret.
Cannot rule out underlying myocardial ischemia. Clinical
correlation is suggested.
CHEST (PA & LAT) Study Date of ___ 5:18 ___
FINDINGS: Dual-lead pacer is unchanged. The heart remains
mildly enlarged. Since the CT torso, there has been no
significant change with mild bibasilar atelectasis again noted.
Gaseous distention of bowel in the upper abdomen noted without
signs of free air.
CTA CHEST W&W/O C&RECONS, NON-CORONARY, CTA Abd&Pelv Study Date
of ___ 5:02 ___
IMPRESSION:
1. No acute aortic abnormality or pulmonary embolus.
2. A 3.2 x 2.3 cm anterior mediastinal mass with internal
calcifications the upper portion of which was partially
visualized on prior CTA neck.
Differential includes lymphoma, thymoma, thyroid lesion or germ
cell tumor. Scattered prominent but nonenlarged mediastinal
lymph nodes.
3. 1-cm left lower lobe nodule and 6-mm right lower lobe
nodule. Given size, short-term followup is recommended as these
lesions are suspicious for metastases.
4. 1 cm intermediate density lesion in the right interpolar
kidney which may represent a cyst or solid lesion. Consider
ultrasound to further
characterize.
5. Top normal caliber of large bowel with air-fluid levels
without wall
thickening or pericolonic fat stranding is nonspecific, it could
be suggestive of a mild enteritis.
6. Trace ascites.
7. Small-to-moderate hiatal hernia.
8. Enlarged prostate.
9. Cholelithiasis without evidence for cholecystitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Doxazosin 8 mg PO HS
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
4. Simvastatin 40 mg PO QPM
5. Senna 8.6 mg PO BID:PRN constipation
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Dipyridamole-Aspirin 1 CAP PO BID
8. Lisinopril 40 mg PO DAILY
9. Isosorbide Dinitrate 30 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Dipyridamole-Aspirin 1 CAP PO BID
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. Doxazosin 8 mg PO HS
5. Isosorbide Dinitrate 30 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Acetaminophen 650 mg PO TID
9. Atorvastatin 80 mg PO DAILY
10. Bisacodyl ___AILY:PRN constipation
11. Lidocaine 5% Patch 1 PTCH TD QPM
12. Metoprolol Tartrate 6.25 mg PO BID
13. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*10 Tablet Refills:*0
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
15. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnoses:
- NSTEMI
- T11 compression fracture
- Mediastinal mass
Secondary diagnoses:
- Lung nodules, kidney nodule
- CLL
- Hypertension
- Coronary artery disease
- Prostate cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___.
___ and CTA torso from ___.
CLINICAL HISTORY: Back pain, question fluid overload.
FINDINGS: Dual-lead pacer is unchanged. The heart remains mildly enlarged.
Since the CT torso, there has been no significant change with mild bibasilar
atelectasis again noted. Gaseous distention of bowel in the upper abdomen
noted without signs of free air.
Radiology Report
HISTORY: Mid back pain radiating to the right flank with some associated
chest pain. Evaluate for thoracic or abdominal aortic aneurysm.
COMPARISON: Chest radiograph, ___.
TECHNIQUE: Axial helical MDCT images were obtained of the chest, abdomen and
pelvis after the administration of IV contrast in the arterial phase.
Multiplanar reformats were generated in the coronal and sagittal planes as
well as thin section maximum intensity oblique images.
DLP: 1128.55 mGy-cm.
FINDINGS:
CTA CHEST: Thyroid is unremarkable. Heart is enlarged with dense coronary
artery calcifications. Left-sided pacer with dual leads are in place. The
thoracic aortic arch is normal in caliber, without focal aneurysmal segment or
dissection. The main pulmonary artery is top normal in caliber, and there is
no pulmonary embolus to the subsegmental level. There are several calcified
mediastinal lymph nodes. There is a partially calcified anterior mediastinal
mass, measuring 3.2 x 2.3 cm (2:37) with internal calcification. There is no
supraclavicular, axillary, hilar or mediastinal lymphadenopathy by CT size
criteria, although there are few scattered top normal prominent mediastinal
lymph nodes.
There is posterior dependent atelectasis bilaterally. There is a 1-cm
pulmonary nodule at the left lung base (2:61). There is a 6-mm ___
nodule in the right lower lobe (2:50). Lungs are otherwise clear. Pleural
surfaces are clear without effusion or pneumothorax.
CTA ABDOMEN: The liver enhances homogeneously without focal lesion, intra- or
extra-hepatic biliary ductal dilatation. The portal vein is patent. There
are several large gallstones measuring up to 2.5 cm without evidence for
cholecystitis. The spleen, pancreas and adrenal glands are unremarkable.
Several subcentimeter renal hypodensities bilaterally are too small to fully
characterize, but likely represent cysts. There is a roughly 1 cm rounded
area of intermediate density in the right interpolar kidney of slightly
different enhancement pattern than the remainder of the kidney. The kidneys
otherwise present symmetric nephrograms without pelvicaliceal dilatation or
perinephric abnormalities.
There is a small-to-moderate sliding hiatal hernia. The stomach, duodenum and
remainder of the small bowel is otherwise grossly unremarkable. The colon is
top normal in caliber with some air-fluid levels, with fluid opacification
seen proximally but otherwise without wall thickening or pericolonic fat
stranding.
Atherosclerotic calcifications are seen along a normal caliber abdominal aorta
without aneurysm or dissection. The celiac axis, SMA, bilateral renal
arteries and ___ are grossly patent. There is no mesenteric or
retroperitoneal lymphadenopathy by CT size criteria. There is no
pneumoperitoneum. There is trace ascites. There is a small fat-containing
umbilical hernia.
CTA PELVIS: The bladder, rectum, and seminal vesicles are unremarkable. The
prostate is enlarged. There is a fat-containing left-sided inguinal hernia.
There is no inguinal or pelvic sidewall adenopathy by CT size criteria.
OSSEOUS STRUCTURES: Well-circumscribed sclerotic focus in the right sacral
ala is compatible with a bone island. There are no focal blastic or lytic
lesions in the visualized osseous structures concerning for malignancy.
IMPRESSION:
1. No acute aortic abnormality or pulmonary embolus.
2. A 3.2 x 2.3 cm anterior mediastinal mass with internal calcifications the
upper portion of which was partially visualized on prior CTA neck.
Differential includes lymphoma, thymoma, thyroid lesion or germ cell tumor.
Scattered prominent but nonenlarged mediastinal lymph nodes.
3. 1-cm left lower lobe nodule and 6-mm right lower lobe nodule. Given size,
short-term followup is recommended as these lesions are suspicious for
metastases.
4. 1 cm intermediate density lesion in the right interpolar kidney which may
represent a cyst or solid lesion. Consider ultrasound to further
characterize.
5. Top normal caliber of large bowel with air-fluid levels without wall
thickening or pericolonic fat stranding is nonspecific, it could be suggestive
of a mild enteritis.
6. Trace ascites.
7. Small-to-moderate hiatal hernia.
8. Enlarged prostate.
9. Cholelithiasis without evidence for cholecystitis.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Back pain
Diagnosed with BACKACHE NOS, HYPERTENSION NOS
temperature: 98.3
heartrate: 80.0
resprate: 16.0
o2sat: 95.0
sbp: 149.0
dbp: 64.0
level of pain: 7
level of acuity: 3.0 | PRIMARY REASON FOR ADMISSION:
___ year old male with CAD s/p PCI with chronic anginal symptoms,
symptomatic bradycardia s/p PPM, malignant melanoma and other
skin cancers s/p multiple resections and CLL with mid thoracic
back pain, found to have no osseous lesions but with CT scan
revealing new mediastinal mass as well as pulmonary nodules. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history significant
for obesity s/p Roux-en-Y gastric bypass done (___) who
presents
to the ED as a transfer from ___ for concern of
abdominal abscess versus pancreatic pseudocyst.
Patient describes a 3-week history of left-sided abdominal
discomfort and pain. Symptoms have been constant with
intermittent worsening in nature where she describes a crampy
___ abdominal pain. Symptoms not associated with any
nausea, vomiting or diarrhea. She did not have medical insurance
so did not go to hospital. This morning, pain was much worse so
she presented to ___. Patient denies any shortness
of
breath or chest pain. Otherwise no recent illness. States she
has
not had an appetite and is only being able to eat a little soup
and grapes. Denies any dysuria or hematuria. No vaginal bleeding
or discharge. Patient is a daily drinker drinking about a box of
wine daily. Last ingestion 5 AM this
morning. No history of alcohol withdrawal seizures. Does not
feel
like she is withdrawing.
Patient went to ___ had a CT scan done which show a
large complex cystic mass occupying much of the left upper
quadrant extending to the upper left pelvis which may represent
multiple pseudocyst formation from prior pancreatitis. An
abscess
is also possible. She also had lab work done which were
pertinent
for a white count of 9.2 with a hematocrit 32.6. AST 63, ALT 26,
alk phos of 241. Lipase of 542. Given CT findings abnormal lab
results, patient transferred here for further eval. She received
1 L of normal saline, morphine and Zofran. Also given Ativan.
Then transferred here for further care.
In the ED:
VS: Tmax 99.8, P 94, BP 120-140/70-84, RR ___, 94-96% on RA
ECG: QTc 383
PE: benign cardiopulmonary, abdominal and neuro exam
Labs: Lipase 291, AST 62, ALT 23, ALP 229, Tbili 0.6, Albumin
2.9, Utox pos opiates but otherwise all negative
Imaging: RUQUS with borderline dilated CHD, no cholelithiasis,
no
evidence of biliary obstruction on OSH CT, second opinion read
of
CT at OSH with likely pancreatic pseudocyst, reactive segmental
colitis
Impression: Pancreatitis, EtOH withdrawal
Interventions: LR @ 250, Ativan 0.5mg IV, dilaudid 0.5mg IV x 6,
valium 20mg, valium 10mg x3, thiamine/folate/MVI, 2 gm MgSulf
Consults: Bariatric surgery consulted, recommended NPO, IVF,
nutrition labs and admission to medicine for pancreatitis. they
reviewed imaging with radiology noting peripancreatic fluid
collections, no abscess, no necrosis
On arrival to the floor patient requested valium for alcohol
withdrawal. She complained of persistent periumbilical pain
which
she states has been constant for the past 2 weeks. She also
reported feeling anxious and very shaky with difficulty holding
a
cup because of the tremors. She states she was feeling like she
was malnourished and questioned why she couldn't eat anything by
mouth. She denies active nausea or vomiting, she denied fevers
or
chills. States she was given jello and broth earlier today which
she tolerated fine.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Anxiety
Allergic Rhinitis
Alcohol Use Disorder / Alcohol Dependence
LTBI s/p INH
History of Roux-en-Y Gastric Bypass - ___
History of breast augmentation
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION
VITALS: reviewed in POE, ___
GENERAL: Alert, anxious, tremulous
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, somewhat tender to palpation in
periumbilical and lower quadrants without guarding or rebound.
Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly
symmetric
SKIN: No obvious rashes or ulcerations noted on cursory skin
exam
NEURO: tremulous, alert, oriented, face symmetric, speech fluent
but with lag in answering time, moves all limbs
PSYCH: anxious, somewhat difficult to engage, answering in short
sentences with some impairment in attention span and memory
recall but difficult to gauge whether or not this was
volitional.
DISCHARGE
VS: ___ 0021 Temp: 98.2 PO BP: 102/67 HR: 74 RR: 18 O2 sat:
97% O2 delivery: RA
Gen - sitting up in bed, comfortable appearing
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft, nontender to deep palpation; no rebound/guarding;
normal bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 11:57PM BLOOD WBC-8.8 RBC-3.02* Hgb-9.4* Hct-29.4*
MCV-97 MCH-31.1 MCHC-32.0 RDW-17.1* RDWSD-60.5* Plt ___
___ 11:57PM BLOOD Glucose-81 UreaN-4* Creat-0.4 Na-139
K-4.2 Cl-101 HCO3-22 AnGap-16
___ 11:57PM BLOOD ALT-25 AST-68* AlkPhos-231* TotBili-0.5
___ 11:57PM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.4 Mg-1.6
Iron-48
___ 09:40AM BLOOD ASA-NEG Ethanol-NEG Tricycl-NEG
SECOND OPINION CT TORSO
1. Large complex peripancreatic collection most likely a
pancreatic
pseudocyst. Difficult to exclude a component of pancreatic
necrosis though overall volume of the pancreas appears
preserved.
2. Segmental colitis along the mid transverse and splenic
flexure likely
reactive with, given contact by adjacent pancreatic pseudocyst.
3. Nonspecific peritoneal nodularity along the anterolateral
right abdominal wall, attention on follow-up.
4. Hepatic steatosis
5. Postsurgical changes from Roux-en-Y gastric bypass without
evidence of
obstruction.
6. The appendix is normal.
LIVER OR GALLBLADDER US
1. Borderline dilated common hepatic duct. On outside hospital
CT, the common hepatic duct and common bile duct taper gradually
toward the ampulla without evidence of obstruction.
2. Peripancreatic fluid collections as assessed on outside
hospital CT 1 day prior.
3. No cholelithiasis.
DISCHARGE
___ 05:06AM BLOOD WBC-4.3 RBC-3.10* Hgb-9.6* Hct-30.7*
MCV-99* MCH-31.0 MCHC-31.3* RDW-16.9* RDWSD-60.4* Plt ___
___ 05:06AM BLOOD Glucose-82 UreaN-3* Creat-0.5 Na-143
K-4.4 Cl-103 HCO3-25 AnGap-15
___ 05:06AM BLOOD ALT-25 AST-53* AlkPhos-175* TotBili-0.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
3. Cetirizine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute alcohol pancreatitis
# Pancreatic pseudocyst
# Transaminitis
# Alcohol abuse complicated by withdrawal
# Peripheral neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with pancreatitis
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.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is trace perihepatic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 8 mm. On outside hospital CT, the common hepatic duct and common bile
duct taper gradually toward the ampulla without evidence of obstruction.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas. And peripancreatic fluid better assessed on outside hospital CT.
Irregularly marginated hypoechoic fluid in the left upper quadrant appears
similar to the outside hospital CT scan obtained 1 day prior.
SPLEEN: Normal echogenicity.
Spleen length: 11.1 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Borderline dilated common hepatic duct. On outside hospital CT, the common
hepatic duct and common bile duct taper gradually toward the ampulla without
evidence of obstruction.
2. Peripancreatic fluid collections as assessed on outside hospital CT 1 day
prior.
3. No cholelithiasis.
Radiology Report
EXAMINATION: SECOND OPINION OF CT ABDOMEN AND PELVIS
INDICATION: ___ female with pancreatitis. Evaluate fluid collection.
TECHNIQUE: Not available as this study was completed at an outside hospital.
DOSE: Not available as this study was completed at an outside hospital.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: There is mild dependent atelectasis in the bilateral lower lobes
and subsegmental atelectasis in the right lower lobe. There is no pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates low attenuation, compatible with hepatic
steatosis. There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: There is significant peripancreatic stranding and peripancreatic
fluid. There is a complex multiloculated peripancreatic collection which
encases the pancreatic tail, contacts the splenic flexure of the colon
anterolaterally, extends inferiorly along the anterior pararenal fascia and
lateral conal fascia and extends medially along the anterior body of the
pancreas tracking along the transverse mesocolon. This collection is
irregular and poorly defined, its approximate measurement is 13.0 x 10.6 x
26.0 cm (ap x tv x cc: 2:31 and 601:63). The overall volume of the pancreas
appears preserved. The splenic vein is attenuated and encased by the
peripancreatic collection though appears patent. There is no convincing
evidence of significant pancreatic necrosis. There is no main ductal
dilatation.
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: Postsurgical changes from Roux-en-Y gastric bypass are
noted. Oral contrast is seen to the ileum. The stomach is otherwise
unremarkable. The small bowel is unremarkable without evidence of
obstruction. The appendix is normal. There is wall thickening of the colon
extending from the splenic flexure to the distal descending colon, which abuts
the complex peripancreatic fluid collection. Subtle peritoneal nodularity is
seen along the right anterolateral body wall best seen on series 4, image 206,
of unclear etiology, attention on follow-up advised.
PELVIS: There is mild wall thickening of the bladder. There is low volume
minimally complex free fluid in the pelvis. (2:78)
REPRODUCTIVE ORGANS: The uterus is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Bilateral breast prosthesis are noted. There is a fat
containing ventral hernia..
IMPRESSION:
1. Large complex peripancreatic collection most likely a pancreatic
pseudocyst. Difficult to exclude a component of pancreatic necrosis though
overall volume of the pancreas appears preserved.
2. Segmental colitis along the mid transverse and splenic flexure likely
reactive with, given contact by adjacent pancreatic pseudocyst.
3. Nonspecific peritoneal nodularity along the anterolateral right abdominal
wall, attention on follow-up.
4. Hepatic steatosis
5. Postsurgical changes from Roux-en-Y gastric bypass without evidence of
obstruction.
6. The appendix is normal.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with pancreatitis and pancreatic pseudocyst,
unclear if alcohol vs stone related; CT with high density material within the
lumen of a dilatedgallbladder// better characterize biliary tree for signs of
stones or sequelae of recent obstruction to explain pancreatitis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Prior CT abdomen done ___
FINDINGS:
Lower Thorax: Trace left-sided pleural effusion. No pericardial effusion. No
confluent airspace consolidation. Bilateral breast prostheses in situ.
Liver: Severe hepatic steatosis with a fat fraction of 25%. No focal
suspicious hepatic lesions. No intrahepatic bile duct dilatation.
Biliary: The CBD is mildly dilated measuring 9 mm diameter. It tapers
smoothly towards the ampulla. No gallstones. No CBD stones.
Pancreas: Decreased T1 signal intensity of the body and tail of the pancreas
in keeping with acute edematous pancreatitis. No nonenhancing areas seen to
suggest pancreatic parenchymal necrosis. Again noted are complex rim
enhancing, multiloculated fluid collection which encases the pancreatic tail,
contacts the splenic flexure of the colon anterolaterally, extends inferiorly
along the anterior pararenal fascia and lateral conal fascia. It also extends
medially along the anterior body of the pancreas tracking along the transverse
mesocolon. The collection is also seen superior to the tail of the pancreas
extending medial to the spleen tracking inferiorly via the posterior pararenal
space.
Spleen: No focal splenic lesions. Small accessory spleen.
Adrenal Glands: The adrenals appear normal.
Kidneys: The kidneys appear normal. No hydronephrosis.
Gastrointestinal Tract: Post surgical anatomy after gastric bypass. Edematous
appearance of the splenic flexure is most likely secondary to adjacent
inflammation from the pancreas. The patient is status post Roux-en-Y gastric
bypass without evidence of obstruction.
Lymph Nodes: A couple of small reactive mesenteric lymph nodes.
Vasculature: The major peripancreatic vessels are patent.
Osseous and Soft Tissue Structures: No suspicious bony lesions. Small foci
of susceptibility in the anterior abdomen is non specific, likely from prior
surgery.
IMPRESSION:
1. Findings in keeping with acute pancreatitis involving the body and tail of
the pancreas. No pancreas non enhancement to suggest pancreatic necrosis.
2. Extensive peripancreatic fluid collections as described above. Appearing
well circumscribed, they may represent acute necrotizing collections vs
walled-off necrosis, the former more likely given the reported ___ weeks of
symptoms.
3. No gallstones or CBD stones to suggest gallstone pancreatitis.
4. The major vessels surrounding the pancreas appears patent.
5. Severe hepatic steatosis. No suspicious focal hepatic lesions.
6. Please note that the previously described right anterior omental soft
tissue nodules is not included in the MRI scan volume and reference is made to
prior CT report dated ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Abscess, Transfer
Diagnosed with Acute pancreatitis without necrosis or infection, unsp, Left lower quadrant pain
temperature: 98.8
heartrate: 94.0
resprate: 18.0
o2sat: 95.0
sbp: 120.0
dbp: 70.0
level of pain: 7
level of acuity: 3.0 | This is a ___ year old female with past medical history of
obesity
status post Roux-en-Y gastric bypass, alcohol abuse, admitted
___ with 2 weeks of persistent abdominal pain found to
acute pancreatitis with pancreatic pseudocyst, course
complicated by alcohol withdrawal, treated conservatively with
subsequent improvement, able to tolerate Bariatric 4 diet, being
discharged home
# Generalized Abdominal pain secondary to
# Acute alcohol pancreatitis
# Pancreatic pseudocyst
# Transaminitis
Patient with history of roux-en-y who presented with 2 weeks of
abdominal pain in setting of ongoing heavy alcohol use, found to
have elevated lipase, OSH imaging with suspected pancreatic
psuedocyst. She was seen by pancreas consult and bariatric
surgery consult, was made NPO, started on IV fluids and prn pain
and nausea medications. Given question of abnormal material
seen in gallbladder on CT scan by surgical service, patient
underwent MRCP to rule out biliary stone or anatomic
abnormality. MRCP showed findings consistent with acute
pancreatitis with extensive peripancreatic fluid collections".
No gallstones or CBD stones were seen to suggest gallstone
pancreatitis. She was recommended for ongoing conservative
management. Patient symptoms rapidly improved and she was able
to rapidly advance her diet. She subsequently tolerated a
bariatric 4 diet without issue and demonstrated ability to
maintain her hydration and nutritional status. She was weaned
off pain medications without issue. Patient able to be
discharged home.
# Alcohol abuse complicated by withdrawal
Demonstrated signs of withdrawal on presentation. Initially
reported drinking a small amount each day, but later revealed it
was closer to 5L box of wine over ___ days. Treated for alcohol
withdrawal with valium CIWA. Gave IV thiamin, PO folate,
multivitamin. CIWA subsequently able to be discontinued and
patient remained stable x 1 day. She received counseling from
social work input, was contemplating quitting and was given
potential information re; resources for assistance.
# Peripheral neuropathy
Reported chronic numbness in feet. Given her history, suspected
to be alcohol-related. Would consider additional workup an
management of this. Zinc level pending at discharge.
# Abnormal MRI Liver
MRCP incidentally showed "Severe hepatic steatosis.". Would
consider hepatology referral as outpatient. Counseled on
alcohol cessation as above.
# History of roux-en-y gastric bypass
As surgery was done in ___, patient does not have local
bariatric provider. Patient was recommended to establish with
one. Patient reported that once her ___ gets approved,
she will establish with a bariatric ___ local to her in
___.
# Abnormal CT Abdomen
OSH CT incidentally showed "Nonspecific peritoneal nodularity
along the anterolateral right abdominal wall." ___ radiology
recommended "attention on follow-up." Would consider discussion
re: utility of repeat imaging in the future and/or additional
workup as outpatient.
Transitional issues
- Discharged home
- Recommended to continue Bariatric 4 diet
- Received alcohol cessation counseling
- Patient reports history of B12 deficiency; would consider
outpatient evaluation and therapy for this
- Discharged with ___ application pending--patient plans
to establish with local PCP and ___ in/near
___
> 30 minutes spent on this discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Shoulder Pain
Major Surgical or Invasive Procedure:
___ I&D SHOULDER RIGHT ARTHROSCOPY
History of Present Illness:
___ PMH of AFib (on Xarelto), OA, Metastatic Prostate cancer
(c/b
bone mets, s/p chemotherapy now on clinical trial
pembrolizumab/radium) who presented to the ED with R shoulder
pain and lightheadedness
Patient noted that he has had weeks of right shoulder pain,
which
feels like sharp stabbing, that is better with rest, worse with
movement, ___ at times, not a/w shoulder swelling/erythema. He
noted that oxycontin/oxycodone help but he tries not to take the
short acting as he feels that it makes his thought process
clouded. He was seen ___ the ED on ___ for such pain where
Xray revealed mild inferior subluxation of the right shoulder
without definite findings of dislocation and no fracture or
suspicious osseous lesions. He was presumed to have adhesive
capsulitis so was discharged with orthopedics f/u which he
attempted to go to today, but was sent to his PCP once ortho
team
identified that he had low BP + orthostatic symptoms. PCP then
sent patient to ED for evaluation.
With regard to lightheadedness, patient noted that it is only
with movement, and is absent at rest. He noted that he feels
very
fatigued when exerting himself, and occasionally slightly short
of breath, but denied chest pain/discomfort. He noted that he
was
without any blood ___ his urine or stool. No melena. Noted that
such symptoms were subacute over the past few weeks, which he
thought was related to overdiuresis so he decreased torsemide
from 40 to 20mg daily. He noted that his lower extremity edema
has been minimal on torsemide but that his RUE has had increased
edema ___ last week or two.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___ Prostate cancer diagnosed: adenocarcinoma ___ 3 cores,
right mid-medial ___ 4+3 involving 40%, right base lateral
___ 4+3 involving 75%, and right base medial ___ 4+4
involving 70%, extensive prostate tumor ___ the anterior gland
with extracapsular extension and invasion of the inferior
bladder
wall, bilateral peripheral zone tumors, and bilateral sidewall
lymphadenopathy, cT3aN1M0
-___ initiated leuprolide and bicalutamide
-___ - external beam radiation, stop bicalutamide
-___ - completed ___ years of leuprolide therapy
-___ - large rise ___ PSA (15.9). Underwent restaging and his
bone scan showed two new lesions at T9 and L4. Therefore, he was
restarted on Lupron. Seen by Dr. ___ 10 fractions of XRT
to his spine and femur as prophylactic therapy
-___ - PSA increased to 7.5 from 0.8-1.7. Started
enzalutamide. Denosumab x 1 dose.
-Docetaxel C1D1 ___ :c/b infection, leg swelling, cough,
diarrhea and was hospitalized with neutropenia.
-Docetaxel C2D1 ___
-Docetaxel C3D1 ___ + neulasta onbody
-Docetaxel C4D1 ___ + neulasta onbody
-Docetaxel C5D1 ___ + neulasta onbody + Lupron
- ___: Progression of known bony metastatic disease
- ___: Screened for protocol ___
- ___: CT-guided bone biopsy
Social History:
___
Family History:
Mother died of colon cancer at ___
Father died ___ ___ of unclear causes
Physical Exam:
Admission Exam:
===============
GENERAL: Pleasant man, ___ no distress, sitting ___ bed
comfortably.
EYES: Anicteric, PERLL
HENT: OP clear. MMM, supple neck
CARDIAC: RRR, normal distal perfusion, trace peripheral edema ___
legs
LUNG: Appears ___ no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi. normal RR
ABD: Soft, non-tender, non-distended, normal bowel sounds
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness. RUE unable to be lifted off bed but has normal
strength ___ forearm, wrists, and fingers. Specifically has
problems with abduction. Patient has improved ROM with passive
movement, but is limited by extreme pain with minor adjustments.
Has tenderness both at AC joint and coracoid process, no
effusion
or erythema. Left shoulder normal.
NEURO: A&Ox3, good attention and linear thought. Sensation to
light touch intact.
SKIN: No significant rashes.
ACCESS: PORT with dressing c/d/i
Discharge Exam:
===============
GENERAL: Sitting ___ chair, no apparent distress
CARDIAC: RRR, no murmurs
LUNG: CTAB, no wheezes or crackles
ABD: BS+. Soft, non-tender, non-distended.
EXT: Warm, well perfused. Pain with active/passive motion of
Right shoulder. Right shoulder tender to palpation
NEURO: A&Ox3.
SKIN: No significant rashes
ACCESS: PORT with dressing c/d/i
Pertinent Results:
Admission Labs:
===============
___ 12:35PM BLOOD WBC-2.5* RBC-1.99* Hgb-5.6* Hct-17.5*
MCV-88 MCH-28.1 MCHC-32.0 RDW-18.0* RDWSD-57.1* Plt Ct-44*
___ 12:35PM BLOOD Glucose-129* UreaN-15 Creat-0.6 Na-129*
K-4.2 Cl-88* HCO3-25 AnGap-16
___ 04:52AM BLOOD Calcium-7.8* Phos-4.0 Mg-2.1
___ 07:35PM BLOOD ALT-47* AST-65* LD(LDH)-320* AlkPhos-283*
TotBili-1.1
Reports:
=======
Us left upper extremity ___:
IMPRESSION:
No evidence of deep vein thrombosis ___ the right upper
extremity.
CXR ___:
IMPRESSION:
Left costophrenic angle not fully included on the image. Given
this, no large pleural effusion or focal consolidation. Likely
mild basilar atelectasis
CT Left upper extremity:
IMPRESSION:
1. Fluid collection with peripheral hyper enhancement ___ the
right
subscapularis muscle is likely tracking from the joint space
into the
subscapularis recess consistent with a moderately large
effusion. Similar
appearing fluid ___ the subacromial subdeltoid bursa is likely
tracking volar via a full-thickness rotator cuff tear however
this would be better evaluated with an MRI of the shoulder.
Tiny locules of air within the fluid collection are presumed
related to prior intervention.
2. Moderate degenerative changes at the right glenohumeral
joint.
3. Multiple sclerotic foci involving the right distal clavicle,
several
vertebral bodies, and second right rib. Appearances are highly
concerning for metastatic disease, given the patient's history
of prostate cancer, recommend further evaluation with bone scan
if it will alter clinical management..
4. Replacement of the normal fatty marrow ___ the right humerus
is nonspecific ___ appearance on CT imaging and could reflect red
marrow reconversion, particularly ___ a patient receiving
chemotherapy. This could also be better evaluated with a
shoulder MRI.
5. Nonvisualization of the proximal portion of the long head of
the biceps
tendon and fluid within at the level of the myotendinous
junction suspicious for a tear.
6. New enlarged right paratracheal lymph node, recommend
dedicated chest
imaging to better evaluate.
7. Multiple small pulmonary nodules, likely unchanged when
compared to the
prior study allowing for slight differences ___ imaging
technique. Continued attention on followup recommended
Unilateral Upper extremity vein: ___
IMPRESSION:
No evidence of deep vein thrombosis ___ the right upper
extremity, however
portions of the subclavian vein are not visualized.
Micro:
___ 2:20 pm SWAB Site: SHOULDER RIGHT.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Susceptibility testing performed on culture # ___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 3:07 pm JOINT FLUID Source: right shoulder.
**FINAL REPORT ___
GRAM STAIN (Final ___:
THIS IS A CORRECTED REPORT ( ___.
Reported to and read back by ___. ___ ___
10:45AM.
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
PREVIOUSLY REPORTED AS (___).
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Discharge Labs:
==============
___ 07:20PM BLOOD WBC-1.2* RBC-2.50* Hgb-7.3* Hct-21.5*
MCV-86 MCH-29.2 MCHC-34.0 RDW-16.4* RDWSD-50.6* Plt Ct-30*
___ 04:55AM BLOOD Neuts-67 Bands-6* Lymphs-14* Monos-5
Eos-3 Baso-0 Atyps-1* ___ Myelos-3* Promyel-1* NRBC-3*
AbsNeut-0.66* AbsLymp-0.14* AbsMono-0.05* AbsEos-0.03*
AbsBaso-0.00*
___ 04:55AM BLOOD Glucose-97 UreaN-10 Creat-0.4* Na-132*
K-3.6 Cl-89* HCO3-34* AnGap-9*
___ 05:15AM BLOOD ALT-37 AST-60* LD(LDH)-358* AlkPhos-215*
TotBili-0.6
___ 04:55AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.8
___ 07:10AM BLOOD CRP-GREATER TH
___ 04:12AM BLOOD CRP-212.3*
___ 03:07PM JOINT FLUID ___ Polys-90*
___ Macro-9
___ 03:07PM JOINT FLUID Crystal-NONE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Gabapentin 600 mg PO BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. LORazepam 1 mg PO QHS:PRN insomnia
6. Metoprolol Succinate XL 125 mg PO BID
7. Omeprazole 20 mg PO NOON
8. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
9. Pravastatin 40 mg PO QPM
10. Rivaroxaban 20 mg PO DAILY
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. Tamsulosin 0.4 mg PO QHS
13. Torsemide 40 mg PO DAILY
14. Asmanex Twisthaler (mometasone) 110 mcg (30 doses)
inhalation QHS
15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral NOON
16. Docusate Sodium 200 mg PO DAILY
17. Leuprolide Acetate 11.25 mg IM Q3MO
18. Polyethylene Glycol 17 g PO DAILY
19. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. CeFAZolin 2 g IV Q8H
2. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
RX *heparin lock flush (porcine) 10 unit/mL 5 mL IV daily and
PRN Disp #*10 Vial Refills:*0
3. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
RX *heparin lock flush (porcine) 100 unit/mL 5 mL IV PRN Disp
#*2 Vial Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QPM
5. Miconazole Powder 2% 1 Appl TP QID:PRN fungal rash
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
8. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Mild
Hold for sedation or RR<12
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*12
Tablet Refills:*0
10. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
Hold for sedation or RR<12
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*8 Tablet Refills:*0
11. Torsemide 20 mg PO DAILY
12. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
13. Asmanex Twisthaler (mometasone) 110 mcg (30 doses)
inhalation QHS
14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral NOON
15. Docusate Sodium 200 mg PO DAILY
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY
17. Gabapentin 600 mg PO BID
18. Levothyroxine Sodium 75 mcg PO DAILY
19. LORazepam 1 mg PO QHS:PRN insomnia
RX *lorazepam 1 mg 1 mg by mouth QHS PRN Disp #*6 Tablet
Refills:*0
20. Metoprolol Succinate XL 125 mg PO BID
21. Omeprazole 20 mg PO NOON
22. Polyethylene Glycol 17 g PO DAILY
23. Pravastatin 40 mg PO QPM
24. Senna 8.6 mg PO BID:PRN Constipation - First Line
25. Tamsulosin 0.4 mg PO QHS
26. HELD- Rivaroxaban 20 mg PO DAILY This medication was held.
Do not restart Rivaroxaban until your doctor says it is ok and
your platelet count has recovered
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
Infectious Arthritis
Secondary Diagnosis:
===================
Prostate Cancer
Hypothyroidism
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old man with R hand swelling// ?DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the right subclavian vein.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with febrile neutropenia// evidence of PNA?
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Right-sided Port-A-Cath terminates in the low SVC without evidence of
pneumothorax. The patient is rotated somewhat to the left. Cardiac and
mediastinal silhouettes are stable. The left costophrenic angle is not fully
included on the image; given this, no large pleural effusion is seen. No
focal consolidation is seen. There is no evidence of pneumothorax.
IMPRESSION:
Left costophrenic angle not fully included on the image. Given this, no large
pleural effusion or focal consolidation. Likely mild basilar atelectasis.
Radiology Report
EXAMINATION: Right shoulder CT with contrast.
INDICATION: ___ PMH of AFib (on Xarelto), OA, Metastatic Prostate cancer (c/b
bone mets, s/p chemotherapy now on clinical trial pembrolizumab/radium) who
presented to the ED with R shoulder pain, for which Xray negative but would
like CT to assess for metastatic lesion vs fracture vs adhesive capsulitis//
___ PMH of AFib (on Xarelto), OA, Metastatic Prostate cancer (c/b bone mets,
s/p chemotherapy now on clinical trial pembrolizumab/radium) who presented to
the ED with R shoulder pain, for which Xray negative but would like CT to
assess for metastatic lesion vs fracture vs adhesive capsulitis
TECHNIQUE: Right shoulder CT with bone reformats.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 26.1 cm; CTDIvol = 30.6 mGy (Body) DLP = 777.2
mGy-cm.
Total DLP (Body) = 777 mGy-cm.
COMPARISON: Chest CT from ___. Right shoulder radiograph from ___.
FINDINGS:
There is fluid seen extending into the subscapularis recess and subscapularis
muscle measuring 3.9 x 4.9 cm. This is likely contiguous with the
glenohumeral joints with fluid tracking into the subscapularis recess of the
joint space. Peripheral enhancement is noted. There is additional rim
enhancing fluid seen within the subacromial subdeltoid bursa. This is also
likely contiguous with the glenohumeral joint the a probable full-thickness
rotator cuff tear of the supraspinatus tendon (09:38). This not be could be
better evaluated with an MRI of the shoulder. There are tiny locules of air
seen within the subacromial subdeltoid bursa (03:21) and in the subcoracoid
recess (03:38) presumed to be related to prior intervention/aspiration.
There are moderate severe degenerative changes at the glenohumeral joint. No
osteolysis or periostitis to suggest osteomyelitis.
There is nonvisualization of the distal portion of the long head of the biceps
tendon in the intertubercular groove, suspicious for a tear. There is fluid
seen close to the myotendinous junction of the long head of biceps (4:61)
measuring 3.3 x 1.4 x 2.3 cm, likely tracking from the glenohumeral joint
space.
Moderate degenerative changes at the acromioclavicular joint with fragmented
osteophytes seen along superior joint margin.
There is no acute fracture or dislocation. There is moderate fatty atrophy of
the supraspinatus muscle.
There is scattered replacement of the fatty marrow in the humerus with soft
tissue density material, this is nonspecific in appearance on CT imaging and
could reflect red marrow or a neoplastic process. This could be better
evaluated with MRI.
Multiple foci of sclerosis are noted, including involving the distal clavicle,
T2 vertebral body, T4, T6 and T7 suspicious for metastatic lesions. An area
sclerosis is also seen in the right fifth rib (9:71) as well as the right
third rib (9:95).
Fusion hardware is seen in the low cervical spine.
In the visualized portions of the right lung there are multiple small nodules
seen. A right middle lobe nodule measures 6 mm (6:99), unchanged compared to
the prior study. A cluster of 3 small nodules each measuring 4 mm (6:96) and
a perifissural nodule measuring 4 mm (6:91) are noted. Allowing for
differences in imaging technique these are likely unchanged when compared to
the prior study but continued attention on follow-up CT chest is recommended.
There is a new enlarged right paratracheal node measuring 1.4 cm in short axis
(6:81).
IMPRESSION:
1. Fluid collection with peripheral hyper enhancement in the right
subscapularis muscle is likely tracking from the joint space into the
subscapularis recess consistent with a moderately large effusion. Similar
appearing fluid in the subacromial subdeltoid bursa is likely tracking volar
via a full-thickness rotator cuff tear however this would be better evaluated
with an MRI of the shoulder. Tiny locules of air within the fluid collection
are presumed related to prior intervention.
2. Moderate degenerative changes at the right glenohumeral joint.
3. Multiple sclerotic foci involving the right distal clavicle, several
vertebral bodies, and second right rib. Appearances are highly concerning for
metastatic disease, given the patient's history of prostate cancer, recommend
further evaluation with bone scan if it will alter clinical management..
4. Replacement of the normal fatty marrow in the right humerus is nonspecific
in appearance on CT imaging and could reflect red marrow reconversion,
particularly in a patient receiving chemotherapy. This could also be better
evaluated with a shoulder MRI.
5. Nonvisualization of the proximal portion of the long head of the biceps
tendon and fluid within at the level of the myotendinous junction suspicious
for a tear.
6. New enlarged right paratracheal lymph node, recommend dedicated chest
imaging to better evaluate.
7. Multiple small pulmonary nodules, likely unchanged when compared to the
prior study allowing for slight differences in imaging technique. Continued
attention on followup recommended.
RECOMMENDATION(S):
1. Evaluation of the fluid around the right shoulder region could be better
performed with an MRI of the right shoulder, including assessment of any
full-thickness rotator cuff tear and the biceps tendon.
NOTIFICATION: Findings and recommendations discussed with Dr. ___ by
telephone at 18:20 on ___ by Dr. ___, approximately 6
hours after discovery of the findings
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/FLUORO
INDICATION: ___ PMH of AFib, OA, metastatic Prostate cancer (c/bbone mets)
who admitted for w/u of acute R. shoulder pain + lightheadedness with T101.1F
on ___, no longer febrile, not on Abx.// Seen by Ortho, recommendation for ___
R. shoulder joint tap with Gram stain, Cx, crystals, cell count to R/O septic
joint. Plt 24, we will plan on giving plt before procedure. If okay with
procedure, please page us (___) about procedure time. Also page if concern
about plts or need for repeat plt count after transfusion.
COMPARISON: Right shoulder CT with contrast ___
PROCEDURE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained.
A pre-procedure timeout confirmed three patient identifiers.
Under fluoroscopic guidance, an appropriate spot was marked. The area was
prepared and draped in standard sterile fashion.
5 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent
fluoroscopic guidance, a 18-gauge spinal needle was advanced into the right
glenohumeral joint. No fluid could be aspirated with initial aspiration
attempt. The needle was repositioned 3 times without aspiration of fluid.
Appropriate position within the joint space was confirmed by injection of
intra-articular contrast. Contrast was seen to track into the subscapularis
recess. Attempted aspiration at this point still did not yield any fluid
therefore 10 cc of normal saline was injected into the joint and 15 cc of
opaque yellow fluid was the re-aspirated. Samples were sent for culture and
sensitivity, cell count and crystal analysis as requested.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in good
condition. There were no immediate complications or complaints.
FINDINGS:
Degenerative changes are noted in the acromioclavicular joint and glenohumeral
joint. Injection of iodinated contrast opacified the joint space with
tracking into the subscapularis recess, presumed to correspond to the fluid
collection seen on the prior CT.
IMPRESSION:
1. Imaging Findings- as above.
2. Procedure - Technically successful reaspiration of right glenohumeral
joint.
I Dr. ___ ___ supervised the Resident/Fellow during the
key components of the above procedure and I have reviewed and agree with the
Resident/Fellow findings/dictation.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old man with metastatic prostate cancer admitted for
septic R. shoulder joint growing coag-positive Staph aureus.// Duplex of
tunneled line to r/o possible subclavian clot that could be superinfected iso
septic R. shoulder joint. ___ MD at ___ if any questions about
order.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: No prior imaging for comparison.
FINDINGS:
The visualized right subclavian vein is patent with antegrade flow, however
portions of the vein are not seen due to overlying dressing.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity, however
portions of the subclavian vein are not visualized.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with Anemia, unspecified
temperature: 97.4
heartrate: 109.0
resprate: 20.0
o2sat: 97.0
sbp: 128.0
dbp: 63.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ is a ___ y.o. male with atrial fibrillation (on
Xarelto), osteoarthritis, metastatic Prostate cancer (c/b bone
mets, s/p chemotherapy now on clinical trial
pembrolizumab/radium) who presented to the ED with
lightheadedness and R shoulder pain that was found to be a
septic R. shoulder joint growing MSSA. He is s/p I&D of R.
shoulder joint on ___ and on cefazolin for 6 week course of
therapy. His hospital course was complicated by pancytopenia and
acute on chronic pain requiring titration of his medications.
=====================
ACUTE ISSUES
=====================
#R. septic shoulder joint
Mr. ___ presented with R. shoulder pain and a documented
fever of 101.1F on ___. Orthopedics was consulted and a R.
shoulder CT was obtained. R. shoulder CT was notable for
multiple sclerotic foci involving right distal clavicle, several
vertebral bodies, and second right rib, though was thought not
to be contributing to his R. shoulder pain. It was also notable
for biceps tendon tear, degenerative changes at R. ___ joint,
fluid collection ___ R. subscapularis muscle tracking from joint
space into subscap recess + fluid collection ___ subacromial
subdeltoid bursa. ___ performed an aspiration of this fluid on
___, and the aspirate was found to grow MSSA. He was initially
started on vanc (___) + ceftriaxone (___) and switched
to cefazolin based on sensitivities. He had an I&D of his septic
R. shoulder joint on ___. ID was consulted regarding antibiotic
use and duration, as well as OPAT coordination. Per ID, he
should continue IV cefazolin 2g q8h until ___ for his R. septic
shoulder joint (___). A duplex U/S of his tunneled line
was obtained to rule out possible infected subclavian clot that
may have seeded his R. shoulder joint; however, U/S was largely
negative for DVT. The subclavian could not be fully appreciated
due to overlying dressings from his I&D, however ID did not
recommend repeat U/S.
#MSSA R Shoulder Infection
He presented with several weeks of worsening shoulder pain and
weakness on the right. He underwent CT of the R shulder on ___
which demonstrated an enhancing fluid collection extending into
the subcapsularis muscle tracking from glenohumeral joint space
with large joint effusion. Orthopedic surgery was consulted and
performed R shoulder arthrocentesis on ___ which demonstrated
87,895 WBC (97% polys) and ultimately grew MSSA. He underwent
I&D on ___ with orthopedic surgery. ID was consulted for
antibiotic management and he was transitioned to cefazolin for
planned 6 week course. He had no positive blood cultures. His
course is as follows: Start date: ___. Stop date: ___.
#Right shoulder pain
He denied any history of prior trauma to the shuolder. Due to
severe uncontrolled pain over the admission his pain medications
were uptitrated. Oxycontin was uptitrated from 10mg BID to 20mg
BID. His oxycodone breakthrough pain dose was increased to
___ q4h. Regarding the etiology of his pain, which persisted
even after I&D, orthopedic surgery felt the patient's CT was
also notable for possible adhesive capsulitis vs. rotator cuff
tea vs. biceps tendonitis. Per Ortho, shoulder MRI was not
necessary at the time of his hospitalization and was more
appropriate for outpatient follow-up. He was scheduled for
orthopedics follow up ___ 2 weeks time.
#RUE Edema
This was likely ___ immobility from painful shoulder, as DVT
study was negative at admission and edema improved gradually,
prior to discharge.
#Metastatic Prostate Cancer:
#Pancytopenia
During his hospitalization, he was on a study regimen of radium
+ pembrolizumab and presented with severe
anemia/thrombocytopenia/leukopenia. He continued to be
pancytopenic. PF-4 Ab was obtained, but was negative sp HIT was
ruled out. The differential for this included prolonged
myelosuppresion from radium treatment or progression/bone marrow
infiltration of his malignancy. He was disenrolled from the
clinical trial. He received pRBC and platelet transfusions to
goal of Hgb 7 and platelet 20 prior to discharge. His
anticoagulation was discontinued due to thrombocytopenia. Bone
marrow biopsy was not seen as an urgent procedure that needed to
be performed during this admission, but could be considered as
an outpatient.
#Hyponatremia
He was thought to have chronic hyponatremia. Given that he was
asymptomatic, we monitored his sodium. He continued to be
asymptomatic at discharge.
#Delirium
He reported 2 prior episodes of delirium the week prior to
admission, once at home and once ___ the ED. He became agitated
after starting a trial of high dose prednisone at night to help
with inflammation + appetite/fatigue on ___. This was
discontinued the following day and he was placed on delirium
precautions; he did not have any further episodes of delirium
while hospitalized.
#Fever
He reportedly had a fever of T101.1F while receiving his blood
transfusion on ___. CXR/UA + UCx neg/BCx neg. Transfusion
reaction work-up was neg. He was afebrile since ___. His fever
was thought to have been caused by his septic R. shoulder joint.
#Lightheadedness
He presented with orthostatic symptoms which are likely ___
hypovolemia from diuretics + anemia. He received IVF and pRBC
while hospialized. He appeared euvolemic on exam prior to
discharge. CTH from ___ negative for acute process.
=====================
CHRONIC ISSUES
=====================
# Hypothyroidism
He was continued on his home levothyroxine.
# Lower extremity edema
This was thought to be secondary to his disastolic heart failure
vs. docetaxol, which can cause lower extremity edema. We
initially held his home torsemide at admission, as he complained
of lightheadedness and there was concern for hypovolemia. He was
restarted on his torsemide on ___, but at a lower dose of 20mg
qd (regular home dose is 40mg qd), given his initial complaint
of lightheadedness. He was discharged on this lower dose.
# Peripheral neuropathy
He was continued on his home gabapentin.
# Paroxysmal atrial fibrillatin
He was continued on his home metoprolol 12.5mg bid. His home
rivaroxaban and all other forms of anti-coagulation were held ___
the setting of thrombocytopenia.
# Hyperlipidemia:
He initially presented with a transaminitis and his home statin
was held during this admission. It was restarted on discharge.
=====================
TRANSITIONAL ISSUES
===================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ yo F with history of infiltrating ductal
breast cancer (triple +, s/p mastectomy and reconstructive
surgery, s/p Cytoxan and Adriamycin followed by Taxol and
Herceptin as well as tamoxifen) who presented to the ED on
___ with four weeks of cough.
She was seen at ___ Urgent Care on ___ with 3.5
weeks of cough with scant sputum and occasional dyspnea with
climbing stairs. CXR with hyperinflation w/o infiltrate. She was
discharged home with 5 days of prednisone (40 mg) and an
albuterol inhaler. She re presented to urgent care on ___ and
vital signs were notable for HR 121 and O2 sat of 91% on room
air. O2 was 90% with ambulation. CXR was notable for mild
bronchial wall thickening at the lung bases. She was given dose
of azithromycin and transferred to ___ ED.
-In the ED, initial VS were: 98.4 97 107/70 20 95% RA
-Labs showed: WBC 12.9, CK MB and trop negative, urine w/small
leuks and few bact, flu negative
-Imaging showed:
--CXR:
Bronchitis at the lung bases.
--CTA:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral ___ opacities and more nodular opacities at
the left lung base in combination with bronchial wall thickening
and mucous plugging is suggestive of a multifocal infectious
process.
3. Calcified left hilar lymph nodes and calcified granulomas in
the left lung are suggestive of prior granulomatous infection.
-Consults: None
-Patient received:
-- 1.5 L NS, 2 grams IV ceftriaxone, ipratropium neb, albuterol
neb, azithromycin (at urgent care)
-Transfer VS were: 102.0 101 116/62 18 96% RA
On arrival to the floor, patient reports that she developed a
cough about four weeks ago. Initially accompanied by sore
throat.
She also had chills, muscle aches, mild congestion and runny
nose
as well as ear discomfort. She felt as though it was a cold, but
her sx did not improve. Two weeks ago had red eyes that improved
with OTC drops. Has been taking nyquil and advil very
frequently.
Did not have any fevers at home. Went to urgent care on ___
and was given prednisone and albuterol, which did not improve
her
sx. Returned to urgent care on ___ since sx were not improving.
Cough has persisted and has become productive-gray to white
sputum. Also notes shortness of breath with exertion and the
sensation of wheezing during these episodes. No associated CP,
n/v, diaphoresis with dyspnea. Has never had dyspnea prior to
this episode.
Denies fevers, n/v, abdominal pain, diarrhea, constipation,
dysuria, change in urinary frequency, leg swelling, CP,
palpitations, skin changes, new lumps/bumps. Endorses decreased
PO intake and decreased appetite. She works at ___ so has been
exposed to sick people and also has a ___ yo nephew that she
spends
time with as well.
REVIEW OF SYSTEMS: See above
Past Medical History:
BREAST CANCER
- Dx ___: L 1.8 cm grade 2 infiltrating ductal CA with clean
lymph nodes, ER positive, PR positive, HER-2/neu positive. Rx
AC,
taxol, herceptin. On tamoxifen since ___. Reconstruction (B
implants).
HYPERLIPIDEMIA
OSTEOPENIA
POSTMENOPAUSAL BLEEDING ON TAMOXIFEN
Social History:
___
Family History:
Mother: CAD, MI
Father: Lung cancer
___ aunt: breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 100.0 121 / 73 96 18 94 Ra
GENERAL: Well appearing female, no acute distress
HEENT: MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Wheezing noted in L middle lobe, otherwise clear to
auscultation b/l without wheezing, rhonci or crackles
ABDOMEN: NABS, non distended, non tender in all four quadrants,
no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
DISCHARGE PHYSICAL EXAM:
VS:
Temp: 99.1 (Tm 100.0), BP: 123/74 (121-123/73-74), HR: 84
(84-96), RR: 18, O2 sat: 94%, O2 delivery: Ra
GENERAL: Well appearing female, no acute distress
HEENT: MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Wheezing noted in L middle lobe, otherwise clear to
auscultation b/l without wheezing, rhonci or crackles
ABDOMEN: NABS, non distended, non tender in all four quadrants,
no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
ADMISSION LABS
--------------
___ 01:00PM BLOOD WBC-12.9* RBC-3.82* Hgb-11.2 Hct-34.6
MCV-91 MCH-29.3 MCHC-32.4 RDW-13.1 RDWSD-43.4 Plt ___
___ 01:00PM BLOOD Neuts-78.4* Lymphs-13.7* Monos-7.0
Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.14* AbsLymp-1.77
AbsMono-0.90* AbsEos-0.01* AbsBaso-0.03
___ 01:00PM BLOOD Glucose-104* UreaN-16 Creat-1.0 Na-135
K-3.9 Cl-95* HCO3-31 AnGap-9*
___ 01:00PM BLOOD CK-MB-<1 cTropnT-<0.01 proBNP-227*
___ 06:50AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.1
___ 01:00PM BLOOD Lactate-0.9
DISCHARGE LABS
--------------
___ 06:50AM BLOOD WBC-12.2* RBC-3.87* Hgb-11.4 Hct-35.3
MCV-91 MCH-29.5 MCHC-32.3 RDW-13.4 RDWSD-45.3 Plt ___
___ 06:50AM BLOOD Glucose-93 UreaN-11 Creat-0.9 Na-142
K-4.2 Cl-103 HCO3-25 AnGap-14
IMAGING
-------
___ CTA CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral ___ opacities and more nodular opacities at
the left lung base in combination with bronchial wall thickening
and mucous plugging is suggestive of a multifocal infectious
process.
3. Calcified left hilar lymph nodes and calcified granulomas in
the left lung are suggestive of prior granulomatous infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Venlafaxine XR 75 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*7
Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. Venlafaxine XR 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-----------------
Acute bacterial bronchitis
SECONDARY DIAGNOSES
-------------------
#HISTORY OF BREAST CANCER
#DEPRESSION
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 worsening cough of almost 4 weeks and sob// r/o
pna
TECHNIQUE: PA and lateral views of the chest
COMPARISON: ___
FINDINGS:
Mild bronchial wall thickening at the lung bases could reflect bronchitis. No
dense infiltrate
The cardio-mediastinal silhouette is unremarkable.
No significant pleural effusion or pneumothorax.
IMPRESSION:
Bronchitis at the lung bases.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with hx of breast cancer and hypoxia on exertion// evaluate
for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP =
6.1 mGy-cm.
2) Spiral Acquisition 4.1 s, 32.3 cm; CTDIvol = 5.7 mGy (Body) DLP = 183.9
mGy-cm.
Total DLP (Body) = 190 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: Hilar lymph nodes are prominent but not
enlarged, and are likely reactive. No mediastinal lymphadenopathy. Calcified
left hilar lymph nodes are noted, and in combination with calcified granulomas
in the lung likely reflect prior granulomatous disease. No mediastinal mass.
The esophagus is patulous.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: ___ opacities in the bilateral lower lobes, with more
focal nodular consolidation primarily at the left lung base is most consistent
with infection. Additionally, there is mucous plugging and bronchial wall
thickening at the bilateral lung bases, suggestive of small airways
inflammation. The upper lobe airways are patent to the subsegmental level.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Bilateral subpectoral breast implants are noted.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral ___ opacities and more nodular opacities at the left lung
base in combination with bronchial wall thickening and mucous plugging is
suggestive of a multifocal infectious process.
3. Calcified left hilar lymph nodes and calcified granulomas in the left lung
are suggestive of prior granulomatous infection.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ILI
Diagnosed with Pneumonia, unspecified organism
temperature: 98.4
heartrate: 97.0
resprate: 20.0
o2sat: 95.0
sbp: 107.0
dbp: 70.0
level of pain: 5
level of acuity: 3.0 | ___ female with history of infiltrating ductal breast cancer
___, triple-posotive, s/p mastectomy and reconstructive
surgery, s/p Cytoxan and Adriamycin followed by Taxol and
Herceptin as well as tamoxifen) who presented to the ED on
___ with four weeks of cough found to have multifocal
infectious process.
==============
ACUTE ISSUES:
==============
#ACUTE BACTERIAL BRONCHITIS
The patient presented with cough, dyspnea on exertion,
leukocytosis, tachycardia, fever, consistent with a pulmonary
infection given her CT findings, most likely acute bacterial
bronchitis vs community acquired pneumonia, likely as
complication of a prior viral respiratory infection. There was
no evidence of PE on CTA. No concern for aspiration. The patient
was initially started on ceftriaxone and azithromycin (day 1 =
___ with good response and ambulatory oxygen saturations
between 94 to 97 % on room air. The patient was safe for
discharge with plan to complete her antibiotic treatment course
at home. Prior to discharge, her antibiotics were transitioned
to a po regimen with cefpodoxime and azithromycin. Plan for a
5-day course (Last dose: ___
================
CHRONIC ISSUES:
================
#HISTORY OF BREAST CANCER
Dx ___ with a left breast cancer. Grade 2 infiltrating
ductal cancer, ER/PR positive,HER-2 positive. S/p mastectomy,
Cytoxan and Adriamycin followed by Taxol and Herceptin. S/p ___
years of letrozole. Stable.
#DEPRESSION
Stable. Continued home venlafaxine.
#CODE: Full (presumed)
#CONTACT:
Name of health care proxy: ___
Relationship: Husband
Phone number: ___
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male chef here for work from ___ reports having
starting on ___ he began to have terrible epigastric pain.
The pain was located in the epigastric region but then radiated
diffusely throughout the upper abdomen. He also had nausea, but
no vomiting initially. The pain continued in waves
intermittently for a few days and was initially present after
eating but then became present all the time and would get worse
with eating or drinking. He on ___ began to have more nausea
and tried taking ___ but the taste was so horrible that
he vomited. Since then he has had nausea and vomiting with
trying to eat and feels that there is "like a ball" in the
epigastric region. He has not been moving his bowels for the
past few days but previously no issues, no weight loss, no
diarrhea. He denies fevers, had a low grade temp in the ED. He
is very thirsty at this time and report poor urine outpt in teh
past 2 days. He reports an episode of horrible epigastric pain
that occured 2 days after he had what he though was bad fish in
___ of this year and a similar episode of again a few days of
abd pain about ___ years ago. With the 2 previous episodes the
pain was no terrible he thought that he was going to die. He
came to medical attention this time before it became so bad. He
does not have a hx of abd pain after eating. He does not
usually see MDs, is otherwise healthy. Is helping a friend with
a restaurant, here in town for about 2 weeks and was feeling
well until this happened.
10 systems reviewed and are negative except where noted in the
HPI above
Past Medical History:
none per the pt
Social History:
___
Family History:
no family hx of pancreatitis or gallstones
Physical Exam:
physical exam most notable for:
Afeb VSS
Cons: NAD, lying in bed
Eyes: E___, no scleral icterus
ENT: MMM
Neck: nl ROM, no goiter
Lymph: no cervical LAD
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
GI: +hypoactive bs,soft, nd, no significant epigastric pain with
palp.
MSK: no significant kyphosis
Skin: no rashes
Neuro: no facial droop
Psych: normal range of affect
Pertinent Results:
___ 08:31PM GLUCOSE-96 UREA N-16 CREAT-1.0 SODIUM-137
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-27 ANION GAP-17
___ 08:31PM ALT(SGPT)-12 AST(SGOT)-19 ALK PHOS-30* TOT
BILI-2.3*
___ 08:31PM LIPASE-416*
___ 08:31PM ALBUMIN-5.1
___ 08:31PM WBC-8.7 RBC-5.18 HGB-15.6 HCT-43.5 MCV-84
MCH-30.0 MCHC-35.8* RDW-13.5
___ 08:31PM NEUTS-56 BANDS-0 ___ MONOS-8 EOS-2
BASOS-0 ATYPS-3* ___ MYELOS-0
___ 08:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:23PM URINE RBC-4* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
Discharge Labs:
___ 07:20AM BLOOD WBC-7.1 RBC-4.37* Hgb-12.9* Hct-36.7*
MCV-84 MCH-29.6 MCHC-35.2* RDW-13.6 Plt ___
___ 07:20AM BLOOD Neuts-58.7 ___ Monos-5.6 Eos-2.9
Baso-0.3
___ 07:20AM BLOOD Glucose-89 UreaN-15 Creat-1.0 Na-142
K-4.0 Cl-107 HCO3-26 AnGap-13
___ 07:20AM BLOOD ALT-10 AST-13 AlkPhos-22* TotBili-2.0*
DirBili-0.4* IndBili-1.6
___ 07:20AM BLOOD Lipase-31
___ 07:20AM BLOOD Albumin-3.7 Calcium-8.4 Phos-3.1 Mg-1.9
___ 07:20AM BLOOD Lipase-31
U/S RUQ:
FINDINGS: The liver demonstrates normal echogenicity. There is
no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. Common bile
duct measures 4 mm. The portal vein is patent. The gallbladder
is normal without evidence of stones or gallbladder wall
thickening. The pancreas is unremarkable without evidence of
focal lesions or pancreatic duct dilatation. The spleen
measures 8.2 cm and has a homogeneous echotexture. Visualized
portions of the right kidney are within normal limits.
IMPRESSION: Normal abdominal ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Epigastric abdominal pain and vomiting. Elevated lipase. Assess
for cholecystitis.
COMPARISON: None available.
FINDINGS: The liver demonstrates normal echogenicity. There is no evidence of
focal lesions. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. Common bile duct measures 4 mm. The portal vein is patent. The
gallbladder is normal without evidence of stones or gallbladder wall
thickening. The pancreas is unremarkable without evidence of focal lesions or
pancreatic duct dilatation. The spleen measures 8.2 cm and has a homogeneous
echotexture. Visualized portions of the right kidney are within normal
limits.
IMPRESSION: Normal abdominal ultrasound.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ACUTE PANCREATITIS, VOMITING
temperature: 100.1
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 117.0
dbp: 77.0
level of pain: 6
level of acuity: 3.0 | ___ male with epigastric pain, nausea, vomiting found to have
pancreatitis of unclear etiology.
Pancreatitis: Lipase of 400 on admission with nausea at
presentation. He has had 2 other episodes requiring
hospiatlization in the past in ___, which were attributed to
"not moving his bowels right." He had pain with the two prior
episodes, but only nausea with this presentation. His appetite
was down and he hadn't been taking food in ___ days due to the
nausea. He denies heavy alcohol use. He denied drug use aside
from marijuana. He had no stones on RUQ. His triglycerides were
48. He is not on any medications at home. Given this is possibly
his third occurrence of pancreatitis over the last year, an MRCP
would be a reasonable next step in evaluation to further
evaluate his anatomy. His lipase normalized and his symptoms
resolved with hydration. He tolerated advancement in his diet
and was discharged in good condition.
Hyperbilirubinemia: His bili was elevated to 2.4 with most of it
being indirect. Question of possible ___ disease, though
hemolysis (mild anemia) is also possible. It was stable on
discharge and may require work-up as an outpatient.
Atypical cells in differential on admission: Resolved on repeat
in the morning.
Transitional issues:
- Establishment of primary care for further work-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neck pain/C2 fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old male with a history of multiple
falls out of bed. At 3am this morning he fell out of bed and
struck the left side of his head/ear on a metal bedrail. He felt
immediate pain in his neck and went back to sleep for ___ hours
and woke with worsened neck pain. He called ___ and was
transported to ___ where he was found to have a C2
fracture on C-spine CT that passes bilaterally through the
transverse foramen and was transferred to ___ for further
evaluation. Neurosurgery service is being consulted for
evaluation of cervical fracture.
He takes gabapentin at home for BUE numbness/tingling/pain
extending from hands up bilateral forearms secondary to carpal
tunnel which he only experiences during certain activities such
as playing the guitar. Denies LOC, dizziness, decreased
sensation in all extremities, loss of bowel/bladder control.
Past Medical History:
#COPD ___ years, last major hospitalization was last year, never
previously intubated, on tiotropium/steroid/albuterol inhalers):
GOLD stage I, PFTs ___ with mild obstructive defect
#HCV (had acute hepatitis at ___,
multiple negative hepatitis C viral loads at BID, consistent
with self-limited infection)
#Anemia
#Anxiety
#Dysphagia
#HLD
#PPD Positive treated with INH ___ years
#Substance Abuse: history of IVDU and PSA, now on methadone
160mg
#Tobacco Abuse
#Baseline Creatinine 1.2-1.3
Social History:
___
Family History:
Mother with ___ MIs and colon cancer, MGF ___ MIs, maternal uncle
died at ___ from MI. Father had alcoholism with liver and kidney
failure.
Physical Exam:
O: Laying flat on stretcher in hard collar in hallway of ED for
examination. No acute distress.
T: 97.3 BP: 124/70 HR:72 R:18 O2Sats:98% RA
Gen: WD/WN, lacking dentition. NAD.
HEENT: Head atraumatic, symmetrical. Pupils: ___ reactive
bilaterally. EOMs and visual acuity intact. Squinting to focus
on
R visual field.
Neck: Hard collar in place.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, month and year.
Motor:
D B T WE WF IP Q H AT ___ G
Sensation: Intact to light touch.
Intrinsics ___ bilaterally.
Reflexes: B Br Pa Ac
Right ___ non-reflexive
Left ___ non-reflexive
No clonus. ? ___ on right non-reproducible.
Upon discharge:
A&Ox3, ASPEN Collar in place
B/L UE ___
B/L ___ ___
SILT
Pertinent Results:
___ Cervical/Head CTA
CT HEAD I -: No acute intracranial process.
CTA HEAD AND NECK: The principal vessels of the neck are patent
throughout
their course, with no evidence of occlusion or dissection. Known
C2 fractures through the bilateral transfers foramina are again
noted better assessed on outside CT of the cervical spine.
No intracranial malformation or aneurysm greater than 3 mm is
detected.
Severe biapical emphysema is present, along with upper
mediastinal
lymphadenopathy, possibly reactive.
Medications on Admission:
1. Cimetidine 300 mg PO BID
2. ClonazePAM 2 mg PO BID
3. Fluticasone Propionate 110mcg 1 PUFF IH BID
4. Methadone 160 mg PO DAILY
5. QUEtiapine Fumarate 150 mg PO QHS
6. Sertraline 200 mg PO DAILY
7. Temazepam 30 mg PO QHS:PRN sleep
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN Dyspnea / Wheeze /
Cough
9. Aspirin 81 mg PO DAILY
10. Simvastatin 40 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea/wheeze/cough
2. Aspirin EC 81 mg PO DAILY
3. Cimetidine 300 mg PO BID
4. ClonazePAM 2 mg PO BID
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
6. Methadone 160 mg PO DAILY
7. QUEtiapine Fumarate 150 mg PO QHS
8. Sertraline 200 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Temazepam 15 mg PO QHS:PRN sleep
11. Tiotropium Bromide 1 CAP IH DAILY
12. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine craving
13. Gabapentin 300 mg PO TID
14. Rolling Walker
Diagnosis: unsteady gait
Prognosis: good
Length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C2 lateral mass 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: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with known C2 fracture. // Evaluate for vascular
injury
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
4) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
5) Spiral Acquisition 4.9 s, 38.3 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,224.3 mGy-cm.
Total DLP (Head) = 2,149 mGy-cm.
COMPARISON: Reference CT head and cervical spine from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
There is a mucous retention cyst in the right maxillary sinus. The remaining
visualized paranasal sinuses and mastoid air cells are clear. The visualized
portion of the orbits are unremarkable.
Again seen is a fractures involving bilateral transverse foramen at the level
of C2 vertebrae as seen on image 5:176 -181.
CTA HEAD:
There is mild atherosclerosis involving bilateral cavernous carotid arteries.
The vessels of the circle of ___ and their principal intracranial branches
appear unremarkable without stenosis, occlusion or aneurysm formation. The
dural venous sinuses are patent.
CTA NECK:
There is a 3 vessel arch. Incidentally seen is hypoplastic left vertebral
artery. There is calcified and noncalcified plaque involving bilateral
carotid bifurcations without any stenosis by NASCET criteria. There is mild
focal narrowing of the left vertebral artery at the C2 transverse process
without evidence of intimal flap for filling defect, likely representing
atherosclerotic disease and turn of the vessel. The carotid and vertebral
arteries and their major branches appear otherwise unremarkable with no
evidence of stenosis orocclusion.
OTHER:
There is extensive centrilobular emphysema involving the visualized upper lung
zones. The prominent mediastinal lymph nodes, for example pretracheal lymph
node on image 5:14 measuring 15 x 9 mm, a right paratracheal lymph node on
image 5:48 measuring 8 x 8 mm. These are likely reactive in etiology. The
thyroid gland appears unremarkable. No cervical lymphadenopathy is seen.
There is atherosclerosis involving the aortic arch.
IMPRESSION:
1. Atherosclerosis involving bilateral carotid bifurcations. Otherwise,
essentially unremarkable CTA of the head and neck.
2. No acute intracranial abnormality.
3. Fractures involving bilateral C2 transverse foramen is again seen.
4. Severe centrilobular emphysema with mediastinal lymphadenopathy in the
visualized upper lung zones.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall, C-spine fracture
Diagnosed with Unsp disp fx of second cervical vertebra, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 97.3
heartrate: 72.0
resprate: 18.0
o2sat: 98.0
sbp: 124.0
dbp: 70.0
level of pain: 5
level of acuity: 2.0 | On ___, the patient was evaluated at an OSH after suffering
a fall and striking his head in his apartment. His head CT
showed no acute findings, however, his cervical spine CT
revealed a right lateral mass fracture of C2 and so he was
transported to ___ for neurosurgical evaluation. He was
placed in a Aspen collar and CTA to his neck revealed no
arterial injury. It was deemed that this would be best managed
with conservative measures including Aspen collar, pain control,
and follow up Cervical Spine CT in 6 weeks. He was evaluated by
the Chronic Pain Service who made recommendations for pain
control given methadone use.
On ___ Patient continued to complain of pain. Regimen was
adjusted. ___ consult was ordered. ___ was unable to evaluate the
patient secondary to pain.
On ___ Patient was stable. Awaiting ___ evaluation. He continued
on recommended pain regimen.
On ___, the patient remained stable and his pain was better
controlled.
On ___, the patient remained stable and worked with physical
therapy. His IV dilaudid was discontinued, as he was out of
acute phase of pain.
On ___, the patient remained neurologically and hemodynamically
stable. He appears comfortable in bed, and is able to
participate in the morning neuro-motor exam without being
limited by pain.
On ___, the patient remained both neurologically and
hemodynamically stable. He was able to participate in the
morning neuro-motor exam without being limited by pain, and able
to make great strides with Physical Therapy - and is now able to
be safely discharged home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Altered mental status, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Obtained per chart, patient not reliable historian, son not
available.
Per son in ___ and chart: ___, h/o dementia, TIA, HTN
alterntating with hypotension, afib on coumadin, ___, mild MS,
mild pulm htn, lower extremity edema discharged from OSH about 2
weeks ago after being treated for PNA saw PCP today and referred
to the ___ for confusion, weakness, ? hypotension. Per son she
has had decreased PO intake and weakness x3 days, required more
supervision taking medications. Also, she had a fall about 4
days ago and hit her head. Has had a cough, no fevers. Also with
abdominal pain, no n/v, no diarrhea/constipation or bloody
stool.
In the ___ initial vitals: 0 97.3 82 100/52 20 100% .
Labs notable for Cr 1.9 (baseline 1.47), K was hemolyzed and
normal on repeat. UA with 8wbc's, <1 epi, neg nitrite. Lactate
2.1. BNP 1881, INR 2.3. Given 500cc NS, 1g Ceftriaxone. CT
abdomen showed
fecal loading. cxr, ct cspine and head unrevealing.
Vitals on transfer :
Today 21:26 0 97.7 72 112/60 18 100% RA
Past Medical History:
Permanent atrial fibrillation, CHADS2 score of 5, on
Coumadin.
Fluctuating blood pressures with periodic hypertension and
hypotension.
Diastolic CHF, ___ Heart Association Class 3.
known ___ systolic ejection murmur loud P2 and a ___ diastolic
murmur heard loudest at the base.
Mild functional MS.
___ pulmonary hypertension.
Lower extremity edema.
Dementia.
History of TIA ___ years ago.
Right hip fracture in ___.
Borderline diabetes.
Fibromyalgia.
GERD.
Hearing loss.
Sinusitis.
Vertigo.
Social History:
___
Family History:
N/c
Physical Exam:
ADMISSION
Vitals - T: 97.5, 162/76, 84, 18, 99%RA
GENERAL: NAD,
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, dentures
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ systolic murmur
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mildly tender in suprapubic region
and superior to this, no rebound
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Oriented to person, date of birth,
___ "snow outside". Could not guess year or date or her age.
Able to do days of week backwards. Speech fluent and
appropriate.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE
Vitals: 98.4 98.1 134-157/59-67 ___ 96-98% RA
General: asleep in bed, easily aroused, NAD
HEENT: sclera anicteric, MMM
Lungs: diffuse crackles, no incr WOB
CV: irregularly irregular, nl rate, nl S1/S2, ___ systolic
murmur best heard over RLSB, no rubs or gallops; no carotid
bruit appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: MS: oriented x name only. More attentive and more linear
thought process than yesterday.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:10PM BLOOD WBC-4.6 RBC-4.74 Hgb-13.5 Hct-41.8 MCV-88
MCH-28.5 MCHC-32.4 RDW-15.2 Plt ___
___ 04:10PM BLOOD Neuts-52.8 ___ Monos-12.2*
Eos-2.2 Baso-0.4
___ 04:10PM BLOOD ___ PTT-41.7* ___
___ 04:10PM BLOOD Plt ___
___ 04:10PM BLOOD Glucose-99 UreaN-52* Creat-1.9* Na-134
K-7.5* Cl-97 HCO3-26 AnGap-19
___ 04:10PM BLOOD ALT-23 AST-81* CK(CPK)-135 AlkPhos-78
TotBili-0.3
___ 04:10PM BLOOD Lipase-97*
___ 04:10PM BLOOD proBNP-1881*
___ 04:10PM BLOOD Albumin-3.5 Calcium-8.7 Phos-4.0 Mg-2.4
___ 04:27PM BLOOD Lactate-2.1* Na-135 K-4.6
___ 06:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:15PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 06:15PM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-1
___ 06:15PM URINE CastHy-32*
___ 06:15PM URINE Mucous-RARE
PERTINENT LABS:
===============
___ 07:31AM BLOOD ___ PTT-47.9* ___
___ 07:31AM BLOOD Lipase-60
___ 05:59PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:59PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:59PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 05:59PM URINE CastHy-6*
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-5.7 RBC-4.46 Hgb-12.5 Hct-38.9 MCV-87
MCH-27.9 MCHC-32.0 RDW-15.0 Plt ___
___ 10:15AM BLOOD ___
___ 06:50AM BLOOD Glucose-80 UreaN-21* Creat-1.1 Na-141
K-3.9 Cl-105 HCO3-28 AnGap-12
___ 06:50AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.1
MICROBIOLOGY:
=============
___ BLOOD CULTURE
Blood Culture, Routine (Pending):
___ URINE
URINE CULTURE (Final ___: <10,000 organisms/ml
IMAGING:
========
CXR ___: Hiatal hernia, small right pleural effusion. No overt
edema or pneumonia.
CT C-spine ___: No acute fracture, malalignment, or prevertebral
soft tissue abnormality.
CT Head ___: 1. No acute infarct, hemorrhage, or fracture.
2. Age-related involutional changes and sequela of chronic small
vessel
ischemic disease.
CT A/P ___: 1. Large fecal loading of the colon, most severe in
the rectum, with probable
mild proctitis.
2. Large hiatal hernia.
CT Head ___: No acute intracranial hemorrhage or mass effect.
Other details as above.
Correlate clinically the to decide on the need for further
workup or followup.
CXR ___: The heart is mildly enlarged, slightly increased in
size since ___. There is increased central
pulmonary vascular congestion, without overt edema. There is no
pneumothorax, focal consolidation, or pleural effusion. Moderate
degenerative changes throughout the thoracic spine appear
stable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Klor-Con M20 (potassium chloride) 20 mEq oral daily
2. Lisinopril 5 mg PO DAILY
3. Warfarin 2.5 mg PO QMWF
4. Furosemide 40 mg PO BID
5. Warfarin 5 mg PO QTRSASU
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS
6. Polyethylene Glycol 17 g PO TID
7. Senna 8.6 mg PO BID
8. Klor-Con M20 (potassium chloride) 20 mEq oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Altered mental status of unclear etiology
Constipation
Acute kidney injury
Secondary diagnoses:
Atrial fibrillation
Diastolic congestive heart failure
Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with afib s/p fall on ___ on warfarin, son concern for
decrease mental status and decrease po intkae // ct head rule out
intracranial hemorrhage c-spine rule out fratureCXR eval for worsening pna
COMPARISON: Chest CT from ___.
FINDINGS:
AP upright and lateral views of the chest provided. Retrocardiac opacity with
an air-fluid level is compatible with known hiatal hernia. There is a small
right pleural effusion. The lungs appear clear without convincing sign of
pneumonia or overt edema. Cardiomediastinal silhouette appears within normal
limits. No acute osseous abnormality.
IMPRESSION:
Hiatal hernia, small right pleural effusion. No overt edema or pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Status post fall 5 days prior with decreased mental status and PO
intake, in a patient with atrial fibrillation on anticoagulation.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 52.9 mGy-cm
CTDI: 891.9 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. Prominent
ventricles and sulci are suggestive of age-related involutional change.
Periventricular white matter hypodensities are consistent with severe chronic
small vessel ischemic disease. No osseous abnormalities seen. There is mild
mucosal thickening in the right maxillary sinus. The other visualized
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
orbits are unremarkable.
IMPRESSION:
1. No acute infarct, hemorrhage, or fracture.
2. Age-related involutional changes and sequela of chronic small vessel
ischemic disease.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: Status post fall 5 days prior with decreased mental status and PO
intake, in a patient with atrial fibrillation on anticoagulation.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 36.7 mGy
DLP: 710.3 mGy-cm
COMPARISON: None
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal narrowing. There is no evidence of infection
or neoplasm.
IMPRESSION:
No acute fracture, malalignment, or prevertebral soft tissue abnormality.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ women with hypotension, generalize weakness and
lethargy, question acute intra-abdominal process.
TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed without
contrast. Multiplanar reformations were provided. IV contrast withheld due
to compromised renal function.
DOSE: DOSE: 486 mGy-cm
COMPARISON: Abdominal MRI from ___, PET-CT from ___.
FINDINGS:
Lung Bases: There is a large hiatal hernia again seen. Tiny right pleural
effusion noted. Imaged portion of the heart unremarkable. The imaged lung
bases are clear.
Abdomen: The unenhanced appearance of the liver is normal. The gallbladder is
unremarkable. The pancreas is atrophic. Known pancreatic IPMN not visualized
on this non contrast exam. The spleen appears normal. Dense aortic
atherosclerotic calcification is noted without aneurysmal dilation. There is
no retroperitoneal lymphadenopathy or hematoma. Adrenal glands are normal
bilaterally. The kidneys appear unremarkable.
Pelvis: Loops of small and large bowel demonstrate no signs of ileus or
obstruction. A candidate appendix is seen on series 2, image 55 appearing
normal. Large fecal loading in the colon noted most severe in the rectum.
There is mild perirectal fat stranding of the possibility of mild proctitis is
raised. Foley catheter seen within the decompressed bladder. No free pelvic
fluid. No free air.
Bones: No worrisome lytic or blastic osseous lesion is seen. Diffuse bony
demineralization is noted. 3 pins stabilize the right femoral neck. There is a
grade 1 anterolisthesis of L4 on L5 which appears unchanged compared to ___ radiograph.
IMPRESSION:
1. Large fecal loading of the colon, most severe in the rectum, with probable
mild proctitis.
2. Large hiatal hernia.
Radiology Report
INDICATION: New infection.
COMPARISON: Chest radiograph from ___.
TECHNIQUE: Frontal and lateral chest radiographs.
IMPRESSION:
The heart is mildly enlarged, slightly increased in size since ___. There is increased central pulmonary vascular congestion, without overt
edema. There is no pneumothorax, focal consolidation, or pleural effusion.
Moderate degenerative changes throughout the thoracic spine appear stable.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with dementia, AF on coumadin, and multiple
other medical problems who was admitted for AMS following OSH treatment for
PNA. Of note, fall w/ headstrike 4 days PTA, no hemorrhage visualized on CT in
ED on day of admission. Now with AMS and INR 4.1. // Evaluate for acute or
subacute hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 785 mGy-cm
CTDI: 55 mGy
COMPARISON: Prior head CT from ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass effect.
Prominence of ventricles and sulci is consistent with age related involutional
changes. Periventricular white matter hypodensities are likely the sequela of
severe chronic small vessel ischemic disease.
No osseous abnormalities seen. There is mild mucosal thickening of the
anterior ethmoidal air cells and right maxillary sinus. The remaining
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. The orbits are unremarkable. Dense atherosclerotic calcifications noted
a the carotid siphons bilaterally.
IMPRESSION:
No acute intracranial hemorrhage or mass effect.
Other details as above.
Correlate clinically the to decide on the need for further workup or followup.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, EPISODIC HYPOTENTION
Diagnosed with URIN TRACT INFECTION NOS
temperature: 97.3
heartrate: 82.0
resprate: 20.0
o2sat: 100.0
sbp: 100.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | This is a ___ year old female with past medical history of
dementia, atrial fibrillation on coumadin, chronic diastolic
heart failure, recent OSH stay for pneumonia, with
post-discharge period complicated by acute metabolic
encephalopathy, admitted ___ and found to have constipation
and ___, volume resuscitated and bowel regimen enhanced,
symptoms resolved, discharged to rehab.
#) Acute Metabolic Encephalopathy - patient with dementia, with
baseline several months prior independent of most ADLs, but over
recent ___ months has had significant decline, presenting with
acute worsening, including agitation and confusion; workup
notable for ___ and constipation (see below); with treatment of
these issues her mental status improved to recent baseline per
family (see below)
#) ___: Cr peaked at 1.9 on admission, secondary to dehydration;
improved with IV hydration, Cr at 1.1 at time of discharge.
ACEi, which was held, was restarted at discharge.
# Constipation - admitted without moving bowels x 1 week; was
passing flatus and no concern for obstruction; CT showed
extensive fecal loading; she received augmented bowel regimen as
well as bisacodyl per rectum followed by manual disimpaction.
Bowel regimen was continued, with regular stooling.
#) ATRIAL FIBRILLATION: CHADS2 = 5. Course was complicated by
INR 4.1, prompting holding of Coumadin on day of discharge.
#) DIASTOLIC CHF: Lasix held in setting of ___ restarted once
patient was taking reliable PO. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of HTN, ___ disease on Sinemet four
times a day, chronic low back pain presents for worsening lower
extremity weakness.
She was recently discharged from rehab and in her usual state of
health until approximately ___ days prior to admission when she
started having difficulty standing and using her walker due to
unsteadiness and weakness in her legs. She fell off the commode
a
week ago but denies head strike or LOC. She states that she just
sat back down whenever she experienced the unsteadiness and that
she did not experience any other falls.
She has not experienced any lightheadedness or palpations when
standing up. She denies any headache, chest pain, SOB, N&V,
abdominal pain, worsening of her back pain, urinary retention,
bladder/bowel incontinence, saddle anesthesia, or other
complaints. No dysuria, urgency, or frequency. No blood in urine
or stool. No f/c. No recent weight loss.
She lives at home with her daughter and uses a walker at
baseline. Her daughter is assisting her with her medications.
She
states that she would be open to going to a rehab facility, but
that she would want to go back home after.
In the ED, initial vitals: T 97.9 HR 67 BP 114/51 RR 18 O2 sat
99% RA
General - thin, no acute distress
HEENT - head NC/AT, bilateral cataracts
Cardiovascular - RRR, 2+ DP pulses bilaterally
Respiratory - CTA bilaterally, no wheezing
GI - abdomen soft, nontender, no rebound or guarding
Neuro - bilateral grip strength ___, bilateral UE strength ___,
bilateral ___ strength ___, sensation intact, down-going Babinski
Musculoskeletal - no spinal midline tenderness, mild left
lumbosacral paraspinal tenderness
Skin - warm and dry
Labs notable for normal CBC, chemistry, negative troponin,
negative serum and utox, and UA with 14 WBC and small leuks.
CXR showed no acute cardiopulmonary abnormality, and CT head
showed no acute process. CT T and L spine showed no acute
fracture or malalignment with chronic L1 compression fracture.
Neurology was consulted, and felt that the patient's neuro exam
was at baseline, and that MRI L spine would be of little utility
given low suspicion for cord compression and that patient would
not surgery. Medicine admission was pursued for case management
input for placement, as well as treatment of possible UTI.
On arrival to the floor, the patient denies any new symptoms.
Of note, per her neurologist's note from ___, on ___
she
was brought to ___ for difficulty standing up and feeling
very weak. UA was negative for UTI. Also had some chronic low
back pain. CT L spine was done showing a severe L1 compression
fracture of unknown chronicity. She was discharged to rehab,
where she has done very well with physical therapy.
During the clinic visit on ___, it was noted that since
her admission to ___ she had noticed that she has had a
lot
of urinary incontinence. She could not feel the need to urinate,
happened every ___ hours but was reportedly slowly getting
better. In the setting of back pain, ___ weakness, and urinary
incontinence, the risk of cord compression was discussed during
this clinic visit. Given that the solution would have been
spinal
surgery should severe compression be found on MRI, the patient
and her family both said that she would not want any surgery.
Because of this, MRI was deferred.
Per her PCP's note from ___, the patient was recently
hospitalized for another fall: The pt was ambulating around her
house with a walker, let go off the walker, and fell into a
radiator and hit her left knee upon the radiator causing
second-degree burn and then also hit her right knee on the
floor.
Patient was admitted to ___ for a period of two
days and then was discharged to rehab, and she was discharged
from rehab to home on ___.
She currently lives at home with her daughter, ___, who
does her pills and manages her medication. She was discharged
from rehab to home with ___ services, Occupational and Physical
Therapy at home.
Past Medical History:
BREAST DUCTAL CARCINOMA IN SITU
COLONIC POLYPS
DEPRESSION ENDOMETRIAL POLYP
FIBROID UTERUS
GOUT
LOW BACK PAIN
OBESITY
OBSTRUCTIVE SLEEP APNEA
REFLUX ESOPHAGITIS
VENOUS STASIS ULCERS
___ DISEASE
Social History:
___
Family History:
mother and sister - DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 PO 177 / 48 68 20 100 Ra
General: laying in bed, cachectic, frail, chronically
ill-appearing, but not toxic
HEENT: NCAT, no lacerations, sclera anicteric, PERRL, EOMI, OP
clear, MMM
Neck: supple, JVP 7-8 cm, no LAD
Resp: normal effort, clear to auscultation bilaterally, no
wheezes, rales, ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Extr: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: two healing abrasions to the left patella with no signs of
surrounding erythema or warmth concerning for infection
Neuro: AAOx3, answering all questions promptly and
appropriately,
CNs2-12 intact, UE and ___ motor strength ___, sensation to light
touch intact throughout, hand tremor present (R>L)
DISCHARGE PHYSICAL EXAM:
Vitals:
Temp: 98.2 (Tm 98.5), BP: 142/62 (99-149/57-69), HR: 65
(60-119), RR: 18 (___), O2 sat: 98% (97-99), O2 delivery: Ra,
Wt: 139.7 lb/63.37 kg
General: sitting in chair for breakfast, chronically
ill-appearing, no acute distress
HEENT: NCAT, no lacerations, sclera anicteric, PERRL, EOMI, OP
clear, MMM
Resp: normal effort, clear to auscultation bilaterally, no
wheezes, rales, ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Extr: warm, well perfused
Skin: two healing abrasions to the left patella with no signs of
surrounding erythema or warmth concerning for infection
Neuro: AAOx3, answering all questions promptly and
appropriately, moving all extremities with purpose, pill-rolling
hand tremor present (R>L)
Pertinent Results:
ADMISSION LABS
--------------
___ 08:10PM BLOOD WBC-4.7 RBC-4.06 Hgb-12.0 Hct-36.8 MCV-91
MCH-29.6 MCHC-32.6 RDW-14.7 RDWSD-49.2* Plt ___
___ 08:10PM BLOOD Neuts-55.9 ___ Monos-12.9
Eos-0.0* Baso-0.0 Im ___ AbsNeut-2.60 AbsLymp-1.44
AbsMono-0.60 AbsEos-0.00* AbsBaso-0.00*
___ 08:10PM BLOOD Glucose-72 UreaN-8 Creat-0.5 Na-142 K-4.1
Cl-101 HCO3-27 AnGap-14
___ 08:10PM BLOOD ALT-16 AST-17 AlkPhos-86 TotBili-0.2
___ 08:10PM BLOOD cTropnT-0.01
___ 09:15PM BLOOD CK-MB-2 cTropnT-0.01
___ 07:15AM BLOOD CK-MB-1 cTropnT-0.02*
___ 08:10PM BLOOD Albumin-3.6
___ 09:15PM BLOOD Calcium-9.1 Phos-3.0 Mg-1.7
___ 08:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS
--------------
___ 07:15AM BLOOD WBC-6.0 RBC-4.20 Hgb-12.5 Hct-37.8 MCV-90
MCH-29.8 MCHC-33.1 RDW-14.6 RDWSD-48.3* Plt ___
___ 07:15AM BLOOD ___ PTT-33.5 ___
___ 07:15AM BLOOD Glucose-88 UreaN-13 Creat-0.6 Na-137
K-4.2 Cl-99 HCO3-28 AnGap-10
___ 07:15AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
URINE STUDIES
-------------
___ 07:00PM URINE RBC-2 WBC-14* Bacteri-FEW* Yeast-NONE
Epi-0 TransE-<1 RenalEp-<1
___ 07:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM*
___ 07:00PM URINE Color-Straw Appear-Clear Sp ___
MICROBIOLOGY
------------
___ 1:53 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
-------
___ CXR
IMPRESSION:
No pneumonia. Chronic borderline cardiac enlargement and mild
vascular
congestion; no evidence of acute cardiac decompensation.
___ MR HEAD W/O CONTRAST
IMPRESSION:
1. No evidence of hemorrhage or infarction.
2. Global parenchymal volume loss and evidence of chronic small
vessel
ischemic disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO QID
3. Citalopram 40 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY:PRN lower extremity swelling
2. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Carbidopa-Levodopa (___) 1 TAB PO QID
6. Citalopram 40 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
-----------------
# Falls
# Weakness
SECONDARY DIAGNOSES
-------------------
# Possible UTI
# ___ disease
# Deconditioning
# Hypertension
# Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old woman with ___ disease and possible left
facial droop// eval for CVA
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 ___, CTA head and neck ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, mass, mass effect, edema or
midline shift.
The ventricles and sulci are prominent. Periventricular and subcortical white
matter FLAIR hyperintensities are noted, a nonspecific finding that most
likely represents the sequelae of chronic small vessel ischemic disease.
There is gross preservation of the principal intracranial vascular flow voids.
Mild mucosal thickening is seen in scattered ethmoid air cells. The remainder
of the visualized paranasal sinuses, middle ear cavities, and mastoid air
cells are well aerated and clear. The patient is status post bilateral lens
replacement.
IMPRESSION:
1. No evidence of hemorrhage or infarction.
2. Global parenchymal volume loss and evidence of chronic small vessel
ischemic disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall, Weakness
Diagnosed with Urinary tract infection, site not specified
temperature: 97.9
heartrate: 67.0
resprate: 18.0
o2sat: 99.0
sbp: 114.0
dbp: 51.0
level of pain: 6
level of acuity: 3.0 | ___ old woman with a history of ___, reflux
esophagitis, breast cancer, ductal carcinoma in situ and
radiation to the left breast, and venous stasis ulcers, who is
presenting with weakness and falls.
ACTIVE ISSUES
-------------
# Falls
# Weakness:
Likely secondary to progressive deconditioning in the setting
known ___ disease with possible acute exacerbation by
possible UTI as below. Prior falls appear to have been
mechanical in nature without characteristics of syncope. While
she reportedly has had episodes of hypotension in the past,
there was a low suspicion that this was contributing to her
presentation as she denied lightheadedness. In addition, blood
pressures during her hospital stay have been normal to elevated.
Evaluated by neurology. Presentation felt to be inconsistent
with cord compression given normal motor exam. Additionally, the
patient has repeatedly stated that she would not want surgery.
Physical therapy was consulted who recommended discharge to
rehab. Her possible urinary tract infection was treated as
below.
# Possible UTI:
Patient presented with pyuria and mild bacteruria. UTI is
possible as patient did not have pyuria on prior UAs, though
this UA borderline and patient is asymptomatic. Given her
worsening weakness and given the lack of other obvious triggers,
the decision was made to treat with Macrobid ___ BID for a
5-day course (___). Treatment course was completed prior to
discharge
# ___ disease
# Deconditioning
# Home safety:
During PCP visit earlier this year, ___ disease thought
to be relatively well controlled given ability to ambulate with
her walker, and eat and drink without tremor. However, while
there may be a contribution of acute medical issues such as a
possible UTI to her current presentation as above, underlying
___ disease is likely a contributing factor to falls,
weakness, and deconditioning. Given the recurrence of her
symptoms, concern for inability of patient to safely take care
of herself at home. Already has OT, ___, and ___ set up. Plan for
discharge to rehab per ___ as above. Recommend discussing
long-term plan pending development of symptoms at rehab. Home
Sinemet ___ mg 4 times a day was continued. Outpatient follow
up with neurology for later is scheduled.
# L knee abrasions:
Patient had fallen earlier this year on her knee. Abrasions
appear to be healing without signs of infection. Wound care was
consulted.
---------------
CHRONIC ISSUES
---------------
# Hypertension
Normotensive on admission. Continued home lisinopril and
amlodipine. Of note, atenolol had been discontinued prior to
admission though patient and her daughter had been confused
about this. They were counseled. Patient should NOT be restarted
on atenolol.
# Depression
Stable. Continued home citalopram 40mg daily (home dose). Of
note, the maximum recommended dose for this age group is 20mg
dialy given concern for QTc prolongation. EKG was obtained and
QTc found to be 429 ms on admission. Thus, home dose was
continued.
-------------------
TRANSITIONAL ISSUES
-------------------
[] completed 5-day course of Macrobid for UTI
[] continued on citalopram 40mg daily (home dose). QTc 429 ms on
admission and 436ms on discharge. Consider adjusting dose to
maximum recommended dose for her age group (20mg daily)
[] continued on amlodipine 5mg daily as prescribed by her
outpatient providers. However, had not been taking this prior to
admission, likely ___ miscommunication. BP controlled on
amlodipine & lisinopril, so discharged on 5mg qd. Please f/u BP
and adjust amlodipine accordingly
[] Per patient and family, patient had not been receiving daily
Lasix prior to admission (despite outpatient clinic notes
indicating that she was on Lasix 20mg daily). Lasix 20mg PO
daily may be used on a prn basis for volume overload / lower
extremity edema (euvolemic on discharge).
# Emergency contact: ___ (daughter, HCP): ___
# Code: Full (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Vicodin
Attending: ___.
Chief Complaint:
Perforation of colon and peritonitis
Major Surgical or Invasive Procedure:
Sigmoidoscopy with dilation of anastamotic stricture and
subsequent perforation - ___
Laparoscopy converted to laparotomy, washout, drainage of
pelvis, and diverting loop ileostomy (for perforated colon with
peritonitis) - ___
Reopening of recent laparotomy, abdominal washout, mobilization
and division of the transverse and descending colon, colon
decompression, and open abdomen - ___
Abdominal exploration and washout - ___
Abdominal washout, partial closure colonic mucous fistula,
placement of a drain - ___
Fascial closure of abdominal wall - ___
History of Present Illness:
___ with h/o perforated diverticulitis s/p robotic sigmoid
colectomy (___) now s/p sigmoidoscopy with dilation for
anastomotic stricture with finding of colonic perforation on CT
scan. He has a known 2 - 2.5cm anastomotic stricture at 20cm
treated with CRE balloon dilations under fluoroscopy on ___,
___, and ___, and presented for repeat sigmoidoscopy
with dilation earlier today due to recurrent symptoms. Per GI
report, sigmoidoscopy was performed under fluoroscopy with
gradual progressive dilation of the anastamotic stricture from
12mm to 16.5mm. Post procedure, he developed lower abdominal
pain and chest pain around 12:15pm, described as located at the
sternum and radiating to both collar bones. The "discomfort"
lasted approximately 15 minutes, then subsided. He denies
shortness of breath, nausea / vomiting, and/or diaphoresis. EKG
demonstrated <___hanges in leads I and II, and he was
subsequently referred to the Emergency Room for further
evaluation. CXR obtained in the ER found free air under the
diaphragam, for which colorectal surgery was consulted.
Past Medical History:
PMHx: perforated diverticulitis, anastomotic stricture, HTN,
obesity, anxiety, strabismus
PSHx: robotic sigmoid colectomy (___), s/p sigmoidoscopy
w/dilation x4 for anastomotic stricture, s/p strabismus
correction as child, removal skin lesion on leg (___)
Social History:
___
Family History:
uncle with colon cancer and negative for inflammatory bowel
disease or other cancers
Physical Exam:
Physical exam on admission:
T 97.8 HR 90 BP 131/80 RR 16 O2sat 97%RA
Gen: NAD although extremely anxious
CV: mild tachycardia
Pulm: CTA bilaterally
Abd: well healed incisions, soft, obese, tender lower abdomen,
no
voluntary guarding or rebound tenderness
Ext: warm, well-perfused
Physical exam on discharge:
98.7, 113, 122/78, 18, 96% RA
Gen: NAD, slightly anxious
CV: tachycardic rate, regular rhythm, no murmurs, rubs, or
gallops
Pulm: CTA
Abd: midline vertical wound has VAC dressing; ileostomy on R -
stoma pink (bridge removed prior to discharge); small scab above
stoma; old mucous fistula site on L covered; old JP site covered
with dry gauze
Back: grade 2 sacral ulcer
Ext: warm, well-perfused, no extremity swelling
Pertinent Results:
___ 05:50AM BLOOD WBC-13.0* RBC-3.77* Hgb-9.9* Hct-30.0*
MCV-80* MCH-26.4* MCHC-33.1 RDW-14.7 Plt ___
___ 04:40PM BLOOD Glucose-101* UreaN-17 Creat-0.5 Na-136
K-3.9 Cl-99 HCO3-27 AnGap-14
___ 04:40PM BLOOD Calcium-8.1* Phos-3.0 Mg-2.4
Medications on Admission:
HCTZ 25mg daily
Lisinopril 20mg daily
Colace
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H
2. Lorazepam 0.5 mg PO Q4H:PRN Anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every our hours as needed
for anxiety Disp #*60 Tablet Refills:*0
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*7 Tablet Refills:*0
4. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth every day (same time
each day) Disp #*3 Tablet Refills:*0
5. Lisinopril 20 mg PO DAILY
___ were taking this medication at home but should stop taking
it and discuss with your primary care physician when to ___
6. LOPERamide 2 mg PO TID
RX *loperamide 2 mg 1 capsule by mouth three times a day Disp
#*100 Capsule Refills:*0
7. Hydrochlorothiazide 25 mg PO DAILY
___ were taking this medication at home but should stop taking
it and discuss with your primary care physician when to ___
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ capsule(s) by mouth every four hours as
needed for pain Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated colon with peritonitis
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: Chest pain, question mediastinal pathology, free air.
COMPARISON: None.
TECHNIQUE: Frontal and lateral views of the chest.
FINDINGS: Evidence of free air is seen beneath the diaphragms, right greater
than left. There are relatively low lung volumes and minimal bibasilar
atelectasis. No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable.
IMPRESSION: Evidence of pneumoperitoneum raising concern for bowel
perforation.
Dr. ___, was paged at 3:40 p.m. at the time of discovery.
Through ED dashboard, the ED team is aware of free air under the diaphragms.
Dr. ___ this at 3:45pm.
Radiology Report
HISTORY: Abdominal pain and free air under chest radiograph in a patient
status post sigmoidoscopy.
TECHNIQUE: MDCT acquired axial images were obtained from the lung bases to
the pubic symphysis after administration of 130 cc Omnipaque intravenous
contrast material as well as 400 cc of Optiray water soluble contrast per
rectum. Coronal and sagittal reformats reviewed.
COMPARISON: CT from ___.
FINDINGS:
The lower chest is unremarkable. The liver enhances homogeneously, without
focal lesion. Gallbladder and biliary tree are normal. The spleen, adrenal
glands, pancreas are normal. The kidneys enhance normally and excrete
contrast symmetrically. There is a duplicated left collecting system. There
are multiple small simple cysts in the bilateral kidneys. One complex cyst in
the lower pole of the right kidney (2:52) appears unchanged with two possible
inferior foci of enhancement, measuring 14-mm. The abdominal aorta is normal
caliber with patent main branches. The portal, splenic, mesenteric veins are
patent.
The stomach and small bowel appear normal. The patient is status post
sigmoidectomy. The colon is distended with gas. The descending colon again
demonstrates wall thickening to the level of the anastamosis with surrounding
stranding and adenopathy. The proximal extent of colonic wall thickening has
progressed to the transverse colon compared to the prior study.
The distal colon demonstrates circumferential wall thickening and extensive
surrounding fat stranding. There is active extravasation of rectal contrast
and air in the distal colon, just proximal to the anastomosis, best seen on
series 2, image 70. There is fluid and fat stranding but no organized
collection. There is large volume pneumoperitoneum as seen on the chest
radiograph.
The bladder, prostate, and seminal vesicles appear normal.
There are no lytic or sclerotic osseous lesions concerning for malignancy.
IMPRESSION:
1. Distal colonic perforation just proximal to the site of the anastomosis
with leakage of air and rectal contrast into the peritoneum. There is no
organized fluid collection.
2. Worsening descending colonic thickening and inflammatory changes, when
compared to the prior study, compatible with colitis, possibly ischemic,
infectious or inflammatory in etiology,
3. 14-mm complex right renal cyst could be further characterized by
ultrasound.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with perforated colon
during sigmoidoscopy with stricture dilatation.
AP radiograph of the chest was reviewed, focusing on the lower chest, upper
abdomen.
The NG tube tip is in the proximal stomach and should be advanced. The
stomach remains distended. There is interval decrease in intraperitoneal air.
The lung bases are essentially clear. Due to different projection of the
radiograph, it's difficult to assess the cardiomediastinal silhouette that
appears to be artificially enlarged.
Radiology Report
REASON FOR EXAMINATION: Perforated diverticulitis after sigmoidectomy with
anastomosis and now with tachycardia, assessment of the central venous line.
AP radiograph of the chest was compared to ___.
The right subclavian line has a somewhat tortuous course with the tip
terminating in the mid SVC at the level of the carina. Correlation with the
output of the line is recommended since it is unlikely to follow the usual
course and potentially can be in one of the chest wall veins. Also, there is
slight interval increase of amount of pleural fluid on the right that should
be also further assessed to exclude the possibility of intrapleural position
of the central venous line.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with bowel perforation,
intubated.
AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is 4.7 cm above the carina. NG tube tip is in the stomach.
The central venous line tip is at the level of mid SVC. There is interval
additional increase in pleural effusion and currently interval development of
left lower lobe atelectasis. Patient is in interstitial pulmonary edema.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with bowel perforation,
intubated, followup.
AP radiograph of the chest was compared to prior study obtained the same day
earlier.
The ET tube tip is 6 cm above the carina. Right subclavian line tip is in the
mid SVC. NG tube tip is in the stomach. Bilateral pleural effusions and
bibasilar areas of atelectasis are demonstrated, but there is improvement of
the left lower lobe atelectasis on the current study. No evidence of
pneumothorax.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Perforated bowel, evaluation for endotracheal tube position.
COMPARISON: ___, 11:14 a.m.
FINDINGS: As compared to the previous radiograph, the position of the
endotracheal tube is not substantially changed. The tube projects 5 cm above
the carina. Also unchanged is the course of the nasogastric tube, the
position of the right subclavian vein catheter.
The patient continues to display bilateral pleural effusions and areas of
bilateral basal atelectasis. Mild pulmonary edema might also be present.
However, there is no evidence for a newly occurred parenchymal opacity
suggesting pneumonia. No pneumothorax.
Radiology Report
INDICATION: History of perforated bowel status post repair. Patient
requiring fluid resuscitation. Please evaluate for fluid status.
COMPARISONS: Chest radiographs dating back to ___.
TECHNIQUE: Single AP portable exam of the chest.
FINDINGS: The ET tube terminates approximately 5.3 cm above the carina.
There is a right-sided subclavian catheter which terminates in the mid SVC.
The lung volumes are low resulting in crowding of the bronchovascular
structures; however, there appears to be mild pulmonary vascular congestion.
The patient continues to display small bilateral pleural effusions and mild
areas of bilateral basilar atelectasis. There may be mild pulmonary edema,
overall unchanged compared to the prior exam. There is no evidence of a
pneumothorax. The heart size is normal. The hilar and mediastinal contours
are normal.
IMPRESSION:
Stable mild bibasilar atelectasis. Mild pulmonary vascular congestion with
mild bilateral pulmonary edema.
Radiology Report
HISTORY: Possible ARDS.
FINDINGS: In comparison with the study of ___, the endotracheal tube is
somewhat further above the clavicles, though only about 6 cm above the carina.
Other monitoring and support devices are unchanged. Continued pulmonary
vascular congestion with hazy opacification at the bases, silhouetting the
hemidiaphragms, consistent with layering pleural effusions and compressive
atelectasis at the bases.
Radiology Report
HISTORY: ___ man status post ex-lap and washout, ileostomy, mucus
fistula, with ? ARDS. Evaluate for interval change.
TECHNIQUE: Portable AP semi-erect chest radiograph was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Continued mild pulmonary edema is seen, and opacification at bilateral bases
is seen, consistent with pleural effusions and associated compressive
atelectasis. The heart size is normal. The right central venous line ends at
the mid-lower SVC, and the gastric tube curls in the stomach. ET tube is
positioned high in the trachea, above the level of the clavicles.
IMPRESSION:
Continued pulmonary edema and bibasilar pleural effusions and compressive
atelectasis. Recommend advancement of ET tube.
Initial findings were conveyed to ___ of the surgical team on ___
at 10:15 immediately following review by Dr. ___.
Radiology Report
HISTORY: Abdominal closure.
COMPARISON: None.
FINDINGS:
Supine views of the chest and abdomen were provided. Enteric tube is seen
with tip in the gastric fundus. 2 surgical drains project over the pelvis as
well as skin staples. There is no radiopaque foreign body identified.
Nonspecific nonobstructive bowel gas pattern is seen. Extremely low lung
volumes identified.
IMPRESSION:
No radiopaque foreign body besides drains and tubes as above.
Findings were discussed with Dr. ___ the phone at time of
interpretation at 21:40 on ___.
Radiology Report
HISTORY: ___ man status post bowel perforation repair, section.
Evaluate volume status.
TECHNIQUE: Portable AP semi-erect chest radiograph was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Bilateral basilar opacification is seen with no focal consolidation or
pneumothorax. The cardiac silhouette is mildly enlarged with mild vascular
congestion. ET tube is in appropriate position, and the gastric tube coils in
the stomach. Right subclavian line ends in the lower SVC in appropriate
position.
IMPRESSION:
Unchanged bilateral pleural effusions and bibasilar atelectasis. Mild
cardiomegaly with mild vascular congestion.
Radiology Report
AP CHEST, 10:55 A.M., ___
HISTORY: ___ male with abdominal sepsis and desaturation.
IMPRESSION: AP chest compared to ___ at 5:07 a.m.:
Moderate bilateral pleural effusions and mild pulmonary edema have both
improved since earlier in the day. Tip of the endotracheal tube at the upper
margin of the clavicles, is no less than 5 cm from the carina. Heart size
normal. No pneumothorax. Upper enteric drainage tube is curled in the
gastric fundus. Right subclavian line ends in the mid-to-low SVC. No
pneumothorax.
Radiology Report
AP CHEST, 3:54 A.M., ___
HISTORY: A ___ man with an anastomotic leak.
IMPRESSION: AP chest compared to ___:
Previous mild pulmonary edema continues to clear since ___. Substantial
right pleural effusion and bibasilar atelectasis remain. The heart size is
normal. Azygous distention suggests elevated central venous pressure. The
tip of the endotracheal tube just below the upper margin of the clavicles with
the chin down, is 4.5 cm above the carina, 2 cm above optimal placement for
the chin in neutral position.
The right subclavian line ends low in the SVC. No pneumothorax.
Radiology Report
AP CHEST, 12:39 P.M., ___
HISTORY: ___ man with bowel perforation and new left subclavian line
placed. Evaluate possible pneumothorax.
IMPRESSION: AP chest compared to ___, 3:54 a.m.:
The tip of the new left subclavian line lies alongside the right line in the
mid-to-low SVC. There is no pneumothorax or mediastinal widening. Moderate
right pleural effusion has been present for several days, as has bibasilar
atelectasis. Heart size normal. No pneumothorax.
The tip of the endotracheal tube above the upper margin of the clavicles,
nearly 6 cm from the carina is 2 cm above standard positioning, as before.
Radiology Report
CLINICAL HISTORY: Fluid overload. Evaluate for pulmonary edema or effusions.
CHEST AP:
___.
The position of the various lines and tubes is unchanged since the prior chest
x-ray. The left lung shows some atelectasis, but is otherwise clear. A right
effusion is present, decreased in size since the prior chest x-ray.
IMPRESSION: Right effusion is somewhat smaller.
Radiology Report
CLINICAL HISTORY: Nasogastric tube repositioned, check position.
CHEST: On the prior ultrasound the nasogastric tube is curled up within the
fundus of the stomach. It has been withdrawn and the tip now lies within the
stomach and is no longer curled.
Elsewhere, the lung changes are unaltered.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: Chest x-ray one day earlier.
FINDINGS: Indwelling support and monitoring devices are in standard position,
and cardiomediastinal contours are stable in appearance. Slight improvement
in small right pleural effusion with adjacent right lower lobe opacity which
probably reflects atelectasis. Left lung is grossly clear except for minimal
linear atelectasis at the left base.
Radiology Report
INDICATION: Bowel perforation after dilation of an anastomotic stricture from
prior sigmoid colectomy. Now septic following diverting ileostomy, multiple
washouts, with interstitial pulmonary edema. The last washout was on
___, followed by closure on ___.
TECHNIQUE: MDCT-acquired axial images of the chest, abdomen, and pelvis were
obtained following the uneventful administration of 130 cc of Omnipaque
intravenous contrast. Coronal and sagittal reformations were performed at 5
mm slice thickness.
CT OF THE CHEST WITH IV CONTRAST:
Included views of the thyroid are within normal limits. A left subclavian
central venous catheter terminates at the lower SVC (2:23). The heart size is
normal. There is a small pericardial effusion (2:38). An endotracheal tube
terminates at the lower trachea (2:7). Small amount of mucous secretion lies
just above the carina (2:12). The airways are otherwise patent to the
subsegmental levels.
There are small bilateral pleural effusions, larger on the right, with
adjacent moderate compressive atelectasis of the bilateral lower lobes (2:31,
35). There are no pulmonary nodules or masses.
There is no mediastinal or hilar lymphadenopathy. The great vessels are
patent and normal in caliber. No large pulmonary embolus is detected to the
segmental levels.
CT OF THE ABDOMEN WITH IV CONTRAST:
There is a left lower quadrant colostomy and right lower quadrant ileostomy
(2:94, 73). Intra-abdominal loops of small and large bowel are normal in
caliber. A nasogastric tube terminates in the stomach lumen (2:54).
Mild ascites is within post-surgical limits. Tiny pockets of fluid track
along both paracolic gutters (2:64, 78) and along the anterior abdomen (2:83),
accompanied by mild neighboring peritoneal wall and fascial enhancement.
Trace pneumoperitoneum is within post-surgical limits (2:52).
The liver, pancreas, spleen, adrenal glands, and kidneys appear normal.
Subcentimeter hypodense lesions throughout both kidneys (2:67, 85, 68) are
unchanged in comparison to the reference CT examination from ___,
and are statistically likely benign cysts.
There is no mesenteric or retroperitoneal lymphadenopathy.
CT OF THE PELVIS WITH IV CONTRAST:
A left lower approach surgical drain loops across the central pelvis (2:104).
A small amount of intrapelvic ascites is seen. No discrete intrapelvic
collection is present. A sigmoid anastomosis appears intact (2:106). The
prostate and bladder are normal. A Foley catheter resides within the bladder,
which contains a moderate amount of gas (2:115). There is no intrapelvic
lymphadenopathy.
OSSEOUS STRUCTURES:
There is no acute fracture. There are no bony lesions concerning for
malignancy or infection.
IMPRESSION:
1. Mild intra-abdominal and intrapelvic ascites within post-surgical limits.
Tiny pockets of fluid along the anterior abdomen and paracolic gutters are
accompanied by mild peritoneal and fascial enhancement, reflecting
inflammatory changes but indistingushable from infection. This is accessible
to US or CT guided aspiration, if warranted.
3. Non-obstructed ileostomy and colostomy.
4. Subcentimeter hypodense renal lesions are statistically likely cysts, but
are too small for further characterization on this single phase study.
5. Small pericardial effusion.
Radiology Report
HISTORY: Postoperative respiratory difficulties.
FINDINGS: In comparison with the study of ___, there are lower lung volumes.
Poor definition of the hemidiaphragms, especially on the right, suggests
atelectatic change with possible effusions. There is an area of increased
opacification just above the minor fissure, which could reflect either fluid
in the fissure or possible developing consolidation in the upper lobe.
The monitoring and support devices have all been removed.
This information has been conveyed to Dr. ___, who is covering for Dr.
___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS, DIVERTICULITIS OF COLON
temperature: 97.8
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 156.0
dbp: 111.0
level of pain: 4
level of acuity: 2.0 | In the ER, after the patient's CXR showed free air under the
diaphragm concerning for perforation, he underwent a CT scan
that showed distal colonic perforation proximal to anastomotic
site. He was taken urgently to the operating room, where he
underwent a laparoscopy converted to laparotomy, washout,
drainage of pelvis, diverting loop ileostomy, placement ___
drain on the same day of presentation, ___. He was started on
Zosyn and Vancomycin and iniially did well. His blood cultures
from that time eventually grew Closridium species not C.
perringens or C. septium and Fusobacterium. However, on POD1,
___, he developed hypotension and tachycardia, concerning for
septic shock. Resuscitation was began and he was transferred to
the MICU, where was managed with levophed. Due to feculent drain
outpu, he was taken back to the operating room on the night of
___ for reopening of recent laparotomy, abdominal washout,
mobilization and division of the transverse and descending
colon, colon decompression, and open abdomen. After the
operation, he returned to the ICU and remained intubated/sedated
with pressor requirements. He was also febrile ___ morning and
had increasing pressor requirements. That same day, he again was
taken to the OR for an abdominal exploration and washout.
Subsequently, he had interstitial pulmonary edema and was
iniiated on the ARDSnet ventilation protocol and his respiratory
acidosis impoved. On ___ afternoon, he was transferred to the
SICU and management was continued. On ___, he underwent an
abdominal washout, partial closure colonic mucous fistula,
placement of a drain. On ___ he improved and no longer requied
pressors. Diuresis for significant volume overload was begun
with lasix drip and albumin, to which he responded. The next
day, ___, he went back to the operating room for the final time
and underwent fascial closure of abdominal wall. A VAC was
placed. Tube feeds through an NGT were begun and advanced, goal
of 45 cc/hour. Flagyl was added. Over the next several days, he
could not be weaned from the vent. He was slightly confused, but
following commands. His line was changed and sent for culture.
His culture and blood culures from that time were negative. He
had some agitation and required precedex. On ___, zosyn was
discontinued and cefepime added. On ___, flagyl was
discontinued. On ___, he was extubated successfully, and on
___ he was transferred to the floor. Fluconazole was added. His
Foley and NGT were removed and he tolerated a regular diet. On
___, all IV antibiotics were discontinued and PO fluconazole and
augmentin were started for a goal total of a 7 day course. The
patient was feeling depressed and overwhelmed, as well as
anxious, but not suicidal. Social work was consulted. ___ was
consulted and evaluated and treated him, eventually recommending
home with physical therapy. He was tachycardic consistently
between 110-120 and sometimes as high as 130-140 on a few
occassions, but denied shortness of breath, chest pain, and had
no leg swelling or increased oxygen requirement. He continued to
do well. The drain and central line were removed. Immodium was
started for high ostomy output. The mucous fistula was capped on
___. Overnight ___, he had a brief episode of tachypnea to
40 with no desaturations on room air, and the symptoms
spontaneously resolved. A CXR done then showed only small
atelectasis vs effusion. On ___, he continued to ambulate,
tolerate a regular diet (goal calories 2800 per nurition), and
his ostomy output improved on Immodium. The following day, he
was discharged home with his home VAC placed while in the
hospital, and asked to follow up with colorectal surgery, as
well as his primary care physician to discuss restarting home
antihypertensive medications and management of his anxiety. On
the day of discharge, he was feeling well, without abdominal
pain, tolerating a regular diet, ambulating, with appropriate
ostomy output. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with hypothyroidism, obesity,
T2DM, recent diagnosis of tracheomalacia, presenting with
worsening shortness of breath.
She reports having shortness of breath with exertion and at rest
for at least the past year. About one year ago she could walk
about one block before having to stop and catch her breath. Her
shortness of breath has since progressed. She was hospitalized
several months ago at ___ for these symptoms
and was treated with steroids. At that time a chest CT was
performed and demonstrated evidence of tracheobronchialmalacia
with evidence of dynamic collapse at distal trachea and
bilateral mainstem. In addition to prednisone, she has had
trials of several different inhaled medications, without
significant improvement. Currently she uses albuterol
nebulizers with partial relief (up to q4hr when she is
symptomatic, several times per week). She becomes SOB after
walking only several feet. She has also had a chronic
nonproductive cough. Describing her shortness of breath, at
times she feels like she cannot get air in or out and also hears
squeaks when she breaths. There are no apparent associated
exacerbating or alleviating factors. She has had negative
allergy testing, although does have rhinorrhea. She has had
additional diagnostic studies for evaluation of shortness of
breath including cardiac cath and multiple CT scans. Cath
reportedly showed one area of 50% stenosis but no other
abnormalities.
Additionally, she has had intermittent swelling in her lower
legs for at least the past several months, especially involving
the right leg. This swelling is generally worse at the end of
the day. She has had negative ___ ultrasounds during prior
hospitalizations for shortness of breath in the past and has
never had leg pain. Several days prior to the current
presentation she had a severe episode of right ankle/foot
swelling for which she kept her leg elevated with gradual
improvement in this symptom.
Ms. ___ was recently hospitalized at ___ with this SOB and
right leg swelling as described above; she was discharged ___
for outpatient management. She was hoping to be evaluated by a
thoracic surgeon, could not get an appointment until ___, and
therefore presented to the ED for evaluation.
On ROS, it is unclear if she has had PND, although she sleeps
with 2 pillows. She has not had hemoptysis, fever, chills, night
sweats, chest pain, or palpitations. She has not recent
illnesses or travel. She does not smoke.
Past Medical History:
- Hypothyroidism
- DM2 (on metformin in the past)
- OSA - no established CPAP use as of yet
- Hyperlipidemia
- Hypertension
- CAD (reported 50% stenosis on catheterization)
Past Surgical History:
- Thyroidectomy for benign nodules
Social History:
___
Family History:
Family history of relatives with DM2, ___ disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 97.8 PO 129 / 67 76 18 95 Ra
___: Alert, oriented, no acute distress, obese, sitting on
side of bed
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP could not be assessed, no LAD
CV: Regular rate, S1 + S2, no murmurs, rubs, gallops audible
Lungs: Symmetric chest rise, clear to auscultation bilaterally,
no wheezes or crackles audible
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No foley
Ext: Warm, well perfused, 1+ pulses b/l, trace LLE edema, 2+ RLE
edema, no erythema or tenderness
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
Vital Signs: 97.7 117 / 74 67 18 97 Ra
___: Alert, oriented, no acute distress, obese, sitting on
side of bed
HEENT: Sclerae anicteric, MMM, oropharynx clear, no apparent
cobble stoning, EOMI, PERRL
Neck: Neck supple, JVP could not be assessed, no LAD
CV: Regular rate, S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally; no stridor, wheezes,
or crackles
Abdomen: Soft, non-tender, bowel sounds present
GU: No foley
Ext: Warm, well perfused, 1+ pulses b/l, trace LLE edema, 2+ RLE
edema, no erythema or tenderness
Neuro: moving all four extremities, A&Ox3
Pertinent Results:
ADMISSION LABORATORY STUDIES
==================================
___ 07:58AM BLOOD WBC-15.6* RBC-4.29 Hgb-12.5 Hct-37.9
MCV-88 MCH-29.1 MCHC-33.0 RDW-16.3* RDWSD-52.1* Plt ___
___ 07:58AM BLOOD ___ PTT-21.8* ___
___ 07:58AM BLOOD Glucose-244* UreaN-27* Creat-0.6 Na-138
K-4.0 Cl-98 HCO3-22 AnGap-22*
DISCHARGE LABORATORY STUDIES
==================================
___ 07:45AM BLOOD WBC-8.7 RBC-4.45 Hgb-13.0 Hct-40.2 MCV-90
MCH-29.2 MCHC-32.3 RDW-16.6* RDWSD-54.2* Plt ___
___ 07:45AM BLOOD Glucose-108* UreaN-20 Creat-0.6 Na-140
K-4.4 Cl-100 HCO3-27 AnGap-17
___ 07:45AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.2
___ 07:45AM BLOOD TSH-1.3
___ 07:45AM BLOOD Free T4-1.9*
IMAGING/REPORTS
==================================
CT TRACHEA W/O CONTRAST:
IMPRESSION:
No or stricture or other fixed structural abnormality of the
trachea. There
is a decrease in tracheal diameter 41-42% upon expiration.
Generalized severe
decrease in lobar bronchial diameter upon expiration is more
than physiologic
expectations and may contribute to mild air trapping.
RIGHT LOWER EXTREMITY DUPLEX ULTRASOUND
No evidence of deep venous thrombosis in the right lower
extremity veins.
PFTS: pending on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 200 mcg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. PredniSONE 60 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
6. Atorvastatin 40 mg PO QPM
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. mometasone-formoterol 200-5 mcg/actuation inhalation 2 puffs
BID
11. Montelukast 10 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. PredniSONE 50 mg PO DAILY
decrease by 10mg every 3 days (i.e. 50 mg for 3 days, then 40mg
for 3 days, etc.)
Tapered dose - DOWN
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 NEB INH Q6H:PRN
Disp #*30 Ampule Refills:*0
3. Atorvastatin 40 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Levothyroxine Sodium 200 mcg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. mometasone-formoterol 200-5 mcg/actuation inhalation 2
puffs BID
11. Montelukast 10 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheobronchomalacia
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 tracheomalacia.// change in CXR?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___, CT chest ___
FINDINGS:
Cardiac silhouette size remains moderately enlarged. The mediastinal and
hilar contours are unchanged. Pulmonary vasculature is not engorged. No
focal consolidation, pleural effusion or pneumothorax is seen. Mild
degenerative changes are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT TRACHEA W/O CONTRAST
INDICATION: ___ year old woman with cough.
TECHNIQUE: Multi detector helical scanning of the chest was performed at end
inspiration, reconstructed as contiguous 5.0 and 1.25 mm thick axial and 2.5
mm thick coronal images of the full chest. Multi detector helical scanning of
the chest was repeated during forced expiration, and reconstructed as
contiguous 5.0 and 1.25 mm thick axial images. Endoscopic navigation and
localization images were reconstructed from both end inspiration and dynamic
expiration scanning, and 3D volume renderings were reconstructed from the
expiration scans. Intravenous contrast agent was not employed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.6 s, 41.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 849.9
mGy-cm.
2) Spiral Acquisition 2.7 s, 42.2 cm; CTDIvol = 4.1 mGy (Body) DLP = 172.1
mGy-cm.
Total DLP (Body) = 1,022 mGy-cm.
COMPARISON: ___ outside hospital chest CT
FINDINGS:
DYNAMIC TRACHEAL IMAGING REPORT
NOW = current study; MRP = most recent prior CT Dynamic Trachea
I. INSPIRATORY TRACHEA
LENGTH from vocal cords/arytenoids to carina: Approximately 13cm
SHAPE: Horseshoe RoundX lenticular Sabre-sheath Crescent
Other:_________
Wall thickening: NX y: unifocal multifocal max thickness: mm
Abn calcification: NX y: unifocal multifocal max thickness: mm
Abn peritrachea: NX y: unifocal multifocal
FOCAL NARROWING (STRICTURE)
1. N X y
II. DYNAMIC TRACHEA
1. At sternal notch
NOW Cor x Sag
INSP: 307.0mm2
EXP: 177.4mm2 I-E/I = 42% decrease
SHAPE during EXP
Horseshoe Round Lenticular Sabre-sheath CrescentX Other:_________
2. Upper margin of azygos (series 302, image 94; series 303, image 85)
NOW Cor x Sag
INSP: 256.3mm2
EXP: 152.0mm2 I-E/I = 41% decrease
SHAPE during EXP
Horseshoe Round Lenticular Sabre-sheath CrescentX Other:_________
III. DYNAMIC BRONCHI
R Main - smallest true diameter
NOW INSP 8mm EXP 3mm
L Main - smallest true diameter
NOW INSP 9mm EXP 3mm
BrI - smallest true diameter
NOW INSP 9mm EXP 4mm
Bronchi: Exp diameter < 3mm
RUL N YX
RBT N YX
LUL NX y
LBT N YX
?Air trapping?
Mild x moderate severe
CHEST CT:
Heart size is normal. No pericardial effusion. Coronary artery calcifications
are minimal. Aortic arch calcifications are minimal. The thoracic aorta is
normal in caliber. The main pulmonary artery is mildly enlarged with a
diameter of 3.4 centimeters, though the right main pulmonary artery is normal
in caliber.
Supraclavicular, axillary, mediastinal and hilar lymph nodes are not enlarged.
No evidence of pulmonary parenchymal abnormality. No pulmonary nodules. No
pleural effusion or pneumothorax. Airways are patent to the subsegmental
level.
The visualized portion of the base of the neck is unremarkable.
The visualized portion of the abdomen is unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified. A
T3 vertebral body hemangioma is noted.
IMPRESSION:
No or stricture or other fixed structural abnormality of the trachea. There
is a decrease in tracheal diameter 41-42% upon expiration. Generalized severe
decrease in lobar bronchial diameter upon expiration is more than physiologic
expectations and may contribute to mild air trapping.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with several months of progressive dyspnea and
intermittent leg swellig// Swelling R>L, evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, Dyspnea
Diagnosed with Other specified diseases of upper respiratory tract, Dyspnea, unspecified
temperature: 97.3
heartrate: 103.0
resprate: 28.0
o2sat: 97.0
sbp: 153.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman w/ hypothyroidism, T2DM, and
recent diagnosis of tracheomalacia, who presented with worsening
longstanding shortness of breath, likely multifactorial with a
large component of tracheomalacia.
ACTIVE ISSUES
=============
#) Tracheomalacia:
Pt has a long standing history of shortness of breath and recent
diagnosis of tracheobronchomalacia, who presented with
persistent shortness of breath. During admission patient
remained with good oxygen saturation on room air and in no
respiratory distress. Interventional Pulmonology was consulted
and started workup for tracheomalacia and evaluating for
possible other etiologies that may be contributing to her
shortness of breath. CT trachea and PFTs were performed during
admission (results pending on discharge). Treated with
nebulizers for symptomatic management of her dyspnea and
continued on prednisone and discharged on a prednisone taper. Pt
should have outpatient follow up with Interventional Pulmonology
for further management.
#) Right lower extremity edema:
Pt noted to have lower extremity edema during admission, right
greater than left. Duplex ultrasound did not show any evidence
of DVT. Edema most likely secondary to venous insufficiency. Pt
recommended to elevate legs and use compression stockings.
CHRONIC ISSUES
==============
# hypothyroid s/p thyroid nodule removal: continued home
Levothyroxine
# Diabetes, DM2: not on insulin. ISS while inpatient
# HTN: continued home metoprolol, losartan
# CAD: continued atorvastatin, clopidogrel
TRANSITIONAL ISSUES
===============================
1. Pt should have follow up with Interventional Pulmonology
2. Need to follow up CT trachea and PFTs (results pending on
discharge)
3. Follow up thyroid studies (sent to rule out thyroid disorder
contributing to dyspnea)
4. Consider further outpatient evaluation of additional issues
that may be contributing to her dyspnea as indicated (including
sleep study to evaluate for OSA, TTE, ENT evaluation for VCD, GI
evaluation for GERD)
5. Need to obtain outside medical records from ___ and ___
___ from previous workup done for her
tracheomalacia
6. Pt scheduled for follow up with Dr. ___ endocrinology
for weight loss management, as her weight may be contributing to
her dyspnea.
7. Pt continued on prednisone during admission for treatment of
tracheomalacia. Patient discharged on a prednisone taper
(decrease by 10mg every three days starting with 50mg).
# CODE STATUS: full, presumed
# CONTACT: ___ (HCP, partner, ___, ___
(nephew, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tylenol / gabapentin
Attending: ___.
Chief Complaint:
fever, dysuria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: ___
.
CC: fever, dysuria
.
HPI/EVENTS: ___ yo M h/o HTN, TIA s/p L CEA ___, BPH admitted
with 2 days of fever, dysuria, frequency and urgency. At
baseline, Mr ___ is very functional, able to ambulate,
independent and lives alone. He was in USOH until 1 wk ago when
he noted bil flank pain radiating to shoulders. Subsequently
noted dysuria, incomplete urination, nausea, and fever. Denies
blood in urine. Presented to the ED where he was found to be
febrile to 101.2. BP stable. WBC 14. No CVA appreciate.
Prostate was enlarged but not tender.
He was given 400mg iv of ciprofloxacin, IVF, ibuprofen,
zofran, ketorolac. Feeling well upon transfer to the floor.
Denies N/V, abd/flank pain, chills.
ROS: per HPI, denies night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, hematuria. A 10 pt
review of sxs was otherwise negative.
Past Medical History:
# HTN/hyperchol
- Stress MIBI ___: mod ___ 5.5 mins (~ ___ METS), 63%.
Normal myocardial perfusion scan.
# L carotid stenosis s/p CEA ___
# TIA ___
- MRI/MRA old thalamic lacune, e/o chronic small vessel
ischemia and <30% stenosis ___ basilar artery
# chronic venous insufficiency, symptomatic R leg varicose veins
s/p leg GSV RFA ___
# OSA
# BPH
# GERD
Social History:
___
Family History:
NC
Physical Exam:
Vital Signs: 98.5 ___ 14 98% on RA
glucose:
.
GEN: NAD, well-appearing, lying in bed, interactive
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: normal BS, NT/ND, no HSM, no flank pain
EXT: warm, no c/c/e
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands, non focal
PSYCH: appropriate
ACCESS: PIV
FOLEY: absent
Pertinent Results:
# (___) WBC 14.1, BUN/Cr ___, TBili 2.3
U/A large ___, nit+, WBC >183
Blood cx
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 8 mg PO HS
2. Fluticasone Propionate NASAL ___ SPRY NU DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Omeprazole 20 mg PO BID
6. Sildenafil 50 mg PO PRN prior to sex activity
7. Simvastatin 40 mg PO DAILY
8. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Doxazosin 8 mg PO HS
3. Fluticasone Propionate NASAL ___ SPRY NU DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Omeprazole 20 mg PO BID
7. Simvastatin 40 mg PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*10 Tablet Refills:*0
9. Ibuprofen 600 mg PO Q8H:PRN pain
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 17 gm powder(s)
by mouth Daily Disp #*20 Packet Refills:*0
11. Sildenafil 50 mg PO PRN prior to sex activity
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
Benign prostate hypertrophy
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 man with fever. // Please evaluate for cause of
fever
TECHNIQUE: CHEST (PA AND LAT)
COMPARISON: ___ and ___
IMPRESSION:
Heart size is top-normal. , unchanged. Tortuous aorta E is unchanged. Lungs
are essentially clear. No appreciable pleural effusion or pneumothorax
demonstrated. Opacity projecting over the heart on the lateral view is
unchanged and most likely reflects extensive fat pad.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with fevers, elevated bilirubin, ?
pyelonephritis, with ongoing fevers despite abx // eval for cbd
dimension/dilation, any other pathology, also, please eval for perinephric
abscess
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___.
FINDINGS:
LIVER: The echogenicity of the liver is homogeneous. The contour of the liver
is smooth. There is no focal liver mass. Main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
No ___ sign was elicited.
PANCREAS: Head, body and tail of the pancreas are within normal limits,
without masses or pancreatic ductal dilatation.
SPLEEN: Normal echogenicity, measuring 10.4 cm.
KIDNEYS: The right kidney measures 10.0 cm. The left kidney measures 10.1 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Normal abdominal ultrasound. Specifically, no US evidence for pyelonephritis
or perinephric fluid collection detected.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Fever, Nausea
Diagnosed with URIN TRACT INFECTION NOS, PYELONEPHRITIS NOS
temperature: 101.2
heartrate: 111.0
resprate: 18.0
o2sat: 100.0
sbp: 135.0
dbp: 96.0
level of pain: 2
level of acuity: 3.0 | ASSESSMENT & PLAN: ___ yo M h/o HTN, TIA s/p L CEA ___, BPH
admitted with 2 days of fever, dysuria, frequency and urgency.
# UTI: Mr. ___ was admitted with fever 101, dysuria, urinary
frequency in setting of BPH. U/A had > 182 WBC/hpf, nit neg. He
was found to have WBC 14 but no flank pain to suggest
pyelonephritis. Prostate exam in ED also did not reveal signs
of prostate tenderness to suggest prostatitis.
He was initially treated with IV cipro and then transitioned
quickly to cipro. He tolerated this well with immediate
defervescence and normalization of WBC to 9. Post-void
residuals were checked x3 and revealed no significant retention
of urine - all <100 cc. He was continued on motrin PRN for
pain/musculoskeletal pain. Doxazosin was also continued - given
some history of poor urinary stream, however, finasteride may be
considered as an outpt to help further optimize urinary
clearance.
Mr. ___ Cr rise to 1.6 on HD2 but quickly improved to 1.3
after hydration.
# Elevated TBili: Mr. ___ had an admit Tbili of 2.3 - most of
which were indirect. Follow up Tbili was 1.6. The etiology is
uncertain - ___ possibility and transient sepsis a
possibility although there was no signs of hypotension during
this stay or in the ED.
# CV: h/o HTN, hyperchol, TIA, s/p L CEA, chronic venous
insufficiency. Mr. ___ was continued on ASA, statin,
metoprolol, HCTZ
# OTHER ISSUES AS OUTLINED.
.
#FEN: [X] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: [X]heparin sc []SCDs
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: None
#COMMUNICATION: pt and step-daughter ___ ___
#CONSULTS: None
#CODE STATUS: [X]full code []DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
hydrochlorothiazide / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug)
Attending: ___.
Chief Complaint:
left hip fracture
Major Surgical or Invasive Procedure:
Surgical fixation of left hip fracture
History of Present Illness:
___ female history of PMR on prednisone who presents with the
above fracture s/p mechanical fall. Patient was on the train
his
morning when she tripped and fell, striking her left hip and the
back of her head. No loss of consciousness. Patient was seen
and evaluated at ___ ED but requested transfer here since she is
a patient of Dr. ___. She endorses left hip pain and possible
initial numbness at time of injury but no current numbness or
tingling. According to chart review she has been taking ___ mg
of
prednisone daily for PMR taper.
Past Medical History:
ECZEMATOUS DERMATITIS
HYPERTENSION
MENOPAUSE
ACTINIC KERATOSIS
KERATOACANTHOMA
CLAVUS/CALLUS/CORN
ACTINIC KERATOSIS
DERMATITIS, ATOPIC
INGUINAL HERNIA
MILIA/MILIUM
OSTEOPENIA
POLYMYALGIA RHEUMATICA
SCOLIOSIS
AORTIC SCLEROSIS
FEMORAL HERNIA
Social History:
___
Family History:
NC
Physical Exam:
Left lower extremity exam
-dressing c/d/I
-fires ___
-silt s/s/sp/dp/t nerve distributions
-foot WWP
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. PredniSONE 2 mg PO DAILY
2. Chlorthalidone 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 30 mg SC QHS
RX *enoxaparin 30 mg/0.3 mL ___t bedtime Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
don't drink/drive while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*30
Tablet Refills:*0
5. Senna 8.6 mg PO BID
6. PredniSONE 2 mg PO ONCE Duration: 1 Dose
7. PredniSONE 0.5 mg PO QAM
8. PredniSONE 1.5 mg PO QPM
9. Chlorthalidone 25 mg PO DAILY
10. PredniSONE 2 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left intertrochanteric hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ yo F s/p mechanical fall on left side, +HS,-LOC// ___
yo F s/p mechanical fall on left side, +HS,-LOC
TECHNIQUE: AP view of the pelvis and two views of the left femur
COMPARISON: ___ pelvis and left hip radiographs..
FINDINGS:
Left intertrochanteric femoral neck fracture is demonstrated with mild lateral
displacement and varus angulation of the distal fracture fragment. Osseous
structures are diffusely demineralized. No dislocation. Mild degenerative
changes of both hips with joint space narrowing and subchondral sclerosis.
Diffuse vascular calcifications are present. No diastases of the pubic
symphysis or sacroiliac joints. Mild degenerative changes are noted in the
lower lumbar spine. Visualized aspect of the left knee demonstrates no gross
acute abnormality. Spiral tacks from prior hernia repair project over the
right pelvis.
IMPRESSION:
Mildly displaced left intertrochanteric femoral neck fracture with mild varus
angulation.
Radiology Report
INDICATION: History: ___ yo F s/p mechanical fall on left side, +HS,-LOC// ___
yo F s/p mechanical fall on left side, +HS,-LOC
TECHNIQUE: Supine AP view of the chest
COMPARISON: Chest radiograph ___ and chest CT ___
FINDINGS:
Mild cardiac enlargement is re-demonstrated. Mediastinal and hilar contours
are within normal limits. Pulmonary vasculature is normal. No focal
consolidation, pleural effusion, or pneumothorax. No displaced fractures are
evident. Mild scoliosis of the visualized thoracolumbar spine is unchanged.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ yo F s/p mechanical fall on left side, +HS,-LOC.
Evaluation for intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.2 cm; CTDIvol = 46.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: No relevant prior imaging for comparison.
FINDINGS:
There is no evidence of intracranial hemorrhage, acute large territorial
infarction, edema,or mass. There is prominence of the ventricles and sulci
suggestive of involutional changes. Periventricular and subcortical
hypodensities are nonspecific, though likely sequela of chronic small vessel
ischemic disease.
There is no evidence of fracture. There is layering fluid and locules of air
within the left maxillary sinus, which may represent sinusitis. Minimal
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.
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Layering fluid and locules of air within the left maxillary sinus, findings
which may represent acute sinusitis and clinical correlation is suggested.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ yo F s/p mechanical fall on left side, +HS,-LOC.
Evaluation for 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 5.1 s, 20.0 cm; CTDIvol = 22.6 mGy (Body) DLP = 452.4
mGy-cm.
2) Sequenced Acquisition 1.0 s, 4.1 cm; CTDIvol = 14.7 mGy (Body) DLP =
60.0 mGy-cm.
Total DLP (Body) = 512 mGy-cm.
COMPARISON: No relevant prior imaging for comparison.
FINDINGS:
Mild anterolisthesis of C2 on C3, C3 on C4, and C5 on C6, likely chronic and
secondary to degenerative change.No acute fractures are identified. Extensive
multilevel degenerative change is noted, including multilevel disc space
narrowing most severe at C3-C4 and C4-C5 and fusion of the facet joints at
these levels. Moderate multilevel anterior and posterior osteophytosis is
demonstrated. Extensive pannus formation with calcification at the
atlanto-axial region. A cyst is seen within the dens which is likely
degenerative in etiology. Mild multilevel canal narrowing secondary to
posterior disc/osteophyte complexes, most notably at C3-C4 and C5-C6. Mild
right-sided neural foraminal narrowing at C3-C4, severe bilateral neural
foraminal narrowing at C4-C5, severe bilateral neural foraminal narrowing at
C5-C6, and moderate bilateral neural foraminal narrowing at C6-C7, secondary
to uncovertebral osteophytes. There is no prevertebral soft tissue swelling.
The thyroid gland is unremarkable. Partially visualized lung apices are
notable for a 3 mm pulmonary nodule at the right upper lobe.
IMPRESSION:
1. No evidence of acute fracture or traumatic malalignment.
2. Extensive multilevel degenerative change, most notably at C4-C5 and C5-C6.
Multilevel subluxations likely degenerative in etiology.
3. Solitary 3 mm pulmonary nodule at the right upper lobe. As per the
___ society guidelines included below, no CT follow-up is recommended
in a low-risk patient, and an optional CT in 12 months is recommended in a
high-risk patient.
RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
INDICATION: Fracture
TECHNIQUE: 3 fluoroscopic spot images of the left hip
COMPARISON: ___
FINDINGS:
3 fluoroscopic spot images of the left hip demonstrate a gamma nail construct
transfixing a intertrochanteric femur fracture. There is good overall
alignment. The total fluoroscopic time is 80.0 seconds. For further details
please see the intraoperative note.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Hip fracture, s/p Fall
Diagnosed with Displaced intertrochanteric fracture of left femur, init, Occ of rail trn/veh injured by fall in rail trn/veh, init
temperature: 98.0
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 180.0
dbp: 72.0
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 a left hip intertrochanteric fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for left short TFN, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home with home ___ was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
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: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right foot pain/ischemia
Major Surgical or Invasive Procedure:
1. Realtime ultrasound-guided access to the left common femoral
artery and placement of a ___ sheath.
2. Selective catheterization of the right peroneal artery, a
third-order vessel.
3. Percutaneous transluminal angioplasty and stenting of the
left common iliac artery using an 8 x 38 iCAST stent.
4. Abdominal aortogram.
5. Right lower extremity angiogram.
6. Percutaneous transluminal angioplasty and stenting of the
left common iliac artery using an 8 x 38 iCAST stent.
7. Percutaneous transluminal angioplasty and stenting of the
right external iliac artery using a 7 x ___ Innova stent.
8. Percutaneous transluminal angioplasty and stenting of the
right peroneal artery and tibioperoneal trunk using a 3 mm x 38
mm Premier Rx coronary stent.
9. Closure of the left common femoral puncture site using an
___ Angio-Seal device.
History of Present Illness:
Mr. ___ is a ___ with history of ESRD on HD, DM, Hep C, PVD
s/p right fem-BKpop bypass and left fem-AKpop bypass ___
___ for a right ___ toe nonhealing ulcer and bilateral lower
extremity rest pain, now presenting with acute worsening right
foot pain. He was in his usual state until ___ days ago when he
started noticing right greater than left calf pain. This morning
he developed severe right foot pain and parasthesias with
discoloration of his right ___ toes. He also noticed decreased
foot and leg sensation up to the level of his midshin. He
therefore presented to ___ for further
evaluation. CTA was obtained at that time which showed occlusion
of the right fem-BK pop bypass graft. Given these findings, he
was started on heparin and transferred to ___ for
furthervascular care.
ROS:
(+) per HPI
(-) Denies fevers, chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, nausea, vomiting,
hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest
pain, shortness of breath, cough, edema, urinary frequency,
urgency
Past Medical History:
PMH:
diabetes, ESRD on HD, Hep C, HTN, HLD
PSH:
- failed left radialcephalic and brachialcephalic fistulas,
functioning right brachialcephalic fistula
- right ___ toe ray amputation
- simultaneous left fem-AK pop bypass and right fem-BKpop bypass
Social History:
___
Family History:
Mother - CAD
Father - diabetes
Physical Exam:
Physical Exam at Discharge:
VS: 98.0, 150/61, 82, 18, 100% RA
HEENT: normocephalic atraumatic
CV: RRR
PULM: breathing comfortably on room air
ABD: Soft, non-tender, no rebound or guarding
Ext: right toes ___ cyanontic/insensate/cold, open ulcer on the
dorsum of the foot with frank bloody ooze, calf tenderness, but
soft
Access: RUE AVF with bruit and thrills.
Pulses: R: p/d/-/- L: p/d/-/d
Pertinent Results:
___ 05:30AM BLOOD WBC-12.3* RBC-2.47* Hgb-7.8* Hct-24.0*
MCV-97 MCH-31.6 MCHC-32.5 RDW-13.6 RDWSD-48.3* Plt ___
___ 05:32PM BLOOD WBC-13.5* RBC-3.34* Hgb-10.6* Hct-31.7*
MCV-95 MCH-31.7 MCHC-33.4 RDW-14.9 RDWSD-51.4* Plt ___
___ 05:30AM BLOOD Glucose-139* UreaN-31* Creat-6.7*# Na-135
K-4.7 Cl-90* HCO3-27 AnGap-18
___ 05:32PM BLOOD Glucose-156* UreaN-33* Creat-6.3* Na-133*
K-7.2* Cl-87* HCO3-29 AnGap-17
___ 05:30AM BLOOD Calcium-9.4 Phos-5.8* Mg-2.4
___ ABI:
Impression significant bilateral multi segmental, primarily
tibial arteryvocclusive disease with severe flow deficit.
___ Veinous Duplex/Vein Mapping
Findings duplex evaluations for both greater saphenous vein.
The right isvpatent with suitable diameters. The left is patent
but diminutive.
Impression patent bilateral greater saphenous veins, diminutive
on the left. Evaluate scanned worksheet
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 200 mg PO QHS
2. Albuterol Inhaler ___ PUFF IH Frequency is Unknown
3. Pantoprazole 20 mg PO Q24H
4. Nortriptyline 25 mg PO TID
5. Metoclopramide 5 mg PO QID
6. Lisinopril 5 mg PO DAILY
7. Januvia (SITagliptin) 100 mg oral DAILY
8. Carvedilol 25 mg PO DAILY
9. BusPIRone 10 mg PO BID
10. amLODIPine 10 mg PO DAILY
11. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/headache
Do not drink alcohol on this medication.
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours as
needed Disp #*30 Tablet Refills:*1
2. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every 24 hours Disp #*14 Tablet Refills:*0
3. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*12
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth two times a day
as needed Disp #*60 Capsule Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
Please do not drink alcohol or drive while on this medication.
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours as
needed Disp #*30 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily as
needed Refills:*0
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet by mouth two times a day
as needed Disp #*60 Tablet Refills:*0
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 2 tablet(s) by mouth three times
a day with meals Disp #*180 Tablet Refills:*3
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN short of breath
11. amLODIPine 10 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. BusPIRone 10 mg PO BID
14. Carvedilol 25 mg PO DAILY
15. Gabapentin 200 mg PO QHS
16. Januvia (SITagliptin) 100 mg oral DAILY
17. Lisinopril 5 mg PO DAILY
18. Metoclopramide 5 mg PO QID
19. Nortriptyline 25 mg PO TID
20. Pantoprazole 20 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
critical right lower limb ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - partially weight bearing
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with limb ischemia, to OR// eval for infiltrate
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided. There is no focal consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Aortic
calcification noted. Imaged osseous structures are intact. No free air below
the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
Study venous duplex extremity.
Reason bypass
Findings duplex evaluations for both greater saphenous vein. The right is
patent with suitable diameters. The left is patent but diminutive.
Impression patent bilateral greater saphenous veins, diminutive on the left.
Evaluate scanned worksheet
Radiology Report
Study arterial extremity rest.
Reason gangrene.
Findings Doppler evaluation was performed of both lower extremities.
On the right Doppler waveforms are biphasic femoral levels only. There
monophasic below. Pulse volume recordings show significant drop-off in the
ankle and are flat line at the metatarsal.
The left waveforms are biphasic at the femoral and popliteal. There
monophasic below. Pulse volume recordings show significant drop-off. The toe
pressure is 24.
Impression significant bilateral multi segmental, primarily tibial artery
occlusive disease with severe flow deficit.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: R Foot pain, Transfer
Diagnosed with Pain in right ankle and joints of right foot, Other disorder of circulatory system
temperature: 98.4
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 180.0
dbp: 82.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ year old male with ESRD on HD,DM,Hep C,PVD
who is status post a right fem-BKpop bypass and left fem-AKpop
bypass ___ for a right ___ toe non-healing ulcer and
bilateral lower extremity rest pain who presented to ___
___ on ___ with evidence of a
right femoral BK pop bypass occlusion with iliac inflow stenosis
on CTA. He was taken to the OR and underwent a thrombectomy RLE
peroneal angioplasty. For details of the procedure, please see
the surgeon's operative note. The patient tolerated the
procedure well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the vascular surgery floor
where he remained through the rest of the hospitalization.
Post-operatively, he did well without any groin swelling.
Nephrology and HD were consulted. He returned to the operating
room on POD for an angio. On POD 3 he underwent HD, he was
having pain in his calf and he was noted to have a CK level
elevated to ___. His CK was checked throughout the stay and
remained stable. His calf remained tender, but soft. On POD 4
his pain improved. He worked with physical therapy wand was
ddeemed appropriate for home with services. On POD 6 he was
able to tolerate a regular diet, get out of bed and ambulate
without assistance, void without issues, and pain was controlled
on oral medications alone. On ___ his discharge and need for
follow-up were explained with the use of an interpreter. He
stayed for one additional day for dialysis then was discharged
home with ___ and home Physical Therapy, and was given the
appropriate discharge and follow-up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ankle pain
Major Surgical or Invasive Procedure:
Left tibia IMN
History of Present Illness:
___ w/ hx of L ACL rupture s/p repair ___ w/ Dr. ___
L ankle pain after motorcycle accident. He was taking a turn
when he hit a patch of sand and fell onto his L side with his
bike landing on top of him. He has immediate pain in L ankle and
was unable to bear weight. Denies weakness or numbness. No LOC
or headstrike. Denies pain in other locations.
Past Medical History:
- L ACL rupture s/p repair ___ w/ Dr. ___
___ History:
___
Family History:
NC
Physical Exam:
In general the patient is an average aged male in NAD
Calm and comfortable
AVSS
Left lower extremity:
Skin intact
+ Edema and ecchymosis
Tenderness to palpation over medial and lateral malleoli
Ankle ROM limited ___ pain
Full, painless AROM/PROM of hip and knee
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
___ 04:54PM ___ PTT-26.8 ___
___ 04:20PM GLUCOSE-98 UREA N-18 CREAT-1.0 SODIUM-133
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-28 ANION GAP-11
___ 04:20PM estGFR-Using this
___ 04:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:20PM WBC-10.2 RBC-4.87 HGB-15.2 HCT-44.6 MCV-92
MCH-31.3 MCHC-34.1 RDW-12.6
___ 04:20PM NEUTS-84.8* LYMPHS-9.9* MONOS-4.6 EOS-0.3
BASOS-0.4
___ 04:20PM PLT COUNT-228
Medications on Admission:
See OMR.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe SC QPM Disp #*14 Syringe
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left distal third tibia fracture & ___ fibula fracture
Discharge Condition:
Pt was A&Ox3 and able to ambulate with crutches. His vital signs
were stable, pain controlled without nausea and tolerating PO's
Followup Instructions:
___
Radiology Report
LEFT TIBIA, FIBULA AND ANKLE FILMS: ___.
HISTORY: ___ male with left ankle pain status post MVC.
FINDINGS: Frontal and lateral views of the left knee. Frontal and lateral
views of the proximal and distal left tibia and fibula. Postoperative changes
of prior ACL repair are seen. There are acute fractures identified through
the tibia and fibula. There is a comminuted proximal left tibial fracture
with mild anterior angulation of the main fracture fragment with respect to
the proximal fibula. Acute obliquely oriented distal left tibial diaphyseal
fracture is seen with approximately 1.4 cm of lateral displacement of the
distal fracture fragment. Degenerative changes are partially visualized at
the left knee.
IMPRESSION: Acute fractures through the proximal left fibula and distal left
tibia as above.
Radiology Report
PORTABLE CHEST: ___.
HISTORY: ___ male pre-op chest x-ray.
COMPARISON: None.
FINDINGS: Single AP view of the chest. The lungs are clear. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormality is identified.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
LEFT TIBIA AND FIBULA FILMS: ___
HISTORY: ___ male with left tib-fib fracture, status post reduction.
COMPARISON: Films from earlier the same day.
FINDINGS: Frontal and lateral views of the proximal and distal left tibia and
fibula demonstrate comminuted fractures of the proximal left fibula and
oblique fractures through the distal left tibia. There has been no
significant interval change in the degree of lateral displacement of the
largest distal tibial fracture fragment. Overlying cast obscures fine bony
detail. Post-operative changes of prior ACL repair are again noted.
Radiology Report
STUDY: Left tib-fib, ___.
CLINICAL HISTORY: Patient with tibial fracture, status post fixation.
FINDINGS: Comparison is made to previous study from ___.
There has been placement of an intramedullary rod and proximal and distal
interlocking screws fixating an oblique fracture through the left distal
tibial shaft. There is also a fracture involving the proximal fibular shaft
with butterfly fragment. There is improvement in anatomic alignment and no
signs of hardware-related complications. The total intraservice fluoroscopic
time was 270 seconds. Please refer to the operative note for additional
details.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Ankle injury, MOTORCYCLE ACCIDENT
Diagnosed with FX ANKLE NOS-CLOSED, FX UPPER END FIBULA-CLOS, MV TRAFF ACC NEC-MOCYCL
temperature: 98.6
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 132.0
dbp: 78.0
level of pain: 3
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left tibia IMN, 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.
Musculoskeletal: Prior to operation, patient was NWB LLE.
After procedure, patient's weight-bearing status was
transitioned to WBAT LLE. Throughout the hospitalization,
patient worked with physical therapy who determined that
discharge to home was most appropriate.
Neuro: Post-operatively, patient's pain was controlled by IV
pain medication and was subsequently transitioned to oxycodone
with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was not transfused blood for acute
blood loss anemia.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #2, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
minoxidil
Attending: ___.
Chief Complaint:
subtherapeutic INR
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ h/o HTN, DMII, ESRD on HD MWF via RUE AV fistula, asthma,
PVD, with recent dx of RUE axillary DVT who presents for
subtherapeutic INR. Of note patient was recently admitted for
RUE swelling and was found to have axillary vein DVT. Despite
history of GI bleed he was started on warfarin. He also had a
Fistulogram on ___ with high grade stenosis of outflow tract
which was fixed with balloon angioplasty.
The patient presents today for low INR. He had INR of 1.38 and
was sent for admission from rehab for heparin bridge. He was
referred in when ___ was trialing lovenox for bridge despie ESRD.
The patient denies any new chest pain no cough no
lightheadedness new hemoptysis or any progression of the
symptoms from his baseline.
INR recently:
___: 1.38
___: 1.47
___: 1.4
___: 2.3
___: 2.6
In the ED, initial vitals were: 96.6 88 149/97 24 100% nasal
- Labs notable for: Trop 0.07, K 5.4 but hemolysed Troponin
0.07
- Patient was given: IV heparin ggt, duoneb
- Vitals prior to transfer: 97.4 87 144/104 22 100% Nasal
Cannula
Unfortunately patient arrived on floor at 6 am and was unable
to obtain ___ interpreter. PAtient however appeared to
be in no distress. With phone interpreter he did appear to be
AAO to person and place; he reported having baseline body aches
he gets before HD.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
1. Benign Hypertension
2. Type 2 Diabetes
3. Stage V chronic kidney disease from diabetic nephropathy
4. Hx of strokes ___ and ___ -> R arm and leg weakness with
slurred speech intermittently
5. Asthma
6. Hypercholesterolemia.
7. PVD
8. Seizures - complex partial
9. Hx of DVT/PE in ___
10. Schizophrenia
11. s/p L CEA
12. Left-to-right femoral-to-femoral bypass with PTFE, Right
femoral endarterectomy with profundoplasty ___
13. left arm AV fistula placement on ___ -> occluded left
brachial artery -> emergent thrombectomy of the left brachial
artery on ___
14. Ischemic colitis which occurred due to hypotension during
dialysis
15. Diverticulosis
16. Fistulogram s/p angioplasty (___)
17. Right axillary DVT ___
Social History:
___
Family History:
Mother died at age ___ and father died at a young age of unknown
cause, sister died during childbirth in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
PHYSICAL EXAM:
Vital Signs: HR 100 BP 179/91 T 97.3 R 20 100 % ion 3 L NC
General: Alert, oriented, moving around, in mild distress,
slightly SOB
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: irregular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally over anterior chest,
bibasilar crackles posterior chest
Abdomen: Soft, non-tender, slightly 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: moving all extremeities
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: 97.8 106/62 (106-169/62-76) 77 (75-82) ___
on RA
General: Alert, oriented, at HD, lying comfortably in bed
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: irregular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally over anterior chest,
diminished lung sounds at R lung base with egophony, dullness to
percussion, and slight rhonchi- overall improvement w/fewer
rhonchi today.
Abdomen: Soft, non-tender, slightly distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Significant swelling of right upper extremity. Warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema. Trace edema
in bilateral lower extremities.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:32PM PTT-83.9*
___ 10:16AM ___ PTT-44.4* ___
___ 02:47AM GLUCOSE-161* UREA N-40* CREAT-5.0*#
SODIUM-133 POTASSIUM-5.4* CHLORIDE-94* TOTAL CO2-22 ANION
GAP-22*
___ 02:47AM estGFR-Using this
___ 02:47AM CK(CPK)-124
___ 02:47AM CK-MB-3 cTropnT-0.07*
___ 02:47AM CALCIUM-8.9 PHOSPHATE-4.7* MAGNESIUM-1.9
___ 02:47AM WBC-7.3 RBC-3.52* HGB-11.0* HCT-33.3* MCV-95
MCH-31.3 MCHC-33.0 RDW-14.6 RDWSD-50.1*
___ 02:47AM NEUTS-69.5 LYMPHS-13.3* MONOS-13.5* EOS-3.0
BASOS-0.4 IM ___ AbsNeut-5.09 AbsLymp-0.97* AbsMono-0.99*
AbsEos-0.22 AbsBaso-0.03
___ 02:47AM PLT COUNT-199
MICROBIOLOGY:
=============
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 1:43 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
MRSA SCREEN (Final ___: No MRSA isolated.
Streptococcus pneumoniae Antigen Detection (___): Pending
IMAGING:
========
Chest PA&LAT (___):
FINDINGS:
Again seen is a right subclavian stent with collapse of the
medial aspect of the stent.
There are diffusely prominent reticular markings, compatible
with mild
interstitial edema, unchanged compared to radiographs from ___.
There is a small, layering right pleural effusion, decreased
from prior.
There is no left pleural effusion. The cardiomediastinal
silhouette and
bilateral hilar contours remain unchanged. There is no
pneumothorax.
There is a healed fracture of the left midclavicle.
IMPRESSION:
Mild interstitial edema, unchanged compared to radiographs of
the chest from ___. Small, layering right pleural
effusion, decreased from prior.
Chest portable (___):
FINDINGS:
Cardiac silhouette is moderately enlarged. Moderate pulmonary
edema persists. Small pleural effusions are suspected. Right
subclavian vascular stents with kinking is unchanged. No acute
osseous abnormalities.
IMPRESSION:
Cardiomegaly with pulmonary edema and small bilateral effusions.
Chest portable (___):
FINDINGS:
The cardiac silhouette is enlarged however to a lesser degree
than prior.
There is decreased pulmonary edema, now mild to moderate in
extent. There are small bilateral pleural effusions. Opacities
in the right lower lung are more conspicuous than on the prior
examination. The appearance of a right subclavian stent is
unchanged.
IMPRESSION:
Persisting pulmonary edema, and slightly decreased in extent
since prior.
Increased right basilar opacities may reflect atelectasis and/or
consolidation.
DISCHARGE AND PERTINENT LABS:
=============================
___ 07:15AM BLOOD WBC-11.6* RBC-3.48* Hgb-10.8* Hct-32.3*
MCV-93 MCH-31.0 MCHC-33.4 RDW-14.3 RDWSD-48.2* Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-203* UreaN-81* Creat-7.1*# Na-135
K-4.2 Cl-94* HCO3-19* AnGap-26*
___ 07:15AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.8
Radiology Report
EXAMINATION: Chest radiographs from ___
INDICATION: ___ year old man with ESRD and RUE DVT now with hypoxia and new O2
requirement// pneumonia vs. pulm edema
TECHNIQUE: AP radiograph of the chest was performed
COMPARISON: Chest radiographs from ___
FINDINGS:
Again seen is a right subclavian stent with collapse of the medial aspect of
the stent.
There are diffusely prominent reticular markings, compatible with mild
interstitial edema, unchanged compared to radiographs from ___.
There is a small, layering right pleural effusion, decreased from prior.
There is no left pleural effusion. The cardiomediastinal silhouette and
bilateral hilar contours remain unchanged. There is no pneumothorax.
There is a healed fracture of the left midclavicle.
IMPRESSION:
Mild interstitial edema, unchanged compared to radiographs of the chest from
___. Small, layering right pleural effusion, decreased from prior.
Radiology Report
INDICATION: ___ year old man with HTN, DMII, ESRD on HD, asthma, RUE AV
fistula and RUE DVT here w/ SOB, crackles and wheezes// fluid overload?
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Cardiac silhouette is moderately enlarged. Moderate pulmonary edema persists.
Small pleural effusions are suspected. Right subclavian vascular stents with
kinking is unchanged. No acute osseous abnormalities.
IMPRESSION:
Cardiomegaly with pulmonary edema and small bilateral effusions.
Radiology Report
INDICATION: ___ year old man with hypoxia, w/volume overload and c/f viral
bronchitis.// evaluate for consolidation, volume overload
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The cardiac silhouette is enlarged however to a lesser degree than prior.
There is decreased pulmonary edema, now mild to moderate in extent. There are
small bilateral pleural effusions. Opacities in the right lower lung are more
conspicuous than on the prior examination. The appearance of a right
subclavian stent is unchanged.
IMPRESSION:
Persisting pulmonary edema, and slightly decreased in extent since prior.
Increased right basilar opacities may reflect atelectasis and/or
consolidation.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Subtherapeutic INR
Diagnosed with Acute embolism and thrombosis of deep veins of r up extrem
temperature: 96.6
heartrate: 88.0
resprate: 24.0
o2sat: 100.0
sbp: 149.0
dbp: 97.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with a history of HTN, DMII, ESRD on HD
MWF via RUE AV fistula, and asthma, with recent diagnosis of RUE
axillary DVT who presents with subtherapeutic INR, and who was
admitted for an inpatient heparin gtt bridge.
# axillary vein DVT:
# Subtherapeutic INR: Patient has a history of requiring
angioplasty of fistula secondary to stenosis, and has history of
recent axillary vein DVT (___), and therefore required an
admission for IV heparin bridge to warfarin. Prior to admission,
patient was taking warfarin dose 3mg daily. He was maintained on
IV heparin until ___, when his INR had been in goal therapeutic
range ___ for >24hrs. Warfarin dose 3.5mg daily and INR 2.7 at
time of discharge on ___. Patient will be on chronic
anticoagulation given his concurrent history of atrial
fibrillation (see below). Patient was also encouraged to sit up
in cardiac chair and elevate his right upper extremity to reduce
swelling secondary to DVT.
# Hypoxia:
# Hypervolemia:
# HCAP: Patient on RA at home, but escalated to a 4LNC in the
setting of tachypnea and dyspnea. Patient's respiratory status
improved with increasing fluid removal at scheduled HD sessions
on MWF, however the improvement was suboptimal, with patient
endorsing pleuritic chest pain, having productive sputum, and
diffuse wheezes and rhonchi. Patient also developed leukocytosis
and CXR was also concerning for a R basilar opacity. Urine
legionella negative. Sputum cx w/commensal respiratory flora.
Strep pneumo pending at time of discharge. Given concern for
both exacerbation of patient's known reactive airway disease and
pneumonia, patient was treated with 5-day prednisone burst (day
1: ___, 40mgx2days, 20mgx3days, off) and with antibiotics:
initially with vancomycin/cefepime on day 1: ___. MRSA swab
resulted negative on ___ and vancomycin was discontinued.
Patient's leukocytosis improved and he was able to wean off
supplemental oxygen. Cefepime was transitioned to PO
levofloxacin for a planned total 8-day course of antibiotics,
scheduled to end on ___. -continue PO levofloxacin for total
8-day course to end on ___.
# Generalized body aches: Patient has diffuse body aches ___ to
chronic back pain and leg pain, which are typically worse after
post-dialysis. He takes Tylenol ___ TID at home which was
continued in house with good pain control.
CHRONIC ISSUES:
# Atrial fibrillation/Atrial flutter: CHADS2Vasc=3 (CVA, DM).
Patient is on warfarin in the outpatient setting and is
rate-controlled on metoprolol succinate 50mg daily. As above,
patient was admitted with subtherapeutic INR, and was bridged
with IV heparin to warfarin with INR goal ___. IV heparin was
discontinued when INR was therapeutic for >24hrs. At time of
discharge, Warfarin dose was 3.5mg daily and INR was 2.7 on
___.
# End stage renal disease on hemodialysis: Patient has ESRD
secondary to diabetic nephropathy. He received his scheduled MWF
HD sessions while in-house, and as above, increased fluid was
removed as part of treatment for hypervolemia. Patient was
continued on his home cinacalcet, nephrocaps, and vitamin D.
# Asthma: Patient was continued on his home fluticasone INH,
albuterol inh, and albuterol nebs q4h:PRN. As above,
exacerbation of his reactive airway disease likely contributed
to his respiratory distress and patient received 5-day
prednisone burst. He was also started on albuterol:ipratropium
duonebs q6h:prn, with improvement in his wheezing.
----------------- |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left-sided abdominal pain, low-grade fevers
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
___ with a history of hemoglobin SC, hypertension who presents
with 2 days of left upper quadrant abdominal pain.
She was seen in ___ on three days prior to presentation
for
vaso-occlusive crisis of the left arm and was given IV narcotics
with improvement in her pain and was discharged with oxycodone.
The next day she developed acute onset of left upper quadrant
abdominal pain. She has had this pain in the past that was
related to her spleen. Her pain is worse now and associated with
nausea and an episode of non-bilious non-bloody vomiting. She
had
a temperature to 100. She reports that breathing or moving
worsens the pain. She denies any cough, urinary symptoms, hip
pain. She does endorse lower back pain over the last few weeks.
She is followed by Dr. ___ in the hematology department for
her
sickle cell anemia.
In the ED, initial VS were: T 97.8, HR 76, BP 143/79, RR 18,
100% RA
Exam notable for: Physical exam shows left upper quadrant
tenderness with no rebound or guarding.
Labs showed:
- CBC: WBC 18.2 (86.6%n), Hgb 7.9, Plt 164
- Lytes:
139 / 99 / 14
------------- 105
3.5 \ 25 \ 1.3
- Ret-Aut: 4.9, Abs-Ret: 0.13
- AST 98, ALT 65, AP 85, Tbili 1.5, Alb 4.2, Lip 15
- Lactate:1.0
- Flu swab negative
Imaging showed:
- CT a/p w/ contrast with:
1. Bilateral lower lobe basal segment mixed ground-glass and
consolidative opacities, possibly atelectasis, developing
infection, or sequela of acute chest syndrome.
2. Enlarged, heterogeneously enhancing spleen. Difficult to
exclude areas of developing infarction.
3. Cholelithiasis.
4. Bilateral femoral head avascular necrosis without evidence
of
collapse.
Patient received:
___ 12:22 IV Ondansetron 4 mg
___ 12:22 IVF NS 1000 mL
___ 12:22 IV HYDROmorphone (Dilaudid)
___ 12:52 IV HYDROmorphone (Dilaudid) .5 mg
___ 13:50 IV Piperacillin-Tazobactam 4.5 g
___ 14:57 IV Vancomycin 1000 mg
___ 16:16 IV Azithromycin 500mg
___ 16:16 IV HYDROmorphone (Dilaudid) .5 mg
___ 16:16 IV Ondansetron 4 mg
___ 17:36 IV Ondansetron 4 mg
___ 19:00 PO Hydroxyurea 500 mg
___ 20:12 IV HYDROmorphone (Dilaudid) .5 mg
Transfer VS were:
On arrival to the floor, patient reports improvement in her
pain
that is mostly located in her lower back
Past Medical History:
-- Hemoglobin SC disease
-- Hypertension
-- Low-grade cervical dysplasia with high-risk HPV
-- Bilateral knee pain
-- Gonococcal cervicitis (teenager)
-- Lymphedema
-- Depression
SURGICAL HISTORY:
-- Tonsillectomy
-- Right neck excisional lymph node biopsy (benign)
-- Postpartum tubal ligation
-- Prior colposcopies and cryosurgery
Social History:
___
Family History:
Per past notes:
- Father with prostate cancer, sickle trait.
- No known history of diabetes or heart disease.
Physical Exam:
ADMISSION EXAM:
===============
VS: 99.6 PO 130 / 78 L Lying 93 18 93 Ra
GENERAL: NAD
HEENT: PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: supple
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 EXAM:
===============
24 HR Data (last updated ___ @ 1150)
Temp: 97.9 (Tm 98.9), BP: 145/80 (mannual) (145-171/80
(mannual)-97), HR: 76 (65-78), RR: 19 (___), O2 sat: 96%
(93-97)
GENERAL: sitting up in bed, appears comfortable and bright
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: mild basilar crackles, breathing comfortably on room air
ABDOMEN: normoactive bowel sounds, TTP in LUQ with no rebound or
guarding, moving in bed with no discomfort
EXTREMITIES: BLE warm with no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 12:00PM BLOOD WBC-18.2* RBC-2.68* Hgb-7.9* Hct-21.7*
MCV-81* MCH-29.5 MCHC-36.4 RDW-14.3 RDWSD-41.3 Plt ___
___ 12:00PM BLOOD Neuts-86.6* Lymphs-3.9* Monos-8.7
Eos-0.2* Baso-0.2 NRBC-0.9* Im ___ AbsNeut-15.77*
AbsLymp-0.72* AbsMono-1.58* AbsEos-0.04 AbsBaso-0.04
___ 12:00PM BLOOD Plt ___
___ 12:00PM BLOOD Ret Aut-4.9* Abs Ret-0.13*
___ 12:00PM BLOOD Glucose-105* UreaN-14 Creat-1.3* Na-139
K-3.5 Cl-99 HCO3-25 AnGap-15
___ 12:00PM BLOOD ALT-65* AST-98* AlkPhos-85 TotBili-1.5
___ 12:00PM BLOOD Lipase-15
___ 12:00PM BLOOD Albumin-4.2
___ 12:12PM BLOOD Lactate-1.0
INTERIM LABS:
===============
___ 06:20AM BLOOD ALT-63* AST-83* LD(LDH)-1209* AlkPhos-92
TotBili-1.2
___ 06:54AM BLOOD ALT-90* AST-107* AlkPhos-121*
___ 06:50AM BLOOD ZINC (SPIN NVY/EDTA)-Test 67 (60-130
mcg/dL)
DISCHARGE LABS:
===============
___ 06:55AM BLOOD WBC-10.6* RBC-3.06* Hgb-9.4* Hct-26.3*
MCV-86 MCH-30.7 MCHC-35.7 RDW-17.1* RDWSD-53.0* Plt ___
___ 06:55AM BLOOD Glucose-87 UreaN-8 Creat-0.8 Na-142 K-4.5
Cl-100 HCO3-30 AnGap-12
___ 06:55AM BLOOD ALT-76* AST-55* LD(LDH)-1007*
AlkPhos-156* TotBili-0.9
MICROBIO:
=========
Blood culture and urine cultures no growth ___
IMAGING:
========
CT abdomen and pelvis with contrast ___:
1. Bilateral lower lobe basal segment mixed ground-glass and
consolidative
opacities, possibly atelectasis, developing infection, or
sequela of acute
chest syndrome.
2. Enlarged, heterogeneously enhancing spleen. Difficult to
exclude areas of
developing infarction.
3. Cholelithiasis.
4. Bilateral femoral head avascular necrosis without evidence of
collapse.
CXR PA&LAT ___:
Left lower lobe consolidative opacity concerning for pneumonia.
Follow up
radiographs after treatment are recommended to ensure resolution
of this
finding.
PENDING
========
Parvovirus antibodies and PCR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydroxyurea 500 mg PO BID
2. OxyCODONE (Immediate Release) 5 mg PO TID
3. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
4. Naproxen 250 mg PO Q12H:PRN Pain - Mild
5. FLUoxetine 20 mg PO DAILY
6. FoLIC Acid 5 mg PO DAILY
7. LORazepam 1 mg PO QHS:PRN insomnia
8. Vitamin D 1000 UNIT PO DAILY
9. maca (bulk) miscellaneous DAILY
10. turmeric root extract ___ mg oral DAILY
11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Polyethylene Glycol 17 g PO BID constipation
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
twice a day Refills:*0
2. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*10 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
Do not take with Ativan.
RX *oxycodone 5 mg 1 tablet(s) by mouth q4h PRN pain Disp #*20
Tablet Refills:*0
5. FLUoxetine 20 mg PO DAILY
6. FoLIC Acid 5 mg PO DAILY
7. Hydroxyurea 500 mg PO BID
8. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
9. LORazepam 1 mg PO QHS:PRN insomnia
Do not take with oxycodone.
10. maca (bulk) miscellaneous DAILY
11. turmeric root extract ___ mg oral DAILY
12. Vitamin D 1000 UNIT PO DAILY
13.Outpatient Lab Work
ICD 9 282.62
Labs to be drawn: CBC, LFTs/Tbili, LDH, Chem-7.
Fax results to: ___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
Sickle cell crisis
Splenic infarct
Pneumonia vs. Acute chest syndrome
Bilateral avascular necrosis of the femoral head
Transaminitis
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with chest pain// evaluate for intra-thoracic
process
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. New consolidative opacity in the left lower
lobe is concerning for pneumonia. The right lung is clear. No pleural
effusion or pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
Left lower lobe consolidative opacity concerning for pneumonia. Follow up
radiographs after treatment are recommended to ensure resolution of this
finding.
Radiology Report
EXAMINATION: CT abdomen/pelvis
INDICATION: ___ with LUQ pain, sickle cell disease.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 22.7 mGy (Body) DLP =
1,203.2 mGy-cm.
Total DLP (Body) = 1,210 mGy-cm.
COMPARISON: ___ chest CTA
FINDINGS:
LOWER CHEST: Mixed ground-glass and consolidative opacities in the lower lobe
basal segments. Heart size appears mildly enlarged. There may be a tiny left
pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. No
evidence of focal lesions. The portal veins are patent. 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. No peripancreatic stranding.
SPLEEN: Spleen remains enlarged measuring up to 16.1 cm in craniocaudal
dimension, but heterogeneously. No discrete focal lesion is identified.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Left kidney is compressed by the adjacent enlarged spleen. The
kidneys are otherwise of symmetric size with normal nephrogram. No evidence
of concerning renal lesions or hydronephrosis.
GASTROINTESTINAL: Stomach is unremarkable. Small bowel loops are
unremarkable. No bowel obstruction. Diverticulosis of the colon is noted,
without evidence of wall thickening and fat stranding. The appendix is
normal.
PELVIS: The urinary bladder is unremarkable. No free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is anteverted. There is a small calcification
in the right adnexa, possibly a small dermoid.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. No significant atherosclerotic
disease.
BONES/SOFT TISSUES: There is no aggressive osseous lesion or acute fracture.
Incidental note is made of bilateral avascular necrosis of the femoral heads
without evidence of collapse. Small, fat containing umbilical hernia.
IMPRESSION:
1. Bilateral lower lobe basal segment mixed ground-glass and consolidative
opacities, possibly atelectasis, developing infection, or sequela of acute
chest syndrome.
2. Enlarged, heterogeneously enhancing spleen. Difficult to exclude areas of
developing infarction.
3. Cholelithiasis.
4. Bilateral femoral head avascular necrosis without evidence of collapse.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Pneumonia, unspecified organism
temperature: 97.8
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 143.0
dbp: 79.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with hemoglobin SC and
hypertension who presented on ___ with 2 days of left upper
quadrant abdominal pain, found to have splenic infarction,
pneumonia vs. acute chest syndrome, and b/l asymptomatic
avascular necrosis of femoral head. She was transfused 3 units
of blood and improved with pain medications, IVF, and
supplemental O2.
#Sickle Cell/Hb C Anemia
#Splenic Infarction
#Pain Crisis
Patient has a history of hemoglobin SC, followed by Dr. ___ in
hematology, and presented with left-sided abdominal pain and
nausea/vomiting, similar to previous splenic pain she had had
before. Three days prior to presentation, she had been seen at
___ for a vaso-occlusive crisis of her left arm and was
given IV narcotics, discharged with oxycodone. The next day, she
developed the LUQ pain and presented to BI on ___. At BI, CT
abd/pelvis revealed an enlarged 16cm spleen with with
heterogeneous enhancement, concerning for splenic infarction.
Surgery was consulted and felt there was no indication for acute
surgical intervention. Patient received 2 units of blood in the
ED on ___ and was given PO dilaudid, IVF, folic acid, and
hydroxyurea. Chronic pain was consulted on ___ and patient was
started on dilaudid PCA and 3 days of toradol. On ___, patient
was transfused another 1 u pRBC and parvovirus studies were sent
for an inappropriate reticulocyte count. When pain was better
controlled, patient was transitioned back to PO dilaudid on
___. She was discharged with a prescription for oxycodone as
she has taken this at home before.
#Acute Chest Syndrome v. Pneumonia
Patient endorsed pain upon breathing and intermittent fevers
upon admission. CXR and CT showed left lower lobe consolidation
concerning for acute chest syndrome v. pneumonia. She was given
supplemental O2 and a five-day course of IV ceftriaxone and PO
azithromycin. On discharge, her breathing was much improved and
was satting high ___ on room air.
#Bilateral Avascular Necrosis of the Femoral Head
Patient notes that she had hip pain a couple of weeks ago, but
on admission did not and was able to bear weight on both legs.
On CT A/P, she was found to have bilateral avascular necrosis of
the femoral head without evidence of collapse. Orthopedic
surgery was contacted, and felt there was no indication for
intervention, as patient was asymptomatic. She has clinic follow
up scheduled.
___
Patient's baseline Cr 0.9, which was elevated to 1.3 on
admission, most likely pre-renal from poor PO intake in setting
of abdominal pain. With IVF, patient's creatinine decreased down
to 0.6.
#Transaminitis
Patient had elevated liver enzymes (peak ALT 106, AST 99), which
was most likely a manifestation of her vaso-occlusive crisis.
She denies a history of substance use and had not started any
new medications, though she notes that she started taking
hydroxyurea the week prior to admission when she started feeling
ill. Patient denied any RUQ pain or tenderness. Labs were
monitored and were downtrending before discharge. There was the
incidental finding of gallstones on CT AP.
#Superficial thrombophlebitis
Patient developed tender, palpable superficial veins in left
forearm and right antecubital fossa where IVs were placed. This
was most likely due to irritation from the IVs, exacerbated by
the SC crisis. There was no erythema or fluctuance, and patient
had good pulses bilaterally. No signs of infection or DVT. Heat
packs were used and the palpable veins subsided, though were not
completely gone by the time of admission.
CHRONIC ISSUES
==============
#Depression/anxiety
Continued home fluoxetine 20mg. Home lorazepam decreased from 1
mg to 0.5 mg i/s/o taking dilaudid while inpatient. She did not
take this while inpatient and says rarely takes it at home.
#Elevated blood pressures
She has a documented history of hypertension, although patient
does not endorse this and she does not take any
anti-hypertensives at home. BPs were often 130s/60s, but did
range as high as 160s/80s. It was difficult to tell if the
spikes were in the setting of pain. Recommend outpatient follow
up.
TRANSITIONAL ISSUES
===================
[ ] Patient discharged with prescription for 5mg oxycodone q4h
and a bowel regimen (Miralax and senna). Please re-assess pain
and adjust medication accordingly.
[ ] Make sure all vaccines for a functionally asplenic patient
are up to date. (Per chart review, patient received PCV13
vaccine on ___, and H. influenza and meningococcal vaccines
in ___
[ ] Follow up on LFTs. If liver enzymes do not improve, consider
further hepatitis workup.
[ ] Follow up on parvovirus PCR and antibodies
[ ] Repeat CXR in 4 weeks to ensure that pneumonia/acute chest
syndrome is resolving (as per Radiology recs)
[ ] Follow-up with hematologist for optimal management of sickle
cell anemia
[ ] Follow-up with orthopedics team to assess severity of
bilateral avascular necrosis of the femoral head
[ ] CT scan showed evidence of gallstones. Patient is currently
asymptomatic.
[ ] Patient's zinc level is 67, the lower limit of normal.
Consider zinc supplementation to possibly decrease sickle cell
crises and infection
[ ] Follow up blood pressure control |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Procainamide / Amiodarone / lisinopril /
All procaine drug / Sulfa (Sulfonamide Antibiotics) / Codeine
Attending: ___.
Chief Complaint:
Constipation
Rectal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of atrial
fibrillation on warfarin, cataracts c/b bilateral vision loss,
significant anxiety, polyneuropathy, HTN, HLD, OA, HFpEF, with
recent admission for rectal pain and severe constipation
(discharged on ___, now representing after numerous
telephone calls to outpatient providers with ongoing concerns
for
severe rectal pain/constipation.
Of note, patient was seen in the ED on ___nd
was
found to have a positive udip and CT positive for hydronephrosis
for which she was prescribed nitrofurantoin and tramadol for
pain. She was also found to have a large stool burden and manual
disimpaction was offered but refused. She later returned to the
ED on ___ with complaints of rectal pain and request for
disimpaction, which she later refused. She was subsequently
admitted to HMED on ___. While on the floor, patient had a
spontaneous large BM with persistent stool ball in rectum seen
on
repeat KUB. She refused oral medications, excepting magnesium
citrate but later allowed Colace, lactulose and PRN magnesium
citrate which led to improvement in her symptoms. She was also
found to have urinary retention with an associated painful,
distended bladder which, when scanned, demonstrated >1L of
urine.
Multiple catheter placements were attempted but these failed and
catheterization was not reattempted after goals of care
discussion when this was deemed to be outside goals of care. For
patients UTI found during her initial ED presentation on ___,
she was treated with ciprofloxacin x 3 days. She was discharged
home after improvement in constipation/rectal pain and after
goals of care conversation with patient status of DNR/DNI
confirmed.
Since discharge, patient has contacted PCP office for rectal
pain, constipation and dysuria. Patient has attempted five doses
of lactulose, without additional medications, without relief of
pain or bowel movement since ___.
In the ED today (___), patient was afebrile, mildly
hypertensive to 150's/90's, otherwise HDS and satting well on
RA.
She refused all bowel medications and IVF. GI was consulted who
recommended inpatient management for titration of bowel regimen
medications and r/o of other contributers to abdominal
pain/concern for infectious process. CT scan was performed which
demonstrated large pancolonic stool burden, without obstruction,
and mild bilateral hydronephrosis c/w prior imaging studies.
On the floor, patient states she has fluctuating "burning,
squeezing pain" that is in her abdomen. She notes this pain
"moves around" but when asked to specify she states the pain is
all over. Of note, patient's daughter, ___, is present, who
is quite distressed regarding her mother's constipation and pain
and feels it has not been treated adequately, with prescribed
pain medications likely contributing. She is happy that her
mother has been admitted and that she is now working with the GI
specialists. She brought record of her mother's intake since her
___ discharge and she did receive 30mL lactulose per day, was
eating well but did not drink more than 16 oz a day. She is
quite
concerned that her mother's temperature is ~99 degrees as she
says her mother always runs ~97 degrees.
Past Medical History:
Atrial fibrillation (on warfarin)
Cataracts ___ c/b bilateral vision loss and suspected ___ syndrome
Polyneuropathy
HTN
HLD
OA
?BPPV
HFpEF
Asthma
IBS
Social History:
___
Family History:
Unable to obtain as patient declines.
Physical Exam:
ADMISSION EXAM:
=================
VITALS: Reviewed in ___
GENERAL: Alert and intermittently moaning on exam
EYES: Anicteric
ENT: Moist mucous membranes
CV: irregularly irregular rhythm; no M/R/G
RESP: Breathing is non-labored
GI: Soft, mildly distended, hyperactive bowel sounds, no
guarding/rebound, no pain to palpation; patient refused rectal
exam
GU: Pain to palpation of suprapubic area with notable bladder
distension
MSK: Moves all extremities
SKIN: No rashes or ulcerations noted
PSYCH: Frustrated
DISCHARGE EXAM:
=================
Temp: 98.4 PO BP: 111/66 HR: 89 RR: 18 O2 sat: 96% O2 delivery:
RA
GENERAL: Elderly cachectic women, appears to be in NAD this AM
CV: pt refused exam
RESP: breathing comfortably with no accessory muscle use
GI: pt refused exam; abdomen appears nondistended
rectal: pt refused exam
SKIN: pt refused exam
MSK: pt refused exam
Neuro: pt refused exam
Pertinent Results:
___ 07:04AM BLOOD WBC-4.5 RBC-3.72* Hgb-11.0* Hct-35.2
MCV-95 MCH-29.6 MCHC-31.3* RDW-14.6 RDWSD-51.3* Plt ___
___ 07:11AM BLOOD Neuts-71.7* Lymphs-14.3* Monos-11.0
Eos-2.2 Baso-0.2 Im ___ AbsNeut-3.31 AbsLymp-0.66*
AbsMono-0.51 AbsEos-0.10 AbsBaso-0.01
___ 07:04AM BLOOD ___
___ 07:04AM BLOOD Glucose-93 UreaN-21* Creat-0.5 Na-140
K-3.8 Cl-99 HCO3-31 AnGap-10
___ 07:04AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1
Discharge Labs:
================
___ 05:50AM BLOOD WBC-3.8* RBC-3.07* Hgb-9.2* Hct-29.6*
MCV-96 MCH-30.0 MCHC-31.1* RDW-14.7 RDWSD-52.1* Plt ___
___ 05:50AM BLOOD ___ PTT-33.7 ___
___ 05:50AM BLOOD Glucose-105* UreaN-22* Creat-0.5 Na-142
K-4.6 Cl-106 HCO3-28 AnGap-8*
___ 07:11AM BLOOD ALT-9 AST-15 AlkPhos-60 TotBili-0.5
___ 05:50AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem 30 mg PO TID:PRN palpitations
2. Warfarin 1 mg PO DAILY16
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Docusate Sodium 200 mg PO DAILY
5. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN Rectal
pain
6. Lactulose 30 mL PO DAILY
7. LORazepam 0.5 mg PO Q4H:PRN anxiety
8. Magnesium Citrate 300 mL PO DAILY:PRN third line constipation
9. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q6H:PRN
Pain - Severe
10. Albuterol Inhaler 1 PUFF IH Q4H:PRN shortness of breath
11. nystatin 100,000 unit/gram topical Q12H
12. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
13. NIFEdipine (Extended Release) 30 mg PO ONCE SBP >180
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Polyethylene Glycol 17 g PO BID
titrate intake as needed for regular bowel movements
4. Thiamine 100 mg PO DAILY
5. Warfarin 2 mg PO DAILY16
FOLLOW UP WITH PCP ___ ___ ON ___ for dosage adjustments.
RX *warfarin 2 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Albuterol Inhaler 1 PUFF IH Q4H:PRN shortness of breath
8. Docusate Sodium 200 mg PO DAILY
9. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN Rectal
pain
10. Lactulose 30 mL PO DAILY
11. LORazepam 0.5 mg PO Q4H:PRN anxiety
12. Magnesium Citrate 300 mL PO DAILY:PRN third line
constipation
13. nystatin 100,000 unit/gram topical Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast.
INDICATION: ___ woman with severe constipation, tympanitic abdomen.
NO_PO contrast. Eval for stool burden or evidence of large bowel obstruction.
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 6.9 s, 54.1 cm; CTDIvol = 11.1 mGy (Body) DLP = 600.3
mGy-cm.
Total DLP (Body) = 600 mGy-cm.
COMPARISON: CT torso from ___ and abdominopelvic CT from outside
hospital dated ___.
FINDINGS:
LOWER CHEST: There heart is slightly enlarged and aortic calcifications are
again demonstrated, similar to the previous study. Small bilateral pleural
effusions are noted, associated with dependent atelectasis similar to prior.
No focal consolidation is present.
ABDOMEN:
HEPATOBILIARY: A 1.2 cm circumscribed hypodensity in segment 5 has not
significantly changed, probably represents a hepatic cyst (02:15). Otherwise,
the liver demonstrates homogeneous attenuation throughout. There is no
evidence of new focal lesions within the limitations of an unenhanced scan.
Central intrahepatic biliary ductal dilatation is unchanged and may be related
to post cholecystectomy state. The gallbladder is not visualized.
PANCREAS: Pancreatic atrophy with diffuse fatty replacement is again
demonstrated. 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: A left parapelvic cyst is largely unchanged. Otherwise, the kidneys
are of normal and symmetric size. There is no evidence of focal renal lesions
within the limitations of an unenhanced scan. There is mild bilateral
hydronephrosis, unchanged. There is no nephrolithiasis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. A large pancolonic stool
burden, including the rectum, is present. The appendix is not visualized.
PELVIS: The urinary bladder is distended and an air locule is present within
lumen. High-density material is seen in the dependent portion of the urinary
bladder, similar to the previous study, could represent small stones. The
distal ureters are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Multilevel degenerative changes without worrisome osseous lesions or
acute fracture.
SOFT TISSUES: Diffuse anasarca is unchanged. Otherwise, the abdominal and
pelvic wall is within normal limits.
IMPRESSION:
1. No sequela of trauma based on unenhanced scan.
2. Large pancolonic stool burden, including large stool ball in the rectum,
without evidence of obstruction.
3. Mild bilateral hydronephrosis with high-density material seen in the
dependent portion of the urinary bladder, similar to previous study, could
represent small stones. Small air locule within the urinary bladder may be
iatrogenic.
4. Small bilateral pleural effusions, unchanged.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Constipation
Diagnosed with Unspecified abdominal pain, Other specified diseases of anus and rectum, Constipation, unspecified, Dehydration, Unspecified atrial fibrillation
temperature: 99.5
heartrate: 78.0
resprate: 18.0
o2sat: 97.0
sbp: 158.0
dbp: 90.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ woman with a history of atrial
fibrillation on warfarin, cataracts c/b bilateral vision loss,
significant anxiety, polyneuropathy, HTN, HLD, OA, HFpEF, with
recent admission for rectal pain and severe constipation
(discharged on ___, now representing after numerous
telephone calls to outpatient providers with ongoing concerns
for
severe rectal pain/constipation, initially refusing bowel
medications/rectal exam, but eventually achieved resolution of
constipation with oral catharctic agents. Experienced transient
BRBPR, with H&H and hemodynamics remaining stable. These were
thought
to be d/t internal hemmorhoidal bleeding and GI was consulted,
at which
point it was discussed that ___ would be necessary to
make definitive
dx. Colonoscopy was not w/in pts GOC, and BRBPR resolved.
ACTIVE ISSUES
=============
#Rectal Pain and constipation
Ms. ___ was recently hospitalized on ___ for rectal pain
with constipation which was partially alleviated by inpatient
stool regimen. On readmission CT scan showed significant stool
burden with no evidence of obstruction. A rectal exam was
performed in the ED without fissures noted but patient initially
refused all further rectal exams. Per patient and daughter they
attempted 5 doses of lactulose at home without resolution of
pain/constipation. GI has recommended go lytely,
methylnaltrexone, tap water and mineral oil enemas, and manual
disimpaction but patient initially refused all treatment.
Patient eventually consented to attempt recommended GI regimen,
with inability to intake adequate volumes of cathartics.
Experienced small volumes of BRBPR, which on exam thought to be
due to internal hemorrhoids. At this point, GI was re-consulted
and recommended against enemas or manual dis-impaction d/t
pancolonic stool burden and risk of rectal intervention I/s/o
bleeding. It was recommended pt continue oral cathartic agents,
and pt and daughter were told that colonoscopy would be
necessary to accurately dx the source of bleeding. Pt and
daughter declined colonoscopy at this time as it was not within
GOC. Pt experienced BMs with maroon blood on ___, with guiac
positive stool sample. H&H and hemodynamics stable throughout
this time. Pt and daughter again made aware that proper workup
would involve full prep with colonoscopy, and decision was made
that this was not within pts GOC.
For pain she received tramadol and Tylenol. Morphine was given
briefly as a trial to see if pt would be able to tolerate enema
or manual disimpaction, but was discontinued after GI
recommended oral cathartics I/s/o rectal bleeding, as opioid
would worsen constipation.
# Bilateral hydronephrosis
___ had a recently diagnosed UTI and urinary retention
with bladder distention and suprapubic pain on exam. She was
treated with course of ciprofloxacin for her UTI which ended on
___. Her constipation is likely contributing to her urinary
retention and suprpubic pain. We have not done any more
catheters to be consistent with comfort goals discussed during
___ hospitalization.
#A fibrillation on Coumadin
Ms. ___ is on ___ at home but has intermittently refused
doses. She has been taking it fairly consistently during this
hospitalization. She is also currently on 60 mg diltiazem PRN
for Afib with RVR. Will go home on previous Warfarin regimen,
but will need to followup as an outpatient with PCP regarding
the utility of remaining on warfarin given her age and the
risk:benefit profile.
TRANSITIONAL ISSUES
===================
[] Goals of care should be clarified as best as possible.
[] Will need ongoing management of chronic constipation.
Tolerating miralax and senna combination
[]Non-emergent evaluation for causes of iron deficiency
(endoscopy does not seem to be within ___ for patient)
[] f/u to determine whether it is within ___ to continue
warfarin as an outpatient, given the fact that pt regularly
refused it as inpatient and what the risk: benefit profile is at
___
[] we changed her warfarin dosing to 2mg daily per her daily INR
values to treat for a fib but this may need to be discontinued
pending goals of care
[] will INR checked at clinic on ___
[] Palliative care appointment ___ at 11AM; this will
likely be critical in managing stress and discomfort of
comorbidities |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
___: Diagnostic Paracentesis.
___: EGD
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with a PMH notable for HCV
cirrhosis, varices s/p banding, HCC s/p TACE in ___
presents with 3 days of progressive shortness of breath and
abdominal distension. The patient additionally reports
intermittant fevers for several months which are typically worse
at night. He had one episode of vomiting yesterday morning which
was nonbloody. He denies any hemoptysis or hematochezia,
abdominal pain, chest pain. He states that he has never had
abdominal distension like this before.
In the ED, initial vitals: 99.6 93 136/67 18 100% ra
The patient underwent a RUQ ultrasound as well as a CXR which
were unremarkable. He was found to have an initial Hct of 18,
down from a baseline of 37 two months ago. Repeat Hct was 16.4.
Guiac positive but no frank melena or BRBPR. Paracentesis was
performed and the fluid was sent for the usual tests revealing
no signs of significant blood or infection in the ascitic fluid.
Hepatology was consulted and they agreed to perform EGD in the
morning. The patient was given 2 units of PRBCs and transferred
to the MICU for further evaluation.
On transfer, vitals were: 98.4 84 126/76 18 100% RA
Past Medical History:
-Cirrhosis due to hepatitis B (non-compliant with treatment of
entacavir) as well as a longstanding alcohol use, c/b portal
hypertension, esophageal varices for which he has undergone
serial band ligation given prior GI bleeding, on nadolol for
secondary prophylaxis of bleeding.
-HTN
-Sleep apnea with CPAP at night
-Atrial Fibrillation (paroxysmal)
-Atypical chest pain
-Mild aortic dilatation
-Reflux esophagitis
-Chronic iron-deficiency anemia
-Chronic neck and back pain
-Depression/anxiety
-s/p L cataract repair
-Large hiatal hernia
-
Social History:
___
Family History:
One of 8 siblings (one brother who died of MI in his ___, 2
brothers with DM). ___ are deceased (father from suicide,
mother with ?liver disease). 5 healthy children. No family
history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: BP: 129/61 P: 79 R: 14 O2: 100 RA
GENERAL: Alert, oriented, no acute distress
HEENT: NCAT, EOMI, PERRLA, edentulous
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: significantly distended with +fluid wave, soft, non-tender,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Some
nonpitting edema of the feet.
SKIN: Warm, no rash, non-jaundiced.
NEURO: CN II-XII grossly intact, speech fluent, moving all
extremities
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.1-98.3, 105-109/51-55, 63-79, 20, 98-99% on RA.
GENERAL: Sitting up in bed, in NAD, resting comfortably.
HEENT: NCAT, EOMI, PERRLA, edentulous
NECK: supple, JVP not elevated, no LAD
LUNGS: Decreased breath sound at left base.
CV: RRR S1 and S2 present, no murmurs, rubs or gallops.
ABD: distended abdomen, but non-tender no rebound or guarding.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Non-pitting edema of the feet.
SKIN: Warm, no rash, non-jaundiced.
NEURO: CN II-XII grossly intact, speech fluent, moving all
extremities
Pertinent Results:
ADMISSION LABS
==============
___ 10:45PM BLOOD WBC-3.0* RBC-2.27*# Hgb-5.0*# Hct-18.0*#
MCV-79*# MCH-22.2*# MCHC-28.0*# RDW-15.8* Plt Ct-84*
___ 10:45PM BLOOD Neuts-46.2* ___ Monos-9.8
Eos-4.4* Baso-0.3
___ 10:45PM BLOOD ___ PTT-34.9 ___
___ 10:45PM BLOOD Glucose-97 UreaN-12 Creat-1.0 Na-138
K-4.0 Cl-107 HCO3-23 AnGap-12
___ 10:45PM BLOOD ALT-19 AST-25 AlkPhos-86 TotBili-0.5
___ 10:45PM BLOOD Albumin-2.6* Calcium-8.4 Phos-3.1 Mg-1.8
DISCHARGE LABS
==============
___ 05:02AM BLOOD WBC-3.9* RBC-2.97* Hgb-7.1* Hct-23.2*
MCV-78* MCH-23.8* MCHC-30.4* RDW-17.8* Plt Ct-84*
___ 05:02AM BLOOD ___ PTT-40.4* ___
___ 05:02AM BLOOD Glucose-112* UreaN-14 Creat-0.9 Na-135
K-3.9 Cl-106 HCO3-23 AnGap-10
___ 05:02AM BLOOD ALT-16 AST-27 AlkPhos-83 TotBili-0.5
___ 05:02AM BLOOD Albumin-2.2* Calcium-7.8* Phos-2.7 Mg-1.8
ANEMIA EVALUATION
=================
___ 05:42AM BLOOD Ret Man-2.2*
___ 05:42AM BLOOD Hapto-76
LIVER STUDIES
=============
___ 07:00AM BLOOD AFP-3.3
ASCITIC FLUID STUDIES
=====================
___ 11:00PM ASCITES WBC-242* RBC-132* Polys-15* Lymphs-21*
Monos-43* Mesothe-3* Macroph-18*
___ 11:00PM ASCITES TotPro-0.7 Glucose-124 Albumin-LESS
THAN
MICROBIOLOGY
============
___ 11:00 pm PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___: BLOOD CULTURE: NO GROWTH (FINAL)
___: BLOOD CULTURE: NO GROWTH (FINAL)
___: MRSA SCREEN; NASAL SWAB: NO MRSA ISOLATED.
___ 5:42 am SEROLOGY/BLOOD ___ ADDED TO ___.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA. (REFERENCE RANGE: NEGATIVE).
___: HELICOBACTER PYLORI STOOL ANTIGEN: NOT DETECTED.
IMAGING
=======
___: CHEST X-RAY (PA AND LATERAL)
FINDINGS:
PA and lateral views of the chest provided. There is a small
left pleural
effusion, new from prior. Mildly elevated right hemidiaphragm
is unchanged. No focal consolidation concerning for pneumonia.
There is a retrocardiac opacity which is compatible with known
moderate hiatal hernia. No signs of pneumonia. No
pneumothorax. Cardiomediastinal silhouette is stable. Bony
structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION:
Small left pleural effusion, moderate hiatal hernia.
___: RIGHT UPPER QUADRANT ULTRASOUND WITH DOPPLER
IMPRESSION:
1. Cirrhosis with sequela of portal hypertension, including
splenomegaly and moderate ascites.
2. Patent main portal vein.
3. Mild gallbladder wall thickening, without evidence of
stones. This is
likely is secondary to third spacing in the setting of ascites.
___: CTA ABDOMEN AND PELVIS
IMPRESSION:
1. Somewhat limited assessment for lower GI bleeding due to
residual oral
contrast in the ascending and proximal transverse colon.
However no definite evidence for active extravasation.
2. Cirrhosis with portal hypertension including splenomegaly and
moderate
hemorrhagic ascites
3. Status post chemo embolization of the liver. The known mass
in the dome of the liver is difficult to visualize
4. Large hiatal hernia
5. Small left pleural effusion and adjacent atelectasis
6. No evidence for retroperitoneal hematoma
7. Hyperdense cyst with calcification in the right kidney
___: MRI LIVER WITH AND WITHOUT CONTRAST
FINDINGS:
The lung bases are grossly clear. There is no pleural or
pericardial
effusion. Large hiatal hernia is present.
The liver is cirrhotic with nodular border and progressive
reticular
enhancement. There is no evidence of steatosis. Multiple T1
hyperintense
regenerative nodules are seen throughout the liver. No of
arterially
hyperenhancing or washing not lesions are identified.
Conventional arterial hepatic anatomy is present. The portal
and hepatic veins are patent.
The spleen is enlarged, measuring 13.5 cm in craniocaudal
dimension. Multiple varices are demonstrated.
The pancreas is normal in size and signal, without focal masses
or ductal
dilatation.
Cortical renal cysts are seen bilaterally. The adrenals are
normal.
There is a moderate amount of ascites.
No concerning retroperitoneal or mesenteric lymphadenopathy
seen.
The bone marrow signal is normal.
IMPRESSION:
1. Cirrhosis with portal hypertension, splenomegaly and
varices. No evidence of malignancy. Patent portal and hepatic
vasculature. Moderate amount of ascites.
2. Large hiatal hernia.
3. Small bilateral pleural effusions.
ENDOSCOPIC PROCEDURES
=====================
___: EGD
Findings:
Esophagus: 2 cords of grade I varices were seen in the lower
third of the esophagus. The varices were not bleeding. A single
clean based ulcer was found near gastroesophageal junction.
There was no evidence of active bleeding.
Stomach: A few clean based, non-bleeding ulcers were found in
the antrum of the stomach.
Duodenum: Multiple small clean based ulcers were found in the
duodenal bulb with no evidence of active bleeding.
Impression:
Multiple ulcers were found in the esophagus, stomach and
duodenum that could contribute anemia via slow, chronic GI
losses. None had high risk stigmata that required intervention.
Ulcer in the gastroesophageal junction
Varices at the lower third of the esophagus
Ulcers in the duodenal bulb
Ulcers in the stomach
Otherwise normal EGD to third part of the duodenum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Entecavir 0.5 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Voltaren (diclofenac sodium) 1 % topical bid pain
4. Acetaminophen 1000 mg PO Q8H:PRN pain
5. Aspirin 81 mg PO DAILY
6. Bumetanide 0.5 mg PO DAILY
7. Clotrimazole Cream 1 Appl TP BID
8. Enalapril Maleate 10 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. ketotifen fumarate 0.025 % ophthalmic QD
12. Lorazepam 1 mg PO QHS:PRN insomnia
13. Multivitamins 1 TAB PO DAILY
14. Nadolol 40 mg PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Prochlorperazine 10 mg PO Q8H:PRN nausea
17. Sucralfate 1 gm PO QID
18. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Bumetanide 0.5 mg PO DAILY
3. Clotrimazole Cream 1 Appl TP BID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Enalapril Maleate 10 mg PO BID
6. Entecavir 0.5 mg PO DAILY
7. Lorazepam 1 mg PO QHS:PRN insomnia
8. Nadolol 40 mg PO DAILY
9. Prochlorperazine 10 mg PO Q8H:PRN nausea
10. Sucralfate 1 gm PO QID
11. Thiamine 100 mg PO DAILY
12. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
13. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
14. Aspirin 81 mg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. ketotifen fumarate 0.025 % ophthalmic QD
17. Multivitamins 1 TAB PO DAILY
18. Voltaren (diclofenac sodium) 1 % topical bid pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Cirrhosis Secondary to Hepatitis B c/b portal hypertension,
esophageal varices, ascites.
Peptic Ulcer Disease
Chronic Iron Deficiency Anemia
Secondary Diagnosis
===================
-Hypertension
-Sleep Apnea on CPAP
-Paroxysmal Atrial Fibrillation
-Mild Aortic Dilatation
-Reflux Esophagitis
-Depression/Anxiety
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with anemia liver // access for PVT
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT of the abdomen dated ___, and MRI of the abdomen 8
dated ___.
FINDINGS:
LIVER: The liver is coarsened and nodular. Multiple hypoechoic regenerative
nodules are seen in the liver. The main portal vein is patent with
hepatopetal flow. There is moderate ascites. A left pleural effusion is also
noted.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: No evidence of gallstones. Mild gallbladder wall thickening is
likely secondary to third spacing the setting of ascites.
PANCREAS: The pancreas is obscured by overlying bowel gas, and is not well
seen.
SPLEEN: Splenomegaly, measuring 15 cm.
KIDNEYS: Limited views of the right kidney demonstrates a 6 mm nonobstructing
stone in the midpole.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhosis with sequela of portal hypertension, including splenomegaly and
moderate ascites.
2. Patent main portal vein.
3. Mild gallbladder wall thickening, without evidence of stones. This is
likely is secondary to third spacing in the setting of ascites.
Radiology Report
INDICATION: ___ year old man with hct of 16, actively dropping. // Please
eval for RP bleed or other source of intraabdominal blood loss
TECHNIQUE: MDCT images were obtained from the lung bases to the lesser
trochanters after administration of oral and intravenous contrast. Coronal
and sagittal reformations were prepared. DLP: 2593 MGY PER CM
COMPARISON: CT examination of ___, MRI examination of ___.
FINDINGS:
CT ABDOMEN: There is a small left sided pleural effusion and atelectasis in
the left lower lobe of the lung. There is a large axial hiatal hernia. The
visualized portions of the heart pericardium are normal. The liver contains
lipiodol consistent with status post chemo embolization. The amount of
lipiodol has decreased from prior examination. There are no definite areas of
arterial hyper enhancement or there is subtle washout in the dome of the liver
on series 4B, ___ 190 measuring approximately 2.7 cm. This corresponds to the
abnormality biopsied on ultrasound. . The liver is small and has a nodular
contour consistent with cirrhosis. The portal vein and hepatic veins are
patent. The hepatic and portal veins are patent. The gallbladder, pancreas,
and adrenals are normal. There is splenomegaly of 13.6 cm. The kidneys
enhance symmetrically and excrete contrast without evidence of hydronephrosis.
There is a sub cm are slightly hyperdense lesion in the right kidney at
midpole most consistent with a hyperdense cyst. There are 2 cysts in the left
kidney at midpole 1 measuring 13 ___ and a second measuring 29 ___ however the
latter measured 23 ___ on the recent noncontrast enhanced scan and therefore
also represents a hyperdense cyst. There are 2 small adjacent calcifications.
The stomach and small bowel are unremarkable. There is no portacaval,
mesenteric and retroperitoneal lymphadenopathy. There is a moderate amount of
ascites throughout the abdomen and pelvis.
CT PELVIS: The appendix is not identified. The colon, rectum, urinary bladder
and are normal. There is no pelvic lymphadenopathy or free fluid.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for
malignancy.
CT angiography subtle hyperdense foci seen on series 4a, image 44 in the colon
at the splenic flexure, image 93 in the small bowel and image 153 at the
anorectal junction 2 not persist on the portal venous phase and are therefore
artifactual.
IMPRESSION:
1. Somewhat limited assessment for lower GI bleeding due to residual oral
contrast in the ascending and proximal transverse colon. However no definite
evidence for active extravasation.
2. Cirrhosis with portal hypertension including splenomegaly and moderate
hemorrhagic ascites
3. Status post chemo embolization of the liver. The known mass in the dome of
the liver is difficult to visualize
4. Large hiatal hernia
5. Small left pleural effusion and adjacent atelectasis
6. No evidence for retroperitoneal hematoma
7. Hyperdense cyst with calcification in the right kidney
Revised findings regarding impression 1. were discussed with Dr. ___ at
10:24 on ___ by Dr. ___ by telephone
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new intubation // ET tube ET tube
COMPARISON: Prior chest radiographs since ___ most recently ___.
IMPRESSION:
Tip of the endotracheal tube is less than a cm from the carina and oriented
toward the rib right main bronchus. This may explain new left lower lobe
collapse responsible for leftward mediastinal shift. Large hiatus hernia is
visible. Right lung is clear.
RECOMMENDATION(S): Withdrawn ET tube 20- 25 mm.
NOTIFICATION: Dr. ___ reported the findings to ___, the get remain get Y
item is way that degree a may is already at ___ year wall ___ by
telephone on ___ at 11:44 AM, 1 minutes after discovery of the findings.
Radiology Report
EXAMINATION: MRI abdomen with and without contrast.
INDICATION: ___ year old man with ___ s/p TACE in ___ with increased
hemorrhagic ascites. // Please assess for HCC.
TECHNIQUE: Multiplanar T1 and T2 weighted sequences were obtained in a 1.5
Tesla magnet including dynamic 3D imaging performed prior to, during, and
after the uneventful administration 8cc of ___.
COMPARISON: CT from ___, MRI from ___.
FINDINGS:
The lung bases are grossly clear. There is no pleural or pericardial
effusion. Large hiatal hernia is present.
The liver is cirrhotic with nodular border and progressive reticular
enhancement. There is no evidence of steatosis. Multiple T1 hyperintense
regenerative nodules are seen throughout the liver. No of arterially
hyperenhancing or washing not lesions are identified. Conventional arterial
hepatic anatomy is present. The portal and hepatic veins are patent.
The spleen is enlarged, measuring 13.5 cm in craniocaudal dimension. Multiple
varices are demonstrated.
The pancreas is normal in size and signal, without focal masses or ductal
dilatation.
Cortical renal cysts are seen bilaterally. The adrenals are normal.
There is a moderate amount of ascites.
No concerning retroperitoneal or mesenteric lymphadenopathy seen.
The bone marrow signal is normal.
IMPRESSION:
1. Cirrhosis with portal hypertension, splenomegaly and varices. No evidence
of malignancy. Patent portal and hepatic vasculature. Moderate amount of
ascites.
2. Large hiatal hernia.
3. Small bilateral pleural effusions.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea, Abdominal distention
Diagnosed with ANEMIA NOS
temperature: 99.6
heartrate: 93.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 67.0
level of pain: 6
level of acuity: 3.0 | ___ with a PMH of HBV cirrhosis, history of alcohol abuse, HCC
s/p TACE, and grade 1 varices, presenting with fatigue and
shortness of breath, now with guaiac positive stool and a
substantial Hct drop found to have ulcers within esophagus,
stomach and duodenum.
# Peptic Ulcer Disease: Patient presented to ___ after several
week history of weakness and shortness of breath. On admission
labs were notable for a hemoglobin of 5 and hematocrit of 18.0.
He denied any melena, bright red blood per rectum, or hematesis.
He was admitted to the MICU for close observation given his
history of HBV cirrhosis and grade I varices. Prior to arrival
in the MICU, patient received 2 units of packed red blood cells.
He underwent a paracentesis which did not reveal evidence of
SBP. Abdominal ultrasound was negative for portal venous
thrombus. Given significant drop in hemoglobin/hematocrit
compared to baseline, he underwent a CTA abdomen and pelvis
which showed no definite evidence for active extravasation and
no evidence of retroperitoneal hematoma. Given history of
esophageal varices, he underwent an EGD which revealed 2 cords
of Grade I varices (no evidence of bleeding) as well as multiple
ulcers found within the esophagus, stomach, and duodenum t hat
could contribute to anemia via slow, chronic GI losses. There
was no high risk stigmata that required intervention. H. pylori
serology was negative. H. pylori stool antigen was also negative
(although patient was on pantoprazole at the time). Patient
remained hemodynamically stable with stable H/H. H/H at the time
of discharge was 7.1/23.2. He was discharged on pantoprazole 40
mg PO Q12H. He was continued on his home medication of
sucralfate 1 gram PO QID. Given his history of cirrhosis and
likely GI bleed, he was started on ceftriaxone in the hospital
for SBP prophylaxis with transition to ciprofloxacin 500 mg PO
daily with end date ___ (total course of 7 days).
Of note, the gastric ulcer was not biopsied and will need to be
biopsied given risk of transformation to malignancy.
As part of further anemia workup, reticulocyte count was 2.2.
Haptoglobin was 76.
# Cirrhosis HBV and EtOH: complicated by Grade I varices,
ascites (new onset). No encephlopathy. CHILDS Class B. He was
continued on entacavir. As noted below he was continued on
bumetanide 0.5 mg PO daily but his HCTZ was discontinued prior
to discharge (to decrease risk of becoming hypovolemic on two
diuretics). He was continued on nadolol 40 mg PO daily given
evidence of grade I varices on EGD. He underwent MRI of the
liver with and without contrast given history of ___ s/p TACE
___. MRI revealed no evidence of malignancy. Given evidence
of ascites, a therapeutic paracentesis was planned, however
there was no good pocket to tap based on bedside ultrasound
evaluation.
# Hepatocellular Carcinoma: s/p TACE ___. AFP obtained
during hospitalization was 3.3. He underwent an MRI of the liver
with and without contrast (as he had an MRI Liver scheduled on
___ given his history of HCC). Results showed cirrhosis
with portal hypertension, splenomegaly, and varices with no
evidence of malignancy.
# Grade I Esophageal Varices: 2 cords of Grade I varices noted
on EGD obtained ___. There was no stigmata of recent
bleeding. He was continued on nadolol 40 mg PO daily.
# Hypertension: In the setting of anemia, anti-hypertensives
were discontinued. When H/H improved, he was restarted on
enalparil maleate 10 mg PO BID. Given that he was on both
hydrochorothiazide and bumetanide, decision was made to
discontinue the hydrochlorothiazide to decrease chances of
becoming hypovolemic. He was continued on bumetanide 0.5 mg PO
daily. Discussion regarding outpatient diuretic regimen should
take place at next outpatient appointment. Blood pressure should
also be monitored as patient's HCTZ was discontinued.
# History of Alcohol Abuse: Continued on multivitamin, thiamine
100 mg PO daily.
# Reflux Esophagitis: Discontinued omeprazole 20 mg PO daily and
transitioned to pantoprazole 40 mg PO BID as noted above (given
evidence of ulcers). He was also continued on sucralfate 1 gram
PO QID.
# Sleep Apnea: Continued on CPAP.
# Paroxysmal Atrial Fibrillation: resolved on own in ___. Not
currently on any medications other than nadolol for the
esophageal varices.
# Depression/Anxiety: Lorazepam 1 mg PO qHS insomnia.
# Vitamin B12 Deficiency: cyanocobalamin 1000 mcg PO qday.
TRANSITIONAL ISSUES
===================
-New Medications: Pantoprazole 40 mg PO Q12H, ciprofloxacin 500
mg PO daily with end date ___.
-Please follow up MRI of the liver as this was pending at the
time of discharge.
-Given evidence of gastric ulcer, will need repeat EGD with
biopsy of the gastric ulcer.
-Patient noted to have lip smacking during hospitalization.
Please consider discontinuing prochlorperazine if concern for
tardive dyskinesia.
-Consider repeat H. pylori stool antigen test as patient was on
high dose PPI at time of sample.
-Given evidence of ulcers in esophagus, stomach, and duodenum,
please consider workup for ___ Syndrome.
-Please follow-up CBC within one week as outpatient. H/H at time
of discharge 7.___.2.
-Patient was noted to have eosinophilia during hospitalization.
Please obtain CBC with differential. If eosinophilia is present
please continue workup with Strongyloides testing as patient
recently went to ___.
-Given microcytic anemia, will need colonoscopy.
-Patient was on bumetanide and hydrochlorothiazide prior to
admission. His HCTZ was discontinued and he was continued on
bumetanide to decrease the diuretic regimen he was on.
-Full Code (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ankle pain
Major Surgical or Invasive Procedure:
ORIF Right distal tibia fx ___ ___
History of Present Illness:
___ s/p fall down 10 stairs with a R distal tib/fib fx (above
existing ankle ORIF hardware).
Past Medical History:
CHF
prior Right ankle fracture s/p ORIF
Social History:
___
Family History:
Non-contributory
Physical Exam:
General: alert, oriented, no acute distress; pain controlled
Resp/Chest: non-labored breathing, no respiratory distress
Abdomen: grossly non-distended
RLE: splint in place, intact (removed and incisional dressings
noted to be satisfactory; short leg cast placed); SILT at toes;
fires FHL/FDL, ___ foot pink, perfused
Pertinent Results:
___ 05:05AM BLOOD WBC-9.9 RBC-3.78* Hgb-11.6* Hct-34.9*
MCV-92 MCH-30.7 MCHC-33.2 RDW-14.7 RDWSD-49.8* Plt ___
___ 06:40AM BLOOD WBC-10.6* RBC-3.34* Hgb-10.5* Hct-31.4*
MCV-94 MCH-31.4 MCHC-33.4 RDW-14.6 RDWSD-50.2* Plt Ct-92*
___ 05:05AM BLOOD Glucose-113* UreaN-22* Creat-1.0 Na-140
K-4.4 Cl-103 HCO3-23 AnGap-14
___ 06:40AM BLOOD Glucose-83 UreaN-12 Creat-0.8 Na-138
K-4.0 Cl-101 ___ AnG___
Medications on Admission:
Lisinopril 2.5 once daily
Potassium chloride 10 mEq once daily
Furosemide 20 mg once daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H
Use for baseline pain control. Discontinue when no longer
needed.
RX *acetaminophen 325 mg 2 capsule(s) by mouth 5 times daily
while awake Disp #*120 Capsule Refills:*1
2. Docusate Sodium 100 mg PO BID
Use to prevent post-operative constipation. Hold for
diarrhea/loose stools.
RX *docusate sodium 100 mg 2 capsule(s) by mouth daily Disp #*20
Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
Use for 4 weeks post-operatively to prevent blood clots.
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneously every
evening Disp #*24 Syringe Refills:*0
4. Gabapentin 300 mg PO BID
Don't take before driving, operating machinery, or with
alcohol/sedatives/hypnotics.
RX *gabapentin 300 mg 1 capsule(s) by mouth twice daily Disp
#*28 Capsule Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discontinue when not needed. Do not take before
driving/operating machinery/with sedatives.
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*15 Tablet Refills:*0
6. Senna 8.6 mg PO DAILY
Use to prevent post-operative constipation. Hold for
diarrhea/loose stools.
RX *sennosides 8.6 mg 2 tablets by mouth nightly Disp #*20
Tablet Refills:*0
7. Furosemide 20 mg PO DAILY
8. Lisinopril 2.5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right distal tibia fracture (above existing ankle ORIF hardware)
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ORIF right ankle
INDICATION: ORIF right ankle
TECHNIQUE: Fluoroscopic guidance for ORIF right ankle
COMPARISON: ___
FINDINGS:
11 intraoperative images were acquired without a radiologist present.
Images show shows evidence of internal fixation of the right ankle.
IMPRESSION:
Intraoperative images were obtained during ORIF right ankle. Please refer to
the operative note for details of the procedure.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with fall// pre op
TECHNIQUE: Semi-erect frontal view of the chest
COMPARISON: No relevant comparison identified.
FINDINGS:
Lungs are clear. The cardiac silhouette is top-normal in size. Mediastinal
and hilar contours are within normal limits. There is mild calcification of
the aortic knob. Pleural spaces are normal.
IMPRESSION:
1. Clear lungs.
2. Mild calcification of the aortic knob. Heart is top normal in size.
Radiology Report
EXAMINATION: DX TIB/FIB AND ANKLE
INDICATION: ___ with fracture s/p reduction// reduction?
TECHNIQUE: AP oblique and cross-table lateral views of the right tibia and
fibula
COMPARISON: Outside images of the right tibia and fibula from ___
at 20:36 and at 23:37
FINDINGS:
Fine bony detail is partially obscured by overlying plaster cast. Again seen
are obliquely oriented distal tibial and fibular fractures, just above and
below previously seen hardware, respectively. Alignment is overall improved
with residual anterolateral displacement of the distal tibial fracture and
residual lateral and anterior displacement of the distal fibular fracture. No
additional fracture is appreciated.
IMPRESSION:
Distal tibial and fibular fractures status post reduction with overall
slightly improved alignment with some residual displacement of each fracture,
as described above.
Radiology Report
EXAMINATION: CT lower extremity with runoff
INDICATION: ___ year old man with ankle injury, diminished pulse// please
characterize ankle for pre-op. also w/ thready pulse, ?vascular injury. please
imaged from mid-tibia distally
TECHNIQUE: Noncontrast images were obtained from the distal right femur
through the toes. Following this, content is enhanced, arterial phase imaging
was obtained of the right lower extremity beginning in the distal femur
through the toes after uneventful administration of 100 cc of Omnipaque 350.
Delayed images were then obtained. MIPS, sagittal, and coronal reformats were
then obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.3 s, 65.1 cm; CTDIvol = 2.4 mGy (Body) DLP = 155.1
mGy-cm.
2) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 21.3 mGy (Body) DLP =
10.6 mGy-cm.
3) Spiral Acquisition 7.9 s, 62.4 cm; CTDIvol = 6.3 mGy (Body) DLP = 390.0
mGy-cm.
4) Spiral Acquisition 7.9 s, 62.4 cm; CTDIvol = 5.3 mGy (Body) DLP = 333.0
mGy-cm.
Total DLP (Body) = 889 mGy-cm.
COMPARISON: Tibia/fibula radiograph from ___ at 06:45
FINDINGS:
Just inferior to the lateral buttress plate of the distal fibula, there is an
obliquely oriented, minimally displaced impacted fracture with approximately 6
mm of lateral displacement of the distal fragment and approximately 10 mm of
anterior displacement of the distal fragment. There is also an obliquely
oriented, distal tibial fracture, just superior to the previously placed inter
fragmentary screws, with approximately 9 mm of lateral displacement of the
distal fragment and approximately 13 mm of anterior displacement of the distal
fragment.
Assessment of distal vasculature is partially obscured due to streak artifact
from overlying hardware. Within these limitations, normal triple vessel runoff
is appreciated from the popliteal fossa through the foot. There are no
filling defects, evidence of thrombus, or contrast extravasation. No
pseudoaneurysm formation identified. There is nonocclusive atherosclerotic
calcification within the right anterior tibial artery. Nonocclusive calcified
plaques are also noted within the peroneal artery. The dorsalis pedis artery
and the dorsal arch vessel branches are patent. No entrapment of arteries
seen at the fracture site.
IMPRESSION:
1. Distal tibial and fibular fractures of the right lower extremity, as
described above. Addendum with details of fracture description from an MSK
dedicated radiologist to follow.
2. Normal three-vessel runoff of the right lower extremity without evidence of
filling defects, thrombus, or contrast extravasation. No pseudoaneurysm
formation or entrapment of arteries noted at the fracture site.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Leg injury, s/p Fall
Diagnosed with Unsp fracture of shaft of right tibia, init for clos fx, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: 99.7
heartrate: 87.0
resprate: 16.0
o2sat: 95.0
sbp: 100.0
dbp: 63.0
level of pain: 5
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 Right distal tibia fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF Right distal tibia fracture
with Dr. ___ 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.
Despite repeated attempts to convince patient that rehab was the
safest option, patient repeatedly declined rehab placement.
Attempts were made with the ___ team to clear him for home,
but he remained limited in his mobility. On ___, ___
re-established contact with the patient and he was noted to have
improved mobility. However, their final recommendations were for
rehab. Patient again declined this. He was seen at bedside again
with Orthopaedic house staff ___s with Dr. ___.
Patient refused to go to rehab, and preferred to go home. He
also requested ___ with an Orthopaedic Surgeon closer to
home in ___. After discussing with Dr. ___ was
agreed that he should ___ with Dr. ___ on ___
___. As he repeatedly refused rehab despite our
recommendations, we felt the safest option was to provide him
with home ___ and OT (versus letting him leave AMA without
either). This was set-up for him on ___ and he was provided
with a rolling walker.
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 spontaneously. His dressings were changed
and a short leg cast was placed. The patient is
non-weightbeawring in the Right lower extremity with BUE assist,
and will be discharged on Lovenox for DVT prophylaxis. The
patient was instructed to follow up with Dr. ___ in 1
week following discharge. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course. He was given a short course of Oxy/Gabapentin for pain
control, with instructions to wean/discontinue when no longer
needed (in addition to avoiding driving, operating machinery, or
taking with sedatives/hypnotics/alcohol). The patient was also
given written instructions concerning precautionary instructions
and the appropriate ___ care. The patient expressed
readiness for discharge.
Of note, after clearing and setting up patient for home
services, he then stated that he did not want anyone coming to
his home. This was revisited, and patient was told that if he
declined home services he would be leaving ___ medical
advice'. Moreover, we reiterated that he needed home services
___ and OT) for safety reasons. He was eventually discharged
with services as previously set-up, and we are hopeful that he
is cooperative with the visiting therapists. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
incidental aneurysm
Major Surgical or Invasive Procedure:
___ diagnostic cerebral angiogram
History of Present Illness:
___ yo F hx HTN and ocular migraines who has had 3 episodes
of visual disturbances since ___ and was found to have 2
aneurysms on MRI during outpatient work up. MRI results were
communicated to the patient today and in the setting of
intermittent right arm numbness she presented to the ED. Pt
describes the previous visual disturbances as being "unable to
see straight." She felt that her eyes were moving in different
directions. All 3 episodes happened when she felt otherwise
exhausted. Has hx migraine HAs when she was younger, none
recently. Occasional HA, no change in frequency or severity.
Deniescurrent HA, nausea, vomiting, current vision changes,
numbness, weakness or tingling.
Past Medical History:
Hypertension
Tobacco dependence
Ankle fracture
Herpes Infection, Other
Colonic adenoma
Alopecia areata
Uterine prolaps
Overweight(278.02)
bh
Osteoporosis
Vitamin D insufficiency
Cerebral aneurysm
Parotid mass
Social History:
___
Family History:
Mother sudden death age ___, unclear cause
FH of breast cancer and ovarian cancer
Physical Exam:
On Discharge:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to
2 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation intact to light touch
Groin: c/d/i, no hematoma, dressing in place
Pertinent Results:
please see OMR for pertinent results
Medications on Admission:
- Betamethasone, Augmented 0.05 % Ointment Apply twice daily for
two weeks and then twice weekly if needed.
- cholecalciferol, vitamin D3, 2,000 units daily
- hydrochlorothiazide 25 mg tablet
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
anterior communicating artery aneurysm
left ICA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Diagnostic cerebral angiogram for evaluation of multiple
aneurysms identified on MRA.
During the procedure the following vessels were selectively catheterized
angiograms were performed:
Left internal carotid artery
Right internal carotid artery
Left vertebral artery
Right common femoral artery
Three-dimensional rotational angiography of the left internal carotid artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation and review
Three-dimensional rotational angiography of the right internal carotid artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation and review
Ultrasound-guided access to the right common femoral artery
INDICATION: This is a ___ female who had multiple episodes of
difficulty with vision. Workup with MRI was concerning for an aneurysm in the
Acom and the left ICA. The patient was admitted through the emergency room
angiogram was performed to further delineate the anatomy.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
Versed and fentanyl throughout the total intra service time of 50 minutes
during which the patient's hemodynamic parameters were continuously monitored
by a trained, independent observer. Patient received a total of 100 mcg of
fentanyl and 2 mg of Versed.
TECHNIQUE: Diagnostic cerebral angiogram
COMPARISON: MRA
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. She was transferred to the fluoroscopic table supine. Moderate
sedation was administered. Bilateral groins were prepped and draped in
standard sterile fashion. A time-out was performed. The right common femoral
artery was identified using anatomic and radiographic landmarks. The right
common femoral artery was accessed using standard micropuncture technique
after infiltration of local anesthetic. Using ultrasound guidance a short 5
___ sheath was introduced, connected to continuous heparinized saline
flush, and secured.
Next a Berenstein catheter was introduced. It was connected to continuous
heparinized saline flush as well as power injector. Is advanced over 038
glidewire through the aorta into the aortic arch. The catheter was positioned
in the left internal carotid artery over the wire.. The wire was removed.
Vessel patency was confirmed via hand injection.. Standard AP and lateral as
well as high magnification oblique three-dimensional rotational image was
obtained of the intracranial circulation. The catheter was withdrawn and a
road map was obtained of the carotid bifurcation.
The catheter was withdrawn the aortic arch and the wire was introduced. The
right internal carotid artery was selected with a catheter over the wire. The
wire was removed. Vessel patency was confirmed via hand injection. Standard
AP and lateral as well as three-dimensional rotational images were obtained.
The catheter was once again withdrawn the aortic arch. The wire was
introduced and a catheter is positioned in the left subclavian artery over the
wire. The wire was removed. The catheter was withdrawn as contrast was
injected in order to identify the region of the left vertebral artery origin.
A roadmap was performed. The left vertebral artery was selected with a
catheter over the wire using roadmap guidance. The wire was removed. Vessel
patency was confirmed via hand injection. Standard AP and lateral
intracranial views were obtained.
Next the diagnostic catheter was removed. Right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Angio-Seal. The patient was
removed from the fluoroscopy table remained at her neurologic baseline without
any evidence of thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Ultrasound the right common femoral artery: There is a single noncompressible,
arterial, pulsatile lumen. There is evidence of access of the wire into the
lumen
Left internal carotid artery: Vessel caliber smooth and regular. There is
opacification the anterior middle cerebral arteries no distal territories.
There is a fetal configuration to the posterior communicating artery. There
is evidence of a 15 x 15 mm aneurysm of the left ICA bifurcation. The venous
phase is unremarkable. The three-dimensional images confirm the aneurysm in
orientation. There is no evidence of additional aneurysm or AVM. There is no
evidence of carotid stenosis in the left cervical carotid based on roadmap
images and NASCET criteria.
Right internal carotid artery. The vessel caliber smooth and regular. There
is opacification the anterior middle cerebral arteries no distal territories.
There is filling of a 15 x 9 cm anterior communicating artery aneurysm that is
inferiorly projecting. The three-dimensional rotational images confirm this.
There is no evidence of additional aneurysm. The venous phase is
unremarkable.
Left vertebral artery: Vessel caliber smooth and regular. There is
opacification the basilar artery as well as the right posterior cerebral
artery and the bilateral superior cerebellar arteries. There is diminutive
flow in the left PCA but there is a fetal configuration on that side. There
is no evidence of aneurysm or AVM. The venous phase is unremarkable.
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
IMPRESSION:
1. 15 x 15 mm left ICA bifurcation aneurysm.
2. 15 x 9 mm anterior communicating artery aneurysm that fills from the right.
RECOMMENDATION(S):
Will discuss at vascular conference plans for treatment
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal MRI, R Arm numbness
Diagnosed with Anesthesia of skin
temperature: 97.8
heartrate: 69.0
resprate: 18.0
o2sat: 97.0
sbp: 179.0
dbp: 102.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ was admitted to neurosurgery service for finding of
incidental finding of anterior communicating artery aneurysm and
Left ICA aneurysm.
#cerebral aneurysms
Patient underwent diagnostic cerebral angiogram on ___
which confirmed aneurysms seen on MRI. No intervention was done
at this time. Groin was angiosealed and she remained on bed rest
for 2 hours. She will follow up outpatient for further
treatment.
At the time of discharge on ___ she was tolerating a regular
diet, ambulating without difficulty, afebrile with stable vital
signs. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / niacin / Crestor / Humira
Attending: ___.
Chief Complaint:
diplopia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ RHM gentleman, past medical history of CAD status
post MI, peripheral vascular disease status post stents,
hyperlipidemia, OSA not on CPAP, CKD, diabetes, HTN, HLD, and
lupus anticoagulant on anticoagulation, presents with a sudden
onset of lightheadedness, blurry vision, and triplicate to
quadruplicate vision.
He was in his usual state of health today when he was at the
___ surgeon's office, where he presented for planned
outpatient removal of squamous cell skin cancer of the left
forearm. While he was sitting in the office, he had a sudden
onset of dizziness (described as lightheadedness), and he began
to see ___ of every object. His vision was also blurry at this
time. He endorses nausea but no vomiting. This episode lasted
for ___ minutes. He has had no prior episodes like this
before. He recalled that the physician did the
___ test and that he kept missing on the right
side.
Per atria's records he had a sudden onset of double vision
lasting ___ minutes with blurry vision. On their documented
exam they noted that the right eye was deviated medially with
right lid ptosis. He cannot complete right finger nose on the
right upper extremity rapid alternating movements were intact
and Romberg was normal. On their exam there are no other
notable deficits. Fingerstick was 209. His blood pressure was
128/64 at that time.
Of note after his vision had resolved he stated that that Dr. ___
___ him go to the bathroom and while he was walking he
noticed he was veering towards the right side. He felt
lightheaded when walking. He denies any vertigo. He notes that
he has had vertigo in the past.
He was sent to ___ ED for further workup.
Of note, he stopped his Coumadin on ___ in preparation for
this outpatient operation. He took Lovenox ___ through
___. He did not take any Lovenox this morning. The initial
plan was to take 6.25 of Coumadin and 100 mg of Lovenox this
evening postoperatively.
Past Medical History:
- CAD s/p inferior MI complicated by ventricular fibrillation,
cardiac arrest in ___.
- ___ - recent EF 60-65%
- obesity
- type 2 diabetes
- hyperlipidemia
- hypertension
- hx of colorectal polyps and diverticulosis
- hx of DVT and PE in ___, + lupus antibodies
- asthma/COPD
- sleep apnea (not using CPAP)
- GERD
- PVD - stents in R. leg and bypass in left leg
- psoriasis
- Autoimmune Hemolytic Anemia - s/p chemotherapy
Social History:
___
Family History:
Mom, dad, and grandparents with heart disease. Brother in ___
with MI. Father with stroke and lung cancer. Brother with colon
cancer.
Physical Exam:
General: obese man in NAD, sitting up in bed,
HEENT: NC/AT
Pulmonary: mildly diminished air movement bilaterally
Cardiac: RRR, nl s1-s2
Abdomen: soft, NT/ND
Extremities: wwp. trace non-pitting edema bilateral legs up to
mid shin, with chronic venous stasis
Skin: there are scaly, slivery lesions on erythematous base in
the extensor surfaces over arms and legs
Neurologic:
-MS: alert, oriented. language is fluent. follows commands. no
dysarthria. mild asterixis bilaterally.
-CN: no ptosis. eyes conjugate at rest. 3 beats of end gaze
nystagmus bilaterally. slight anisocoria with R>L, both briskly
reactive. no diplopia or skew seen. face is symmetric.
palateelevates symmetrically. tongue midline.
-Motor
[Delt] [Bic] [Tri] [ECR] [FEx] [IP] [Quad] [Ham] [TA] [Gas]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 4* 5 5
-Sensory: no deficits to light touch throughout
-Reflexes: toes downgoing bilaterally
-Coordination: no dysmetria on FNF
-Gait: deferred
Pertinent Results:
===ADMISSION LABS===
___ 12:20PM BLOOD WBC-8.1 RBC-3.61*# Hgb-11.3*# Hct-34.7*#
MCV-96 MCH-31.3 MCHC-32.6 RDW-18.0* RDWSD-63.3* Plt ___
___ 12:20PM BLOOD ___ PTT-28.0 ___
___ 12:20PM BLOOD Glucose-154* UreaN-65* Creat-2.7* Na-139
K-3.9 Cl-93* HCO3-28 AnGap-22*
___ 12:20PM BLOOD ALT-33 AST-36 AlkPhos-57 TotBili-0.6
___ 12:20PM BLOOD proBNP-141
___ 12:20PM BLOOD Albumin-4.8 Calcium-10.7* Phos-3.8 Mg-2.4
___ 06:50PM BLOOD Triglyc-628* HDL-23* CHOL/HD-7.6
LDLmeas-58
___ 06:50PM BLOOD %HbA1c-6.0 eAG-126
___ 06:50PM BLOOD TSH-1.4
___ 12:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:56PM BLOOD Lactate-1.9
===RELEVANT RESULTS===
CTA HEAD AND NECK ___
1. Severe atherosclerotic calcification causing severe stenosis
at the
proximal left subclavian artery, with unremarkable distal
run-off.
2. Heavy atherosclerotic calcification of the origin of the
left vertebral artery from the left subclavian artery V2 segment
of the left vertebral artery demonstrates lack of
opacification/heavily diminished opacification with
reconstitution at the level of V3, likely due to retrograde
collateral flow from the patent right vertebral artery.
3. Given the stenosis at the origin of the left subclavian
artery with
differential upper extremity blood pressures, it is possible
that the lack of opacification of the left vertebral artery is
secondary to steal syndrome.
Although, occlusion of the left vertebral artery is more likely
due to
atherosclerotic disease, and the left vertebral artery itself
would be
expected to be opacified in the setting of subclavian steal.
This can be
further evaluated with ultrasound of the left vertebral artery.
4. The circle of ___ and its principal intracranial branches
are patent.
MRI ___
1. No acute intracranial abnormality on noncontrast MRI head.
Specifically no acute infarct.
2. There is lack of flow related signal of the left vertebral
artery beginning at the distal V1 segment to the V4 segment.
Contrast opacification seen in the V3 segment on earlier CTA is
likely secondary to retrograde flow. There is no evidence of
intramural thrombus or luminal thrombus on T1 fat saturated
sequences with apparent preserved flow voids the left vertebral
artery. Overall, in conjunction with evidence of high-grade
stenosis of the proximal left subclavian artery with preserved
flow related signal distally, the constellation of findings
would suggest subclavian steal. Retrograde flow in the left
vertebral artery can be definitively evaluated with ultrasound.
3. Allowing for mild atherosclerotic disease, unremarkable MRI
brain.
TTE ___
The left atrium and right atrium are normal in cavity size. With
maneuvers, there is early appearance of agitated
saline/microbubbles in the left atrium/left ventricle most
consistent with a patent foramen ovale. The estimated right
atrial pressure is ___ mmHg. Mild symmetric left ventricular
hypertrophy with normal cavity size, and regional/global
systolic function (biplane LVEF = 66 %). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size is normal with mild global free wall
hypokinesis. The diameters of aorta at the sinus, ascending and
arch levels are normal. Increased velocity consistent with a
significant gradient/coarctation (peak 36 mmHg) at the distal
aortic arch. The aortic valve leaflets are mildly thickened
(?#). No aortic regurgitation is seen. The mitral valve leaflets
are structurally normal. An eccentric, jet of mild to moderate
(___) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is high normal. There is no pericardial
effusion.
IMPRESSION: Likely patent foramen ovale. Likely aortic
coarctation. Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild-moderate mitral regurgitation. Likely aortic coarctation.
Increased PCWP.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
___ CAROTID SERIES
Pending final read
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insuline Glargine (Toujeo Solostar) 60 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Atenolol 25 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H:PRN hearburn
5. Vitamin D ___ UNIT PO DAILY
6. Torsemide 100 mg PO DAILY
7. Calcipotriene 0.005% Cream 1 Appl TP BID
8. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
9. Clobetasol Propionate 0.05% Soln 1 Appl TP BID
10. Desonide 0.05% Cream 1 Appl TP BID
11. Voltaren (diclofenac sodium) 1 % topical TID W/MEALS
12. Pravastatin 40 mg PO QPM
13. fenofibrate micronized 200 mg oral DAILY
14. Benzonatate 100 mg PO TID:PRN cough
15. Enoxaparin Sodium 100 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
16. Tamsulosin 0.4 mg PO QHS
17. Allopurinol ___ mg PO DAILY
18. Metolazone 2.5 mg PO 1X/WEEK (MO)
19. ___ MD to order daily dose PO DAILY16
20. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
21. Docusate Sodium 100 mg PO BID
22. Halobetasol Propionate 0.05 % topical BID
23. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
Discharge Medications:
1. Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insuline Glargine (___ Solostar) 60 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Warfarin 4 mg PO DAILY16
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
5. Allopurinol ___ mg PO DAILY
6. Atenolol 25 mg PO DAILY
7. Benzonatate 100 mg PO TID:PRN cough
8. Calcipotriene 0.005% Cream 1 Appl TP BID
9. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
10. Desonide 0.05% Cream 1 Appl TP BID
11. Docusate Sodium 100 mg PO BID
12. fenofibrate micronized 200 mg oral DAILY
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. Halobetasol Propionate 0.05 % topical BID
15. Metolazone 2.5 mg PO 1X/WEEK (MO)
16. Pantoprazole 40 mg PO Q12H:PRN hearburn
17. Pravastatin 40 mg PO QPM
18. Tamsulosin 0.4 mg PO QHS
19. Torsemide 100 mg PO DAILY
20. Vitamin D ___ UNIT PO DAILY
21. Voltaren (diclofenac sodium) 1 % topical TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: nonfocal
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ with dizziness diplopita and differential BPS in arms (30
point difference), weval for evidence of cva, arterial occlusion, or
dissection.
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 Omnipaque350 intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
3) Spiral Acquisition 5.5 s, 43.2 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,344.0 mGy-cm.
Total DLP (Head) = 2,171 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are prominent, compatible with involutional change.
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:
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. Incidental note is made of a fetal type origin of
the right posterior cerebral artery. A millimetric infundibulum arises from
the supraclinoid portion of the left carotid artery (3:79).
CTA NECK:
There is severe atherosclerotic calcification causing stenosis at the proximal
left subclavian artery (3:79), with distal opacification. The left vertebral
artery origin is also heavily calcified (3:111), and the V2 segment of the
left vertebral artery is demonstrate lack of contrast opacification or
severely diminished opacification, and reconstitutes at the level of V3,
likely due to retrograde collateral flow from the patent right vertebral
artery. Atherosclerotic calcification of the bilateral carotid bifurcations
does not result in stenosis of the cervical internal carotid arteries by
NASCET criteria. Arteries unremarkable.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Severe atherosclerotic calcification causing severe stenosis at the
proximal left subclavian artery, with unremarkable distal run-off.
2. Heavy atherosclerotic calcification of the origin of the left vertebral
artery from the left subclavian artery V2 segment of the left vertebral artery
demonstrates lack of opacification/heavily diminished opacification with
reconstitution at the level of V3, likely due to retrograde collateral flow
from the patent right vertebral artery.
3. Given the stenosis at the origin of the left subclavian artery with
differential upper extremity blood pressures, it is possible that the lack of
opacification of the left vertebral artery is secondary to steal syndrome.
Although, occlusion of the left vertebral artery is more likely due to
atherosclerotic disease, and the left vertebral artery itself would be
expected to be opacified in the setting of subclavian steal. This can be
further evaluated with ultrasound of the left vertebral artery.
4. The circle of ___ and its principal intracranial branches are patent.
RECOMMENDATION(S): Further evaluation of impression 2 and 3 with ultrasound
is recommended.
NOTIFICATION: The above findings and recommendation were communicated via
telephone by Dr. ___ to Dr. ___ at 13:50 on ___, 5 minutes
after discovery.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old man with triplicate vision x 10 mins// stroke
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
2D time of flight MR angiography of the neck was performed. Axial T1 fat
saturated sequences through the neck performed.
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: CTA head and neck of ___
FINDINGS:
MRI Brain:
There is no intra or extra-axial mass, acute hemorrhage or infarct. The
sulci, ventricles and cisterns are within expected limits for the patient's
age. The major intracranial flow voids are preserved. There is mild mucosal
thickening of the ethmoid air cells. Trace fluid signal is seen in the
bilateral mastoid tips. The orbits are unremarkable.
MRA brain: Mild numeral irregularity of the bilateral internal carotid
arteries is compatible with mild atherosclerotic calcification. The
intracranial vertebral and internal carotid arteries and their major branches
otherwise appear normal without evidence of high-grade stenosis, occlusion, or
aneurysm formation.
MRA neck: Within confines of 2 dimensional time-of-flight MRA technique and
motion artifact at the neck base, re-identified is lack of flow related signal
of the left vertebral artery beginning at the distal V1 segment to the V4
segment. Contrast opacification seen in the V3 segment on earlier CTA is
likely secondary to retrograde flow. There is no stenosis of the cervical
internal carotid arteries by NASCET criteria. Within confines of technique,
the visualize common carotid and right vertebral arteries are unremarkable.
Re-identified is severe stenosis of the left subclavian artery near its
origin.
There is no evidence of T1 hyperintense signal within the lumen of the left
vertebral artery or crescentic T1 hyperintense signal along the vessel wall to
suggest thrombus or dissection. Of note, there appears to be uninterrupted
flow voids through the left vertebral artery on the T1 fat saturated
sequences.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast MRI head. Specifically no
acute infarct.
2. There is lack of flow related signal of the left vertebral artery beginning
at the distal V1 segment to the V4 segment. Contrast opacification seen in
the V3 segment on earlier CTA is likely secondary to retrograde flow. There
is no evidence of intramural thrombus or luminal thrombus on T1 fat saturated
sequences with apparent preserved flow voids the left vertebral artery.
Overall, in conjunction with evidence of high-grade stenosis of the proximal
left subclavian artery with preserved flow related signal distally, the
constellation of findings would suggest subclavian steal. Retrograde flow in
the left vertebral artery can be definitively evaluated with ultrasound.
3. Allowing for mild atherosclerotic disease, unremarkable MRI brain.
RECOMMENDATION(S): Further evaluation of impression 2 with ultrasound.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with ?left subclavian steal syndrome//
specifically, interested in flow direction on left vertebral artery
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: MRA head and neck ___
FINDINGS:
RIGHT:
The right carotid vasculature has moderate degree of calcified atherosclerotic
plaque.
The peak systolic velocity in the right common carotid artery is 59 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 71, 75, and 114 cm/sec, respectively.
The peak end diastolic velocity in the right internal carotid artery is 30
cm/sec.
The ICA/CCA ratio is 1.9.
The external carotid artery has peak systolic velocity of 87 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild degree of heterogeneous atherosclerotic
plaque.
The peak systolic velocity in the left common carotid artery is 73 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 44, 82, and 70 cm/sec, respectively.
The peak end diastolic velocity in the left internal carotid artery is 23
cm/sec.
The ICA/CCA ratio is 1.1.
The external carotid artery has peak systolic velocity of 103 cm/sec.
The vertebral artery is patent with retrograde flow suggestive of subclavian
steal.
IMPRESSION:
1. Moderate calcified atherosclerotic plaque yielding a 40-59% degree
stenosis
2. Mild calcified atherosclerotic plaques yielding a less than 40 degree
percent stenosis.
3. Retrograde flow in the left vertebral artery suggestive of subclavian
steal
RECOMMENDATION(S): The ultrasound findings confirm the diagnosis from the
prior CTA of the head that the patient has subclavian steal syndrome related
to an occluded left subclavian artery ostium. The left vertebral artery is
patent but has retrograde flow. An interventional radiology consult is
recommended for subclavian artery stenting.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA
Diagnosed with Diplopia
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a ___ man with HTN, HLD, DM, OSA, and
+lupus anticoagulant antibodies who was admitted ___ with
transient neurologic symptoms including ?diplopia and right
upper extremity ataxia in the setting of being bridged with
lovenox and off coumadin for a planned dermatological procedure.
Imaging shows no infarct, but left vertebral lack of flow and
left subclavian stenosis suggestive of a vertebral steal
syndrome. His history and resolution of deficits suggests either
a TIA (given subtherapeutic lovenox dosing) vs steal phenomenon.
His Cr was elevated on admission to 2.7. Because of this, he was
bridged with a heparin drip until he reached a therapeutic INR
between ___. On discharge, his INR was 2.1. He will need his INR
checked again this week.
As part of his stroke workup, he had a TTE completed, which
showed a ?coarctation of the aorta. Vascular surgery was
consulted and recommended outpatient follow up. It also turns
out that he is only on warfarin and not on Plavix or ASA, though
it is on his medication list. He will need to have this
clarified with vascular surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Percocet / Bactrim / Linzess
Attending: ___.
Chief Complaint:
Fever, leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of urosepsis and obstructing kidney stones, aortic
stenosis, afib on Xarelto, BPV, CHF with diastolic dysfunction,
Barretts esophagus with dysphagia, hypothyroid, chronic
lymphedema, HTN and ischemic colitis who is presenting with
lower back pain for the past month and chills that started last
night.
She has a history of getting very sick quickly and ending up in
septic shock with infections in the past. Her granddaughter's
wedding is tomorrow at 3 ___ and she is upset to possibly miss
this. She denies urinary symptoms, but does not usually have
these with her UTI. She endorses severe shaking chills that
started last night and then recurred today. She used Tylenol
last night and today and an elevated temperature of ___. She
also has increased incontinence over the last 2 weeks which is
another indication of UTI per patient.
She also endorses increasing redness and drainage from her left
lower extremity for the past few days.
She denies fall or trauma. She denies bowel incontinence. She
denies numbness, weakness or tingling of her lower extremities.
She denies nausea, vomiting, diarrhea, chest pain, shortness of
breath, change in her chronic abdominal pain. Her chronic back
pain is also unchanged from baseline.
In the ED, initial VS were: 100.9 56 185/59 16 98% RA
Exam notable for: Left anterior ___ with redness and weeping and
warmth compared to right ___ of equal size. Bilateral 4+ edema of
the ___. Midline spinal tenderness of L2-L4, no paraspinous
muscle tenderness. Mild Right CVAT. NTND abd. RRR. Mild crackles
bilaterally.
Labs showed:
- WBC: 10.4 (PMN 95%), Hgb 11.3 (baseline)
- INR 1.3
- Na 140, K 4.7 (hemolyzed), Cr 0.8 (baseline)
- Lactate 1.2
- U/A 1.023, ___, +Nit, 47 WBC, mod Bact, 1 Epi
Imaging showed:
- CXR: no acute process
- CTU (NC): no acute abnormality, hydronephrosis or perinephric
abnormality, or fracture. Nonobstructive nephrolithiasis and
diverticulosis without diverticulitis.
Patient received:
Acetaminophen 1000 mg
IV Ceftriaxone 1 gm
Amiodarone 200 mg
Rosuvastatin Calcium 5 mg
Lisinopril 20 mg
Allopurinol ___ mg
Tramadol 50 mg
Rivaroxaban 20 mg
Lidocaine 5% Patch
Transfer VS were: 98.1 64 131/67 16 99% RA
On arrival to the floor, patient reports that she has not had
any more chills. She c/o her chronic back pain and says her left
leg is more painful than her right. She did not notice the
erythema on the left leg. She denies acutely worsening edema,
dyspnea or exercise tolerance.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Atrial fibrillation
CAD
HFpEF
Aortic stenosis
HTN
HLD
Urosepsis
Recurrent UTIs
Urinary incontinence
Thyroid cancer s/p partial thyroidectomy
Hyperparathyroidism
Hypothyroidism ___ ___'s
Nephrolithiasis, obstructive
Stasis dermatitis / Lymphedema
Gout
GERD
___ esophagus
Ischemic colitis
BPPV
Chronic back pain
OA knees
Morbid obesity
OSA
Hearing loss
Social History:
___
Family History:
Father who had a renal calculus once, DM, mother with congestive
heart failure, and a brother with ESRD on HD, DM
Physical Exam:
=====================
ADMISSION
=====================
VS: 135/55 55 20 96% RA
Weight; 115.67 kg
GENERAL: WDWN woman in NAD
HEENT: EOMI, PERRL, anicteric sclera, hearing aid in place, MOM,
OP clear
NECK: supple, no LAD, JVD to below chin at 30 degrees
HEART: RRR, normal S1/S2, III/VI SEM RUSB
LUNGS: NLB on RA, CTAB
ABDOMEN: soft, nondistended, mildly tender in LLQ, no
rebound/guarding, +BS
EXTREMITIES: no cyanosis, severe lymphedema BLE to hips equally
with B/L distal stasis growths. LLE with erythema extending to
mid thigh, ill defined border with associated warmth and
tenderness with purulent cellulitis distal LLE
GU: trace left sided back pain at CVAT
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, face symmetric, moving all 4 extremities with
purpose
SKIN: warm and well perfused
=====================
DISCHARGE
=====================
VS: 97.9, 151/76, 53 18 97 Ra
GENERAL: AOx3, lying in bed, NAD
NEURO: AOx3, no focal deficits.
EYES: Anicteric sclera
ENT: MMM
NECK: Supple
CV: RRR, III/VI systolic murmur at RUSB
RESP: CTAB
GI: soft, NT/ND, Bowel sounds present
MSK: Lymphedema B/L extending to her hips. B/L distal stasis
growths, Her LLE demonstrates erythema extending to the mid-shin
with poorly demarcated borders. There is associated mild TTP and
warmth. No evidence of purulence.
EXT: warm and well perfused; no clubbing or cyanosis.
Pertinent Results:
====================
ADMISSION LABS
====================
___ 07:45PM BLOOD WBC-10.4*# RBC-3.74* Hgb-11.3 Hct-35.7
MCV-96 MCH-30.2 MCHC-31.7* RDW-14.0 RDWSD-49.0* Plt ___
___ 07:45PM BLOOD Neuts-95.1* Lymphs-2.1* Monos-2.3*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.91*# AbsLymp-0.22*
AbsMono-0.24 AbsEos-0.00* AbsBaso-0.01
___ 07:45PM BLOOD ___ PTT-34.2 ___
___ 07:45PM BLOOD Glucose-95 UreaN-22* Creat-0.8 Na-140
K-4.7 Cl-102 HCO3-24 AnGap-14
___ 07:45PM BLOOD Calcium-9.6 Phos-2.9 Mg-2.1
___ 07:55PM BLOOD Lactate-1.2
====================
PERTINENT RESULTS
====================
MICROBIOLOGY
====================
__________________________________________________________
___ 6:42 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 7:10 am SWAB Source: LLE drainage material.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 2 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM------------- 0.5 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
__________________________________________________________
___ 8:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000
CFU/mL. PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
__________________________________________________________
___ 7:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
====================
IMAGING
====================
CXR (___): No acute intrathoracic process. Specifically, no
signs of pneumonia.
===
CTU Abdomen/Pelvis (___):
1. No acute abnormality in the abdomen or pelvis to explain
patient's reported back pain and fever. Specifically, no
evidence of hydronephrosis or perinephric abnormality. No
fracture.
2. Nonobstructive nephrolithiasis.
3. Sigmoid colonic diverticulosis without evidence of
diverticulitis.
4. No evidence of acute appendicitis.
5. A small focus of gas in the bladder is nonspecific but likely
related to
instrumentation. Please correlate clinically.
====================
DISCHARGE LABS
====================
___ 09:15AM BLOOD WBC-4.2 RBC-3.42* Hgb-10.4* Hct-32.6*
MCV-95 MCH-30.4 MCHC-31.9* RDW-14.1 RDWSD-49.4* Plt ___
___ 09:15AM BLOOD Glucose-105* UreaN-28* Creat-0.8 Na-145
K-4.4 Cl-107 HCO3-24 AnGap-14
___ 09:15AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Lidocaine 5% Ointment 1 Appl TP TID
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Amiodarone 200 mg PO DAILY
7. Rivaroxaban 20 mg PO DAILY
8. Rosuvastatin Calcium 5 mg PO QPM
9. Torsemide 10 mg PO EVERY OTHER DAY
10. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
11. Omeprazole 20 mg PO DAILY
12. Levothyroxine Sodium 200 mcg PO DAILY
13. Vitamin D ___ UNIT PO 1X/WEEK (___)
14. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Cephalexin 500 mg PO Q6H
Last day: ___
RX *cephalexin 500 mg 1 capsule(s) by mouth Every 6 hours Disp
#*14 Capsule Refills:*0
3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth Every 6 hours Disp #*20
Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Amiodarone 200 mg PO DAILY
6. Levothyroxine Sodium 200 mcg PO DAILY
7. Lidocaine 5% Ointment 1 Appl TP TID
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Lisinopril 20 mg PO DAILY
10. Loratadine 10 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Rivaroxaban 20 mg PO DAILY
14. Rosuvastatin Calcium 5 mg PO QPM
15. Torsemide 10 mg PO EVERY OTHER DAY
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY:
- Cellulitis
- Urinary tract infection
SECONDARY:
- Lymphedema
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 (SINGLE VIEW)
INDICATION: ___ with fever and chills and back pain// ?pna
COMPARISON: Prior study is dated ___
FINDINGS:
AP portable upright view of the chest. The lungs are clear bilaterally. The
cardiomediastinal silhouette is stable. No large effusion or pneumothorax.
No signs of congestion or edema. Bilateral AC joint arthropathy noted.
IMPRESSION:
No acute intrathoracic process. Specifically, no signs of pneumonia.
Radiology Report
EXAMINATION: CT abdomen and pelvis without intravenous contrast
INDICATION: ___ with midline spinal tenderness of L2-L4, right CVAT, fever.//
?pyelonephritis, kidney or ureteral stone, hydronephrosis, diverticulitis,
occult spinal fracture
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered. Coronal and sagittal reformations were
performed and reviewed on PACS.
DOSE: Total DLP (Body) = 730 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: There is mild atelectasis in the bilateral lower lobes. There is
no pericardial or pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
Sub-capsular calcification at the dome (series 2:5), is unchanged from CT
abdomen pelvis ___. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There are multiple
simple cysts in the bilateral kidneys measuring up to 2.4 cm across maximal
diameter in the upper pole of the right kidney (series 601: 46). There is an
exophytic intermediate density rounded focus in the lower pole the left kidney
measuring 1.5 cm across maximal diameter (series 2:30) which is grossly
unchanged as compared to CT ___, likely representing a hemorrhagic
or proteinaceous cyst. There are multiple nonobstructive calculi in the
bilateral kidneys measuring up to 7 mm in the lower pole of the left kidney
(series 601:36). There is no hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. There is extensive sigmoid
diverticulosis evidence of diverticulitis. The appendix is not visualized but
there is no secondary sign of acute appendicitis.
PELVIS: There is a small focus of gas in the anti dependent portion of the
bladder (series 2:59). There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable. There is pelvic floor
descent.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There are 2 aneurysms
measuring 1.9 cm (series 2:21) and 1.1 cm a partially calcified (series 2:24)
likely rising from the superior mesenteric arteries and common hepatic
arteries, respectively, unchanged from CT abdomen pelvis ___. The
abdominal aorta is tortuous. Extensive atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is levoscoliosis centered T12-L1. There are moderate to severe
degenerative changes of the lumbar spine. There are moderate to severe
degenerative changes of bilateral left greater than right hip joints.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute abnormality in the abdomen or pelvis to explain patient's reported
back pain and fever. Specifically, no evidence of hydronephrosis or
perinephric abnormality. No fracture.
2. Nonobstructive nephrolithiasis.
3. Sigmoid colonic diverticulosis without evidence of diverticulitis.
4. No evidence of acute appendicitis.
5. A small focus of gas in the bladder is nonspecific but likely related to
instrumentation. Please correlate clinically.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chills, Lower back pain
Diagnosed with Urinary tract infection, site not specified, Cellulitis of left lower limb
temperature: 100.9
heartrate: 56.0
resprate: 16.0
o2sat: 98.0
sbp: 185.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is an ___ y/o woman with history of recurrent
urinary tract infections complicated by urosepsis, obstructive
nephrolithiasis, urinary
incontinence, HFpEF, AS, thyroid cancer s/p partial resection,
___ esophagus, chronic back/knee pain, lymphedema who
presented with back pain and chills and was found to have
urinary tract infection and left lower extremity cellulitis.
===============
ACUTE ISSUES:
===============
# Urinary tract infection: Patient presented with chills and was
found to have pansensitive E. coli urinary tract infection.
Imaging was without obstructive nephrolithiasis and showed no
radiographic evidence of pyelonephritis. The patient was
initially given ceftriaxone, and given allergy to Bactrim and
drug-drug interactions with amiodarone, will complete 7-day
treatment course with
cephalexin (Last day: ___.
# Cellulitis: Patient was noted to have left lower extremity
erythema and serous drainage consistent with nonpurulent skin
and soft tissue infection. She was initially given vancomycin
and ceftriaxone and narrowed to cephalexin as above. She was
treated with tramadol for discomfort.
# Lymphedema: Patient has longstanding history of lymphedema
that increased her vulnerability to cellulitis as above. She
will follow up in the lymphedema ___ further management.
===============
CHRONIC ISSUES:
===============
# Chronic back pain
# OA knees: Lidocaine 5% Patch daily. Tramadol as above.
# Atrial fibrillation: Continued amiodarone and rivaroxaban.
# HFpEF: Continued lisinopril, torsemide.
# Aortic stenosis: Stable.
# HTN: Continued lisinopril.
# HLD: Continued rosuvastatin.
# Hypothyroidism ___ hashimoto's, thyroid cancer s/p resection:
Continued levothyroxine.
# Gout: Continued allopurinol.
# GERD c/b ___ esophagus: Continued omeprazole.
# OSA not on CPAP
======================
TRANSITIONAL ISSUES
======================
- Patient to continue cephalexin 500 mg Q6H to complete 7-day
course for E. coli urinary tract infection and cellulitis (Last
day: ___
- Patient provided with tramadol for increased discomfort due to
cellulitis
- Patient will follow up in the ___ clinic
- Communication: ___, friend, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / gluten / lactose / lactulose
Attending: ___.
Chief Complaint:
Umbilical Laparoscopic Incision Site Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per Colorectal Surgery Admit Note:
___ w chronic slow transit constipation s/p laparoscopic
subtotal colectomy ___ w post-op ileus and unexpected viable
intrauterine pregnancy (now ~___ wks pregnant) p/w pain at her
umbilical incision that has been increasing since she was
discharged on ___. Pt reports pain to the right of her
umbilical incision that has been increasing to the point where
she can no longer walk or
move, prompting her presentation to the ED. Pt states her other
incisions have minimal to no pain. Other than the incisional
pain, pt has been well. No changes in medications. Some nausea
in
the AM, which she attributes to her pregnancy, but no emesis.
Moving her bowels. Eating and drinking without issue. No fevers
or chills.
Past Medical History:
1) Constipation
2) Depression
3) Remote history of eating disorder ___ years ago, now resolved.
Past Surgical History:
1) Foot surgery
Social History:
___
Family History:
Significant for prostate cancer (paternal grandfather) and
breast cancer (maternal grandmother, two aunts).
Physical Exam:
Discharge Physical Exam
General: Doing well, eating a regular diet, tolerating pain
medications without issue, ambulating with only small amount of
splinting of abdomen
VSS
Neuro: A&OX3
Cardio/Pulm: RRR, no increased shortness of breath, no increased
work of breathing
And: lap sites healing well, specifically umbilical site with
small amount of eschar, healthing, no purulent drainage or sign
of infection, lower abdomen slightly round, minimally tender to
palpation, no obvious bulging of the incison line or umbilicus
suggesting significant hernia.
___: no lower extremity edema
Pertinent Results:
___ 12:00AM BLOOD WBC-7.1 RBC-3.48* Hgb-10.6* Hct-30.1*
MCV-87 MCH-30.5 MCHC-35.2* RDW-13.0 Plt ___
___ 12:00AM BLOOD Neuts-71.8* ___ Monos-3.9 Eos-1.2
Baso-0.5
___ 12:00AM BLOOD Glucose-95 UreaN-9 Creat-0.4 Na-135 K-3.7
Cl-103 HCO3-20* AnGap-16
___ 12:00AM BLOOD Albumin-3.6 Calcium-9.1 Phos-3.5 Mg-1.8
MRI of Abdomen ___
MRI ABDOMEN W/O CONTRAST Study Date of ___ 12:09 ___
IMPRESSION:
1. Small hernia at the umbilicus containing mesenteric fat and
postsurgical change. No fluid collection or bowel is seen
within this small hernia.
2. Mildly dilated small bowel is slightly improved from the
prior CT and may represent a resolving ileus or partial small
bowel obstruction.
3. Small to moderate amount of free fluid adjacent to the
inferior liver and extending along the right pericolic gutter,
slightly decreased compared to prior CT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Duloxetine 30 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. LOPERamide 1 mg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Pyridoxine 25 mg PO Q6H
6. Ranitidine 150 mg PO DAILY
7. Unisom (doxylamine) (doxylamine succinate) 25 mg oral QHS
8. Lorazepam 0.5 mg PO Q4H:PRN anxiety
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Duloxetine 30 mg PO DAILY
3. LOPERamide 1 mg PO DAILY
4. Lorazepam 0.5 mg PO Q4H:PRN anxiety
5. Pyridoxine 25 mg PO Q6H
6. Ranitidine 150 mg PO DAILY
7. Prenatal Vitamins 1 TAB PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Unisom (doxylamine) (doxylamine succinate) 25 mg oral QHS
10. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
take this for the shortest amount of time only, do not drink
alcohol or drive a car while taking
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Umbilical Incision Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI abdomen without contrast.
INDICATION: Increasing incisional pain within the umbilicus in a patient
status post laparoscopic subtotal colectomy for slow transit and constipation
in ___.
TECHNIQUE: Multiplanar T1 and T2 weighted sequences of the abdomen were
obtained in a 1.5 Tesla magnet without the administration of IV contrast.
COMPARISON: CT abdomen/ pelvis from ___.
FINDINGS:
The liver is homogeneous and normal in signal intensity without a gross mass.
There is no intra or extrahepatic biliary duct dilation. The gallbladder is
without stone or wall thickening. A small to moderate amount of free fluid is
seen in the inferior perihepatic region and right pericolic gutter, similar to
that seen on the prior CT. The spleen is homogeneous and normal in size. The
pancreas demonstrates no focal mass, peripancreatic stranding, fluid
collection, or ductal dilation. The adrenal glands are normal in size and
configuration. The kidneys are symmetric and normal in size, without
hydronephrosis. Foci of T2 hyperintensity in the left kidney are consistent
with tiny simple renal cysts. The aorta is normal in caliber. There is no
retroperitoneal or mesenteric lymph node enlargement.
The patient is status post subtotal colectomy. Small bowel in the right lower
quadrant and epigastric region remain dilated, measuring up to 4.5 cm (8:6),
slightly improved compared to the prior CT. At the periumbilical incision
site, there is mild herniation of the underlying mesenteric fat and adjacent
soft tissue signal with susceptibility artifact, likely reflective of
postsurgical changes. No bowel is seen within this small hernia, and there is
no fluid collection.
A gravid uterus is partially imaged. No osseous lesion concerning for
infection or malignancy is identified.
IMPRESSION:
1. Small hernia at the umbilicus containing mesenteric fat and postsurgical
change. No fluid collection or bowel is seen within this small hernia.
2. Mildly dilated small bowel is slightly improved from the prior CT and may
represent a resolving ileus or partial small bowel obstruction.
3. Small to moderate amount of free fluid adjacent to the inferior liver and
extending along the right pericolic gutter, slightly decreased compared to
prior CT.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with OTH CURR COND-ANTEPARTUM, ABDOMINAL PAIN OTHER SPECIED
temperature: 97.3
heartrate: 79.0
resprate: 16.0
o2sat: 99.0
sbp: 104.0
dbp: 71.0
level of pain: 7
level of acuity: 3.0 | ___ was admitted to the inpatient Colorectal Surgery
Service with Umbilical Incision pain. All laboratory values were
stable and she did not have a fever or any other sign of
systemic infection. The high risk OB team was consulted given
that she is approximately 16 weeks pregnant and had been
previously followed by them during her last admission. An MRI of
the abdomen was ordered to evaluate for abscess or hernia. The
read showed a possible small hernia with fat necrosis. This was
reviewed with Dr. ___ this was a nonsurgical issue and
there was no fluid collection under the umbilical incision site.
There were no other significant finding on MRI related to the
surgery, infact, small bowel dilation and post-surgical fluid
was improved. She was monitored closely overnight. She tried a
Lidocaine patch which did not help significantly. PO Dilaudid
did help. All medication choices were discussed with OB. The
following morning she was slightly improved. She had her
baseline nausea, which improves with food and throughout the
day. She is nauseated every morning at home, which seems very
consistent with morning sickness. ___ was very concerned about
her surgical incisions. I examined the incisions and offered
reassurance, she will continue to shower and pat the incision
dry. We went over the MRI symptoms again with her husband
present. She will be seen ___ at ___ and will follow-up
with Dr. ___. It seemed most of the pain was with movement and
she felt as though she had to support her abdomen with her hand.
We tried an abdominal binder for support prior to discharge. She
was discharged home in the care of her husband. The major
aspects of her discharge plan was discussed with OB. She was
sent home with a small prescription for Dilaudid to use if
Tylenol is not covering the pain. We will follow her closely. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fall from standing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male smoker with a history of
metastatic throat cancer s/p laryngeal tracheal resection, s/p
removal of L lower jaw, who presented via EMS for evaluation of
AMS s/p fall with positive head strike on ___.
Per patient's family, he was noted to have continually ingested
EtOH through out the day. Per EMS, family notes the patient had
a mechanical fall from standing, with positive head strike, and
subsequently exhibited altered mental
status with slurred speech. Upon these findings, the family
notified EMS, who states the patient was alert and oriented x3
upon their arrival. En route, the patient was dehydrated but
otherwise hemodynamically stable, and Mr. ___
received 700 mls fluid en route to the ED. Upon arrival to ED
Triage, the patient became hypotensive, and displayed episodic
AMS with slurred speech.
Past Medical History:
Throat cancer s/p resection, chemo, radiation ___ years ago
AAA s/p open repair
R knee meniscus surgery
alcohol abuse
Social History:
___
Family History:
unknown
Physical Exam:
PE: Upon admission ___
AVSS
A&O x 3
C-collar in place
Slightly ucomfortable lying in bed
PE: Upon discharge ___
VS: 97.3, 125/75, 79, 18, 99%RA
A&O x 3
C-collar in place
Relatively comfortable sitting in chair
Pertinent Results:
___ 05:38PM PO2-91 PCO2-30* PH-7.29* TOTAL CO2-15* BASE
XS--10 COMMENTS-GREEN TOP
___ 05:38PM GLUCOSE-96 LACTATE-5.1* NA+-128* K+-4.5
CL--97
___ 05:38PM HGB-10.2* calcHCT-31 O2 SAT-90 CARBOXYHB-6*
MET HGB-0
___ 05:38PM freeCa-0.94*
___ 05:30PM UREA N-21* CREAT-1.3*
___ 05:30PM estGFR-Using this
___ 05:30PM LIPASE-71*
___ 05:30PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:30PM WBC-4.9 RBC-2.84* HGB-10.1* HCT-33.4*
MCV-118* MCH-35.5* MCHC-30.2* RDW-13.1
___ 05:30PM PLT COUNT-171
___ 05:30PM ___ PTT-22.7* ___
___ 05:30PM ___-SPINE W/O CONTRAST Study Date of
___
IMPRESSION:
1. Bilateral C6 laminar fractures and obliquely oriented
fracture of the right
C7 articular pillar/superior articular facet, with extension
into the
transverse process, as described above. If neurologic symptoms
are present,
MRI is recommended for better characterization.
2. Nondisplaced fractures of the left fifth and sixth, and
possibly the third
transverse processes without extension to the transverse
foramina.
3. Medial left first and second rib fractures.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
IMPRESSION:
No acute intracranial abnormality. Small left occipital scan
laceration,
closed with staples. No evidence of underlying fracture
Medications on Admission:
Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
do not exceed >4g per 24 hours
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
do not drive or use machinery while taking this medication
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID constipation Duration: 2 Weeks
do not use when having loose stool
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
head laceration
left medial rib fractures of ribs 1 and 2
a fracture of bilateral C6 laminae with extension into C6-7
facet and anterolisthesis of C6 on C7
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Trauma.
TECHNIQUE: Supine view of the chest. Supine view of the pelvis.
COMPARISON: None. Correlation is made to same day CT of the chest abdomen
and pelvis.
FINDINGS:
The view of the chest is limited due to overlying trauma board. Known left
first and second rib fractures are better seen on CT scan. Lungs are grossly
clear, hyperinflated. The cardiomediastinal silhouette is within normal
limits.
Single view of the pelvis is also limited by trauma board. There is no
definite fracture. Degenerative changes noted in the lumbar spine.
IMPRESSION:
Limited views of the chest and pelvis demonstrating no definite acute
abnormalities, left rib fractures better seen by CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ s/p fall, hypotensive // Eval for injury
TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base
through the vertex, without IV administration of contrast. Reformatted coronal
and sagittal and thin-section bone algorithm-reconstructed images were
acquired, and all images are viewed in brain and bone window on the
workstation.
DOSE: DLP (mGy-cm): 1014.9.
CTDIvol (mGy): 55.8.
COMPARISON: None.
FINDINGS:
There is no intracranial hemorrhage, edema, mass effect, or acute vascular
territorial infarction. The ventricles and sulci are prominent, in keeping
with age related global atrophy. Periventricular and subcortical white matter
hypodensities reflect the sequelae of chronic small vessel ischemic disease.
Right parietal encephalomalacia may be from prior infarct. There is no shift
of the normally midline structures.The basal cisterns appear patent and there
is preservation of the gray-white matter differentiation.
A small left occipital laceration is present, closed with skin staples
(2b:20). No underlying fractures identified.The included paranasal sinuses,
right mastoid air cells, and middle ear cavities are clear. Partial
opacification of the left mastoids is noted. The orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality. Small left occipital scan laceration,
closed with staples. No evidence of underlying fracture.
Radiology Report
EXAMINATION: CT C-SPINE WITHOUT CONTRAST.
INDICATION: ___ s/p fall, hypotensive // Eval for injury
TECHNIQUE: Axial helical MDCT images were obtained of the cervical spine.
Reformatted coronal and sagittal images were also reviewed.
DOSE: DLP: 946.6 mGy-cm.
COMPARISON: The study is read in conjunction with concurrently obtained CT of
the head and CT of the torso.
FINDINGS:
Nondisplaced fractures are noted through the bilateral C6 lamina (02:54), with
an adjacent obliquely oriented fracture of the right C7 articular
pillar/superior articular facet (2:56,58; 602:24), with extension into the
right C7 transverse process (02:57). Nondisplaced fractures through the left
fifth and sixth transverse processes and possibly the left third transverse
process are also noted, with no evidence of extension into the transversarium
foramen at those levels. The overall cervical lordosis is preserved, with no
evidence of spondylolisthesis. The vertebral body heights and disc spaces are
maintained. No critical spinal canal stenosis is identified. A calcified disc
osteophyte complex at the C3-4 level is also noted. There is no prevertebral
soft tissue edema. Acute posterior left first and second rib fractures are
identified.
Medial left first and second rib fractures are present (2:73, 2:67).
Bilateral apical emphysematous changes and pleural parenchymal scarring is
present. Atherosclerotic calcifications seen at the carotid bulbs
bilaterally. The thyroid gland is somewhat atrophic, with subcentimeter
nodularity noted in the isthmus (2:68) and right thyroid lobe (2:67).
Postsurgical changes of left neck dissection is identified, submandibular
gland is not clearly seen. Postsurgical changes involving possible graft of
the left mandible is only partially visualized. Mastoid tips are partially
opacified.
IMPRESSION:
1. Bilateral C6 laminar fractures and obliquely oriented fracture of the right
C7 articular pillar/superior articular facet, with extension into the
transverse process, as described above. If neurologic symptoms are present,
MRI is recommended for better characterization.
2. Nondisplaced fractures of the left fifth and sixth, and possibly the third
transverse processes without extension to the transverse foramina.
3. Medial left first and second rib fractures.
NOTIFICATION: The changes in the above impression from the original wet read
were communicated to Dr. ___ by Dr. ___ in person at 20:45, at the time of
attending review.
Radiology Report
EXAMINATION: CT CHEST, ABDOMEN, AND PELVIS
INDICATION: Trauma.
TECHNIQUE: Multidetector CT through the chest, abdomen, and pelvis was
performed following IV contrast administration with multiplanar reformations
provided.
COMPARISON: The study is read in comparison with concurrently obtained CT of
cervical spine.
FINDINGS:
CHEST: The thoracic aorta is normal in course and caliber without evidence of
focal injury, dissection, or aneurysm. Moderate atherosclerotic
calcifications are noted in the coronary arteries, aortic annulus, and aortic
arch. There is no mediastinal hematoma. The airways centrally patent. The
main pulmonary artery and central branches appear patent. The heart is normal
in size and shape. No pleural or pericardial effusion is seen.
Severe bilateral apical predominant emphysematous changes are present, with no
evidence of pleural effusion or pneumothorax. No concerning nodules or masses
are identified. A subcentimeter hypodense nodule in the right thyroid lobe is
incidentally noted (2:1).
ABDOMEN: The liver and spleen appear intact without focal abnormality, except
for a subcentimeter right hepatic lobe hypodensity (2:61), too small to
characterize. There is no intra or extrahepatic biliary ductal dilatation, and
the portal veins appear patent. The gallbladder, pancreas, and right adrenal
gland appear normal. A 1.2 cm nodule seen within the left adrenal gland which
is incompletely characterized on this contrast-enhanced exam. Bilateral renal
cysts are noted (2:65, 2:68) as well as other hypodensities which are too
small to characterize. Otherwise, the kidneys enhance symmetrically and
excrete contrast promptly without hydronephrosis or focal lesion of concern.
The intra-abdominal aorta contains moderate atherosclerotic calcium burden,
with a patent celiac axis, superior mesenteric and inferior mesenteric artery.
There is no abdominal aortic aneurysm. There is no retroperitoneal hematoma or
lymphadenopathy. No free air or free fluid is seen.
The stomach is distended with air and ingested material, and the duodenum and
small bowel are moderately distended with air, with no evidence of focal
injury or mechanical obstruction. The intra-abdominal loops of large bowel are
unremarkable.
PELVIS: Loops of small and large bowel demonstrate no signs of obstruction.
There is no evidence of mesenteric injury. Foley catheter seen within the
decompressed bladder. There is no pelvic free fluid.
BONES: Multiple healed left sided rib fractures are seen (2:19, 2:25).
Degenerative changes in the lumbar spine include disc height loss at the L4-5
level, with adjacent endplate sclerosis and anterior osteophytosis.
Transitional lumbosacral anatomy include a partially sacralized L5 vertebral
body on the left (601b:38). Acute left second and first rib fractures are
better seen on CT of the cervical spine.
IMPRESSION:
1. Left first and second rib fractures are better seen on concurrent CT
cervical spine. No other evidence of acute traumatic injury in the chest,
abdomen or pelvis.
2. Severe emphysema.
3. Coronary artery atherosclerotic disease.
4. Gastric distention, with mild dilation of small bowel loops, with no
evidence of mechanical obstruction, likely ileus.
5. 1.2 cm left adrenal nodule, statistically benign likely an adenoma but
incompletely characterized on this single phase exam.
6. Nodular thyroid.
NOTIFICATION: The above findings and changes from the original wet read were
communicated by Dr. ___ to Dr. ___ telephone at approximately 20:45,
at the time of attending review.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST
INDICATION: ___ year old man +ETOH s/p fall with confirmed bilateral c6
laminar fx, R c7 articular pillar fracture // evaluate ligamentous injury /
further define fx
TECHNIQUE: Routine MRI of the cervical spine using sagittal and axial T1, T2
and STIR images
COMPARISON: Prior CT scan of the cervical spine dated ___.
FINDINGS:
There are fractures of the bilateral C6 lamina, the right superior facet of
C7, and the right inferior facet of C5 as was seen on recent prior CT scan.
There is increased fluid within the facet joints noted on the right at C6-C7
and C7-T1. There is an anterior wedge fracture of the T1 vertebral body with
hyperintensity seen in this region on IDEAL images consistent with a recent
fracture which, given the clinical history, is likely acute.
Mild anterior subluxation of C6 on C7 is again noted. There is also anterior
dislocation of the right superior facet of C7.
The craniovertebral junction is unremarkable. The cord is normal in signal
intensity and morphology.
There are small midline disc protrusions at C3-C4, C4-C5, and C5-C6 which are
narrowing the anterior CSF space without contacting the cord.
The visualized soft tissues of the neck are unremarkable.
IMPRESSION:
1. Anterior wedge fracture of the T1 vertebral body with associated
hyperintensity seen on ideal images. Given the clinical history, this likely
represents an acute fracture.
2. Fractures of the bilateral C6 lamina, right C7 superior facet, and right C5
inferior facet as seen on prior CT scan.
3. Small midline disc protrusions at C3-C4, C4-C5, and C5-C6 without cord
deformity or abnormal cord signal.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, ALTERED
Diagnosed with FX C6 VERTEBRA-CLOSED, UNSPECIFIED FALL, FX C7 VERTEBRA-CLOSED, OPEN WOUND OF SCALP
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | This patient is a ___ year old male smoker with a history of
metastatic throat cancer s/p laryngeal tracheal resection, s/p
removal of L lower jaw, who presented via EMS for evaluation of
AMS s/p fall with positive head strike on ___.
He was evaluated upon arrival. Imaging revealed T1 vertebral
body fracture, and C6 laminar fractures bilaterally for which
the patient was placed into a collar. He was also found to have
left medial rib fracture of ribs 1 and 2.
The patient was seen by ACS and orthopedics as well as physical
therapy. During his stay in the hospital the patient required 1L
FW restriction for low Na. His chem were monitored. He was also
placed on a CIWA scale and was administered a banana bag.
The patient did well throughout his stay in the hospital. Neuro:
The patient was alert and oriented throughout hospitalization;
pain was initially managed with IV pain medication and then
transitioned to oral pain medication once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient's diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient will be discharged with the c-collar in
place. The patient understands that the collar must stay on for
8 weeks. 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: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left buttock wound
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o appendectomy for perforated appendicitis
complicated by ARDS, ECMO, and subsequent renal failure and
right hip disarticulation who returns today for left buttock
wound. He has had a pressure sore there for some time and has
daily ___ care and was noted to have increasing redness and
warmth around the area. He denies any fevers, chills, or foul
odor drainage. He does report that he was putting extra pressure
on this area over the last few says while working out. He is now
home, off all dialysis, and otherwise feels well.
Past Medical History:
large B cell lymphoma- in remission
Allergic Rhinitis
Hx of Orchitis
ADD
Perforated appendicitis
Right hip disarticulation
Social History:
___
Family History:
No known family history of leukemia or lymphoma. Has a sister
with melanoma.
Physical Exam:
Discharge Physical Exam:
Vitals: T 98.8 HR 103 BP 96/52 RR 20 100RA
GEN: A&O, NAD
HEENT: normocephalic/atraumatic, EOMI, PERRLA, moist mucous
membranes
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Extremiteis: on left buttock small 2cm open decubitus ulcer on
left buttock with surrounding induration and erythema. It is
warm but nothing currently draining, it is not fluctuant or
boggy
Neuro: A&OX3, sensorimotor function intact
Pertinent Results:
Lab Results:
___ 07:30AM BLOOD WBC-12.8* RBC-3.94* Hgb-11.3* Hct-35.2*
MCV-89 MCH-28.7 MCHC-32.1 RDW-14.1 RDWSD-45.6 Plt ___
___ 06:20AM BLOOD WBC-10.4* RBC-3.91* Hgb-11.2* Hct-34.6*
MCV-89 MCH-28.6 MCHC-32.4 RDW-14.1 RDWSD-45.3 Plt ___
___ 11:21AM BLOOD WBC-9.7 RBC-3.83*# Hgb-10.8*# Hct-33.9*#
MCV-89 MCH-28.2 MCHC-31.9* RDW-14.2 RDWSD-45.2 Plt ___
___ 07:30AM BLOOD Glucose-85 UreaN-13 Creat-1.3* Na-138
K-4.6 Cl-99 HCO3-24 AnGap-20
___ 06:20AM BLOOD Glucose-96 UreaN-12 Creat-1.2 Na-138
K-4.4 Cl-101 HCO3-25 AnGap-16
___ 11:21AM BLOOD Glucose-92 UreaN-11 Creat-0.9# Na-138
K-4.9 Cl-100 HCO3-26 AnGap-17
Imaging Results:
US BUTTOCKS, SOFT TISSUE LEFT Study Date of ___ 1:43 ___
IMPRESSION:
No drainable fluid collection. Soft tissue heterogeneity may
reflect the
presence of edema versus phlegmon.
MRI MSK PELVIS W&W/O CONTRAST Study Date of ___ 11:32 AM
IMPRESSION:
Findings are compatible with a large area of phlegmon
interdigitating within
the left gluteal muscular fibers spanning an area of 9.1 x 3.3
cm. No
evidence of osteomyelitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO TID
2. Heparin 5000 UNIT SC BID
3. LORazepam 0.5 mg PO QID PRN anxiety
4. Milk of Magnesia 30 mL PO Q6H:PRN constipation
5. Omeprazole 20 mg PO DAILY
6. Senna 17.2 mg PO BID
7. Nephrocaps 1 CAP PO DAILY
8. Bisacodyl 10 mg PO DAILY:PRN constipation
9. Fexofenadine 180 mg PO DAILY:PRN allergies
10. Triple Antibiotic (neomycin-bacitracnZn-polymyxnB) 3.5mg-400
unit- 5,000 unit/gram topical TID
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
12. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth every 12 hours Disp #*20 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Fexofenadine 180 mg PO DAILY:PRN allergies
6. Gabapentin 100 mg PO TID
7. LORazepam 0.5 mg PO QID PRN anxiety
8. Omeprazole 20 mg PO DAILY
9. Senna 17.2 mg PO BID
10. Triple Antibiotic (neomycin-bacitracnZn-polymyxnB)
3.5mg-400 unit- 5,000 unit/gram topical TID
Discharge Disposition:
Home With Service
Facility:
___
___:
Left buttock phlegmon, possible myonecrosis, not a drainable
fluid collection
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: US BUTTOCKS, SOFT TISSUE LEFT
INDICATION: ___ year old man with left buttock sore and induration// fluid
collection?
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left gluteal area.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left gluteal area. A defect of the skin is seen representing the sore in this
area. There is subcutaneous edema and ill-defined heterogeneous, hypoechoic
area as in the subcutaneous tissue underlying this defect. No discrete fluid
collections are seen..
IMPRESSION:
No drainable fluid collection. Soft tissue heterogeneity may reflect the
presence of edema versus phlegmon.
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old man with left buttock wound and surrounding erythema
and induration// soft tissue infection? fluid collection?
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis
were acquired in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
COMPARISON: Ultrasound left buttock soft tissues ___
FINDINGS:
RECTUM AND INTRAPELVIC BOWEL: No bowel obstruction.
BLADDER AND DISTAL URETERS: Within normal limits
PROSTATE, SEMINAL VESICLES, AND SCROTUM: Within normal limits
LYMPH NODES: There are mildly enlarged pelvic and left inguinal lymph nodes
which are likely reactive.
VASCULATURE: Vasculature is patent.
OSSEOUS STRUCTURES AND SOFT TISSUES: There is extensive edema and inflammation
within the left gluteal musculature corresponding to the site of the patient's
cutaneous defect. Within this region, there is ill-defined fluid with
adjacent enhancement but no discrete defined enhancing rim measuring over an
area of approximately 9.1 x 3.3 cm compatible with phlegmon.
Patient is status post right BKA with resection of the right femoral head.
Again seen is ill-defined mild stranding and enhancement surrounding the right
hip joint. No evidence of osteomyelitis on today's study.
IMPRESSION:
Findings are compatible with a large area of phlegmon interdigitating within
the left gluteal muscular fibers spanning an area of 9.1 x 3.3 cm. No
evidence of osteomyelitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Buttock pain, Wound eval
Diagnosed with Cutaneous abscess of buttock
temperature: 98.2
heartrate: 113.0
resprate: 18.0
o2sat: 100.0
sbp: 117.0
dbp: 69.0
level of pain: 4
level of acuity: 3.0 | ___ with h/o appendectomy for perforated appendicitis
complicated by ARDS, ECMO, and subsequent renal failure and
right hip disarticulation who returns today with left buttock
wound. He has had a pressure sore there for some time and has
daily ___ care and was noted to have increasing redness and
warmth around the area. He denies any fevers, chills, or foul
odor drainage. Soft tissue U/S demonstrated soft tissue
heterogeneity reflective of edema versus phlegmon. MRI
demonstrated phlegmon interdigitating within the left gluteal
muscular fibers spanning an area of 9.1 x 3.3 cm. Interventional
Radiology was consulted and reported that there was no drainable
fluid collection. After discussion with the patient it was
determined that he would go home with PO augmentin x10 days and
close follow-up with Acute Care Surgery clinic this week to
re-evaluate the wound. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / lidocaine / mexiletine /
Gentamicin / Avelox / generic levothyroxine
Attending: ___
___ Complaint:
recurrent diverticulits
Major Surgical or Invasive Procedure:
___ Laparoscopic sigmoid resection.
___ Laparoscopic washout, placement of drain and
diverting ileostomy.
History of Present Illness:
Per Colorectal Surgery Consultation Note:
HPI:
___ w one prior episode of uncomplicated sigmoid diverticulitis
treated at an OSH approximately 2 months ago, who was admitted
to
medicine service on ___ w one day of severe lower abdominal
pain, found on CT scan to have uncomplicated sigmoid
diverticulitis. Patient was placed on IV Unasyn but kept on a
regular diet and continues to complain of severe lower abdominal
pain with little improvement. Given patient's recent history of
diverticulitis and lack of improvement on this hospitalization,
colorectal surgery is consulted for further recommendations on
management.
The patient had his first episode of diverticulitis
approximately
2 months ago when he presented to ___ with severe
RLQ abdominal pain and CT confirmed uncomplicated sigmoid
diverticulitis. He was given a 10 day course of PO cipro/flagyl
and discharged from the ED, but returned 6 days later with
worsening pain. At this point the CT was repeated and unchanged.
He was admitted and treated with IV Unasyn for 6 days, then
discharged home on a 2 week course of PO cipro and flagyl. He
reports being completely pain and symptom free for approximately
7 weeks. About one week ago, he began experiencing bloating
sensation and increased stool frequency, but no diarrhea. Of
note, the patient has a history of small intestinal bacterial
overgrowth which had been treated with rifaximin, and the
symptoms seemed consistent with his prior episodes. However, two
days prior to admission, the patient began experiencing severe
b/l lower abdominal pain, which prompting him to come to the ED
at ___. CT scan here again demonstrated sigmoid diverticulitis
without evidence of perforation, abscess, or fluid collection.
Patient reportedly had normal colonoscopy in ___ at ___, including no evidence of diverticulosis. He
denies fevers, chills, unintentional weight loss, BRBPR or
melena.
Past Medical History:
PMH:
- multiple cardiac arrests, s/p PCI in ___
- small intestinal bacterial overgrowth syndrome
- sinusitis
- hypothyroidism
- HTN
- HLD
- glaucoma
PSH:
sinus surgery, multiple PCI and cardiac stents, last in ___,
Laparoscopic washout, placement of drain and diverting ileostomy
Social History:
___
Family History:
Father and brother w hx of diverticulitis. No history of IBD or
GI malignancies
Physical Exam:
General at discharge: Pt doing well, tolerating regular diet,
pain improved
VSS
Neuro: A&OX3
Cardio/Pulm: no chest pain or shortness of breath
Abd: obese, soft, minimally tender, surgical sites intact,
ostomy intact, JP drain in place
Pertinent Results:
___ 04:32AM BLOOD WBC-8.8 RBC-3.38* Hgb-10.0* Hct-28.7*
MCV-85 MCH-29.5 MCHC-34.7 RDW-14.9 Plt ___
___ 05:46AM BLOOD WBC-11.8* RBC-4.10* Hgb-12.0* Hct-35.6*
MCV-87 MCH-29.2 MCHC-33.6 RDW-14.8 Plt ___
___ 06:38PM BLOOD WBC-11.9* RBC-3.98* Hgb-11.6* Hct-33.6*
MCV-85 MCH-29.1 MCHC-34.4 RDW-14.1 Plt ___
___ 05:40AM BLOOD WBC-11.3* RBC-4.04* Hgb-11.7* Hct-34.8*
MCV-86 MCH-28.9 MCHC-33.5 RDW-14.3 Plt ___
___ 05:20AM BLOOD WBC-8.6 RBC-3.72* Hgb-11.0* Hct-32.1*
MCV-86 MCH-29.7 MCHC-34.4 RDW-14.5 Plt ___
___ 12:45PM BLOOD WBC-9.7 RBC-3.83* Hgb-11.1* Hct-32.5*
MCV-85 MCH-29.1 MCHC-34.3 RDW-14.0 Plt ___
___ 07:20AM BLOOD WBC-9.5 RBC-3.72* Hgb-10.9* Hct-32.6*
MCV-88 MCH-29.3 MCHC-33.4 RDW-14.7 Plt ___
___ 07:20AM BLOOD WBC-9.5 RBC-3.70* Hgb-10.8* Hct-32.3*
MCV-87 MCH-29.3 MCHC-33.5 RDW-14.0 Plt ___
___ 05:00AM BLOOD WBC-11.6* RBC-3.74* Hgb-11.3* Hct-32.7*
MCV-88 MCH-30.2 MCHC-34.5 RDW-14.5 Plt ___
___ 06:40AM BLOOD WBC-12.6* RBC-3.86* Hgb-11.1* Hct-33.6*
MCV-87 MCH-28.9 MCHC-33.1 RDW-14.7 Plt ___
___ 10:50PM BLOOD WBC-14.4* RBC-4.13* Hgb-12.2* Hct-35.4*
MCV-86 MCH-29.4 MCHC-34.3 RDW-13.9 Plt ___
___ 06:50AM BLOOD WBC-14.4* RBC-4.19* Hgb-12.3* Hct-35.6*
MCV-85 MCH-29.2 MCHC-34.5 RDW-14.1 Plt ___
___ 05:49AM BLOOD WBC-11.4* RBC-4.18* Hgb-12.3* Hct-35.8*
MCV-86 MCH-29.3 MCHC-34.3 RDW-15.0 Plt ___
___ 04:32AM BLOOD Glucose-93 UreaN-21* Creat-2.6* Na-141
K-4.1 Cl-110* HCO3-21* AnGap-14
___ 03:59PM BLOOD Glucose-117* UreaN-23* Creat-3.0* Na-139
K-3.8 Cl-105 HCO3-21* AnGap-17
___ 05:46AM BLOOD Glucose-108* UreaN-21* Creat-3.1*# Na-139
K-4.0 Cl-104 HCO3-24 AnGap-15
___ 05:40AM BLOOD Glucose-100 UreaN-9 Creat-1.3* Na-139
K-3.9 Cl-104 HCO3-25 AnGap-14
___ 05:20AM BLOOD Glucose-109* UreaN-6 Creat-0.9 Na-141
K-3.7 Cl-106 HCO3-24 AnGap-15
___ 07:10AM BLOOD Glucose-110* UreaN-9 Creat-0.8 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
___ 12:45PM BLOOD Glucose-103* UreaN-12 Creat-0.7 Na-139
K-3.7 Cl-105 HCO3-22 AnGap-16
___ 07:20AM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-26 AnGap-14
___ 07:20AM BLOOD Glucose-85 UreaN-19 Creat-0.8 Na-144
K-3.8 Cl-108 HCO3-25 AnGap-15
___ 05:40PM BLOOD Glucose-92 UreaN-19 Creat-0.8 Na-142
K-3.8 Cl-107 HCO3-24 AnGap-15
___ 04:32AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.0
___ 03:59PM BLOOD Calcium-8.3* Phos-3.8 Mg-1.9
___ 05:46AM BLOOD Calcium-8.7 Phos-4.7* Mg-2.2
___ 05:40AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.2
___ 05:20AM BLOOD Albumin-2.9* Calcium-8.4 Phos-3.3 Mg-2.2
Iron-30*
___ 05:20AM BLOOD calTIBC-207* Ferritn-437* TRF-159*
___ 12:45PM BLOOD calTIBC-191* Ferritn-561* TRF-147*
___ 12:45PM BLOOD Triglyc-133 HDL-16 CHOL/HD-6.7 LDLcalc-64
___ 07:20AM BLOOD Triglyc-139 HDL-11 CHOL/HD-9.2 LDLcalc-62
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 6:30 ___
IMPRESSION:
Findings consistent with acute uncomplicated sigmoid
diverticulitis.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 10:54 AM
IMPRESSION:
1. Extravasation of rectal contrast at the anastomotic site
consistent with moderate- sized anastomotic leak that tracks
superior to the anastomosis.
Large amount of free air surrounding the anastomosis and within
the
peritoneum, retroperitoneum and tracking into the mediastinum.
2. Fluid collection in the anterior pelvis superior to the
anastomosis
measuring 6.1 x 3.4 cm.
CHEST PORT. LINE PLACEMENT Study Date of ___ 2:18 ___
IMPRESSION: Interval placement of right subclavian PICC line
which has its tip in the mid SVC. Cardiac and mediastinal
contours are stable. Residual but improved bibasilar streaky
opacities suggestive of atelectasis. No pulmonary edema or
pneumothorax.
RENAL U.S. Study Date of ___ 9:30 AM
IMPRESSION:
No evidence of hydronephrosis bilaterally..
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Fexofenadine 180 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Acebutolol 200 mg PO DAILY
6. ClonazePAM 0.5 mg PO BID
7. Omeprazole 40 mg PO DAILY
8. Pulmosal (sodium chloride) 7 % inhalation prn
9. Levothyroxine Sodium 200 mcg PO Q
___
10. Levothyroxine Sodium 300 mcg PO Q ___
11. Vitamin D 3000 UNIT PO DAILY
12. Cyanocobalamin Dose is Unknown PO DAILY
13. AndroGel (testosterone) 1.62 % (20.25 mg/1.25 gram)
transdermal daily
14. Travatan Z (travoprost) 1% ophthalmic ___
Discharge Medications:
1. Acebutolol 200 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. ClonazePAM 0.5 mg PO BID
4. Fexofenadine 180 mg PO DAILY
5. Levothyroxine Sodium 200 mcg PO Q
___
6. Levothyroxine Sodium 300 mcg PO Q ___
7. Omeprazole 40 mg PO DAILY
8. Vitamin D 3000 UNIT PO DAILY
9. Acetaminophen 1000 mg PO Q8H:PRN pain
do not take more than 3000mg in 24 hours or drink alcohol
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*50 Tablet Refills:*0
10. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*28 Tablet Refills:*0
11. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
do not drink alcohol while taking this medication
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*50 Tablet Refills:*0
12. LOPERamide 2 mg PO BID
please monitor your ileostomy output.
RX *loperamide [Anti-Diarrhea] 2 mg 1 tablet by mouth twice a
day Disp #*60 Tablet Refills:*1
13. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*42 Tablet Refills:*0
14. Psyllium Wafer 1 WAF PO BID
RX *psyllium [Metamucil] 1.7 g 1 wafer(s) by mouth twice a day
Disp #*60 Wafer Refills:*1
15. travoprost 0.004 % ___ continue home med
16. AndroGel (testosterone) 1.62 % (20.25 mg/1.25 gram)
transdermal daily
17. Aspirin 325 mg PO DAILY
18. Pulmosal (sodium chloride) 7 % inhalation prn
19. sodium chloride 0.9 % 20 ml into JP drain daily
Please flush JP drain with 20ml of sterile normal saline and
draw back as instructed
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % 20 ml JP
drain once a day Disp #*60 Syringe Refills:*1
20. Outpatient Lab Work
Please draw a creatinine on ___, at d/c creat is 2.6,
please call ___ if not returning to normal, it has
improved prior to discharge.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diverticulitis with anastomotic leak after sigmoid colectomy.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new R PICC // 47cm R basilic DL PICC -
___ ___ Contact name: ___: ___ R basilic DL PICC -
___ ___
COMPARISON: Comparison to prior study dated ___ at 12:33
FINDINGS:
Portable AP upright chest from ___ at 14:28 is submitted.
IMPRESSION:
Interval placement of right subclavian PICC line which has its tip in the mid
SVC. Cardiac and mediastinal contours are stable. Residual but improved
bibasilar streaky opacities suggestive of atelectasis. No pulmonary edema or
pneumothorax.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ with refractory diverticulitis worsening on IV abx now s/p
laparoscopic sigmoid colectomy s/p leak w diverting ileostomy and JP drain in
left lower quadrant with a rapidly rising creatinine to 3.1 // bilateral renal
ultrasound to rule out 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 12.8 cm. There is
a left renal lower pole cyst measuring 8.6 cm. There is no hydronephrosis,
stones, or masses bilaterally. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
The bladder is partially filled and otherwise normal.
IMPRESSION:
No evidence of hydronephrosis bilaterally..
Radiology Report
INDICATION: Left lower quadrant pain. History of diverticulitis.
COMPARISON: None.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
with intravenous contrast. Sagittal and coronal reformations were also
performed.
FINDINGS:
The visualized lung bases appear clear. There are no pleural effusions.
Coronary artery calcifications are noted.
The liver shows a few subcentimeter hypodense foci that are too small to
characterize, but doubtful in clinical significance. The gallbladder,
pancreas, adrenal glands, and spleen appear within normal limits. The kidneys
are also unremarkable aside from a moderately large but simple cyst arising
from the left lower pole, which measures up to 82 x 70 mm in the axial
___.
The stomach and small bowel appear within normal limits. Along the mid sigmoid
colon there is an area of focal fat stranding about diverticula in the mid
sigmoid with adjacent fascial thickening. Findings are most consistent with
sigmoid diverticulitis. There is no free air or fluid collection.
The distal ureters, bladder, prostate, and seminal vesicles are unremarkable.
Patchy vascular calcification is noted. The major mesenteric arteries and
veins appear patent. There is no lymphadenopathy or ascites.
There are no suspicious lytic or blastic bone lesions. The L5-S1 interspace
is mildly narrowed with a vacuum disc phenomenon. Lower thoracic interspaces
are also mildly narrowed.
IMPRESSION:
Findings consistent with acute uncomplicated sigmoid diverticulitis.
DOSE: 1057.1 mGy-cm.
Radiology Report
INDICATION: ___ year old man with dyspnea and low grade temp on POD3 //
evaluation of acute intrapulmonary process
FINDINGS:
Heart is upper limits of normal in size. Lungs are clear except for linear
bibasilar opacities suggestive of atelectasis.
COMPARISON:
None available.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ M POD4 lap sigmoid colectomy for refractory diverticulitis now
febrile 101 and increasing pain. Please give IV and Rectal contrast. //
Evaluation of acute intra-abdominal process, fluid collection and exam of
anastomosis.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.Oral
contrast was administered.
Subsequently the patient returned to the department and a non contrast CT
pelvis followed by a CT pelvis after the administration of rectal contrast was
obtained.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
DOSE: DLP: 1053.9 mGy-cm (abdomen and pelvis.
COMPARISON: The abdomen pelvis from ___
FINDINGS:
ABDOMEN: There is atelectasis at the lung bases. Pneumomediastinum is seen
tracking along the esophagus and in the anterior epicardial space. The liver
enhances homogenously without any focal lesions or intra or extrahepatic
biliary dilatation. The main portal vein is patent. The gallbladder is
distended but there is no evidence of wall thickening or pericholecystic
fluid. The pancreas, spleen and adrenal glands are unremarkable. The kidneys
enhance and excrete contrast symmetrically without any hydronephrosis. 8.1 x
7.0 cm cyst is noted arising from the lower pole of the left kidney. The
stomach and small bowel are unremarkable and nonobstructed. There is no free
fluid within the abdomen. There is a large amount of pneumoperitoneum tracking
in the anterior pararenal space, around the pancreas, extending into the
diaphragmatic hiatus and within the anterior abdomen. The aorta is of normal
caliber without evidence of aneurysm there is mild atherosclerotic disease.
PELVIS: Rectal contrast was administered. An anastomosis is identified at the
rectosigmoid junction (series 7:31). A large amount of extraluminal air is
present within the pelvis. Extraluminal rectal contrast is present tracking
just posterior to the anastomosis (07:28) and superior to the anastomotic site
(07:24). This collection of extraluminal contrast measures approximately 6.1
x 0.8 cm. Superior to this extraluminal contrast is a fluid collection in the
anterior pelvis measuring 6.1 x 3.4 cm. There is no peripheral enhancement and
no oral contrast in this region. The sigmoid colon is thickened likely due to
adjacent inflammation. A Foley catheter is present within the bladder which is
predominately collapsed.
BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Small foci
of air are noted in the midline and right lateral anterior abdominal wall.
IMPRESSION:
1. Extravasation of rectal contrast at the anastomotic site consistent with
moderate- sized anastomotic leak that tracks superior to the anastomosis.
Large amount of free air surrounding the anastomosis and within the
peritoneum, retroperitoneum and tracking into the mediastinum.
2. Fluid collection in the anterior pelvis superior to the anastomosis
measuring 6.1 x 3.4 cm.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___
___ telephone at 05:00 on ___ immediately after completion of the
exam appear
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with refractory diverticulitis now s/p
laparoscopic sigmoid colectomy w diverting ileostomy POD 5. Pt developing
persistent abdominal/L flank pain. Please give po IV contrast // Assess for
fluid collection
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: 941.3 mGy-cm (abdomen and pelvis.
COMPARISON: CT abdomen and pelvis from ___
FINDINGS:
ABDOMEN:
There is bibasilar atelectasis. The visualized heart and pericardium are
unremarkable.
Again seen is a large amount of pneumoperitoneum in the anterior abdomen,
surrounding the pancreas and within the left pericolic region. The liver
enhances homogenously without any focal lesions or intra or extrahepatic
biliary dilatation. The main portal vein is patent. The gallbladder, pancreas,
spleen and adrenal glands are unremarkable. The kidneys enhance and excrete
contrast symmetrically without any hydronephrosis. A cyst arising from the
lower pole of the left kidney measures 7.9 x 7.2 cm.
GI: Patient is status post sigmoidectomy with a diverting ileostomy for an
anastomotic leak. Oral contrast is seen within the stomach, small bowel and
parts of the colon. The diverting ileostomy is present in the right lower
quadrant without evidence of obstruction. An anastomosis is present at the
rectosigmoid junction. There is no definite evidence of extraluminal contrast
to suggest leak. There are multiple loops of dilated small bowel in the left
abdomen without a definite transition point, likely due to an ileus. There is
persistent fluid within the pelvis and free A drain is present within the
pelvis.
PELVIS:
The bladder has air within it. The rectum is unremarkable. Suture lines are
noted at the distal sigmoid colon. A drain is placed within the pelvis and
there is a small amount of fluid, mesenteric stranding and locules of air
likely from recent surgery.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. There is a 3.4 x 2.7 cm fluid
collection with air in the right anterior abdominal wall likely related to
recent surgery.
IMPRESSION:
1. Loops of dilated small bowel in the left abdomen without a definite
transition likely due to ileus. No evidence of obstruction.
2. Status post sigmoid resection with diverting loop ileostomy. No evidence
of leak of oral contrast. Large amount of intra and retroperitoneal free air
as seen previously.
3. Small fluid collection in the low right anterior abdominal wall likely due
to recent surgery.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with DIVERTICULITIS OF COLON
temperature: 98.0
heartrate: 64.0
resprate: 15.0
o2sat: 100.0
sbp: 153.0
dbp: 65.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ was admitted to the inpatient medicine service on
___ for treatment of acute Diverticulitis. Colorectal
surgery was consulted as he was given intravenous antibiotics
and continued to have pain. On ___ the patients abdomen
continued to be tender. On ___ the patient had not had
resolution of pain depsite 48 hours of intravenous antibiotics,
this included changing therapy, the patient was brought to the
OR with Dr. ___. On ___ a Laparoscopic sigmoid
resection was preformed. He did well post-operatively and
recovered in the PACU, he was then transferred to the inpatient
unit. On ___ he was doing well and his laboratory vaules
were stable. The foley catheter was removed. On ___ the
patient was noted to have a small amount of erythema around the
umbilical site.
On ___ the patient had a slightly temperature to 100.3 and
blood and urine cultures were sent which were negative. On
___ he continued to have a low grade temperature to 100.2
with some Dyspnea. A chest Xray was preformed which showed that
the lungs were clear except for some atelectasis. The patient
had multiple small bowel movements. On ___ the patient's
temperature reached ___ F with abdominal tenderness with a white
blood cell count to 14.4. A CT with rectal contrast showed
anastomotic leak and the patient was taken to the operating room
for Laparoscopic washout, placement of drain and diverting
ileostomy. On ___ the patient complained of nausea and
heartburn. EKG and troponins were done given the patients
cardiac history however, were negative. An NGT was placed with
900cc out. On ___ the ngt continued to put out a liter of
outpur. The patient complained on incresed left flank pain
however his cital signes were stable. A urinealysis was again
sent which was negative. The drain was left in place, it was
drainiange brown liquid to serosang. This was likely related to
the previous leak. On ___ the foley catheter wsa removed
and the patient voided without issue. The ileostomy was putting
out liquid stool therefore the nasogastric tube was clamped. On
___ the patient tolerated clear liquids and the intravenous
fluids were dicontinued. He was transiitoned to home medications
and medications by mouth. On ___ the patient complained of
worsened abdominal pain. A CT scan was obtained which showed
Small fluid collection, likely ileus, but no obstruction. On
___ he continued clear liquids. He had elevated ileostomy
output and this was repleted with intravenous fluid boluses. A
PICC line was placed without issue. The ileostomy continued to
have increased output. He was given psyllium and loperamide. On
___ the patient's diet was advanced to regular which was
tolerated well. The patient's pain was stable. On ___ a
vancomycin trough was therapeutic. On ___ Creatinine was
noted to be 3.1, a FeNa was 0.3%, UA: 14WBC, neg Eos. Sediment
pnd. A Renal US was obtained and normal. He was given
intravenous fluids as it was decided he was likely dehydrated
and contrast dye. On ___ intravenous antibiotics were
transitioned to cipro/flagyl by mouth. On ___ the patient's
creatinine was improved to 2.6 and he was discharged home with
the drain in place and this was to stay in place until at least
his follow-up appointment. THe patient was supported by the
nursing staff and seen by social work and the wound ostomy
nursing team while in house. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdomnal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
EGD - ___
EUS - ___
History of Present Illness:
___ y/o F PMH of ___'s thyroiditis, past abdominal
surgeries (hysterectomy/cholecystectomy) and anxiety who
presents for worsening of her chronic abdominal pain that she
has had since ___ after a bout of C.diff at ___
___ to abx treatment she received while being treated for
pyelonephritis. The C.diff resolved but states that she has had
residual abdominal pain described most mid-epigastric, extending
around her R side to her back, presently a ___ with
improvement of ___. Nothing particularly makes it better
besides not eating and pain is worse with eating. Denies any
fevers or chills, GERD-like symptoms, CP or SOB. No sick
contacts or change in diet/meds, just a remote history of travel
in ___ in ___.
She had diarrhea for a few months but states that now the stool
is just soft, consistency of pudding, but no blood/greenish
stools. She states she has had nausea and nonbilious/nonbloody
vomiting over the same period of time only with eating/drinking
and has only been able to drink occasional Naked juice shakes.
She still has an appetite but reports having a recent weight
loss 10 lbs the past month with a 20 pound loss since ___.
Endorses night sweats. Cancer screening up to date with last
colonoscopy at 50 that was unremarkable and normal mammogram.
All pap smears have been normal.
Of note, she recently had a EGD at ___ with
evidence of gastritis. A biopsy was performed but unknown
results. At the time recommended to use Ranitidine for 3 months
treatment. Had a MRCP at some point but no gallstones noted.
Past Medical History:
Past Medical History:
Congenital L Renal Agenesis
___'s Thyroid - thyroidism
Anxiety
Subdural aneurysm in sinus cavity
h/o acute pancreatitis in ___
Multiple UTI's and C.diff in ___
Past Surgical History:
L5-S5 Fusion for verterbral collapse in ___
Hysterectomy ___
Cholecystectomy ___
Social History:
___
Family History:
Family History:
Father died of colon cancer at ___
Paternal GF, nephew and sister with UC
Brother with diverticulosis
Mother died of emphysema, had diverticulitis
Physical Exam:
ADMISSION EXAM:
Physical Exam:
Vitals - 97.6 120/83 68 18 100/RA.
General - Alert&orientedx3 in no acute distress
HEENT - Sclera anicteric, MMM mildly tachy, 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-distended, hyperactive bowel sounds present
but no high pitched sounds, no rebound tenderness or guarding,
no organomegaly, from mid to deep palpation there was tenderness
along the mid-epigastric region across to the R flank along the
rib cage and to the back. Mild tenderness on deep palpation of
the lower abdominal quadrants but not focal to any specific area
like McBurney's point. Negative Rovsing's sign.
GU - no foley
Ext - warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro - CNs2-12 intact, motor function grossly normal
Skin - no rashes or lesions, olive colored skin but no jaundice
and does not appear bronze particularly in non-sun exposed areas
DISCHARGE EXAM:
Pertinent Results:
___ 06:30AM BLOOD WBC-4.2 RBC-4.01* Hgb-11.7* Hct-33.7*
MCV-84 MCH-29.2 MCHC-34.7 RDW-13.0 Plt ___
___ 06:30AM BLOOD Glucose-76 UreaN-7 Creat-0.6 Na-144 K-3.8
Cl-108 HCO3-27 AnGap-13
___ 06:00AM BLOOD ALT-55* AST-35 LD(LDH)-150
___ 12:55PM BLOOD ALT-55* AST-22 AlkPhos-87 TotBili-0.3
___ 12:55PM BLOOD Lipase-30
___ 06:00AM BLOOD calTIBC-259* VitB12-417 Folate-11.3
Ferritn-83 TRF-199*
___ 06:00AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9 Iron-115
___ 06:00AM BLOOD TSH-10*
___ 01:10PM BLOOD IgA-140
___ 01:10PM BLOOD tTG-IgA-4
EUS (___):
Impression: Common Bile Duct: The bile duct was dilated to 8 mm
but was otherwise normal without any intrinsic stones or sludge.
Pancreas: The pancreas parenchyma, pancreas duct, and
___ vasculature were normal.
Ampulla: Normal ampulla.
Otherwise normal upper EUS to second part of the duodenum.
Recommendations: The findings do not account for the symptoms.
Return to hospital floor.
___ with Dr. ___
___ (___):
Impression: Normal EGD to third part of the duodenum with
biopsies (biopsy, biopsy)
Recommendations: Will follow up biopsy report and inform
patient.
Proceed with EUS today.
Return to hospital floor.
___ with Dr. ___.
CT Scan (___):
IMPRESSION:
1. No acute intra-abdominal process to explain the patient's
symptoms.
Appendix not definitely seen without inflammatory changes in the
right lower quadrant to suggest appendicitis. Moderate fecal
load.
2. Mild intrahepatic biliary prominence may be normal in the
setting of
cholecystectomy. Correlate with labs to determine the role of
MRCP.
3. Absent left kidney.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Diazepam 5 mg PO QHS Anxiety
3. Ranitidine 300 mg PO DAILY
4. Ondansetron 4 mg PO Q 8H
5. Gabapentin 600 mg PO BID
Discharge Medications:
1. Diazepam 5 mg PO QHS Anxiety
2. Gabapentin 600 mg PO BID
3. Ranitidine 300 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day
Disp #*30 Capsule Refills:*3
5. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth QIDACHS Disp #*60
Tablet Refills:*1
6. Senna 1 TAB PO BID Constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice a day Disp
#*30 Tablet Refills:*1
7. Levothyroxine Sodium 75 mcg PO DAILY
RX *levothyroxine 75 mcg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
8. Ondansetron 4 mg PO Q 8H
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 8
hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Weight loss and pain. Assess for pancreatitis, appendicitis or
mass.
TECHNIQUE: CT images were obtained from the lung bases to the pubic symphysis
following the uneventful intravenous administration of Omnipaque contrast
medium. Multiplanar reformations were prepared.
COMPARISON: None.
FINDINGS:
CT ABDOMEN WITH CONTRAST: The imaged lung bases are clear without pleural or
pericardial effusion. The liver is normal attenuation. Mild intrahepatic
biliary ductal dilatation could be normal in a post cholecystectomy state.
The portal and hepatic veins appear patent. A tiny hepatic hypodensity (2:19)
is too small to be accurately characterize by CT. The pancreas, spleen and
right adrenal gland are unremarkable. The left adrenal gland has a pancake
morphology in the setting of an absent left kidney. The right kidney enhances
and excretes contrast appropriately without hydronephrosis. The stomach and
small bowel are largely unremarkable. The appendix is not definitively
identified though there is no right lower quadrant stranding to suggest
appendicitis. A moderate fecal load is seen in the colon. There is no
mesenteric or retroperitoneal adenopathy. No free air or free fluid is seen
in the abdomen. The aorta and major branches are patent and normal in caliber
without significant atherosclerotic calcification.
CT PELVIS WITH CONTRAST: The bladder and rectum are unremarkable. The uterus
is either surgically absent or atrophic. Surgical clips are seen in the left
adnexa. There is no pelvic or inguinal adenopathy. No pelvic free fluid is
seen.
OSSEOUS STRUCTURES: No suspicious lytic or blastic bony lesion is seen to
suggest osseous malignancy. Posterior rod and screw fusion at L5-S1 is noted
without hardware related complications.
IMPRESSION:
1. No acute intra-abdominal process to explain the patient's symptoms.
Appendix not definitely seen without inflammatory changes in the right lower
quadrant to suggest appendicitis. Moderate fecal load.
2. Mild intrahepatic biliary prominence may be normal in the setting of
cholecystectomy. Correlate with labs to determine the role of MRCP.
3. Absent left kidney.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN EPIGASTRIC
temperature: 98.6
heartrate: 80.0
resprate: 16.0
o2sat: 96.0
sbp: 164.0
dbp: 87.0
level of pain: 10
level of acuity: 3.0 | ___ y/o F PMH of ___'s thyroiditis, anxiety, recent
recurrent UTI and Cdiff who presented to the ED with several
months of abdominal pain, nausea and vomiting likely ___
gastroparesis.
.
*** Active Diagnoses ***
.
# Nausea / Vomiting / Abdominal Pain: Likely Gastroparesis:
Likely diagnosis for her abdominal pain given feelings of n/v
almost immediately after eating with significant improvement on
reglan such that pt could tolerate regular PO intake. Could be
due to her bout of C. diff that led to gut distention and
gastroparesis. Additionally, lab evaluation with Celiac panel,
LFTs, CRP, stool studies, H pylori , and lipase were all
unremarkable. CT abd/pelvis also unremarkable. Seen by GI who
performed EGD and EUS that were unremarkable with no further
evidence of gastritis. F/u arranged with GI on outpt basis and
continue Reglan until that time. EKG was performed for baseline
QTc of 440.
.
# Weight loss
Appears most likely from lack of eating from above reason. Per
charts only lost 9 lbs over 6 month period vs pt initial report
of 20+. Will likely improve now that is tolerating regular PO
intake.
.
# Anemia:
Believed to dilutional after given 3L of IVF, stable while here
with iron studies/vitb12/folate all normal. Hct at discharge
35.3.
.
#Hypothyroidism:
TSH found to be elevated at 10 so dosage increased from her
50mcg to 75mcg. Pt setup and instructed to ___ with PCP
for further dose adjustment and re-check of her TSH in ___
weeks.
.
*** Chronic Issues ***
.
# Anxiety:
Stable, on fluoxetine. Pt directed to consider talking with
therapists since the loss of her mother.
.
*** Transitional Issues ***
.
- ___ with GI to evaluate whether further evaluation
needed on outpt basis such as gastric emptying study
.
- Touch base with PCP regarding repeat TSH check given
adjustment of her levothyroxine from 50mcg to 75mcg
.
- Given pt on reglan, consider repeat EKG to evaluate for
prolongation of QTc interval. Normal while checked here.
.
- Discussed pt seeing psych or therapist given difficulties
coping after loss of her mother this past year. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Codeine / Percocet / Bactrim DS / vancomycin
Attending: ___
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old male who presents with weakness
since waking up yesterday morning. He has a history of
hypereosinophilia (HES) which he states causes him vague diffuse
body pains and weakness (despite now normal eosinophil count),
and he has been in rehab since discharge from this hospital on
___. He was initially admitted at this last
hospitalization
for joint pains and worsening lower extremity ulcers. At that
time he was also found to have a DVT and was placed on coumadin
after heparin bridge. Pt states that he woke up 1 day PTA and
noticed he had wet the bed. He then tried to get up but felt
too
weak to stand. He required help getting to the commode and was
unable to maintain standing posture for more than a few seconds.
He says he was weak before but this is a new feeling. He feels
weak all over but left is weaker than right side, and this is
new. Denies headache, numbness, tingling, parasthesias, or
worsening joint pain.
Neuro ROS: Positive for wakness. Negative for headache, loss of
vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies
numbness,
parasthesiae. No bowel incontinence.
General ROS: no 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 habits. No dysuria. Endorses chronic diffuse arthralgias
or myalgias. Denies rash.
Past Medical History:
--Hypereosinophilic Syndrome (see OMR for full details)
--Lower Extremity Cellulitis
--Venous stasis ulcers -- RLE non-healing chronic venous stasis
ulcers w/ recurrent infections (cultures in the past have grown
CoNS, MSSA, pseduomonas, GBS, E. coil, enterobacter, VRE and
bacteroides), ulcer debridement w/ skin graft/wound vac ___, debridement ___, STSG ___.
--Right thigh DVT ___ which was thought to be ___ HES
--Sciatica
--Hypertension
--Bilateral knee osteoarthritis
--GERD
--OSA on CPAP
--Remote hx of eczema
--Hx of C5-C6 fracture in ___
--Bilateral inguinal hernia repair at age ___ or ___
--Blood clot removed from anterior shin on right leg, s/p trauma
--Bilateral ear implants to correct cartilage defect in pinna
--Lymph node biopsy ___ (cat scratch fever)
--Rotator cuff repair ___
--Lap band bariatric surgery ___
Social History:
___
Family History:
No early deaths. Father died at ___ of MI. Mother died at ___ of
CHF. No family history of hematological disease or heme
malignancies, mother with rheumatological disease.
Physical Exam:
Physical Exam:
Vitals: T: 97.9, P: 80, R:16 BP: 113/62 SaO2: 95% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no LAD. No nuchal rigidity
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS, obese
Extremities: warm, edematous, chronic venous stasis changes
bilat ___
___: no rashes or lesions noted, ecchymoses from heparin on
arms.
Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Able to follow both
midline
and appendicular commands. No right-left confusion. Able to
register 3 objects and recall ___ at 5 minutes. No evidence of
apraxia or neglect
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension. Normal prosody. There were
no paraphasic errors. Able to read without difficulty.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor: Normal bulk, tone throughout. Exam severely limited by
shoulder and knee pain bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 3 ___ ___ 3 4 4 4 4 5 5
R 4 ___ ___ 3 4 4 4 4 5 5
Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 2 1
R 3 2 3 2 1
Plantar response was flexor bilaterally. No cross adductors or
clonus.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF and RAM on right, but refuses to do left arm due to pain.
Cannot lift either leg high enough to do HKS.
Gait: deferred
Discharge exam:
Afebrile, VSS.
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no LAD. No nuchal rigidity
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, obese
Extremities: warm, edematous, chronic venous stasis changes
bilat ___
___: no rashes or lesions noted, ecchymoses from heparin on
arms.
Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension. Normal prosody.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without 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: Normal bulk, tone throughout. Exam severely limited by
shoulder and knee pain bilaterally..
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ ___ 3 4 4 4 4 5 5
R 4 ___ ___ 3 4 4 4 4 5 5
Sensory: No focal deficits.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF and RAM on right, but much slower with left arm due to pain.
Cannot lift either leg high enough to do HKS.
Pertinent Results:
___ 09:45AM CHOLEST-124
___ 09:45AM %HbA1c-5.2 eAG-103
___ 09:45AM TRIGLYCER-74 HDL CHOL-43 CHOL/HDL-2.9
LDL(CALC)-66
___ 09:45AM TSH-1.6
___ 01:12AM LACTATE-1.4
___ 12:30AM GLUCOSE-107* UREA N-28* CREAT-0.8 SODIUM-131*
POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-26 ANION GAP-15
___ 12:30AM ALT(SGPT)-12 AST(SGOT)-12 ALK PHOS-71 TOT
BILI-0.5
___ 12:30AM LIPASE-58
___ 12:30AM ALBUMIN-3.4* CALCIUM-8.8 PHOSPHATE-3.6
MAGNESIUM-2.0
___ 12:30AM WBC-3.3* RBC-3.70* HGB-10.2* HCT-32.2* MCV-87
MCH-27.6 MCHC-31.7 RDW-17.1*
___ 12:30AM NEUTS-93.5* LYMPHS-2.6* MONOS-3.3 EOS-0.2
BASOS-0.2
___ 12:30AM PLT COUNT-433
___ 12:30AM ___ PTT-36.1 ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atovaquone Suspension 1500 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID
4. Citalopram 20 mg PO DAILY
5. Furosemide 20 mg PO DAILY
Please hold for SBP <100.
6. Gabapentin 600 mg PO TID
7. Levofloxacin 500 mg PO Q24H
8. Lisinopril 40 mg PO DAILY
Please hold for SBP <100.
9. Lorazepam 1 mg PO HS:PRN Insomnia
Please hold for oversedation or RR <10.
10. Nystatin Oral Suspension 5 mL PO QID Mouth pain
11. OLANZapine 5 mg PO HS
12. Omeprazole 40 mg PO DAILY
13. PredniSONE 5 mg PO DAILY
14. ValGANCIclovir 900 mg PO Q24H
15. Vitamin D 800 UNIT PO DAILY
16. HYDROmorphone (Dilaudid) ___ mg IV Q6H:PRN Pain/premedicate
before dressing changes
17. Acetaminophen 650 mg PO Q6H
18. Docusate Sodium 100 mg PO BID
19. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain
20. Miconazole Powder 2% 1 Appl TP BID:PRN fungal rash
21. Morphine SR (MS ___ 30 mg PO Q12H
22. Polyethylene Glycol 17 g PO DAILY:PRN constipation
23. Senna 1 TAB PO BID:PRN Constipation
24. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
25. Warfarin 2.5 mg PO DAILY16
please titrate dose for INR goal ___, since INR 2.8 and rising,
dose is reduced to 2.5mg for ___ and ___ and can resume
___ if he is in steady range
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Atovaquone Suspension 1500 mg PO DAILY
4. Calcium Carbonate 500 mg PO QID
5. Citalopram 20 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Furosemide 20 mg PO DAILY
Please hold for SBP <100.
8. Gabapentin 600 mg PO TID
9. HYDROmorphone (Dilaudid) ___ mg IV Q6H:PRN Pain/premedicate
before dressing changes
10. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain
11. Levofloxacin 500 mg PO Q24H
12. Lisinopril 40 mg PO DAILY
Please hold for SBP <100.
13. Lorazepam 1 mg PO HS:PRN Insomnia
Please hold for oversedation or RR <10.
14. Miconazole Powder 2% 1 Appl TP BID:PRN fungal rash
15. Morphine SR (MS ___ 30 mg PO Q12H
16. Nystatin Oral Suspension 5 mL PO QID Mouth pain
17. OLANZapine 5 mg PO HS
18. Omeprazole 40 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. PredniSONE 5 mg PO DAILY
21. Senna 1 TAB PO BID:PRN Constipation
22. ValGANCIclovir 900 mg PO Q24H
23. Vitamin D 800 UNIT PO DAILY
24. Warfarin 3 mg PO DAILY16
please titrate dose for INR goal ___, since INR 2.6 on
admission, we kept his dose at 3mg daily during this admission
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Weakness - generalized
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: New left-sided weakness.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal, thin-section bone reconstruction algorithm
images were acquired.
COMPARISON: NECT of the head ___.
FINDINGS: There is no hemorrhage, edema, mass effect, or evidence of
infarction. Subtle hypodensity in the posterior limb of the right internal
capsule may be due to artifact and is not appreciated on NECT of the head of
___. The ventricles and sulci are normal in size and configuration.
The basal cisterns are patent. Gray-white matter differentiation is
preserved. The calvaria are unremarkable. The visualized paranasal sinuses,
mastoid air cells and middle ear cavities are clear. Previously noted
polypoidal lesion in nasopharynx is again noted.
IMPRESSION:
1. No acute intracranial abnormality.
2. Subtle hypodensity in the posterior limb of the right internal capsule may
be due to artifact. Recommend correlating this with neurologic deficits.
Radiology Report
INDICATION: Weakness. Evaluation for pneumonia.
___.
FINDINGS: Portable AP radiograph demonstrates no focal consolidation, pleural
effusion, or pneumothorax. Lung volumes are low with mild elevation of the
left hemidiaphragm. The cardiomediastinal silhouette is normal. There is no
pleural effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Question stroke.
COMPARISON: CT from ___ and ___.
TECHNIQUE: Axial CT images were acquired through the head without intravenous
contrast. Thereafter, images were acquired through the head and neck
following the uneventful intravenous administration of iodine-based contrast.
From these latter images, multiplanar maximum intensity projection reformats,
as well as three-dimensional vascular reconstructions, volume-rendered images
and curved reformatted images were created.
FINDINGS:
CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage, edema, mass
effect or vascular territorial infarction. Ventricles and sulci are normal in
size and in configuration. A polypoid lesion sitting within the nasopharynx
described on previous CT examinations is redemonstrated (series 2, image 1).
There is mild mucosal thickening in the superior aspect of the frontal sinus,
as well as posteriorly in the left aspect of the sphenoid sinus. Mastoid air
cells are clear.
CT ANGIOGRAM OF THE HEAD AND NECK: Images at the upper thorax up to the
thoracic inlet are limited to streak artifact, likely secondary to patient
habitus. That being said, there is a normal three-vessel branching pattern to
the aortic arch. The origin of both common carotids is normal, as is that of
the left vertebral artery, though this latter is difficult to evaluate
secondary to the technical matters discussed above. In addition, note is made
of a markedly diminutive right vertebral artery, the origin of which is not
clearly visualized. The aortic bifurcations are clear bilaterally and there
is no hemodynamically significant stenosis. The minimum diameter of the right
internal carotid artery proximally is 8.8 mm, in comparison to the diameter of
4.1 mm distally. Similar measurements on the left are 9.6 mm proximally and
4.5 mm distally.
Intracranial circulation reveals a moderate amount of atherosclerotic
calcification along the cavernous portions of the internal carotid arteries
bilaterally. Anatomy is conventional in orientation. There are no luminal
caliber irregularities to suggest thromboembolic filling defect, dissection or
aneurysm.
Soft tissue structures of the neck reveal bilateral palatine tonsilliths.
There is no space-occupying mass in the neck or lymphadenopathy by size
criteria. The thyroid is notable for a posterior nodule extending from the
right lobe, the precise margins of which are difficult to measure given the
artifact at this level. Imaged portions of the lung apices are clear as are
imaged portions of the mediastinum. Degenerative changes are present in the
spine, though there is no suspicious sclerotic or lytic lesion.
IMPRESSION:
1. No acute intracranial hemorrhage or evidence of vascular territorial
infarction. If concern persists, and the patient is able, would consider MRI
for further evaluation.
2. No evidence of aneurysm, pseudoaneurysm, dissection or thromboembolic
filling defect. Notably, the level of the thoracic inlet is limited due to
streak artifact and thus the origin of the diminutive right vertebral artery
and normal caliber left vertebral artery is not well evaluated.
3. Right posterior thyroid nodule. Precise margination is difficult given
the streak artifact. If not already performed, would recommend comparison to
thyroid function tests and thyroid sonography on a non-urgent basis.
4. Soft tissue in the nasopharynx, likely a polyp. If relevant clinically,
this could be correlated to direct examination.
Radiology Report
HISTORY: ___ male with recent possible right-sided stroke, now with
new changes in mental status. Assess for hemorrhage given anticoagulation.
COMPARISON: Non-contrast head CT from ___.
TECHNIQUE: MDCT axial images of the brain were obtained without intravenous
contrast. Coronal and sagittal reformations were prepared.
NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, mass, mass effect,
or infarction. Previously described subtle hypodensity in the posterior limb
of the right internal capsule is not evident on the current study and likely
reflected artifact previously. Gray-white matter differentiation is
preserved. Ventricles and sulci are normal in size and configuration. There
is no shift of the usually midline structures. Suprasellar and basilar
cisterns are widely patent. There is no scalp hematoma or acute skull
fracture. A polypoid lesion within the nasopharynx is unchanged from prior
examination (2:1). The visualized paranasal sinuses and mastoid air cells are
well aerated.
IMPRESSION: No evidence of hemorrhage or infarction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: WEAKNESS
Diagnosed with OTHER MALAISE AND FATIGUE
temperature: 96.3
heartrate: 98.0
resprate: 16.0
o2sat: 95.0
sbp: 124.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to ___ for concern for evolving
stroke on wet read of CT head obtained in ED. The final read of
this CT was normal. He could not tolerate an MRI/MRA, so CTA
was obtained and was also WNL on wet read. (Final read pending).
Just before midnight on ___ he had an episode of mental
status change when he was woken up for neuro check which
resolved in a few minutes after being awake. Because of this,
there was concern for an evolving intracranial process, and a
___ CT scan was performed. The CT scan was negative for any
acute intracranial process. In addition, Mr. ___ had a few
desaturations overnight - he requires CPAP but refused a face
mask. He was given nasal prongs which were thought to be not
helpful as he is a mouth breather while sleeping. It is felt
that this mental status change could be secondary to CO2
retention while sleeping as this resolved within 5 minutes of
awaking.
Mr. ___ continued to have upper extremity weakness and
pain, L>R, throughout his admission. His L lower extremity
weakness improved. His INR was therapeutic at 2.9, so we did not
adjust his coumadin dose.
We also contacted his Heme/Onc team for recommendations about
his pain control medications given his increase in upper
extremity pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Ultram
Attending: ___.
Chief Complaint:
low back and left thigh pain
Major Surgical or Invasive Procedure:
drainage of superficial seroma
History of Present Illness:
___ F recently discharged 8 days ago s/p two-staged anterior and
posterior L4-S1 fusion by Dr. ___ had been recovering
well for the first week after surgery but reports worsening pain
over the last week. The pain is particularly in her left thigh.
She came into the ED for further evaluation. She has full
strength and intact sensation throughout. No bowel or bladder
changes. The pain feels similar to when she previously
expereinced a PE. Given her recent surgery, ortho spine was
consulted.
Past Medical History:
HTN
HLD
hypothyroidism
anxiety
Social History:
___
Family History:
noncontributory
Physical Exam:
On examination the patient is well developed, well nourished,
A&O x3 in NAD. AVSS.
Range of motion of the lumbar spine is somewhat limited on
flexion, extension and lateral bending due to pain.
Ambulating well with the assistance of a walker and ___, with
lumbar corset brace for support.
Gross motor examination reveals good strength throughout the
bilateral lower extremities.
There is no clonus present.
Sensation is intact throughout all affected dermatomes.
The anterior and posterior lumbar incisions are clean, dry and
intact without erythema, edema or drainage.
The patient is voiding well without a foley catheter.
Pertinent Results:
___ 03:55AM BLOOD WBC-9.8 RBC-3.51* Hgb-11.0* Hct-33.6*
MCV-96 MCH-31.5 MCHC-32.8 RDW-13.9 Plt ___
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST
INDICATION: ___ year old woman with back pain/seroma/s/p lumbar fusion //
hematoma vs. infection hematoma vs. infection
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging wasperformed. Post-contrast images were obtained.
COMPARISON: No prior MRI. Prior x-ray dated ___.
FINDINGS:
Patient is status post L4-S1 posterior spinal fusion with interbody spacers.
Alignment is maintained. There is abnormal T2/STIR signal in the L1 and L2
vertebral bodies with post-contrast enhancement within these vertebral bodies
as well as within the intervertebral disc space. There is signal abnormality
noted in the L4 through S1 vertebral bodies which is likely postoperative all
the infection cannot be entirely excluded. There is a central/left paracentral
disc protrusion at L1-L2 without significant spinal canal stenosis. There is
disc bulge at L2-L3 without significant spinal canal stenosis. There is no
canal compromise in the region of surgery. There is clumping of the nerve
roots noted beginning at L4 and extending through to the level of S1
suspicious for arachnoiditis.
Postoperative images reveal enhancing tissue in the operative bed and epidural
space which is most likely postoperative granulation tissue.
There is a superficial collection in the posterior subcutaneous tissues which
measures 12.0 cm SI by 5.7 cm TV and is likely postoperative.
A right-sided extra renal pelvis is incidentally noted.
IMPRESSION:
1. Abnormal T2 signal and enhancement within the L1 and L2 vertebral bodies
with post-contrast enhancement also noted within the L1-L2 intervertebral disc
space. While these findings could be seen in degenerative disease, infection
cannot be excluded. Comparison to prior studies would be useful.
2. Patient is status post L4-S1 posterior spinal fusion. There is no canal
compromise in the region of surgery There is mild clumping of the nerve roots
in this region suggesting a arachnoiditis.
3. 12.0 cm SI x 5.7 cm TV fluid collection in the posterior subcutaneous
tissues likely postoperative
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with left leg pain. Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, superficial femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
The right common femoral vein was not able to be imaged secondary to patient
discomfort.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: History: ___ with lower back pain 2 weeks post op from L4-S1
fusion.
TECHNIQUE: AP and lateral radiographs of the lumbar spine.
COMPARISON: Intraoperative radiograph ___
FINDINGS:
5 non-rib-bearing lumbar vertebral bodies are present. There has been L4-S1
posterior spinal fusion with interbody spacers. Hardware appears satisfactory
in alignment with no perihardware lucency. Morcellized bone graft is noted
lateral to the fusion hardware. Loss of disc height at L1-2 with endplate
sclerosis is unchanged from ___.
No evidence of fracture.
Vascular calcifications of the abdominal aorta noted. No significant
sacroiliac joint sclerosis. Radiopaque density to the left of the L2-3
interspace may represent an ingested pill.
IMPRESSION:
Status post L4-S1 posterior spinal fusion with no evidence of hardware
complication or acute traumatic injury.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Leg numbness, L Leg pain
Diagnosed with LUMBAGO, ARTHRODESIS STATUS
temperature: 99.0
heartrate: 92.0
resprate: 18.0
o2sat: 99.0
sbp: 146.0
dbp: 86.0
level of pain: 10
level of acuity: 2.0 | ___ presented to the ___ emergency department on
___ with worsening back and left leg pain. She has recently
undergone an anterior and posterior L4-S1 fusion about 10 days
ago. Lumbar radiographs were reviewed which showed appropriate
alignment of the lumbar spine in both coronal and sagittal
planes. The hardware is in place anteriorly and posteriorly
without evidence of loss of fixation or complication. Venous US
of the left lower extremity was negative for deep venous
thrombosis. Mrs. ___ was admitted to the Ortho Spine service
for pain control and physical therapy evaluation. IV steroids
were continued for 24 hours during the hospital stay. Acute pain
service was consulted and changes were made to patients
medications. An MRI of lumbar spine which revealed a
post-operative seroma without any central canal compromise. ___
was consulted for ambulation and recommended that Mrs. ___
would benefit from an acute rehabilitation facility. Hospital
course was otherwise unremarkable. On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalexin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ TAVR
___ Tunneled HD line
History of Present Illness:
Mr. ___ is a ___ year-old ___ speaking male with PMH
notable for triple-vessel CAD s/p DES to OM2 on ___, severe
AS, Stage V CKD (not yet on HD), T2DM, EtOH cirrhosis, and L ACA
CVA (___) who initially presented to the ED with chest pain.
He reports substernal chest pain that began this afternoon while
at rest. It is unclear whether he took nitroglycerin at home. He
reports compliance with his home aspirin/Plavix. His wife called
EMS and he was taken to the ___ ED. While in route, patient
received nitroglycerin gtt, which was stopped on arrival to the
___ ED.
Notably, he was recently admitted to ___ from ___
for chest pain c/w unstable angina. After discussion with his
outpatient nephrologist, he underwent coronary angiography and
was found to have 3VD, s/p DES to OM. He was started on
aspirin/Plavix at this time and continued on his home metoprolol
and statin. Regarding his severe AS, plan was for outpatient
follow-up for consideration of TAVR vs. SAVR.
On arrival to the ED, initial vitals BP 107/53 HR 87 RR 22 O2
98% RA.
Initial labs notable for:
- WBC 8/.7, Hgb 8.7, INR 1.1
- pro-BNP 9850
- ALT 55, AST 64, AP 91, Tbili 0.3,
- trop-T 0.1, MB 7
- BUN 72, Cr 6.2, glucose 57, AG 27
- Lactate 5.3
ECG: STE aVR 3mm with diffuse depressions --> CODE STEMI called
Consults:
- Cardiology: Bedside echo with hypokinesis of anterior wall and
mild collapse of IVC. Recommend admission to CCU for possibly
STEMI
Patient received:
- 1L NS, IV morphine sulfate 4mg x1, heparin gtt, IV ondansetron
4mg x1
Transfer vitals: BP 88/51 HR 82 RR 20 O2 97% RA
On arrival to the CCU, patient reports that his chest pain has
resolved. He denies abdominal pain but endorses intermittent
nausea. His wife is at the bedside and endorses the above
history.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative.
Past Medical History:
. CVD Risk Factors
- HTN
- HLD
- T2DM
- Stage V CKD
- Former tobacco use
2. Cardiac History
- CAD with 3VD s/p DES to ___
- Severe aortic stenosis
3. Other PMH
- L ACA CVA (___)
- Depression
- EtOH cirrhosis
- BPH
Social History:
___
Family History:
Father MI ___, Mother stroke ___
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VS: 97.8 109/68 (82) 83 17 93% 2L NC
GENERAL: Well-appearing, well-developed male, in NAD
HEENT: NC/AT, EOMI, PERRL anicteric sclera, dry MM
NECK: Supple. JVP 10cm at 90 degrees
CARDIAC: RRR, grade IV/VI systolic murmur heard best at LUSB
with
radiation to carotids
LUNGS: CTAB, breathing comfortably on RA, no wheezes, rhonci, or
rales
ABDOMEN: Soft, non-tender, non-distended, active bowel sounds,
no
appreciable hepatomegaly
EXTREMITIES: No c/c/e
SKIN: Warm, well-perfused, no rashes
PULSES: Distal pulses palpable and symmetric
NEURO: Alert, answers to name, moving all extremities with
purpose, no facial asymmetry
========================
DISCHARGE PHYSICAL EXAM:
========================
VS: Temp: 98.7 (Tm 99.3), BP: 127/66 (107-129/54-69), HR: 73
(63-74), RR: 18 (___), O2 sat: 97% (95-100), O2 delivery: RA
GENERAL: Well-appearing, well-developed male, resting
comfortably in bed at HD
NECK: Supple. JVP 8-10 cm at 45 degrees.
CARDIAC: RRR, grade ___ systolic murmur heard best at LUSB
LUNGS: faint bibasilar crackles, breathing comfortably, no
wheezes or rhonchi anteriorly
ABDOMEN: Soft, non-tender, non-distended, active bowel sounds,
no appreciable hepatomegaly
EXTREMITIES: trace BLE edema
SKIN: Warm, well-perfused, spider angioma right chest.
NEURO: Alert, answers to name, moving all extremities with
purpose, no facial asymmetry
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 01:15AM ___ PTT-26.7 ___
___ 01:15AM PLT COUNT-184
___ 01:15AM NEUTS-75.6* LYMPHS-16.1* MONOS-4.7* EOS-1.6
BASOS-1.3* IM ___ AbsNeut-6.57* AbsLymp-1.40 AbsMono-0.41
AbsEos-0.14 AbsBaso-0.11*
___ 01:15AM WBC-8.7 RBC-2.93* HGB-8.7* HCT-26.8* MCV-92
MCH-29.7 MCHC-32.5 RDW-13.2 RDWSD-44.4
___ 01:15AM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-5.4*
MAGNESIUM-2.3
___ 01:15AM CK-MB-7 proBNP-9850*
___ 01:15AM cTropnT-0.10*
___ 01:15AM ALT(SGPT)-55* AST(SGOT)-64* CK(CPK)-146 ALK
PHOS-91 TOT BILI-0.3
___ 01:15AM estGFR-Using this
___ 01:15AM GLUCOSE-57* UREA N-72* CREAT-6.2* SODIUM-145
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-13* ANION GAP-27*
___ 01:37AM LACTATE-5.3*
___ 04:15AM LACTATE-5.9*
===============
DISCHARGE LABS:
===============
___ 01:30AM BLOOD WBC-8.4 RBC-2.27* Hgb-6.8* Hct-20.2*
MCV-89 MCH-30.0 MCHC-33.7 RDW-12.9 RDWSD-41.6 Plt ___
___ 01:30AM BLOOD ___ PTT-60.9* ___
___ 01:30AM BLOOD Glucose-92 UreaN-47* Creat-5.0* Na-137
K-3.9 Cl-97 HCO3-26 AnGap-14
___ 01:30AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.3
=============
MICROBIOLOGY:
=============
___ 2:22 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 2:23 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:22 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:24 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:49 am BLOOD CULTURE Source: Venipuncture #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH
======================
IMAGING/OTHER STUDIES:
======================
___ Duplex Dop Abd/Pel Limited
Normal appearance of hepatic parenchyma. Unchanged bilobed
hepatic cyst in the left hepatic lobe. Patent portal vein. No
ascites. Relatively normal appearance of the gallbladder. Trace
pericholecystic fluid may be related to reported underlying
liver disease versus cardiac insufficiency.
___ TTE
The left atrial volume index is mildly increased. The right
atrium is mildly enlarged. There is no evidence of an atrial
septal defect or patent foramen ovale by 2D/color Doppler or
agitated saline at rest and with maneuvers. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is mild
(non-obstructive) focal basal septal hypertrophy. The visually
estimated left ventricular ejection fraction is 65%. There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Tissue Doppler suggests an increased left
ventricular filling pressure (PCWP greater than 18mmHg). Normal
right ventricular cavity size with normal free wall motion. The
aortic sinus diameter is normal for gender with mildly dilated
ascending aorta. The aortic arch diameter is normal with a
mildly dilated descending aorta. The aortic
valve leaflets are severely thickened. There is severe aortic
valve stenosis (valve area index less than 0.6 cm2/m2). There is
mild [1+] aortic regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve prolapse. The transmitral
E-wave deceleration time is short (<140ms). There is mild [1+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is mild [1+] tricuspid
regurgitation. There is SEVERE pulmonary artery systolic
hypertension. There is a trivial pericardial effusion.
___ Aorta and Branches
Extensive atherosclerotic calcification within the abdominal
aorta without
evidence of abdominal aortic aneurysm.
___ TTE
The left atrium is normal in size. The right atrium is mildly
enlarged. There is no evidence for an atrial septal defect by
2D/color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
a normal cavity size. There is normal regional and global left
ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 63 %. There is no resting left
ventricular outflow tract gradient. Tissue Doppler suggests an
increased left ventricular filling pressure (PCWP greater than
18mmHg). Normal right ventricular cavity size with normal free
wall motion. The aortic sinus is mildly dilated with mildly
dilated ascending aorta. The aortic arch is mildly dilated.
There is no evidence for an aortic arch coarctation. A ___ 3
aortic valve bioprosthesis is present. The prosthesis is well
seated with normal leaflet motion and gradient. There is a
paravalvular jet of mild [1+] aortic regurgitation. The mitral
valve leaflets are mildly thickened with no mitral valve
prolapse. There is trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The pulmonary artery systolic pressure
could not be estimated. There is a trivial pericardial effusion.
Liver cyst(s) are seen.
___ Tunneled Dialysis Line
Patent left internal jugular vein. Final fluoroscopic image
showing 23 cm
tunneled dialysis catheter with tip terminating in the right
atrium.
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.
Medications on Admission:
1. Clopidogrel 75 mg PO DAILY
2. Sodium Bicarbonate 650 mg PO TID
3. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild
4. Allopurinol ___ mg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Clotrimazole Cream 1 Appl TP BID:PRN fungal
8. Cyanocobalamin 1000 mcg PO DAILY
9. Donepezil 10 mg PO DAILY
10. Fexofenadine 180 mg PO DAILY
11. HydrALAZINE 50 mg PO Q6H
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Nephrocaps 1 CAP PO DAILY
14. Rosuvastatin Calcium 40 mg PO QPM
15. Tamsulosin 0.4 mg PO DAILY
16. Vitamin D ___ UNIT PO DAILY
17. Fish Oil (Omega 3) ___ mg PO BID
18. Multi-Vitamins with Iron (pediatric multivit-iron-min)
___ mg oral DAILY
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
2. Lanthanum 500 mg PO TID W/MEALS
3. sevelamer CARBONATE 800 mg PO TID W/MEALS
4. Warfarin 3 mg PO DAILY16
5. Allopurinol ___ mg PO EVERY OTHER DAY
6. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild
7. amLODIPine 10 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Clotrimazole Cream 1 Appl TP BID:PRN fungal
10. Cyanocobalamin 1000 mcg PO DAILY
11. Donepezil 10 mg PO DAILY
12. Fexofenadine 180 mg PO DAILY
13. Fish Oil (Omega 3) ___ mg PO BID
14. Multi-Vitamins with Iron (pediatric multivit-iron-min)
___ mg oral DAILY
15. Nephrocaps 1 CAP PO DAILY
16. Rosuvastatin Calcium 40 mg PO QPM
17. Tamsulosin 0.4 mg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
==================
PRIMARY DIAGNOSES:
==================
Undifferentiated shock
Type II non-ST elevation myocardial infarction
Severe aortic stenosis, status post transcatheter aortic valve
replacement
Chronic kidney disease, initiated on hemodialysis
Aspiration pneumonia
Paroxysmal atrial fibrillation
======================
CHRONIC/STABLE ISSUES:
======================
Coronary artery disease with known three vessel disease, status
post drug eluting stent to OM2
Hypertension
Normocytic anemia
Ethanol cirrhosis
Type II diabetes mellitus
Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CAD, severe AS, ESRD here with hypotension
c/f infection vs. cardiogenic shock.// concern for infection concern for
infection
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Moderate cardiomegaly has increased, mild pulmonary edema is new. No
appreciable pleural effusion. No pneumothorax.
Rightward deviation and left-sided indentation of the cervical trachea may be
slightly more pronounced today than in ___, usually due to an enlarged
thyroid. Most recent thyroid ultrasound was performed ___ showing
bilateral thyroid nodules.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with etoh cirrhosis, here with hypotension c/f
infection vs. cardiogenic shock, assess for ascites for diagnostic tap, if
possible// ascites
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Multiple prior comparisons, most recent from ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is bilobed hepatic cyst in the left hepatic lobe
with thin septation, not significantly changed dating back ___. There is no
concerning focal liver mass.. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. 3
mm gallbladder polyp is seen along the body of the gallbladder. Trace
pericholecystic fluid is seen.
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.
Spleen length: 10.7 cm
KIDNEYS: Limited views of the right kidney show no hydronephrosis. Again seen
is a 2.5 cm simple cyst in the lateral aspect of the right kidney.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Normal appearance of hepatic parenchyma. Unchanged bilobed hepatic cyst in
the left hepatic lobe. Patent portal vein. No ascites.
2. Relatively normal appearance of the gallbladder. Trace pericholecystic
fluid may be related to reported underlying liver disease versus cardiac
insufficiency.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory distress and worsening hypoxia//
interval change interval change
IMPRESSION:
Compared to chest radiographs ___ and ___.
Since ___ the then new pulmonary vascular congestion in the left lung and
moderate enlargement of cardiac silhouette of both cleared. However there is
now relatively uniform severe opacification on the right that I hesitate to
attribute to either pleural effusions since the examination is reported as
having been performed with the patient upright or pneumonia in the absence of
air bronchograms or obscuration of any contours in the right hemithorax.
RECOMMENDATION(S): Chest CT. Repeat chest radiograph to see if chest CT
scanning is indicated.
NOTIFICATION: The findings were discussed with ___., M.D. by ___
___, M.D. on the telephone on ___ at 9:33 am, 1 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with severe AS, NSTEMI, low grade fever WBC and
new consolidation// PNA? Please sit up as much as possible during film
PNA? Please sit up as much as possible during film
IMPRESSION:
Compared to chest radiographs ___.
Mild cardiomegaly has increased. Consolidation in the right midlung is more
clearly defined, probably pneumonia. Lower lobe findings could be a
combination of asymmetric edema and pleural effusion, as well as pneumonia.
No left pleural abnormality. No pneumothorax.
Rightward shift of the trachea at the thoracic inlet is attributable to
enlarged thyroid. Patient had thyroid ultrasound on ___ describing
multinodular goiter.
Radiology Report
EXAMINATION: AORTA AND BRANCHES
INDICATION: ___ year old man with severe aortic stenosis// TAVR vascular
access sizing
TECHNIQUE: Grayscale and color Doppler ultrasound of the abdominal aorta was
performed.
COMPARISON: None.
FINDINGS:
The aorta measures 2.6 cm in the proximal portion, 2.8 cm in mid portion and
2.4 cm in the distal abdominal aorta. The lumen of the aorta measures 1.7 cm
in the proximal portion, 2.2 cm in the midportion, and 2.0 cm in the distal
portion. There is severe calcified atherosclerotic plaque.
Wall-to-wall color flow is seen within the aorta with appropriate arterial
waveforms.
The right common iliac artery measures 1.6 cm and the left common iliac artery
measures 1.8 cm. The lumen of the right common iliac artery measures 1.1 cm
and the lumen of the left common iliac artery measures 1.3 cm.
The right kidney measures 9.7 cm and the left kidney measures 9.1 cm.
Bilateral kidneys appear mildly atrophic without hydronephrosis.
IMPRESSION:
Extensive atherosclerotic calcification within the abdominal aorta without
evidence of abdominal aortic aneurysm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p TAVR placement with cough// evidence of pneumonia/ pulm
edema? evidence of pneumonia/ pulm edema?
IMPRESSION:
Comparison to ___. The pre-existing parenchymal opacity at the
right lung bases has completely cleared. On the current image, there is no
evidence of parenchymal abnormalities. No pulmonary edema. No pneumonia. No
pleural effusions. Stable borderline size of the cardiac silhouette. No
pneumothorax.
Radiology Report
INDICATION: ___ with PMH notable for triple-vessel CAD s/p DES to OM2 on
___, severe AS, DM with worsening CKD-5 now requiring initiation of HD.//
placement of LEFT tunneled dialysis catheter
COMPARISON: Radiograph of the chest dated ___
TECHNIQUE: OPERATORS: Dr. ___ radiologist, performed the
procedure.
ANESTHESIA: Intravenous administration of 50 mcg of fentanyl was performed
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, ortho solution, 1% lidocaine
CONTRAST: 10 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 11.1 min, 94 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 left upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent left internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a Amplatz wire was
advanced however would not passed easily into the IVC. A MPA catheter and
Glidewire were used to attempt to get access to the IVC. Due to difficulty, a
small contrast injection was performed which demonstrated position within the
atrium and the hepatic veins. Ultimately, a hepatic vein was selected and the
Amplatz wire was passed into the a hepatic vein.
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
using the introducer of the peel-away sheath supplied. Following this, the
peel-away sheath was placed over the Amplatz wire through which the catheter
was threaded into the right side of the heart with the tip in the right
atrium. The sheath was then peeled away. The catheter was sutured in place
with 0 silk sutures. Steri-strips were also used to close the venotomy
incision site. Final spot fluoroscopic image demonstrating good alignment of
the catheter and no kinking. The tip is in the right atrium. The catheter was
flushed and both lumens were capped. Sterile dressings were applied. The
patient tolerated the procedure well.
FINDINGS:
Patent left internal jugular vein. Final fluoroscopic image showing 23 cm
tunneled dialysis 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: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Unstable angina, Athscl heart disease of native coronary artery w/o ang pctrs, Chest pain, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UTA
level of acuity: 2.0 | ___ with background history notable for triple-vessel CAD,
status post DES to OM2 on ___, severe AS, Stage V CKD (not
yet on HD), T2DM, EtOH cirrhosis, and L ACA CVA (___) who
initially presented to the ED with chest pain, found to have STE
in aVR with diffuse depressions c/f STEMI. Patient was in shock
in the ED thought to be cardiogenic. He was treated medically
for his MI and received a TAVR during this hospitalization. His
baseline CKD worsened requiring hemodialysis which was started
inpatient.
====================
ACUTE/ACTIVE ISSUES:
====================
# Shock
Hypotensive in ED with lactate elevated to 5.3, status post 1L
IVF with improvement in SBP to 100. Most likely cardiogenic
shock in the setting of possible ischemia vs. worsening AS,
although unclear. Bedside echo without evidence of tamponade.
Low suspicion for PE or tension pneumothorax given stable
respiratory status. His lactate downtrended in ED and
normalized, with stable blood pressures throughout the remainder
of admission.
# Type II NSTEMI
# CAD with known 3VD, s/p DES to OM2
# Severe AS
Patient presented with unstable angina, found to have ECG
changes concerning for global ischemia. Coronary angiogram prior
to this hospitalization on ___ with 3VD and DES to OM2. ECG
changes did not appear consistent with in stent restenosis.
Troponins/CK-MB rose during initial hospitalization, with high
concern for global ischemia in the setting of severe AS, though
patient continued to deny chest pain and repeat ECGs did not
suggest ischemia. Peaked at 4.85, CK-MB peaked at 116. Cardiac
surgery was consulted and echo was performed showing severe
aortic stenosis. Cardiac surgery recommended TAVR as patient was
high risk for SAVR. TAVR was completed one week into
hospitalization after resolution of pneumonia, without
complication. Discussion was had regarding
antiplatelet/anticoagulant therapy going forward, given
requirement for anticoagulation for paroxysmal atrial
fibrillation. Decision was made to continue warfarin and
clopidogrel alone for duration of DAPT (at least three months),
before transitioning to aspirin/warfarin upon completion of
planned DAPT therapy. Goal INR is 2.0-3.0.
# CKD stage 5
Cr 6.2 on presentation, up from 5.6 on ___ post-cath. 7.0 on
___, status post cath with contrast. Discussion was had
regarding further contrast load necessary for TAVR procedure and
possibility of HD requirement, which patient understood and
accepted. Decision was made to initiate HD post TAVR procedure.
Left tunneled line was placed on ___ and HD was initiated on
___. Patient underwent four sessions without issue prior to
discharge. Will start outpatient HD at ___ Dialysis
Center, with a planned ___ schedule at
4PM.
# Aspiration pneumonia
Pneumonia, thought to be secondary to aspiration, was present on
admission treated with five day course of Unasyn.
# Paroxysmal atrial fibrillation
New noted ___, persisted for 12 hours, before spontaneous
conversion to sinus rhythm. Remained in NSR since. CHADS2VASC 6.
Anticoagulation was started with warfarin, with a goal INR of
2.0-3.0, and rate control was maintained with carvedilol 12.5mg
BID.
======================
CHRONIC/STABLE ISSUES:
======================
# HTN
Hydralazine was discontinued in the setting of starting
hemodialysis. Amlodipine 10mg and carvedilol 12.5mg will be
continued on discharge.
# Normocytic anemia
Likely secondary to renal disease with component of iron
deficiency anemia. The patient was transfused twice during the
course of admission (___).
# EtOH cirrhosis
Poorly understood history. Has remote history of ascites, no
known history of hepatic encephalopathy or SBP. Due for variceal
screening. Abdominal US was negative for ascites.
# T2DM
Hypoglycemic to 50's in ED, improved to 70's on re-check. The
patient was on an insulin sliding scale while admitted.
# BPH
Home tamsulosin was initially held but restarted prior to
discharge.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
H 1 blocker / H 2 blockers / sulfites / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Celebrex
Attending: ___.
Chief Complaint:
RUQ Pain
Major Surgical or Invasive Procedure:
Port Placement
History of Present Illness:
___ yo gentleman with newly diagnosed pancreatic cancer, high
CEA,
liver lesion, starting FOLFIRINOX, presenting with CT finding
showing possible reactivated TB during chemotherapy presenting
with RUQ pain after liver biopsy 2 days prior. He had been
taking
PO hydromorphone with minimal effect, and felt pain worsenining;
was told to come into the ED. Denies fevers, chills, CP/SOB. He
does endorse constipation for five days, and has been taking
colace/senna at home.
In the ED, CT scan performed which showed new small amounts of
nonhemorrhagic perihepatic ascites and new nonhemorrhagic pelvic
free fluid, with persistent pancreatic fluid collections.
He was noted in clinic to have CT with possible TB, and was
placed in a TB rule out room.
Past Medical History:
ONC HISTORY (per OMR):
___ y/o pharmacist who was well until ___ when he
started to develop diffuse, low-level abdominal pain which
insidiously became more severe with radiation to back, bloating,
early satiety, abnormal bowels, and weight loss.
He was seen by his PCP and CT scan was performed in ___ that
showed changes of necrotizing pancreatitis with fluid collection
around the pancreas and cavernous thrombosis of the portal vein.
Referred to Dr. ___ pancreatitis w/u unremarkable (no
gallstones, normal labs, no new meds, or viral prodrome). PV
changes felt to be chronic and heme w/u was recommended to r/o
hypercoagulable state. Conservative management was recommended
with 6-week f/u MRCP. His symptoms improved and interval MRCP
performed on ___ which showed an infiltrative mass in the body
of the pancreas extending into the neck and out of the pancreas
with extensive vascular involvement, and liver (segment 4A) and
peritoneal (2 small nodules) lesions concerning for metastatic
disease.
Underwent EUS on ___ which showed an >4cm mass in the
pancreatic
neck extending to the head and duodenum. Extensive cystic
changes around the pancreas limited further characterization of
the mass (largest cyst 5cmwith significant solid component) and
peripancreatic fluid collections ranging from 2-5cm. Multiple
varices were noted at the porta-hepatis.
FNA of the pancreas, body showed malignant cells consistent with
adenocarcinoma. From ___ CA ___: ___
In addition to the pancreatic mass, MRCP showed 8 x 12 mm
hypoenhancing lesion in segment 4a concerning for metastatic
disease and biopsy was recommended.
He had a CT chest on ___ which showed a small cavity with
surrounding micronodules in the right upper lobe concerning
possibly related to old tuberculosis. He works in the ___
hospital. He report annual TB testing has been negative.
He does related chronic sinusitis with surgery in the past and
reportedly colonized with pseudomonas.
PMH/PSH: Depression, arthritis, allergic rhinitis, IBS, GERD,
exercise-induced asthma, h/o rheumatic fever (childhood), L
achilles tear, b/l arthroscopies, deviated septum repair
Social History:
___
Family History:
Father with prostate and kidney CA (late ___. Brother with
colon cancer (diagnosed age ___. Sister died of unprovoked
PE.
Physical Exam:
General: NAD
VITAL SIGNS: 98.5 ___ 18 97%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, ND, no masses or hepatosplenomegaly, mild tenderness
to palpation in RUQ.
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
___ 04:20PM BLOOD WBC-8.4 RBC-4.62 Hgb-13.4* Hct-41.5
MCV-90 MCH-29.0 MCHC-32.3 RDW-12.8 RDWSD-42.1 Plt ___
___ 07:02AM BLOOD WBC-5.5 RBC-4.33* Hgb-12.6* Hct-38.6*
MCV-89 MCH-29.1 MCHC-32.6 RDW-12.7 RDWSD-41.7 Plt ___
___ 07:02AM BLOOD Glucose-108* UreaN-12 Creat-0.6 Na-139
K-4.5 Cl-102
___ 04:20PM BLOOD ALT-160* AST-48* AlkPhos-183* TotBili-1.0
___ 07:02AM BLOOD ALT-62* AST-25 AlkPhos-364* TotBili-0.8
___ 07:02AM BLOOD Mg-2.0
CT Abd:
1. New small amount of nonhemorrhagic perihepatic ascites.
2. New small amount of predominantly nonhemorrhagic pelvic free
fluid, with a
small hematocrit level in the deep pelvis.
3. Redemonstration of a known pancreatic head mass, better
characterized on
prior MRCP.
4. Multiple stable pancreatic walled off fluid collections with
surrounding
peripancreatic stranding.
5. Stable cavernous transformation of the portal vein.
Evaluation of known
superior mesenteric vein thrombosis and splenic vein thrombosis
is limited
however, there is attenuation of the splenic vein, likely
secondary to known
thrombosis.
6. Persistent enlargement of the left adrenal gland, concerning
for metastatic disease as characterized on prior MRCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 2 mg PO DAILY
2. ClonazePAM 0.5 mg PO QHS:PRN insomnia
3. Creon 12 2 CAP PO TID W/MEALS
4. Cetirizine 10 mg PO Q12H
5. Venlafaxine XR 300 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. ARIPiprazole 2 mg PO DAILY
2. Cetirizine 10 mg PO Q12H
3. ClonazePAM 0.5 mg PO QHS:PRN insomnia
4. Creon 12 2 CAP PO TID W/MEALS
5. Venlafaxine XR 300 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
8. Polyethylene Glycol 17 g PO BID:PRN Constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Daily
Disp #*30 Packet Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN Nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
12. Pyridoxine 50 mg PO DAILY
RX *pyridoxine 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
13. Isoniazid ___ mg PO DAILY
RX *isoniazid ___ mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Cancer
Latent TB
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with history of pancreatic adenocarcinoma s/p
recent biopsy with acute onset abdominal pain. // abdominal pain
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is
moderate amount of stool in the ascending colon.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonobstructive bowel gas pattern. Moderate amount of stool in the ascending
colon.
Radiology Report
EXAMINATION: Abdomen and pelvic CT.
INDICATION: NO_PO contrast; History: ___ with s/p liver biopsy severe RUQ
abdominal painNO_PO contrast // eval for perforation
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 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP =
18.1 mGy-cm.
2) Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 12.4 mGy (Body) DLP = 669.7
mGy-cm.
Total DLP (Body) = 688 mGy-cm.
COMPARISON: MRCP from ___ and abdominal/pelvic CTA from ___.
FINDINGS:
LOWER CHEST: There is minimal bibasilar atelectasis. There is no pleural or
pericardial effusion,
ABDOMEN:
HEPATOBILIARY: 12 mm hypodensity within segment 4 of the liver is again
present, and remains concerning for metastatic disease as characterized on
prior dedicated MRCP. The liver otherwise demonstrates homogenous
attenuation throughout. There is no evidence of new focal lesions. There is
no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits. There is a mall a small amount of non
hemorrhagic perihepatic ascites.
PANCREAS: Known pancreatic head mass is better characterized on MRCP dated ___, now measuring approximately 3.5 x 3.1 cm. There are multiple
peripancreatic fluid collections, the largest encasing the pancreatic tail and
measuring 4.4 x 2.9 cm, which overall remain stable since prior CT
examination.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape. There is
persistent enlargement of the left adrenal gland, measuring 12 x 10 mm and
showing increased attenuation
URINARY: There is a 19 mm hypodensity upper pole of the right kidney which is
likely a renal cyst. The kidneys are of normal and symmetric size with normal
nephrogram. There is otherwise 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 not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of predominantly nonhemorrhagic pelvic free fluid, with a a small
hematocrit level noted within the deep pelvis.
REPRODUCTIVE ORGANS: The prostate gland is mildly enlarged.
LYMPH NODES: There are multiple small retroperitoneal and mesenteric lymph
nodes. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. There is cavernous transformation of the portal vein. Evaluation
of known superior mesenteric vein thrombosis and splenic vein thrombosis is
limited. However, there is attenuation of the splenic vein, likely secondary
to known thrombosis.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. New small amount of nonhemorrhagic perihepatic ascites.
2. New small amount of predominantly nonhemorrhagic pelvic free fluid, with a
small hematocrit level in the deep pelvis.
3. Redemonstration of a known pancreatic head mass, better characterized on
prior MRCP.
4. Multiple stable pancreatic walled off fluid collections with surrounding
peripancreatic stranding.
5. Stable cavernous transformation of the portal vein. Evaluation of known
superior mesenteric vein thrombosis and splenic vein thrombosis is limited
however, there is attenuation of the splenic vein, likely secondary to known
thrombosis.
6. Persistent enlargement of the left adrenal gland, concerning for metastatic
disease as characterized on prior MRCP.
NOTIFICATION: The findings were discussed with Dr. ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:30 AM, 20 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW) IN O.R.
INDICATION: ___ male with left port placement.
TECHNIQUE: Multiple fluoroscopic images of the chest.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The final image shows a left Port-A-Cath with the tip terminating in the
region of the cavoatrial junction.
IMPRESSION:
Left Port-A-Cath placement with the final image showing the tip terminating in
the region the cavoatrial junction.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with pancreatic cancer, rule out TB, now s/p
portacath placement. // Assess for pneumothorax, portacath location.
Contact name: ___: ___ Assess for pneumothorax,
portacath location.
IMPRESSION:
The left subclavian Port-A-Cath extends to the mid to lower portion of the
SVC. No evidence of procedure related pneumothorax. No evidence of acute
cardiopulmonary disease.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Right sided abdominal pain
Diagnosed with Unspecified abdominal pain
temperature: 97.7
heartrate: 104.0
resprate: 18.0
o2sat: 100.0
sbp: 113.0
dbp: 75.0
level of pain: 2
level of acuity: 3.0 | ___ yo gentleman with newly diagnosed pancreatic cancer who
presented with CT finding showing possible reactivated TB during
chemotherapy and with RUQ pain.
Abdominal pain
- Likely related to recent liver biopsy and/or underlying
malignancy. CT done on admission without concerning findings and
hemoglobin remained stable throughout the admission. LFTs were
monitored and stable. He was started and discharged on oxycodone
PRN with good pain control.
Latent TB
- Prior to admission the patient had a chest CT with a cavitary
lesion that was concerning for latent TB and subsequent
reactivation during upcoming chemotherapy. ID was consulted. The
patient was place din a negative pressure room and sputum
studies were done. At the time of discharge returned test were
negative. ID felt it prudent to treat the patient for latent TB
given the cavitary lesion on chest CT so he was started on
isoniazid and pyridoxine. He will follow up with ID as an
outpatient.
Pancreatic Cancer
- A port was placed as previously scheduled during the
admission. He will follow up with his primary oncologist as an
outpatient later this week with plans to start FOLFIRINOX.
Constipation
- The patient was admitted with constipation, likely narcotic
induced and he was started on a bowel regimen with improvement.
He will continue on colace, senna, and miralax. |
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, lightheadedness, fainting during nuclear stress test
Major Surgical or Invasive Procedure:
s/p pacemaker implantation
History of Present Illness:
___ year old man with CAD s/p DES to LAD and LCx (___ ___,
NIDDM, HLD, & HTN p/w syncope for 45 sec today during outpatient
nuclear stress test. Patient describes going to the test at 10am
this morning, without having anything to eat/drink for 12 hours.
He was feeling otherwise well and had the dye infusion for 45
minutes. He then proceeded to have the basal rest images
performed and about ___ minutes into it, patient began to see
purple, and soon after passed out with no recollection of other
symptoms. He denied having any CP, SOB, n/v, palps, diaphoresis,
lightheadedness, dizziness, vertigo prior to passing out. When
he came to, patient began to experience nausea but NO other
symptom. Defibrillator pads were placed on the patient but was
not used as patient spontaneously converted into a sinus rhythm
after about a 45 sec pause. The test was then canceled and pt
brought to ED. Pt presented to cardiologist Dr. ___ on
___ c/o increasing DOE for past several months, no chest
pain, but similar to his presentation in ___ to ___ where 4
stents were placed in the LAD and LCx. Last stress test ___
suggested inferolateral ischemia and medical therapy was
initiated.
.
Over the past year, he has reported increasing shortness of
breath when he exerts himself, particularly when he is swimming.
He does not report chest pain and has not had any associated
numbness, lightheadedness, or syncope. The dyspnea resolves when
he stops exerting himself. During last clinic visit, Dr. ___
___ the options of proceeding directly to cardiac
catheterization versus obtaining an exercise sestamibi stress
test to document the location of any potential coronary
ischemia. Patient prefered to proceed with a stress test first.
.
In the ED, initial vitals were 55 125/66 18 99% 10L
Non-Rebreather. Patient denied CP, but stated that he had SOB
after passing out. Also had some mild lower abd pain. Labs
notable for lactate 3.4, d-dimer ___, Cr 1.2, BUN 21, HCO3 19,
INR 1.0, trop <0.01, HCT 40.6. Received zofran 4mg x1. Vitals
prior to transfer: 97.8. HR:71 (sinus). BP: 104/58. O2: 98%
3LNC. RR: 18.
.
On arrival to the floor, patient VSS, completely asx, just
hungry. No recent illness, diarrhea, nausea, no recent travel.
.
ROS as above, otherwise negative.
Past Medical History:
1. CARDIAC RISK FACTORS: NIDDM, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Three Vessel CAD with 4 DES to mLAD and mCX
AAA repair with endovascular graft (___)
3. OTHER PAST MEDICAL HISTORY:
COPD with emphysema - FEF25-75% 20% of predicted. FEV1 2.45
L - 91% predicted.
Mild hyrdronephrosis
50pack year h/o smoking, quit ___ yrs ago
prostate cancer s/p xrt
hypothyroidism
Social History:
___
Family History:
There is a family history of hypertension, diabetes, and heart
disease but not of stroke. His mother died at ___ years of bowel
cancer. His father died at age ___ years of an MI. His sister is
healthy.
Physical Exam:
Admission PEx:
VS: 97.4 133/64 80 96%RA
I/O: 1000/600
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CARDIAC: RR, normal S1, S2. No m/r/g.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. +2dp
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge PEx:
VS: 96.8 123/63 73 16 94%RA
Weight 88kg
GENERAL: NAD. Oriented x3.
NECK: Supple, no JVP. 6-7 cm suprasternal soft tissue mass, non
tender, non mobile.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs. superficial tenderness over
PPM area, bandaged, c/d/i
LUNGS: CTAB, no rales, crackles or wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Palpable distal pulses
SKIN: No stasis dermatitis, ulcers.
Pertinent Results:
Labs on Admission:
___ 12:00PM BLOOD WBC-5.8 RBC-4.70 Hgb-13.9* Hct-40.6
MCV-86 MCH-29.6 MCHC-34.3 RDW-13.9 Plt ___
___ 12:00PM BLOOD Neuts-61.1 ___ Monos-4.9 Eos-1.3
Baso-0.6
___ 12:00PM BLOOD ___ PTT-29.0 ___
___ 12:00PM BLOOD Glucose-206* UreaN-21* Creat-1.2 Na-135
K-4.8 Cl-103 HCO3-19* AnGap-18
___ 12:00PM BLOOD proBNP-172
___ 12:00PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9
___ 12:00PM BLOOD D-Dimer-2151*
___ 12:10PM BLOOD Lactate-3.4*
___ 01:20PM URINE Color-Straw Appear-Clear Sp ___
___ 01:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:20PM URINE Hours-RANDOM
Labs on Discharge:
___ 06:50AM BLOOD WBC-5.6 RBC-4.41* Hgb-13.1* Hct-39.0*
MCV-88 MCH-29.6 MCHC-33.5 RDW-13.9 Plt ___
___ 06:50AM BLOOD Glucose-216* UreaN-17 Creat-1.1 Na-137
K-4.1 Cl-102 HCO3-26 AnGap-13
___ 06:50AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9
Imaging/Procedures:
EKG ___: Sinus rhythm @58. Occasional ventricular premature
beat. Generalized low QRS voltages. No previous tracing
available for comparison.
CXR: No acute cardiopulmonary process.
CTA Chest/Abd:
IMPRESSION:
1. No pulmonary embolism. Infrarenal abdominal aortic aneurysm
with evidence of endoleak, likely type II from a right-sided
lumbar artery. No evidence of impending hemorrhage.
2. Linear lucency in the left first rib appears to be
well-corticated and may represent remote fracture.
3. A linear lucency in the left S1 with no evidence of
cortication may
represent a more recent traumatic fracture. Please correlate
with clinical
history.
4. Thickened bladder wall likely represents combination of
collapse and
hypertrophy from chronic outlet obstruction due to enlarged
prostate, but
cannot exclude infectious process. Please correlate with urine
analysis.
EKG ___: Sinus rhythm with ventricular premature beats and
demand atrial pacing. Generalized low QRS voltage. Compared to
the previous tracing of ___ demand atrial pacing and
ventricular premature beats are new. QRS voltage is lower.
CXR ___: A dual-chamber pacemaker is present, with one lead
in the right ventricle, the other in the right atrium. No
pneumothorax is present. The lung fields are clear.
Medications on Admission:
ATENOLOL 25 mg Tablet daily
ATORVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet -
one Tablet(s) by mouth daily
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - one Tablet(s) by mouth daily
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 60 mg
Tablet Extended Release 24 hr - one Tablet(s) by mouth daily
NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet,
Sublingual - one Tablet(s) sublingually daily
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - one Tablet(s) by mouth daily
GEMFIBROZIL - (Prescribed by Other Provider) - 600 mg Tablet -
one Tablet(s) by mouth twice daily
GLYBURIDE-METFORMIN - 5 mg-500 mg Tablet - one Tablet(s) by
mouth
twice daily
LEVOTHYROXINE - (Prescribed by Other Provider) - 100 mcg Tablet
- one Tablet(s) by mouth daily
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - one Capsule(s) by mouth daily
PIOGLITAZONE [ACTOS] - (Prescribed by Other Provider) - 30 mg
Tablet - one Tablet(s) by mouth daily
TERAZOSIN - (Prescribed by Other Provider) - 5 mg Capsule - one
Capsule(s) by mouth daily
CALCIUM CARBONATE [CALCIUM 500] - (Prescribed by Other Provider)
- Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Tablet, Chewable - one Tablet(s) by mouth daily
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 6 doses.
Disp:*6 Capsule(s)* Refills:*0*
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain,
SOB: can repeat every five minutes up to 3 pills total. If
taking ___ pill, please call ___.
9. glyburide-metformin ___ mg Tablet Sig: One (1) Tablet PO
twice a day.
10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
14. Calcium+D Oral
15. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
16. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every ___
hours as needed for pain for 10 days.
Disp:*qs Tablet(s)* Refills:*0*
17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. linagliptin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
asystole
Secondary:
Diabetes Mellitus type 2
Coronary Artery Disease
Hypertension
___ Prostatic Hyperplasia
Abdominal Aortic Aneurysm
Chronic Obstructive Pulmonary Disease
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal AP portable view.
CLINICAL INFORMATION: ___ male with history of shortness of breath
and bradycardia.
COMPARISON: None.
FINDINGS: AP portable views of the chest were obtained. No focal
consolidation, pleural effusion, or evidence of pneumothorax is seen. The
cardiac and mediastinal silhouettes are unremarkable. Calcification of the
aorta is likely present. There is no widening of the mediastinum.
Degenerative changes are seen at the acromioclavicular joints.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: History of AAA repair and chest pain. Please evaluate for
dissection or AAA leak.
COMPARISON: No prior studies available for comparison.
TECHNIQUE: Intravenous contrast was administered and arterial phase imaging
was acquired. Non-contrast axial images were acquired through the chest.
FINDINGS:
CTA: The pulmonary vasculature shows no filling defect to suggest pulmonary
embolism. Significant arthrosclerotic changes are noted throughout the
coronary vessels, particularly the left anterior descending and the left
coronary artery. Atherosclerosis is seen throughout the thoracic and
abdominal aorta, extending into the bilateral iliacs and femoral arteries. The
patient is status post aorto-biiliac endovascular stent with stent positioned
immediately inferior to the left renal artery. A 4.5 x 4.8 x 4.4 cm
infrarenal abdominal aortic aneurysm with hyperdensity evident within the
aneurysmal sac well inferior to the presumed junction of the aorto and iliac
graft junction. Hyperdensity appears to extend from a right lumbar collateral
vessel (3:144). No surrounding mesenteric changes to suggest impending
rupture of aneurysmal sac. The ostia of the renal, celiac, and superior
mesenteric arteries appears widely patent.
CT CHEST: No focal pulmonary opacifications or nodules evident. Diffuse
predominantly upper lobe centrilobular and paraseptal emphysematous changes
noticed with bullous emphysema noted anteriorly bilaterally. Minimal
dependent atelectatic changes are noted in the posterior aspect of the lungs.
The heart size is normal without pericardial effusion. There is a small
hiatal hernia.
CT ABDOMEN: Although this exam is not tailored for evaluation of the
intra-abdominal parenchyma, there is no discrete lesion identified within the
liver. There is no intrahepatic or extrahepatic biliary ductal dilatation.
The gallbladder is unremarkable. The pancreas and spleen are normal. The
bilateral adrenal glands are normal. The bilateral kidneys are normal in size
and excrete contrast symmetrically. Multiple simple renal cysts are
identified in both kidneys. No stones are evident. There is no
hydronephrosis or hydroureter identified. The stomach, small and large bowel
are unremarkable. There is no retroperitoneal, mesenteric, or portacaval
lymphadenopathy evident.
CT PELVIS: The appendix is visualized and is unremarkable. The rectum and
sigmoid colon are unremarkable. The bladder wall appears somewhat thickened.
This may reflect collapse around an inserted Foley catheter or hypertrophy due
to chronic outlet obstruction due to an enlarged prostate measuring 6 cm in
its greatest dimension. The seminal vesicles are unremarkable. There is no
pelvic sidewall or inguinal lymphadenopathy evident. There is no free fluid
in the pelvis.
OSSEOUS STRUCTURES: There are no suspicious lytic or blastic lesions evident.
A well-corticated linear lucency is noted in the left first rib anteriorly,
likely represents a remote fracture(3:2). In addition, there is a linear
lucency with cortical stepoff noted within the left posterior bridge of S1
with no evidence of bony healing and may represent a more recent trauma.
Please correlate clinically.
IMPRESSION:
1. No pulmonary embolism. Infrarenal abdominal aortic aneurysm with evidence
of endoleak, likely type II from a right-sided lumbar artery. No evidence of
impending hemorrhage.
2. Linear lucency in the left first rib appears to be well-corticated and may
represent remote fracture.
3. A linear lucency in the left S1 with no evidence of cortication may
represent a more recent traumatic fracture. Please correlate with clinical
history.
4. Thickened bladder wall likely represents combination of collapse and
hypertrophy from chronic outlet obstruction due to enlarged prostate, but
cannot exclude infectious process. Please correlate with urine analysis.
Radiology Report
CLINICAL HISTORY: Pacemaker placed. Check position.
CHEST, PA AND LATERAL
A dual-chamber pacemaker is present, with one lead in the right ventricle, the
other in the right atrium. No pneumothorax is present. The lung fields are
clear.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P SYNCOPAL/BRADY
Diagnosed with SYNCOPE AND COLLAPSE, CARDIAC DYSRHYTHMIAS NEC, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: nan
heartrate: 55.0
resprate: 18.0
o2sat: 99.0
sbp: 125.0
dbp: 66.0
level of pain: 13
level of acuity: 1.0 | ___ y M with past medical history of DM2, CAD s/p PCI + stent
placement, hyperlipidemia, COPD who presented with syncopal
episode and sinus arrest during an elective nuclear stress test
for ongoing DOE (MI equivalent in the past).
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Hydrocodone / Zestril
Attending: ___.
Chief Complaint:
Chest Pain/Fracture Tibia/Suicidal Ideation
Major Surgical or Invasive Procedure:
ORIF left leg (___)
History of Present Illness:
___ homeless female with HCV, CAD s/p NSTEMI,polysubstance abuse,
s/p R TKR, L knee injury in ___ who presents with chest pain
s/p cocaine ingestion brought in by ambulance after being found
in the ___ area intoxicated now found to have fractured left
tibia.
Patient states she was having chest pain before coming to the
hospital unable to describe the pain as she was intoxicated and
generally is a poor historian. Chest pain has now resolved on
admission.
She drank approximately half a pint of hard alcohol some point
prior to admission, unknown time of last drink. She denies any
other ingestions. In the ED she was found to have positive Utox
for cocaine and opiates.
She reports having had fall approximately ___ wks ago and
hurting her
left leg. She has been using a wheelchair that she found on the
streets to get around and has been unable to walk. She describes
severe pain in her left leg. She was seen at outside clinic
where plain films were not performed. As per the ortho note she
has been intermittently walking on leg with pain. Also noted to
have DVT on previous admission which is now resolved as per
imaging done in ED.
In the ED, initial vital signs were: 97.2 76 146/78 18 97%. In
the ED she stated her chest pain had improved. She denied sob,
abdominal pain, nausea or vomiting. CXR was obtained, Troponins
were 0.03 and 0.02. She was evaluated by psychiatry and now on
___ for suicidal ideation and plan to overdose on her pills.
Evaluated by orthopedics in the ED that recommended Xray and CT
imaging. Per ortho: will likely need total knee replacement
possibly on this admission. She was given lovenox 40mg x1 for
PPX in the ED.
As per psychiatry patient needs to be admitted for SI once
medically cleared.No psych facility would accept patient with
restrictions of mobility and contact precautions except for Deac
4 no bed there until ___ and decision was made to admit
patient to medicine.
On Transfer Vitals were: 79 148/86 19 98% RA. On the floor
patient was complaining of left knee pain. No chest pain,
shortness of breath. Continues to endorse suicidal ideation.
Patient is notably a poor historian.
Past Medical History:
-Polysubstance abuse (crack, EtOH, ?heroin)
-Benign Hypertension
-Hyperlipidemia
-Asthma
-Hepatitis C
-Depression
-H/o endocarditis x 2 (last in ___
-Bilateral DVT ___, took 4 months of coumadin)
-Coronary artery disease s/p NSTEMI in ___
-PFO (per discharge summary ___
-H/o CVA: L ?___ stroke (___) per NSU note ___ (but per
neurology review of prior CT head: L inferior MCA division
stroke) with L facial droop
-"Rheumatoid arthritis" ___ inpatient evaluation showed neg
CCP, mildly elevated RF, and osteoarthritic changes but no
erosions suggestive of inflammatory arthropathy on hand, knee,
or foot x-rays.
-PPD positive s/p Isoniazid treatment x 6 months
-Right breast cancer s/p resection and subsequent mastectomy
(DFCI)
-S/p L eye enucleation ___ (possibly ___ infxn)
-S/p ex-lap after abdominal stab wound
-SVC draining into rt coronary sinus
- Affective Dysregulation: Recent admission to psych given
suicidal thoughts on the medical floor (without organized plan),
psych was unclear whether there was a primary mood disorder.
Seroquel beneficial.
Social History:
___
Family History:
Per prior notes, father with diabetes ___. Mother and
brother with alcoholism. Son with OCD.
Physical Exam:
ADMISSION EXAM:
======================
Vitals - T: 98.7 BP: 150/75 HR: 74 RR: 19 02 sat: 98%RA
GENERAL: NAD, elderly woman laying in bed
HEENT: AT/NC, L eye enucleate, anicteric sclera, pink
conjunctiva, MMM, no upper teeth, few bottom teeth intact
NECK: nontender supple neck, no appreciable JVD
CARDIAC: RRR, loud ___ holosystolic murmur heard throughout the
precordium, S1 markedly diminished, normal S2, no gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: midline scar; nondistended, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: RLE s/p knee replacement, nontender,
nonerythematous. LLE very tender to touch, visible deformity
below the knee grossly swollen in comparison to RLE, both legs
appear to be swollen L>R. Knee itself is tender.
PULSES: 2+ ___ pulses bilaterally
NEURO: CN II-XII intact, AxOx3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, multiple healed scars
DISCHARGE EXAM:
========================
T 98.3 HR 70 BP 122/80 RR 18 100% on RA
NAD, A+OX3
LLE:
Wounds well healed with no surrounding erythema or discharge
Unlocked ___ in place
Compartments soft and compressible
WWP toes
SILT over S/S/SP/DP/T distributions
Motor intact GSC, TA, ___
Pertinent Results:
ADMISSION LABS:
======================
___ 04:00AM BLOOD WBC-2.8* RBC-3.90* Hgb-10.5* Hct-34.7*
MCV-89 MCH-26.9* MCHC-30.2* RDW-18.1* Plt ___
___ 04:00AM BLOOD Neuts-39.4* Lymphs-46.4* Monos-7.3
Eos-6.7* Baso-0.3
___ 04:00AM BLOOD ___ PTT-28.3 ___
___ 04:00AM BLOOD Glucose-76 UreaN-18 Creat-1.5* Na-140
K-3.6 Cl-103 HCO3-23 AnGap-18
___ 04:00AM BLOOD ASA-NEG Ethanol-90* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:17AM BLOOD Lactate-2.2*
___ 09:20AM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:20AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
___ 09:20AM URINE RBC-0 WBC-12* Bacteri-FEW Yeast-NONE
Epi-17
___ 09:20AM URINE 3PhosX-OCC
___ 09:20AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
PERTINENT LABS:
======================
___ 04:00AM BLOOD cTropnT-0.03*
___ 09:50AM BLOOD cTropnT-0.02*
DISCHARGE LABS:
======================
___ 08:30AM BLOOD WBC-3.6* RBC-3.40* Hgb-9.3* Hct-30.6*
MCV-90 MCH-27.5 MCHC-30.5* RDW-16.4* Plt ___
___ 08:30AM BLOOD Glucose-81 UreaN-18 Creat-1.3* Na-139
K-4.8 Cl-104 HCO3-27 AnGap-13
IMAGING:
======================
Left Knee & Tibia X-rays (___) - Radiology Report
1. No evidence of hardware complication.
2. Callus formation around the proximal tibial and fibular
fractures, similar
to ___.
3. Severe tricompartmental degenerative joint disease.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H pain
2. Amlodipine 10 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
5. Glycerin Supps ___AILY constipation
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
7. Nicotine Patch 14 mg TD DAILY
8. Polyethylene Glycol 17 g PO DAILY constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Aripiprazole 10 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Diltiazem Extended-Release 120 mg PO DAILY
13. Docusate Sodium 100 mg PO BID:PRN constipation
14. QUEtiapine Fumarate 25 mg PO BID
15. Calcium Carbonate 500 mg PO BID
16. Loratadine 10 mg PO DAILY
17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
18. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN Pain
Discharge Medications:
1. Apixaban 5 mg PO BID Duration: 3 Months
Last dose to be given on ___
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*44 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H pain
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
4. Amlodipine 10 mg PO DAILY
5. Aripiprazole 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Diltiazem Extended-Release 120 mg PO DAILY
9. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
11. Nicotine Patch 14 mg TD DAILY
12. QUEtiapine Fumarate 25 mg PO BID
13. Senna 8.6 mg PO BID:PRN constipation
14. Glycerin Supps ___AILY constipation
15. Loratadine 10 mg PO DAILY
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
17. Polyethylene Glycol 17 g PO DAILY constipation
18. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q3H Disp #*80 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left subacute proximal tibia 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: Chest radiograph.
INDICATION: History: ___ with CP after cocaine // evidence of pneumonia or
pneumothorax
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiographs dated ___, CT chest dated ___.
FINDINGS:
Interval development of mild interstitial pulmonary edema. There is no lobar
consolidation, pneumothorax, or pleural effusion. Mild cardiomegaly is stable.
The aortic arch is calcified. The enlarged right hila is unchanged from ___,
better characterized on prior CT chest.
IMPRESSION:
Mild cardiomegaly and mild interstitial pulmonary edema.
Radiology Report
EXAMINATION: DX KNEE AND TIB/FIB
INDICATION: ___ female with pain/inability to walk // rule out
fracture
TECHNIQUE: Five views of the left knee and ankle.
COMPARISON: Radiographs from ___ and ___.
FINDINGS:
There is a transversely oriented fracture through the proximal left tibia and
fibula with posterior angulation of the tibial fracture, new from ___. However, there is associated callus formation suggesting a non-acute
fracture. Lucencies can represent physiologic changes but pathologic fracture
cannot be excluded. There continues to be severe tricompartmental
degenerative changes within the knee.
IMPRESSION:
1. Subacute transverse fractures of the proximal tibia and fibula with
posterior angulation of tibial fracture. Lucencies in the fracture site can
represent physiologic changes but pathologic fracture cannot be excluded.
2. Severe tricompartmental degenerative changes of the left knee.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 10:21 AM, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with left leg pain and unclear compliance with
anticoagulation from pop DVT identified in ___ // Rule out DVT or
prorgession from pop DVT from ___
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Bilateral lower extremity venous duplex from ___
FINDINGS:
There is normal respiratory variation in the common femoral veins bilaterally.
There is normal compressibility and flow in the left common femoral vein.
Proximal/mid/distal superficial femoral vein is fully compressible. Normal
compressibility and wall-to-wall flow is demonstrated in the left popliteal
vein.
The study could not be completed as a result of patient discomfort. Therefore,
the calf veins were not assessed and augmentation of femoral vein could not be
performed.
IMPRESSION:
Limited exam due to patient discomfort. No evidence of deep venous thrombosis
in the left lower extremity veins to the level of the popliteal vein. The calf
veins were not assessed.
Radiology Report
EXAMINATION: CT LOW EXT W/O C LEFT
INDICATION: ___ year old woman with left subacute proximal tib fracture //
further clarification of fracture pattern (Please obtain CT scan of left knee
down to the lower third of tibia)
TECHNIQUE: Contiguous axial multidetector CT images from the left distal
femur to the mid tibia/fibula without intravenous contrast. Multiplanar
reformations.
Total DLP: 1484 mGy-cm
COMPARISON: Knee radiographs same day and earlier radiographs including
___
FINDINGS:
There is a subacute fracture of the proximal left tibia and fibula with
exuberant surrounding periosteal new bone. The fracture line and cortical
discontinuity is still visible. There is mild impaction and mild varus
angulation of the distal tibia with little displacement. There is no cortical
bridging.
Severe degenerative changes with subchondral sclerosis, subchondral cyst
formation and osteophyte are most prominent in the medial compartment.
Intra-articular body is demonstrated along the anterior aspect of the lateral
compartment (series 800b, image 38). A moderate-sized left knee joint effusion
is present.
There is fragmentation of the medial tibial plateau, with a triangular
articular fragment measuring 2.6 x 1.5 cm (series 7, image 92, series 800b,
image 35). This appears similar allowing for difference in technique to
previous radiograph from ___.
IMPRESSION:
1. Subacute left tibial and fibular shaft fractures with callus formation.
2. Severe tricompartmental osteoarthritis, and there is nonacute fragmentation
of the medial tibial plateau with a triangular articular fragment arising from
the anteromedial aspect of the medial tibial plateau.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with tib/fib fx, prolonged immobility. Evaluate
for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Left lower extremity duplex dated ___
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Radiology Report
HISTORY: ORIF.
FINDINGS: Images from the operating suite show placement of a fixation device
about previously described fracture of the proximal tibia. Adjacent fibular
fracture is seen. Further information can be gathered from the operative
report.
Radiology Report
INDICATION: ___ year old woman with proximal tibia fx s/p ORIF, rule out DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Multiple prior lower extremity DVT study stricter comparison made
to study from ___.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal compressibility, flow and augmentation in the left common
femoral and proximal and mid superficial femoral veins. Flow was seen within
the left popliteal vein. Compressibility, flow and augmentation was not
performed in the distal superficial femoral vein, popliteal vein, and calf
veins due to lack of patient cooperation.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. Very limited assessment of the left lower extremity veins due to lack of
patient cooperation. No evidence of deep vein thrombosis in the left common
femoral and proximal and mid superficial femoral veins. The remaining lower
extremity veins were not visualized.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ 2 wks s/p L tibia ___ plate.
TECHNIQUE: Left knee, three views.
COMPARISON: ___.
FINDINGS:
Again seen is callus formation around the transverse fractures of the proximal
tibia and fibula, similar to prior. Lateral cortical plate and screws are now
seen across the proximal tibia. There is no perihardware lucency. Severe
tricompartmental degenerative changes are again seen along with a
moderate-sized joint effusion.
IMPRESSION:
1. No evidence of hardware complication.
2. Callus formation around the proximal tibial and fibular fractures, similar
to ___.
3. Severe tricompartmental degenerative joint disease.
Radiology Report
INDICATION: ___ 2 wks s/p L tibia ___ plate // fx healing f/u
COMPARISON: Prior exam from ___.
FINDINGS:
In this patient with recent ORIF, there is a lateral plate and screw fixation
traversing the fracture in the proximal shaft of the tibia. Alignment is near
anatomic. Bones are diffusely demineralized. Soft tissues are prominent.
Degenerative changes of the left knee are again noted, severe.
IMPRESSION:
Left tibial fracture post ORIF, near anatomic alignment.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Right sided chest pain
Diagnosed with CHEST PAIN NOS, DRUG ABUSE NEC-UNSPEC
temperature: 97.2
heartrate: 76.0
resprate: 18.0
o2sat: 97.0
sbp: 146.0
dbp: 78.0
level of pain: 13
level of acuity: 3.0 | ___ year old homeless woman with HCV, CAD s/p NSTEMI,
polysubstance abuse who presents with acute on chronic left knee
pain, found to have a subacute proximal left tibia fracture.
# Left tibia fracture: Patient reports falling 2 weeks ago and
has been having pain in left knee since. She has had multiple
falls over the past yaer. She reports going to a clinic where no
Xrays were taken. She states she was using a wheelchair and has
been walking on the leg, however the pain was very severe. Xray
and CT of LLE show subacute fracture of the proximal left tibia
and fibula with exuberant surrounding periosteal new bone.
Previous Xrays do not show any evidence of deformity in the
tibia apart from severe osteoarthritis. No evidence of bony
lesions.
The patient was taken to the operating room with Orthopaedic
surgery on ___ for a left proximal tibia ___ plate, 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 on the Orthopaedic
surgery service. The patient was initially given IV fluids and
IV pain medications, and progressed to a regular diet and oral
medications. The patient was given perioperative antibiotics.
She was given pharmacologic anticoagulation for her left
popliteal DVT (see below). The patient worked with ___ who
determined that discharge to rehab was appropriate. Due to her
being homeless, she had a prolonged hospital course as most
rehab facilities would not accept her. Staples were removed at 2
weeks as the wound had adequately healed. X-rays of the tibia &
knee demonstrated evidence of callus formation at the fracture
site with good alignment of hardware and tibia. Knee is in
stable varus angulation with severe degenerative changes.
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, wounds were healing well
(staples removed at 2 weeks post-op), and the patient was
voiding/moving bowels spontaneously. The patient is weight
bearing as tolerated in the left lower extremity and will be
discharged with ASA 325 mg po daily x 2 weks for DVT prophylaxis
as she has completed her course of apixaban for her DVT and had
no evidence of DVT on ___ LENIS. 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.
The medicine and psychiatry services were consulted during this
admission for assistance in the management of her medical and
psychiatric comorbidities. Their recommendations are highlighted
below.
# Left popliteal DVT: ___ ___ showed left popliteal DVT.
Started on anticoagulation on ___ with enoxaparin eventually
switched to apixaban 5mg BID given CKD. ___ on ___ with no
evidence of DVT. Completed course of apixaban on the day of
discharge - ___.
# Depression/Mood disorder: Patient expressing depression and no
desire to live. Feels depressed since her son was shot in ___.
Patient was admitted under ___- evaluated by pscyhiatry
and found to have suicial ideation. After surgery, psychiatry
continued to follow, and the patient was no longer suicidal,
stating her SI to be in relation to her knee pain which is now
resolving s/p surgical fixation. Psychiatry cleared the patient
for medical rehab facility.
# HTN: Continued on diltiazem ER 120 mg po daily & amlodipine 10
mg po daily that were started at the last hospitalization.
# Chronic renal failure: Baseline Cr approximately 1.3-1.8.
Increased to 2.0 post-op but normalized to her baseline of 1.3 1
week prior to hospital discharge.
# Normocytic anemia: During hospital stay, the patient's Hct
ranged from 29 - 35. This appears close to her baseline of low
to mid ___ according to lab results in our system dating back to
___. Etioogy of her anemia may be secondary to CKD. There were
no signs of bleeding. It may be worth considering further work
up of her cause of anemia as an outpatient.
# Polysubstance abuse: The patient reports using drugs the day
she arrived to the ED (cocaine and alcohol). Patient has history
of withdrawal seizures from alcohol. CIWA scores <10 since
admission. No evidence of EtOH withdrawal during this
hospitalization.
# Asthma: Patient reports having a history of asthma, last
hospitalization had recommended outpatient PFTs. Patient had
been given ipratropium and albuterol nebs prn. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
phenobarbital
Attending: ___.
Chief Complaint:
Nausea/Vomiting and Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with a history of HIV
(CD4 306 on ___, VL 200K ___ on ART), adrenal
insufficiency on hydrocortisone/midodraine and alcohol
withdrawal c/b hallucinosis in the past with recent admission
for such who presents with back pain, acute hepatitis.
Mr ___ describes 3 days of symptoms of nausea, vomiting,
back pain and fever. Describes his fever as shaking chills and
sweating, but did not formerly take his temperature. He says he
takes the medications he is supposed to and only drank about two
beers a day, last drink yesterday. Unable to keep much else down
otherwise. Denied drinking any other substances or any other
forms of alcohol. Reports a mild frontal headache and chronic
lower back pain, which has worsened within the past 3 days.
Denies any numbness or weakness or vision change. Denies any
loss of bowel or bladder control. Denies passing out or falling,
waking up in unusual positions. No other drugs than what he was
supposed to have been prescribed. No recent trauma. No recent
travel.
ED COURSE
- Initial VS: 10 99.2 110 118/78 16 96% RA
- No exam documented
- Labs notable for ALT: 1017 AP: 223 Tbili: 0.4 Alb: 3.9 AST:
2650 Lip: 68 EtOH 296. H/H ___ Eos% 15 (AbsEo 79) 2 bands / 1
atyp on diff. Urine barbituates positive. AG 19 U/A blood SM RBC
1 lactate 2.3
- RUQUS, CT head, and CXR without acute process
- Pt was given 1000cc NS, folate, thiamine, and reglan
- VS prior to transfer: 0 97.9 84 150/86 15 100% RA
Past Medical History:
HIV+
Hypertension
Adrenal insufficiency ___ hypopituitarism
Neuropathy
Chronic lower back pain
Alcohol misuse
Social History:
___
Family History:
Notable for an older brother with diabetes ___.
Physical Exam:
ADMISSION
GEN: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, VFF
without diploplia or blurry vision on exam, PERRL, neck supple,
JVP not elevated
CV: tachy, regular, nl S1 + S2, no murmurs, rubs, gallops
Lungs: Faint rales in b/l bases, improve with cough,
intermittent cough throughout exam
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Back: focal spinous process over L4-5, no paraspinal tenderness.
No CVAT. No intbility, stop off.
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.
GU: Normal rectal tone, empty vault. Enlarged prostate
DISCHARGE
Vitals: 98.5 ___ 18 96 RA
GEN: Very fatigued with the covers pulled over his head.
HEENT: No oral lesions. No thrush. Poor dentition
___: RRR, no MRG
RESP: No increased WOB, no wheezing, rhonchi or crackles
ABD: Soft, NTND. Liver edge felt under costal margin. No
splenomegaly
EXT: Warm, no edema
MSK: Previously TTP over L4-L5 spinous process. No paraspinal
muscle tenderness
NEURO: Responding minimally due to fatigue. No inducible
asterixis on exam.
Skin: No rash.
Pertinent Results:
ADMISSION
=======================
___ 01:10AM BLOOD WBC-4.8 RBC-3.99* Hgb-11.4* Hct-34.0*
MCV-85 MCH-28.6 MCHC-33.5 RDW-14.8 RDWSD-45.5 Plt ___
___ 01:10AM BLOOD Neuts-27* Bands-2 ___ Monos-8
Eos-15* Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-1.39*
AbsLymp-2.30 AbsMono-0.38 AbsEos-0.72* AbsBaso-0.00*
___ 01:10AM BLOOD ___ PTT-28.9 ___
___ 01:10AM BLOOD Glucose-74 UreaN-5* Creat-0.6 Na-133
K-3.6 Cl-91* HCO3-23 AnGap-23*
___ 01:10AM BLOOD ALT-1017* AST-2650* CK(CPK)-557*
AlkPhos-223* TotBili-0.4
___ 01:10AM BLOOD Lipase-68*
___ 09:50AM BLOOD Albumin-3.4* Calcium-7.2* Phos-1.9*
Mg-1.6 UricAcd-9.3*
___ 01:10AM BLOOD Osmolal-356*
___ 01:10AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
PERTINENT
=========================
___ 10:05AM BLOOD WBC-5.1# Lymph-37 Abs ___ CD3%-95
Abs CD3-1792 CD4%-10 Abs CD4-189* CD8%-83 Abs CD8-1569*
CD4/CD8-0.12*
___ 01:10AM BLOOD Neuts-27* Bands-2 ___ Monos-8
Eos-15* Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-1.39*
AbsLymp-2.30 AbsMono-0.38 AbsEos-0.72* AbsBaso-0.00*
___ 09:40PM BLOOD Glucose-188* UreaN-4* Creat-0.5 Na-125*
K-3.8 Cl-89* HCO3-25 AnGap-15
___ 01:10AM BLOOD ALT-1017* AST-2650* CK(CPK)-557*
AlkPhos-223* TotBili-0.4
___ 01:10AM BLOOD Lipase-68*
___ 09:50AM BLOOD cTropnT-<0.01
___ 09:40PM BLOOD Calcium-7.6* Phos-1.4* Mg-2.0
___ 01:10AM BLOOD calTIBC-224* Ferritn-6046* TRF-172*
___ 09:50AM BLOOD Hapto-110
___ 03:05PM BLOOD %HbA1c-5.3 eAG-105
___ 03:05PM BLOOD Triglyc-256* HDL-13 CHOL/HD-11.5
LDLcalc-86
___ 01:10AM BLOOD Osmolal-356*
___ 03:05PM BLOOD Osmolal-274*
___ 05:31AM BLOOD TSH-1.9
___ 09:50AM BLOOD Cortsol-20.1*
___ 01:10AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Positive* IgM HAV-Negative
___ 03:05PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 03:05PM BLOOD ___
___ 03:05PM BLOOD IgG-2208*
___ 01:10AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:50AM BLOOD Acetmnp-NEG
___ 03:05PM BLOOD Acetmnp-NEG
___ 01:10AM BLOOD HCV Ab-Negative
___ 08:42PM URINE Hours-RANDOM UreaN-139 Creat-38 Na-117
___ 12:16AM URINE Hours-RANDOM UreaN-357 Creat-100 Na-41
___ 08:42PM URINE Osmolal-333
___ 12:16AM URINE Osmolal-305
___ 01:30AM URINE bnzodzp-NEG barbitr-POS* opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 10:05AM BLOOD WBC-5.1# Lymph-37 Abs ___ CD3%-95
Abs CD3-1792 CD4%-10 Abs CD4-189* CD8%-83 Abs CD8-1569*
CD4/CD8-0.12*
___ 01:10AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Positive* IgM HAV-Negative
___ 01:10AM BLOOD HCV Ab-Negative
Test Result Reference
Range/Units
CERULOPLASMIN 28 ___ mg/dL
ALPHA-1-ANTITRYPSIN QN 105 83-199 mg/dL
IMMUNOGLOBULIN G SUBCLASS 1 1622 H 382-929 mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 195 L 241-700 mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 211 H ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 44 ___ mg/dL
IMMUNOGLOBULIN G, SERUM 2283 H ___ mg/dL
STRONGYLOIDES AB IGG NEGATIVE
=============================
DISCHARGE
=============================
___ 05:42AM BLOOD WBC-6.2 RBC-3.64* Hgb-10.6* Hct-32.0*
MCV-88 MCH-29.1 MCHC-33.1 RDW-15.2 RDWSD-48.2* Plt ___
___ 05:42AM BLOOD Neuts-13* Bands-0 Lymphs-56* Monos-24*
Eos-4 Baso-2* Atyps-1* ___ Myelos-0 AbsNeut-0.81*
AbsLymp-3.53 AbsMono-1.49* AbsEos-0.25 AbsBaso-0.12*
___ 05:42AM BLOOD Glucose-86 UreaN-8 Creat-0.5 Na-136 K-4.5
Cl-102 HCO3-25 AnGap-14
___ 05:42AM BLOOD ALT-214* AST-128* AlkPhos-140*
TotBili-0.2
___ 05:42AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.0
=============================
IMAGING
=============================
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION:
1. Chronic appearing right parietal infarct.
2. Chronic left maxillary sinus disease.
3. No clear acute intracranial abnormality on noncontrast head
CT. Of note MRI would be more sensitive for the detection of
intracranial infection.
___ Imaging LIVER OR GALLBLADDER US
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. No cholelithiasis or biliary dilatation.
___ Imaging LUMBO-SACRAL SPINE (AP
IMPRESSION:
Superior endplate scalloping involving T12, L1, L2, and L4 and
probably also to a lesser degree at L3 and L5, compatible with
multiple, subtle, nonacute vertebral body fractures. In
retrospect, the appearances are similar to ___,
including discogenic and facet degenerative changes and
retrolisthesis at L5/S1. If clinically indicated, MRI could
help for further assessment.
Mild degenerative changes about both SI joints, similar to
prior.
Faint aortic calcification, an unusual finding in someone of
this age. Is the patient a diabetic or do they have
vasculopathy
___ Imaging DUPLEX DOPP ABD/PEL
IMPRESSION:
1. Patent hepatic vasculature.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
3. Mild gallbladder wall edema, likely reactive in the setting
of acute
hepatitis.
___ Imaging MR ___ & W/O CONT
IMPRESSION:
1. No evidence for abscess formation.
2. Multilevel degenerative changes, most severe at the L5-S1
level with
moderate to severe bilateral neural foraminal narrowing at this
level.
3. Grade 1 retrolisthesis of L5 on S1, with ___ type 1 changes
at this
level.
=============================
MICRO
=============================
HIV-1 Viral Load/Ultrasensitive (Final ___:
222,000 copies/ml.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
HBV Viral Load (Final ___:
HBV DNA detected, less than 20 IU/mL.
___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
91 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Hydrocortisone 5 mg PO QAM
3. Hydrocortisone 2.5 mg PO QPM
4. Midodrine 5 mg PO TID
5. Mirtazapine 15 mg PO QHS
6. Multivitamins 1 TAB PO DAILY
7. Thiamine 100 mg PO DAILY
8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes, blurry
vision
9. Nicotine Patch 7 mg TD DAILY
10. Darunavir 800 mg PO QAM
11. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
12. RiTONAvir 100 mg PO DAILY
13. Gabapentin Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes, blurry
vision
RX *dextran 70-hypromellose [Artificial Tears] 0.1 %-0.3 % ___
drops per eye PRN Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Hydrocortisone 5 mg PO QAM
RX *hydrocortisone 5 mg 1 tablet(s) by mouth qam Disp #*30
Tablet Refills:*0
4. Hydrocortisone 2.5 mg PO QPM
RX *hydrocortisone 5 mg 0.5 (One half) tablet(s) by mouth qpm
Disp #*15 Tablet Refills:*0
5. Midodrine 5 mg PO TID
RX *midodrine 5 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
7. Nicotine Patch 7 mg TD DAILY
RX *nicotine 7 mg/24 hour As directed once a day Disp #*2 Each
Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
9. Citalopram 20 mg PO DAILY
RX *citalopram 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. Acetaminophen 650 mg PO Q8H:PRN Pain
11. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
12. Sodium Chloride Nasal ___ SPRY NU QID:PRN Nasal congestion
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute hepatitis
Hyponatremia
Nutritional Deficiency
Alcohol Abuse
Suicidal Ideation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with hiv, fever, // eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
The heart is not enlarged. Within limits of plain film radiography, no hilar
or mediastinal lymphadenopathy is detected. No CHF , focal infiltrate or
consolidation, pleural effusion or pneumothorax detected.
IMPRESSION:
No acute intrathoracic process identified. In particular, no infiltrate or
consolidation detected.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with hiv, fever, // eval for infection
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
Hypodensity in the right parietal lobe with encephalomalacia is likely related
to old infarct. There is no evidence of hemorrhage, edema, or mass/mass
effect. There is prominence of the ventricles and sulci suggestive of
involutional changes.
There is no evidence of fracture. There is mucosal thickening of the left
maxillary sinus with hyperostosis of the sinus compatible chronic sinus
disease. The remaining 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. Chronic appearing right parietal infarct.
2. Chronic left maxillary sinus disease.
3. No clear acute intracranial abnormality on noncontrast head CT. Of note
MRI would be more sensitive for the detection of intracranial infection.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with n/v and elevated LFTs // eval for
cholecystitis or CBD dilation
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis dated ___ and abdominal ultrasound
dated ___
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 6 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The head, body, and tail of the pancreas are within normal limits,
without masses or pancreatic ductal dilatation.
SPLEEN: Normal echogenicity, measuring 10.1 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. No cholelithiasis or biliary dilatation.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE.
INDICATION: ___ year old man with HIV, poorly controlled, fevers, lumbar back
pain // ? abscess.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of 6 mL of
Gadavist contrast agent.
COMPARISON: Lumbar spine radiographs ___.
FINDINGS:
Limited examination secondary to patient motion artifact. There is minimal
grade 1 retrolisthesis of L5 on S1. As seen on prior lumbar radiograph, there
is demonstration of endplate scalloping of the L1, L2, L4 and L5 vertebral
bodies. There is loss of intervertebral disc height at the L5-S1 level, with
associated T1 hypointense and T2/STIR hyperintense signal of the endplates at
this level, likely reflecting type ___ ___ changes. Vertebral body and
intervertebral disc signal intensity appear otherwise normal. The spinal cord
appears normal in caliber and configuration. There is no evidence of
infection or neoplasm.
At the T12-L1, L1-L2, and L2-L3, there is no significant spinal canal stenosis
or neural foraminal narrowing.
At the L3-L4 level, there is mild facet hypertrophy causing mild bilateral
neural foraminal narrowing. There is no spinal canal stenosis.
At the L4-L5 level, there is minimal disc bulge and facet hypertrophy
resulting in mild bilateral neural foraminal narrowing. There is no spinal
canal stenosis.
At the L5-S1 level, there is central disc protrusion which contacts the
traversing nerve roots bilaterally and results in mild anterior thecal sac
deformity. There is narrowing of the right and left lateral recesses with
moderate to severe bilateral neural foraminal narrowing.
The sacroiliac joints and the visualized paravertebral structures are
unremarkable.
IMPRESSION:
1. No evidence for abscess formation.
2. Multilevel degenerative changes, most severe at the L5-S1 level with
moderate to severe bilateral neural foraminal narrowing at this level.
3. Grade 1 retrolisthesis of L5 on S1, with ___ type 1 changes at this
level.
Radiology Report
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: ___ year old man with HIV p/w n/v/d and low back pain ___ years
with TTP over L4-L5 spinous process // evaluate for fracture
COMPARISON: Lumbar spine films dated ___
FINDINGS:
There are 5 non-rib-bearing vertebral bodies.
Mild superior endplate scalloping at multiple vertebral body levels is noted.
This appears to involve T12, L1, L2, and L4 and possibly L3 and L5. Loss of
vertebral body height is most pronounced at L1 and L2, where it represents
approximately 33% loss of vertebral body height. No obvious retropulsion.
There is mild disc space narrowing and minimal spurring and suspected grade 1
retrolisthesis at L5/S1. As before, the L3/4 and L4/5 disc spaces appear
widened, though this could be artifact due to changes in surrounding vertebral
bodies. Disc heights are otherwise preserved without other levels of
spondylolisthesis.
Mild moderate facet arthrosis is seen from L3 through S1. Previously suggested
spondylolysis at L5 is not clearly identified on this exam, but could be
obscured by overlapping bony structures. The spinous processes, including L4
and L5, are grossly unremarkable.
Small amounts of scattered aortic calcification are noted.
Mild degenerative changes about both SI joints again noted.
IMPRESSION:
Superior endplate scalloping involving T12, L1, L2, and L4 and probably also
to a lesser degree at L3 and L5, compatible with multiple, subtle, nonacute
vertebral body fractures. In retrospect, the appearances are similar to ___, including discogenic and facet degenerative changes and
retrolisthesis at L5/S1. If clinically indicated, MRI could help for further
assessment.
Mild degenerative changes about both SI joints, similar to prior.
Faint aortic calcification, an unusual finding in someone of this age. Is the
patient a diabetic or do they have vasculopathy?
NOTIFICATION: The impression and recommendation above was entered by Dr. ___
___ on ___ at 15:08 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ man with acute hepatitis. Evaluate hepatic vein
patency (was excluded on prior study).
TECHNIQUE: Targeted grayscale, color, and spectral Doppler evaluation of the
right upper abdomen was performed.
COMPARISON: Abdominal ultrasound dated ___.
FINDINGS:
Liver: The hepatic parenchyma is diffusely echogenic. No focal liver
lesions are identified. No ascites.
Bile ducts: No intrahepatic biliary ductal dilation. The common hepatic duct
measures 4 mm.
Gallbladder: The gallbladder edema is mild, likely reactive in the setting of
acute hepatitis. No abnormal wall thickening or stones.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic uncinate and tail obscured by overlying bowel
gas. No main pancreatic ductal dilation.
Spleen: The spleen was not imaged.
Kidneys: Limited views of the right kidney do not show hydronephrosis.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is approximately 20 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
IMPRESSION:
1. Patent hepatic vasculature.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
3. Mild gallbladder wall edema, likely reactive in the setting of acute
hepatitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HIV, adrenal insufficiency and ETOH w/d with
new fever // Eval for infection Eval for infection
IMPRESSION:
In comparison with the study of earlier in this date, there are slightly lower
lung volumes. No evidence of acute focal pneumonia, vascular congestion, or
pleural effusion.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with Dorsalgia, unspecified, Alcohol abuse with intoxication, unspecified
temperature: 99.2
heartrate: 110.0
resprate: 16.0
o2sat: 96.0
sbp: 118.0
dbp: 78.0
level of pain: 10
level of acuity: 3.0 | ___ h/o HIV (CD4 306 on ___, VL 200K ___ on ART),
adrenal insufficiency on hydrocortisone/midodraine and alcohol
withdrawal c/b hallucinosis in the past with recent admission
for EtOH withdrawl requiring phenobarbital taper in the ICU who
presents with back pain, nausea and vomiting found to have acute
hepatitis of unclear etiology and severe metabolic derangements.
#Acute Hepatitis, possible DRESS: Patient initially presented
with 3 days of nausea and vomiting. Was found to have a
significantly elevated transaminitis with ALT/AST 1017/2650 and
normal bilis consistent with a hepatocellular pattern of injury.
The etiology in a known alcoholic with HIV on ART with
questionable compliance is likely multifactorial. Pt has
steatohepatitis which is seen on U/S and has had previously
tranaminitis (though not as severe), likely from EtOH and ART,
specifically truvada. Given significant elevation there is
concern for viral hepatitis as EtOH alone can not explain this
degree of transaminitis. Patient is HBcAb positive, so is at
risk for reactivation given his steroids for AI and
immunocompromised state. EBV, CMV, HCV and HBV viral loads
undetectable with IgG positivity for EBV and CMV. HCV Ab
negative. Elevated ferritin, though iron is normal ruling out
hemochromatosis. Patient is born in ___, and presents with
eosinophilia which may be concerning for a parasitic infection
though strongyloides Ab negative and stool O&P negative as well.
Patient does not have stigmata of chronic liver disease and his
synthetic function is intact with relatively normal albumin, INR
and plts. He denies any ingestions, other than EtOH, APAP levels
are negative x2 and he denies any new medications, though
darunavir can cause acute hepatitis. Given his alcohol abuse,
there was also concern for ischemic injury if the patient had
been down for a period of time, but his CK was not significantly
elevated to have concern for rhabdo. U/S with Doppler was
negative for thrombotic/obstructive disease. Infiltrative
processes and parenchymal texture would be better characterized
with cross sectional imaging. Autoimmune testing including AMA
and ___ is negative. Ceruloplasmin was wnl. Given patient's
recent admission requiring phenobarbital, in addition to his
elevated eosinophilia and significantly elevated transaminitis,
there is a strong suspicion for DRESS. Patient was given
supportive care and his LFTs quickly downtrended.
#Severe metabolic and electrolyte derangements: Patient
presented with a anion gap of 19 and ethanol level of 296.
Measure sOsm 356 with Osm gap of 4 when corrected for EtOH.
Lactate was only slightly elevated. Patient denied any other
ingestions. Patient had hypokalemia, hypomagnesemia and
hypophosphatemia on presentation. Upon receiving mIVF with ___ NS his hypophosphatemia dramatically decreased along with
his serum sodium. uOsm 333. The patient likely has poor
nutrition with decreased solute intake evidenced by a BUN of 4,
therefore there was concern for refeeding syndrome and beer
potomania physiology to explain his progressive hyponatremia,
though urine electrolytes not entirely c/w this diagnosis,
likely multifactorial with ?component of SIADH. Electrolytes
corrected with repletion and hyponatremia improved with
increased PO intake and fluid restriction. Given concern for
severe nutritional deficiency, thiamine has been replenished in
addition to Ensure supplementation with meals.
#Alcohol abuse/intoxication: patient with multiple admissions
for alcohol use, now presenting with acute intoxication. Has
history of hallucinosis in the past, unclear if DT or seizures.
Scheudled lorazepam was used given his hepatic injury. Patient
did not score on CIWA and was able to be quickly downtitrated.
#Eosinophilia: Patient has new eosinophilia on presentation.
Absolute eosinophilia count 720. Trop negative. Could be ___ AI,
though patient is taking steroids and is hemodynamically stable.
Parastitic disease was also ruled out. Acute onset is likely not
related to malignancy. As above, eosinophilia may be secondary
to DRESS.
# Back Pain: Patient endorses back pain and has focal tenderness
on exam over lower lumbar spine (without paraspinal tenderness).
Lumbar XR shows non-acute fractures. No perineal paresthesia and
rectal tone normal rules out compression/cauda equina syndrome.
Given immunocompromised state, a lumbar spine MRI was obtained
which showed chronic degenerative changes and no fracture,
abscess or neoplasm.
#Adrenal insufficiency: BP suggests that patient is compensated,
but eosinophilia might suggest still adrenal insufficiency.
Steroids were recently uptitrated at last admission from 5 ->
7.5 total daily.
#HIV on ART: last CD4 in the 306 in ___, but with an
active viral load 200K. Repeat CD4 in house was 189, viral load
pending. Patient admits to inconsistent medication use.
Quantiferon gold negative ___. Truvada increases rates of
steatohepatitis and darunavir may cause acute hepatitis per
pharmacy. Will hold ART for now given unsure compliance and
concern for worsening liver dysfunction. Also, patient with need
PJP ppx in the future. No signs of thrush. Therefore, his ART
and prophylaxis may be held for now and restarted after
outpatient follow up.
#Anemia, thrombocytopenia: Likely secondary to alcohol abuse. No
evidence of bleeding. Stable from prior. MCV 85, likely has
multifactorial cause as liver dysnfunction and poor nutrition
should cause a macrocytic anemia.
#Sinus Tachycardia: Rates 100-110s. No chest pain, trop
negative. No dyspnea. Does not appear septic. Patient is not
complaining of pain. Likely due to alcohol withdrawal.
#Suicidal Ideation: Patient verbalized active SI to ED staff.
This is in the setting of acute intoxication. He has repeated
suicidal ideation on the floor and was seen by psychiatry who
placed him on a ___. Patient was started on citalopram.
He was discharged from the medical ward at ___ to the
psychiatry ward at ___.
TRANSITIONAL ISSUES
[]discuss reinitiating ART and starting PJP ppx for CD4 count
189
[]Make hepatology and primary care physician ___
[]Patient discharged on a 1.5 L fluid restriction given
hyponatremia. ___ discontinue if sodium normalizes.
[]On ___, recommend rechecking CBC w/ diff, electrolytes, and
LFT's to trend eosinophilia, sodium, and LFT abnormalities.
[]Consider outpatient orthopedics ___ given spine MRI results. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy with lysis of adhesions.
History of Present Illness:
___ w/ metastatic rectal carcinoid tumor s/p open LAR w/
colonic J pouch, segment VII liver resection, and sigmoid
colostomy for symptoms of obstruction on ___. Was previously
doing fine and now has presented with 1 day history of bloating,
nausea, obstipation, and left sided abdominal pain. History
obtained
through phone interpreter.
Past Medical History:
Illness: HTN, DM2, Metastatic carcinoid tumor of the rectum
Past Medical History: Open low anterior resection with colonic J
pouch to low rectal anastomosis ___, segment 7 liver resection
for metastatic carcinoid tumor ___
PSHx: end sigmoid colostomy ___, ___, segment 7 liver
resection ___, ___, open LAR w/ J pouch ___,
___, hysteroscopy with polypectomy and dilatation and
curettage ___, ___
Medications: Amlodipine ?dose, glipizide 10', lisinopril 40',
metformin 1000'', sunitinib 37.5' (2 weeks on, 1 week on),
calcium-vitamin D3, vitamin B12
Allergies: NKDA
Social History:
___
Family History:
Her mother died at age ___ from bronchitis and her father who
died at age ___ from old age.
Physical Exam:
Gen: Well appearing, in no acute distress
Cardiac: Normal s1 and s2, no MRG
Pulm: Clear to auscultation bilaterally
GI: Abdomen soft, mildly distended, nontender. Lap site clean,
dry and intact.
Pertinent Results:
___ 06:26AM BLOOD WBC-3.2* RBC-2.35* Hgb-8.2* Hct-24.6*
MCV-105* MCH-34.9* MCHC-33.3 RDW-14.3 RDWSD-54.9* Plt Ct-79*
___ 05:40AM BLOOD WBC-3.8* RBC-2.52* Hgb-8.7* Hct-26.5*
MCV-105* MCH-34.5* MCHC-32.8 RDW-14.5 RDWSD-55.4* Plt Ct-81*
___ 06:44AM BLOOD WBC-4.1 RBC-2.44* Hgb-8.4* Hct-26.0*
MCV-107* MCH-34.4* MCHC-32.3 RDW-15.2 RDWSD-59.5* Plt Ct-71*
___ 06:55AM BLOOD WBC-4.0 RBC-3.02* Hgb-10.6* Hct-31.7*
MCV-105* MCH-35.1* MCHC-33.4 RDW-15.2 RDWSD-58.0* Plt Ct-92*
___ 03:15PM BLOOD WBC-7.0# RBC-3.51* Hgb-12.4 Hct-35.5
MCV-101* MCH-35.3* MCHC-34.9 RDW-14.9 RDWSD-54.8* Plt ___
___ 03:15PM BLOOD Neuts-63.0 ___ Monos-2.9*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-4.41# AbsLymp-2.36
AbsMono-0.20 AbsEos-0.00* AbsBaso-0.01
___ 06:26AM BLOOD Plt Ct-79*
___ 05:40AM BLOOD Plt Ct-81*
___ 06:44AM BLOOD Plt Ct-71*
___ 11:05AM BLOOD ___ PTT-27.7 ___
___ 06:26AM BLOOD Glucose-174* UreaN-6 Creat-0.7 Na-137
K-4.0 Cl-107 HCO3-24 AnGap-10
___ 05:40AM BLOOD Glucose-133* UreaN-7 Creat-0.8 Na-137
K-3.9 Cl-106 HCO3-24 AnGap-11
___ 06:44AM BLOOD Glucose-128* UreaN-20 Creat-0.9 Na-140
K-3.8 Cl-109* HCO3-27 AnGap-8
___ 06:55AM BLOOD Glucose-126* UreaN-18 Creat-0.9 Na-142
K-3.8 Cl-109* HCO3-25 AnGap-12
___ 03:15PM BLOOD Glucose-130* UreaN-13 Creat-0.7 Na-140
K-4.0 Cl-104 HCO3-20* AnGap-20
___ 11:05AM BLOOD ALT-14 AST-27 AlkPhos-46 TotBili-0.9
___ 03:15PM BLOOD ALT-16 AST-28 AlkPhos-54 TotBili-1.1
___ 11:05AM BLOOD Lipase-14
___ 03:15PM BLOOD Lipase-28
___ 06:26AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.0
___ 05:40AM BLOOD Calcium-7.9* Mg-2.1
___ 06:44AM BLOOD Calcium-7.4* Phos-2.2*# Mg-2.0
___ 06:55AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.9
___ 03:15PM BLOOD Albumin-4.4
___ 03:15PM BLOOD HoldBLu-HOLD
___ 03:15PM BLOOD LtGrnHD-HOLD
___ 03:19PM BLOOD Lactate-3.0*
CT ___:
1. Findings concerning for closed loop small bowel obstruction
with "whirl"
sign in the right mid abdomen. Moderate volume abdominal
ascites noted.
Difficult to exclude early bowel ischemia.
2. Gastric distention with possible stricture at the level of
the pylorus.
3. Multiple liver lesions compatible with known sites of
metastasis.
4. Postsurgical changes including end colostomy, ___
pouch.
5. Duplicated right renal collecting system with mild fullness
of the lower
pole moiety, unchanged.
6. Mild thickening of the distal esophagus could reflect
esophagitis.
Medications on Admission:
Amlodipine 0 mg PO Frequency is Unknown
GlipiZIDE 10 mg PO DAILY
Lisinopril 40 mg PO DAILY
MetFORMIN (Glucophage) 1000 mg PO BID
Cyanocobalamin 1000 mcg PO DAILY
Sutent 37.5 mg capsule
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4 Disp #*30 Tablet
Refills:*0
3. Amlodipine 0 mg PO Frequency is Unknown
4. GlipiZIDE 10 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Cyanocobalamin 1000 mcg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Carcinoid tumor and small-bowel obstruction related to internal
hernia.
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: ___ year old woman with history of metastatic neuroendocrine
tumor, transfer from outside hospital with report of bowel obstruction.
TECHNIQUE: CT performed at an outside hospital with oral and intravenous
contrast material with axial, coronal and sagittal reformations.
DOSE: Dose DLP: ___ mGy-cm
COMPARISON: Prior CT (SPECT) from ___ as well as a MRI of the
abdomen from ___ 4
FINDINGS:
LOWER CHEST: The imaged lung bases are clear aside from mild dependent
atelectasis. The imaged portion of the heart is unremarkable. Mild
thickening of the distal esophagus may reflect esophagitis.
ABDOMEN:
HEPATOBILIARY: Multiple hypodense liver lesions are compatible with metastasis
as seen on prior imaging studies. The largest lesion is seen within segment 8
measuring approximately 4.7 x 4.7 cm. The main portal vein is patent. There
is stable mild prominence of the common bile duct measuring up to 8 mm. The
gallbladder appears normal.
PANCREAS: The pancreas enhances normally without ductal dilation or discrete
focal lesion. 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: Duplicated right renal collecting system is noted with stable mild
fullness of the lower pole moiety and ureter without discrete distal
obstruction. No worrisome renal lesion is seen. Bilateral perinephric
stranding is seen, unchanged from prior and nonspecific.
GASTROINTESTINAL: The stomach is distended containing contrast and ingested
material. There is mild narrowing at the level of the gastric antrum though
contrast is seen passing through this level into small bowel. The duodenum
appears normal. There is progressive dilation of small bowel loops which can
be traced to a point of abrupt caliber transition in the right mid abdomen
where there is a 360 degree "whirl" of the mesentery and small bowel. There
are 2 discrete transition point both centered at the mesenteric whirl, best
seen on series 2 image 59. Findings are concerning for a closed loop
obstruction. Mesenteric free fluid is small to moderate in volume. No
evidence of hypoenhancing small bowel to suggest ischemia. Distal small bowel
is entirely decompressed. The appendix is normal. The colon is unremarkable
and contains a mild fecal load. An end colostomy is seen in the left mid
abdominal wall. No definite evidence for malignant obstruction or mesenteric
mass.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS: The urinary bladder appears moderately distended and normal. The
uterus and adnexal structures appear unremarkable. There is a ___ pouch
at the distal colon/rectum. Presacral soft tissue thickening may reflect
treatment related changes. No free fluid tracks into the lower pelvis. No
pelvic sidewall adenopathy is seen. No inguinal hernia or adenopathy.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions.
IMPRESSION:
1. Findings concerning for closed loop small bowel obstruction with "whirl"
sign in the right mid abdomen. Moderate volume abdominal ascites noted.
Difficult to exclude early bowel ischemia.
2. Gastric distention with possible stricture at the level of the pylorus.
3. Multiple liver lesions compatible with known sites of metastasis.
4. Postsurgical changes including end colostomy, ___ pouch.
5. Duplicated right renal collecting system with mild fullness of the lower
pole moiety, unchanged.
6. Mild thickening of the distal esophagus could reflect esophagitis.
NOTIFICATION: Findings were discussed in person with Dr. ___.
Gender: F
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: SBO, Transfer
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.0
heartrate: 76.0
resprate: 18.0
o2sat: 98.0
sbp: 171.0
dbp: 88.0
level of pain: 13
level of acuity: 2.0 | Ms. ___ came to us on ___. She had a CT scan which showed a
closed loop small bowel obstruction. She had an NGT placed, made
NPO and given IV fluids. Thus, she underwent an exploratory
laparotomy with lysis of adhesions on ___. She tolerated the
procedure well and was transferred to the PACU in stable
condition. On ___, her foley was removed and she was voiding
spontaneously. Her NG tube was removed and her diet was advanced
to clears but however, she developed an early postop ileus and
needed to have her NG tube placed back in and diet made NPO. She
was given milk of magnesia and this seemed to help her pass gas
so her diet was then advanced and NG discontinued once again.
Her pain was initially controlled with a dPCA but once she was
tolerating PO, she was switched to oral pain medications. She
passed stool in her ostomy, was tolerating a regular diet and
ambulating so she was deemed fit for discharge home with ___ for
ostomy teaching. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Codeine / Topamax / Dilaudid / Percocet
Attending: ___.
Chief Complaint:
Right hip & labial numbness, back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o R thalamic stroke (___) and C4-5/C5-6 DDD presents
with ___ weeks of LBP radiating across top of buttock that
started a couple days after doing some cleaning and bending
over,
and 1 day of progressive numbness across her right hip that
travels down to her right groin and labia, stating it now feels
like "if I touch it I might as well be touching another person
because I cannot feel it." She also has numbness over her
proximal right anterior thigh, which has developed since coming
to the ED. Denies any new weakness or difficulty walking, denies
any loss of strength, and no new bowel or frank bladder
incontinence. Of note, she also had a colonscopy yesterday.
Because of her symptoms she called her neurologist, Dr.
___ advised her to come to the ED for evaluation.
Past Medical History:
Right thalamic stroke (___), melanoma ___ and C5-6 DDD,
trigeminal neuralgia, occipital neuralgia, myofascial pain,
postherpetic neuralgia, urge incontinence, HTN, HLD, NASH, ? ___ disease
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
O: T 98.4, HR 58, BP 180/69, RR 16, SPO2 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ERRL EOMs intact b/l
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
___ throughout all 4 extremities
Sensation:
complete absence of light touch sensation in left L1 dermatome
and possibly extending in to L2 dermatome, but can feel cold
sensation in these dermatomes although reduced compared to right
side. Intact proprioception in toes.
Rectal exam normal sphincter control
On discharge:
AAO x 3, strength full in lower extremities. Right hip numbness
and tingling through to labia majoria (right side only).
Sensation intact otherwise.
Pertinent Results:
___ MRI L spine
1. L4-5 degenerative disc disease and facet arthropathy
resulting in grade 1 anterolisthesis, moderate to severe spinal
canal stenosis, and mild bilateral neural foraminal stenosis.
2. Multilevel degenerative facet arthropathy.
3. No retroperitoneal hematoma.
___ CT abdomen and pelvis with contrast
1. No evidence for an intra-abdominal mass causing compression
of peripheral nerves
2. Incidental findings include an angiomyolipoma of the lower
pole of the left kidney and a subcentimeter hypodense lesion in
the liver that is too small to characterize but likely
represents a cyst or hemangioma.
___ 08:45PM BLOOD WBC-6.8 RBC-4.68 Hgb-13.5 Hct-40.9 MCV-87
MCH-28.8 MCHC-33.0 RDW-14.5 RDWSD-45.9 Plt ___
___ 08:45PM BLOOD Neuts-64.7 ___ Monos-8.2 Eos-0.7*
Baso-0.6 Im ___ AbsNeut-4.41 AbsLymp-1.74 AbsMono-0.56
AbsEos-0.05 AbsBaso-0.04
___ 08:45PM BLOOD ___ PTT-31.7 ___
___ 08:45PM BLOOD Glucose-119* UreaN-22* Creat-0.8 Na-142
K-4.5 Cl-106 HCO3-28 AnGap-13
Medications on Admission:
Acyclovir dose uncertain
Amlodipine 2.5 q am, 5mg q ___
Atenolol 25mg BID
Atorvastatin 80mg daily
Estradiol 0.5mg BID
Lasix 20mg QOD PRN
Lidoderm patch prn
Lisinopril 40mg BID
Aspirin 81mg daily
Discharge Medications:
1. Amlodipine 2.5 mg PO QAM
2. Amlodipine 5 mg PO HS
3. Aspirin 81 mg PO DAILY Hx of Stroke
4. Atenolol 25 mg PO BID
5. Atorvastatin 80 mg PO QPM
6. Diclofenac Sodium ___ 50 mg PO BID Pain
7. Estradiol 0.5 mg PO BID
8. Tizanidine 4 mg PO BID
9. Lisinopril 40 mg PO BID
10. Lidocaine 5% Patch 2 PTCH TD QAM
11. Outpatient Physical Therapy
Dx: L4-5 herniated nucleus pulposes
Discharge Disposition:
Home
Discharge Diagnosis:
L4-5 herniated nucleus pulposes
Right hip pain, numbness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST
INDICATION: *** CODE CORD *** History: ___ with LBP and R groin numbness IV
contrast to be given at radiologist discretion as clinically needed // eval
for cauda equina. PLEASE INCLUDE T11 AND T12. Please include eval for
retroperitoneal hematoma at these levels. eval for cauda equina
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed.
COMPARISON: No prior examinations of the lumbar spine are available.
FINDINGS:
There is very mild grade 1 anterolisthesis at L4-5. Alignment is otherwise
preserved. Marrow signal is within normal limits. There is desiccation of
the intervertebral discs with moderate disc height loss at L4-5. The distal
thoracic spinal cord is normal in course, caliber, and signal. The conus is
normal in appearance and position, terminating at L1-2.
T11-12: There is no disc herniation. There is no spinal canal or neural
foraminal stenosis.
T12-L1: There is no disc herniation or spinal canal stenosis. There is facet
arthropathy but no neural foraminal stenosis.
L1-2: There is no disc herniation or spinal canal stenosis. There is
ligamentum flavum thickening and facet arthropathy but no neural foraminal
stenosis.
L2-3: There is a diffuse disc bulge, ligamentum flavum thickening, and facet
arthropathy. There is no significant spinal canal or neural foraminal
stenosis.
L3-4: There is a mild diffuse disc bulge, ligamentum flavum thickening, and
facet arthropathy. There is mild spinal canal stenosis. There is no
significant neural foraminal stenosis.
L4-5: There is grade 1 anterolisthesis disc uncovering, a diffuse disc bulge
with a central protrusion, ligamentum flavum thickening with cystic changes
(image 9, series 3), and facet arthropathy. There is moderate to severe
spinal canal stenosis and mild bilateral neural foraminal stenosis.
L5-S1: There is a broad-based disc protrusion and facet arthropathy. There
is no significant spinal canal or neural foraminal stenosis.
The paravertebral soft tissues are normal. There is no retroperitoneal
hematoma. There is a probable cyst in the left kidney.
IMPRESSION:
1. L4-5 degenerative disc disease and facet arthropathy resulting in grade 1
anterolisthesis, moderate to severe spinal canal stenosis, and mild bilateral
neural foraminal stenosis.
2. Multilevel degenerative facet arthropathy.
3. No retroperitoneal hematoma.
Radiology Report
INDICATION: ___ year old woman with numbness in right L1 distribution, back
pain, and L4-5 disc herniation. // Please perform with and without contrast.
Concern for intra-abdominal process compressing peripheral nerves.
TECHNIQUE: MDCT images were obtained from the lung bases to the lesser
trochanters after administration of oral and intravenous contrast. Coronal
and sagittal reformations were prepared. DLP: 835 mGy per cm
COMPARISON: None
FINDINGS:
CT ABDOMEN: The lung bases are clear. The visualized portions of the heart
pericardium are normal. The liver enhances homogeneously and there is a
subcentimeter hypodense lesion in the dome of the liver on series 5, ___ 12.
This is too small to characterize but statistically most likely represents a
cyst or hemangioma. . 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 there is
a 1.5 cm low-density lesion in the lower pole of the left kidney measuring -70
___ consistent with an angiomyolipoma. . The stomach and small bowel are
unremarkable. There is no portacaval, mesenteric and retroperitoneal
lymphadenopathy. There is no free air or free fluid.
CT PELVIS: The appendix is normal. The colon, rectum, urinary bladder are
normal. There is no pelvic lymphadenopathy or free fluid.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for
malignancy.
IMPRESSION:
1. No evidence for an intra-abdominal mass causing compression of peripheral
nerves
2. Incidental findings include an angiomyolipoma of the lower pole of the left
kidney and a subcentimeter hypodense lesion in the liver that is too small to
characterize but likely represents a cyst or hemangioma.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, R Inguinal pain, RLQ abdominal pain
Diagnosed with SKIN SENSATION DISTURB
temperature: 98.4
heartrate: 58.0
resprate: 16.0
o2sat: 99.0
sbp: 180.0
dbp: 69.0
level of pain: 6
level of acuity: 2.0 | Mrs. ___ was admitted to the Neurosurgery service for
work-up of her right hip, genital pain and paresthesia. She was
initially kept NPO and give IV fluids in case she needed a
surgical procedure. A MRI of the L spine revealed a herniated
disc at L4-5, but no pathology at L1 to explain her symptoms.
Neurology was consulted to assist in working up her
paresthesias/pain. Per their recommendation, a CT of the
abdomen and pelvis was obtained to rule out pathology that could
cause compression of a peripheral nerve. That scan was negative
for any process causing nerve compression.
Mrs. ___ was discharged home on the afternoon of ___. Per
her discharge instructions, she should follow up with Dr. ___
___ Neurosurgery and Dr. ___ Neurology. An EMG was
ordered to further work-up her right-sided paresthesia.
Differential diagnoses, per Neurology, are meralgia paresthetica
or genitofemoral nerve pathology.
The patient was afebrile, hemodynamically and neurologically
intact.
**Attending of record at time of discharge was Dr. ___
___, MD. |