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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / sulfamethoxazole / trimethoprim
Attending: ___.
Chief Complaint:
Right intertrochanteric hip fracture
Major Surgical or Invasive Procedure:
Right TFN
History of Present Illness:
___ female history of depression, anxiety, dementia
who presents today from her nursing home after an unwitnessed
fall. She was unable to bear weight or ambulate following the
incident. She complained of immediate pain. She denied any
other injuries. Unclear if she sustained head strike or loss of
consciousness. She is confused at baseline and a poor
historian.
Per her ___ she does not walk with assistance of a walker or
cane
and suffers frequent falls. On arrival her trauma evaluation
was
negative for any other injuries.
Past Medical History:
Depression, anxiety, dementia
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM
==============
Vitals: T 98.4, HR 101, BP 134/80, RR 18, O2 98%RA
General: Lying in bed, awakens to voice and quickly falls back
asleep.
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: NR, RR. Nl S1/S2, no m/r/g
Lungs: CTAB, no wheezes, rales, or rhonchi
GI: soft, NT/ND, BS+, no rebound tenderness or guarding, no
organomegaly
Extremities: warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neuro: CN2-12 intact, no focal deficits
Skin: No rash or lesion
PSYCH: Unable to assess.
DISCHARGE EXAM
==============
VITALS:
24 HR Data (last updated ___ @ 1129)
24 HR Data (last updated ___ @ 1448)
Temp: 98.0 (Tm 98.2), BP: 110/63 (110-148/63-82), HR: 90
(83-100), RR: 16 (___), O2 sat: 93% (92-93), O2 delivery: Ra
GENERAL: Lying in bed, appearing calm
HEENT: Normocephalic, atraumatic. Pupils equal,
round, and reactive bilaterally, EOMI. Dry MM with yellow
crusts
on lips diffusely.
Neck: No JVP elevation. L-sided thyroid mass.
CV: RRR, no M/R/G on auscultation.
Lungs: No use of accessory muscles for breathing, decreased
bibasilar lung sounds L>R.
Abdomen: Soft, nontender to palpation, no hepatosplenomegaly.
Ext: WWP. No edema. R leg is internally rotated, patient is
moving all limbs independently. R hip surgical site is cdi with
staples in place, mild TTP
Neuro: Oriented to self. PERRL, EOMI. Moving all four limbs
independently.
Pertinent Results:
ADMISSION LABS
==============
___ 08:27AM BLOOD WBC-8.9 RBC-4.45 Hgb-13.5 Hct-43.1 MCV-97
MCH-30.3 MCHC-31.3* RDW-13.2 RDWSD-47.3* Plt ___
___ 08:27AM BLOOD Neuts-68.4 Lymphs-18.7* Monos-9.7 Eos-1.8
Baso-0.3 Im ___ AbsNeut-6.05 AbsLymp-1.66 AbsMono-0.86*
AbsEos-0.16 AbsBaso-0.03
___ 08:27AM BLOOD ___ PTT-23.3* ___
___ 08:27AM BLOOD Plt ___
___ 08:27AM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-138
K-5.0 Cl-101 HCO3-27 AnGap-10
___ 08:27AM BLOOD ALT-8 AST-20 AlkPhos-60 TotBili-0.8
___ 08:27AM BLOOD cTropnT-<0.01
___ 08:27AM BLOOD Albumin-3.9 Calcium-9.6 Phos-3.3 Mg-2.0
NOTABLE LABS
============
___ 05:00AM BLOOD Hapto-163
___ 06:01AM BLOOD ___ 06:01AM BLOOD TSH-4.7*
___ 08:27AM BLOOD TSH-5.1*
___ 06:01AM BLOOD Free T4-0.8*
___ 06:01AM BLOOD 25VitD-27*
___ 06:01AM BLOOD ALT-9 AST-33 LD(LDH)-464* AlkPhos-80
TotBili-0.7
___ 05:00AM BLOOD ALT-6 AST-24 LD(LDH)-484* AlkPhos-68
TotBili-0.5
DISCHARGE LABS
==============
URINE
=====
___ 01:32PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:39PM URINE Color-Straw Appear-Clear Sp ___
___ 01:32PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 02:39PM URINE Blood-SM* Nitrite-POS* Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:32PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 02:39PM URINE RBC-4* WBC-0 Bacteri-FEW* Yeast-NONE
Epi-0
___ 01:32PM URINE CastHy-1*
___ 02:32PM URINE Hours-RANDOM UreaN-563 Creat-196 Na-LESS
THAN
MICRO
=====
___ 2:39 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
STUDIES/IMAGING
===============
RIGHT PELVIS/FEMUR PLAIN FILM ___
IMPRESSION:
Intertrochanteric right femoral neck fracture with varus
angulation.
CXR ___
IMPRESSION:
Patchy bibasilar opacities likely reflect atelectasis, though
underlying pneumonia is difficult exclude.
___ ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
There is prominence of the ventricles and sulci suggestive of
involutional changes. Nonspecific periventricular white matter
hypodensities are suggestive of mild-to-moderate chronic small
vessel ischemic disease. 7 mm parietal bone lesion series 3,
image 40, likely benign venous legal hemangioma in the absence
of history of malignancy.
There is no evidence of fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
No acute intracranial process.
Remainder as above.
CT TORSO ___
IMPRESSION:
1. Intertrochanteric right femoral neck fracture with varus
angulation.
2. No acute intrathoracic or intra-abdominal process.
3. Endometrial thickening measuring up to 14 mm. Recommend
further evaluation with pelvic ultrasound on a nonemergent
basis, as endometrial carcinoma cannot be excluded.
4. Enhancing 3.4 cm left thyroid mass. Recommend further
evaluation with thyroid ultrasound on a nonemergent basis.
5. Subcentimeter liver lesions are indeterminate and too small
to
characterize, but may represent hemangiomas
RECOMMENDATION(S):
1. Pelvic ultrasound.
2. Thyroid ultrasound.
CT C-SPINE ___
IMPRESSION:
1. No acute fracture.
2. Degenerative changes cervical spine, as above.
3. Thyroid nodules, largest 3.3 cm, ultrasound recommended, see
below.
RECOMMENDATION(S):
Thyroid nodule. Ultrasound 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.
CXR ___
IMPRESSION:
Compared to chest radiographs ___.
Atelectasis is still severe in the left lower lobe, moderate on
the right. Upper lobes are clear. Lungs elsewhere are clear.
Heart is moderately enlarged, distorted by severe thoracic
scoliosis.
THYROID US ___
IMPRESSION:
Limited ultrasound evaluation due to limited cooperation.
Partially seen is a left thyroid nodule better characterized on
recent CT.
CXR ___
IMPRESSION:
Severe kyphoscoliosis limiting evaluation of the chest x-ray.
Within this limitation no acute pulmonary abnormality beyond
small amount of pleural effusion on the left.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral DAILY
3. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Mirtazapine 15 mg PO QHS
7. Divalproex (DELayed Release) 250 mg PO BID
8. Propranolol 10 mg PO BID
9. LORazepam 1 mg PO TID
10. QUEtiapine Fumarate 50 mg PO TID
11. Gabapentin 100 mg PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. Divalproex Sod. Sprinkles 125 mg PO BID
2. Heparin 5000 UNIT SC BID
Continue until ___
3. Ibuprofen Suspension 800 mg PO Q8H Duration: 5 Days
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Duration: 5 Days
5. Levothyroxine Sodium 50 mcg PO DAILY
6. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q4H:PRN
Disp #*17 Tablet Refills:*0
7. OxyCODONE (Immediate Release) 2.5 mg PO QHS
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*4 Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. Thiamine 100 mg PO DAILY
10. Acetaminophen 1000 mg PO Q8H
11. LORazepam 1 mg PO QHS
12. LORazepam 0.5 mg PO QAM
13. Polyethylene Glycol 17 g PO DAILY
14. QUEtiapine Fumarate 25 mg PO QHS
15. QUEtiapine Fumarate 25 mg PO BID:PRN agitation
16. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral
DAILY
17. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
18. Escitalopram Oxalate 20 mg PO DAILY
19. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third
Line
20. Mirtazapine 15 mg PO QHS
21. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
22. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN dry
23. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intertrochanteric hip fracture
Acute toxic metabolic encephalopathy
community acquired UTI
___
Hypoxemic respiratory failure
Leukocytosis
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: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with trauma, hip pain// hemorrhage, fracture
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.9 cm; CTDIvol = 47.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Nonspecific periventricular white matter hypodensities are suggestive of
mild-to-moderate chronic small vessel ischemic disease. 7 mm parietal bone
lesion series 3, image 40, likely benign venous legal hemangioma in the
absence of history of malignancy.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Remainder as above.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with trauma, hip pain// hemorrhage, fracture
hemorrhage, 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 5.0 s, 19.8 cm; CTDIvol = 22.5 mGy (Body) DLP = 446.0
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
Total DLP (Body) = 506 mGy-cm.
COMPARISON: None.
FINDINGS:
No fracture. No prevertebral edema. Mild anterolisthesis C3-C4, T2-T3,
likely degenerative. Findings consistent with benign bone island C2 vertebral
body.
Multilevel degenerative changes, disc space narrowing, disc osteophyte
complexes, multilevel probably mild-to-moderate central canal narrowing most
prominent at C3-C4 level, and multilevel moderate to severe foraminal
narrowing. Multiple thyroid nodules, largest measures 3.3 cm, ultrasound
suggested.
IMPRESSION:
1. No acute fracture.
2. Degenerative changes cervical spine, as above.
3. Thyroid nodules, largest 3.3 cm, ultrasound recommended, see below.
RECOMMENDATION(S):
Thyroid nodule. Ultrasound 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 CHEST/ABD/PELVIS W/ CONTRAST
INDICATION: History: ___ with trauma, hip pain// hemorrhage, fracture
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.4 s, 58.3 cm; CTDIvol = 15.4 mGy (Body) DLP = 895.3
mGy-cm.
Total DLP (Body) = 895 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. Heart is moderately enlarged.. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Extensive bibasilar atelectasis. Lungs otherwise clear. 5 mm
subpleural left lower lobe nodule is noted (02:43). Airways are patent to
segmental levels.
BASE OF NECK: There is a heterogeneously enhancing 3.4 x 2.9 cm left thyroid
mass.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Multiple subcentimeter hypodense lesions are too small to characterize, though
several demonstrate faint nodule peripheral enhancement suggesting hemangioma.
There is no evidence of intrahepatic or extrahepatic biliary dilatation.
Small layering stones versus sludge are noted within the gallbladder.
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.
No hydronephrosis. Few subcentimeter hypodensities in the right kidney are
too small to characterize. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. There is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: Endometrium is thickened measuring up to 14 mm. A 5.0 x
5.5 cm heterogeneously enhancing mass arising exophytically from the fundus of
the uterus likely represents a large exophytic fibroid. A talk is seen on ___
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: There is an intertrochanteric right femoral neck fracture with varus
angulation. No other fractures. Severe dextroconvex scoliosis of the
thoracic and levoconvex scoliosis of the lumbar spine are noted. Chronic
appearing left-sided rib fractures are noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Intertrochanteric right femoral neck fracture with varus angulation.
2. No acute intrathoracic or intra-abdominal process.
3. Endometrial thickening measuring up to 14 mm. Recommend further evaluation
with pelvic ultrasound on a nonemergent basis, as endometrial carcinoma cannot
be excluded.
4. Enhancing 3.4 cm left thyroid mass. Recommend further evaluation with
thyroid ultrasound on a nonemergent basis.
5. Subcentimeter liver lesions are indeterminate and too small to
characterize, but may represent hemangiomas
RECOMMENDATION(S):
1. Pelvic ultrasound.
2. Thyroid ultrasound.
Radiology Report
EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO RIGHT
INDICATION: Right hip fracture, ORIF
COMPARISON: Right femur radiographs ___
FINDINGS:
4 intraoperative images were acquired without a radiologist present.
Images show steps in surgical fixation of comminuted intertrochanteric
fracture with a gamma nail. Post repair images demonstrate improved fracture
alignment.
IMPRESSION:
Intraoperative images were obtained during surgical fixation of the comminuted
intertrochanteric fracture. Please refer to the operative note for details of
the procedure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old woman with new o2 requirement// etiology of o2
requirement etiology of o2 requirement
IMPRESSION:
Compared to chest radiographs ___.
Atelectasis is still severe in the left lower lobe, moderate on the right.
Upper lobes are clear. Lungs elsewhere are clear. Heart is moderately
enlarged, distorted by severe thoracic scoliosis.
Radiology Report
EXAMINATION: THYROID U.S.
INDICATION: ___ year old woman with psych history, admitted after fall causing
R IT fracture now s/p repair, hospitalization c/b persistent AMS, found to
have mild hypothyroidism and an enhancing 3.4 cm left thyroid mass.// better
evaluation/assessment of L thyroid mass
TECHNIQUE: Grey scale and color Doppler ultrasound images of the neck were
obtained.
COMPARISON: CT from ___
FINDINGS:
Limited ultrasound evaluation due to limited cooperation.
The right lobe measures: (transverse) 1.4 x (anterior-posterior) 0.2 x
(craniocaudal) 3.7 cm.
The left lobe measures: (transverse) 1.4 x (anterior-posterior) 2.7 x
(craniocaudal) 3.4 cm.
Isthmus anterior-posterior diameter is 0.2 cm.
The thyroid parenchyma is heterogenous and has normal vascularity.
Previously described left thyroid nodule is hardly seen given its posterior
and deep location. Portion visualized of the nodule measures 2.3 x 2.2 x 3.3
cm. This nodule appears solid, slightly hypoechoic.
IMPRESSION:
Limited ultrasound evaluation due to limited cooperation. Partially seen is a
left thyroid nodule better characterized on recent CT.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypoxia, and leukocytosis. Concern for
infection.// Please evaluate for pneumonia.
TECHNIQUE: Chest AP
COMPARISON: Chest x-ray from 5 days ago
FINDINGS:
Severe kyphoscoliosis. Cardiac silhouette is mildly enlarged, stable compared
to the prior study. Blunting left costophrenic angle consistent with small
amount of pleural effusion. No acute pulmonary abnormality.
IMPRESSION:
Severe kyphoscoliosis limiting evaluation of the chest x-ray. Within this
limitation no acute pulmonary abnormality beyond small amount of pleural
effusion on the left.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ with hypoxia, hip pain// pna, fracture
COMPARISON: None
FINDINGS:
Portable AP view of the chest provided.
Lung volumes are low. Patchy left basilar opacities likely reflect
atelectasis. No large pleural effusion or pneumothorax. Heart size is mildly
enlarged. Mediastinal silhouette is otherwise within normal limits. There is
severe dextroconvex scoliosis of the mid thoracic spine and levoconvex
scoliosis of the imaged thoracolumbar spine.
IMPRESSION:
Patchy bibasilar opacities likely reflect atelectasis, though underlying
pneumonia is difficult exclude..
Radiology Report
EXAMINATION: DX PELVIS AND FEMUR
INDICATION: History: ___ with right hip pain, fall// fracture/dislocation
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the right hip. Frontal and lateral radiographs of
the right knee were also obtained.
COMPARISON: None
FINDINGS:
There is an intertrochanteric right femoral neck fracture with varus
angulation. Mild degenerative changes of bilateral hip joints. Status post
total right knee arthroplasty which appears appropriately position. No
evidence of hardware complication. There is no suspicious lytic or sclerotic
lesion. There is no soft tissue calcification or radio-opaque foreign body.
IMPRESSION:
Intertrochanteric right femoral neck fracture with varus angulation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hip pain, s/p Fall
Diagnosed with Pain in right hip
temperature: 99.6
heartrate: 75.0
resprate: 20.0
o2sat: 87.0
sbp: 139.0
dbp: 82.0
level of pain: 10
level of acuity: 1.0 | ___ PMHx recurrent severe depression who came to the hospital
after a fall at her nursing home, found to have a R
intertrochanteric hip fracture. She underwent repair with
Orthopedic Surgery on ___. Hospital course was complicated
by encephalopathy (hyper/hypo active delirium), hypoxia, ___ and
Klebsiella UTI. She improved and was discharged to rehab near
her mental status baseline.
Of note, she had a markedly elevated LDH and a leukocytosis that
was of unclear etiology. She also had uterine thickening and an
exophytic uterine mass (possibly fibroid) that warrants follow
up as an outpatient (PCP and ___ were made aware).
TRANSITIONAL ISSUES
===================
[] Patient will require heparin ppx through ___ per
orthopedic surgery recs (4wks)
[] Patient will require orthopedics follow-up 2wks after
discharge with ___, NP
[ ]Staples to be removed at follow-up appointment in 2 weeks
[] Patient was started on levothyroxine 50mcg qDay. Repeat TFTs
in ___
[] Patient will require repeat thyroid US as an outpatient to
evaluate L thyroid mass
[] Should consider nonemergent pelvic US vs. MRI to evaluate
incidental endometrial thickness measuring up to 14mm
(endometrial carcinoma cannot be excluded)
[] ECG was notable for inferior Q-waves, patient should have
HbA1C/lipids evaluated, consider initiation of ASA/statin
[ ] Repeat CBC and LDH 1 week after discharge and send result to
PCP. Discharge WBC 16.9, discharge LDH 500.
[ ] Ibuprofen and lansoprazole should be stopped on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Aspirin / Codeine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy
History of Present Illness:
___ w/ 4 day history of right sided groin pain. He is s/p left
inguinal hernia repair in ___. He has noted an increasing bulge
over the last several days in his right groin which has become
increasingly tender to palpation. He denies any nausea,
vomiting, fevers, chills, diarrhea, constipation or changes in
his bowel habbits.
Past Medical History:
HTN
Surg Hx:
Exlap with SBR s/p GSW ___
left inguinal hernia repair with mesh ___
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Vitals: 97.4 65 135/84 18 98 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, no rebound or guarding,
normoactive bowel sounds, right inguinal region TTP with
reducible mass
Ext: No ___ edema, ___ warm and well perfused
On discharge:
VS: 97.8, 70, 130/82, 18, 100% RA
Gen: AAOx3, NAD
CV: RRR no m/r/g
Pulm: CTAB no w/r/r
Abd: Soft, appropriately tender around incision sites,
non-distended, +BS, incision c/d/i
Ext: No c/c/e, WWP
Pertinent Results:
___ 11:30AM BLOOD WBC-5.2 RBC-4.88 Hgb-14.4 Hct-42.1 MCV-86
MCH-29.4 MCHC-34.1 RDW-13.5 Plt ___
Medications on Admission:
Denies
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Non-incarcerated symptomatic right inguinal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Recurrent right groin bulge, pain and tenderness, now status post
reduction. Evaluate bowel obstruction, internal hernia sac.
COMPARISON: None available.
TECHNIQUE: Axial MDCT images were obtained through the abdomen and pelvis
after the uneventful administration of oral contrast and 130 cc Omnipaque
intravenous contrast. Sagittal and coronal reformats were generated.
Total exam DLP: 444 mGy-cm.
CTDI: 42 mGy.
FINDINGS:
There is mild bibasilar atelectasis. There is no pleural or pericardial
effusion.
CT OF THE ABDOMEN: The liver enhances homogeneously with no evidence of focal
hepatic lesions. The gallbladder is unremarkable. The portal vein is patent.
The adrenal glands, pancreas and spleen are within normal limits. The kidneys
enhance symmetrically and excrete contrast without evidence of hydronephrosis
or masses.
Contrast is seen within the stomach, small bowel, colon and reaching the
rectum with no evidence of obstruction. Surgical changes are seen in small
and large bowel with evidence of an ileocolic and gastrojejunal anastomosis
(2:24, 35). At the level of the ileocolic there is focal dilation of the
proximal portion with evidence of fecal stagnation (2:43). There is no bowel
wall abnormality. There is no free fluid or free air. The abdominal aorta
and its major branches are patent. There is no mesenteric or retroperitoneal
lymph node enlargement by CT size criteria.
CT OF THE PELVIS: The urinary bladder and terminal ureters are within normal
limits. The rectum is grossly unremarkable. There is no inguinal or pelvic
lymph node enlargement by CT size criteria. There is mild prominence of fat
surrounding the right vas deferens and inguinal region in the right. There is
no pelvic free fluid.
OSSESOUS STRCUTURES: Degenerative changes are noted in the lower lumbar spine
and right hip. No blastic or lytic lesion concerning for malignancy is
present.
IMPRESSION:
1. No evidence of small bowel obstruction.
2. Patient is status post ileocolic and gastrojejunal anastomosis with mild
focal dilation of bowel loop proximal to ileocolic anastomsis with evidence of
fecalization/ stagnation.
Findings discussed with ___ by ___ via telephone on
___ at 15:25, time of discovery.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: RIGHT GROIN PAIN
Diagnosed with UNILAT INGUINAL HERNIA
temperature: 97.4
heartrate: 65.0
resprate: 18.0
o2sat: 98.0
sbp: 135.0
dbp: 84.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ was admitted to the ___ service with HPI as stated
above. A CT scan demonstrated a small fat-containing right
inguinal hernia with no evidence of bowel loops within it as
well as evidence of previous abdominal surgery. He was taken to
the operating room for a right inguinal hernia repair which went
without complication. The patient was extubated and went to the
PACU and then to the floor in stable condition.
Pain was well-controlled on an appropriate regimen of pain
medicines and the patient remained afebrile in the postoperative
period. He tolerated an advanced diet without nausea or
vomiting. He was discharged to home on ___ with
appropriate prescriptions and instructions to follow up in ___
weeks in ___ clinic as well as what signs and symptoms of which
to be vigilant. He expressed appropriate understanding of all
instructions and was discharged to home in good condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Augmentin
Attending: ___.
Chief Complaint:
Bright red blood per rectum, diarrhea
Major Surgical or Invasive Procedure:
Flex sigmoidoscopy (___)
History of Present Illness:
Ms. ___ is a ___ woman with history of pan-ulcerative
colitis on balsalazide, IBS, and bipolar disorder, who presents
with bright red blood per rectum and diarrhea for 1 month.
Aside from a brief flare ___ year ago in the setting of quitting
tobacco, the patient has not had a flare up of her UC since age
___. She states that ___ weeks ago she started having stools with
blood in the absence of abdominal pain which has progressed to
frank bloody diarrhea. At the onset of the abdominal pain, she
continued taking her medications and stuck to a BRAT diet. Her
oral intake was okay until this week when she developed
constant, lower abdominal pain ("something expanding in my
stomach") and nausea. The abdominal pain is exacerbated by oral
intake, including water, and migrates to her epigastrium after
meals. It
also gets worse just before a bowel movement and improves
slightly after defecation. She reports having up to 6 BMs per
day without eating and at least 10 episodes/day with oral
intake. She does not report rectal pain/cramping. She has had no
recent antibiotic or NSAID use. No recent sick contacts. Does
not report
fevers or chills. Endorses mild weight loss (116lbs down from
baseline weight 120 lbs).
The patient was started on oral prednisone 30 mg 5 days prior to
presentation with little relief. This was increased to 50 mg on
the day prior to admission, though the patient did not pick up
this new prescription. She was seen by her GI physician (Dr.
___, who referred her to the emergency room for IV
steroids, sigmoidoscopy, and admission for likely UC flare.
On additional review of systems, the patient does not report
headache, vision changes, lightheadedness, palpitations, chest
pain, or dyspnea. She is currently on her period. She does not
report any UTI symptoms, rashes, or difficulty ambulating.
In the ED:
Initial vital signs were notable for: T 98.3, HR 95, BP 111/86,
RR 16, O2 sat 100% on RA
Exam notable for:
Abd: +BS, nondistended but diffusely tender; no rebound or
guarding
Rectal: normal external appearance; frank red blood; no internal
hemorrhoids
Labs were notable for: WBC 11.0 (59% neuts, 31% lymphs), Hgb
12.0, CRP 72.2, albumin 3.3, K 2.9, lactate 1.5
Imaging studies were notable for: KUB that was unremarkable
Patient was given: 20mEq of IV KCl
Consults: GI: RECOMMENDATIONS
- Diet: diet as tolerated
- mIVF if unable to tolerate PO
- Pain control: ok for APAP; avoid opiates, NSAIDS
- Hold on anti-diarrheal agents
- No indication for CT abdomen/pelvis at this time
- Repeat CRP at 72 hours to assess for improvement on steroids
and decide on need for rescue therapy
- F/u C. diff; if negative, initiate Methylprednisolone 20 mg IV
q8h
- No role for antibiotics at this time
- Plan for flexible sigmoidoscopy tomorrow - please make NPO
after midnight with mIVF
Vitals on transfer: T 98.2, HR 86, BP 118/72, RR 16, O2 sat 100%
on RA
Upon arrival to the floor, the patient confirmed the above
history. She noted that her trigger may have been stress in the
setting of switching jobs, as well as decreasing her nicotine
amount . Otherwise, does not report fevers, chills, chest pain,
shortness of breath, vomiting, and changes in bladder habits.
Past Medical History:
Pan-ulcerative colitis: diagnosed ___, c/b SBO in ___, in
clinical remission in ___ on balsalazide therapy
Mild IBS
Bipolar disorder
Acne
H/o hyponatremia requiring hospitalization secondary to
psychogenic polydipsia (hospitalized ___
Chlamydia (___)
Social History:
___
Family History:
No history of intestinal disease
Mother: ___ "organs shut down".
MGM: Diabetes, Stroke, HTN.
MGF: COPD, Lung and stomach cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
VITALS: T 98.2 PO, BP 105 / 74, HR 81, RR 16, O2 sat 98% on RA
GENERAL: Alert and interactive. In no acute distress. Tearful
and anxious.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes.
Oropharynx is clear.
NECK: Supple. No LAD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops/thrills.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
ABDOMEN: Hyperactive bowel sounds, non distended, tender in the
bilateral lower quadrants and RUQ to deep palpation. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or lower extremity edema.
Pulses Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: A&Ox3, moving all 4 extremities with purpose.
DISCHARGE PHYSICAL EXAM
=======================
VS: Temp 98.4 BP 106/68 HR 60 RR 18 97% on RA
GEN: NAD. Lying comfortably in bed.
HEENT: MMM. NC/AT.
NECK: Supple.
CV: RRR with normal S1 & S2, no m/r/g.
LUNGS: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
ABD: Soft, non-tender to light palpation. Voluntary guarding.
Normoactive BS.
EXT: Warm, No ___ edema or erythema.
SKIN: Dry, No rash.
NEUROLOGIC: A&Ox3, moving all 4 extremities with purpose.
Pertinent Results:
ADMISSION LABS:
==============
___ 02:40PM WBC-11.0* RBC-3.78* HGB-12.0 HCT-34.7 MCV-92
MCH-31.7 MCHC-34.6 RDW-12.2 RDWSD-41.1
___ 02:40PM NEUTS-59.0 ___ MONOS-8.0 EOS-1.0
BASOS-0.5 NUC RBCS-0.2* IM ___ AbsNeut-6.48* AbsLymp-3.40
AbsMono-0.88* AbsEos-0.11 AbsBaso-0.05
___ 02:40PM CRP-72.2*
___ 02:40PM GLUCOSE-85 UREA N-5* CREAT-0.8 SODIUM-139
POTASSIUM-2.9* CHLORIDE-96 TOTAL CO2-29 ANION GAP-14
___ 02:40PM ALT(SGPT)-6 AST(SGOT)-11 ALK PHOS-81 TOT
BILI-<0.2
___ 02:40PM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-2.6*
MAGNESIUM-2.0
PERTINENT LABS:
==============
___ 02:40PM BLOOD Lipase-92*
___ 02:40PM BLOOD CRP-72.2*
___ 12:49PM BLOOD CRP-96.2*
___ 08:57AM BLOOD CRP-55.0*
___ 02:53PM BLOOD Lactate-1.5
___ 03:40PM BLOOD SED RATE 17
___ 03:40PM URINE UCG-NEGATIVE
___ 03:40PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 03:40PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM*
___ 03:40PM URINE RBC-1 WBC-5 BACTERIA-FEW* YEAST-NONE
EPI-9
DISCHARGE LABS:
===============
___ 08:57AM BLOOD WBC-14.9* RBC-3.70* Hgb-12.0 Hct-35.0
MCV-95 MCH-32.4* MCHC-34.3 RDW-12.5 RDWSD-43.2 Plt ___
___ 08:57AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-143 K-4.2
Cl-100 HCO3-27 AnGap-16
___ 08:57AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.0
PERTINENT IMAGING/PROCEDURES:
============================
___ Flex sigmoidoscopy:
Edema, erythema, friability, and granularity in the rectum and
sigmoid colon compatible with ulcerative colitis.
___ Rectosigmoid, biopsy:
-Chronic mild active colitis.
- No granulomata or dysplasia identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 50 mg PO DAILY
2. Amphetamine-Dextroamphetamine 30 mg PO DAILY
3. balsalazide 2250 mg oral TID
4. Omeprazole 40 mg PO DAILY
5. Divalproex (DELayed Release) ___ mg PO DAILY
6. erythromycin-benzoyl peroxide ___ % topical DAILY
7. Gabapentin 200 mg PO TID
8. Mirtazapine 60 mg PO QHS
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
2. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth 4 times per day Disp
#*46 Capsule Refills:*0
3. PredniSONE 40 mg PO DAILY
40mg through ___ 30mg through ___, 20mg through ___, 10mg
through ___
RX *prednisone 10 mg 4 tablet(s) by mouth every day Disp #*100
Tablet Refills:*0
4. Amphetamine-Dextroamphetamine 30 mg PO DAILY
5. balsalazide 2250 mg oral TID
6. Divalproex (DELayed Release) ___ mg PO DAILY
7. erythromycin-benzoyl peroxide ___ % topical DAILY
8. Gabapentin 200 mg PO TID
9. Mirtazapine 60 mg PO QHS
10. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth every day Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
#Primary:
Ulcerative colitis flare
C.diff infection
#Secondary:
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with UC flare x1 month with abdominal pain// eval for free
air
COMPARISON: Prior study from ___
FINDINGS:
Supine and upright views of the abdomen pelvis were provided. The bowel gas
pattern is unremarkable demonstrating no signs of ileus or obstruction. No
free air seen below the right hemidiaphragm. No worrisome calcifications.
Imaged lung bases are clear. Bony structures appear intact
IMPRESSION:
Unremarkable exam.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Ulcerative colitis, unspecified, without complications
temperature: 98.3
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 111.0
dbp: 86.0
level of pain: 4
level of acuity: 3.0 | ___ with a history of pan-ulcerative colitis on balsalazide,
IBS, and bipolar disorder, who presented with BRBPR and diarrhea
x1 month found to have C diff infection and ulcerative colitis
flare, treated with PO Vancomycin and steroids.
# Ulcerative colitis
Patient with h/o UC, presented with bloody diarrhea and
abdominal pain, consistent with UC flare. This was likely
exacerbated by or triggered by C diff infection. Patient
evaluated by GI with flex sig on ___ which showed diffuse
erythema, edema and friability of the mucosa, pathology
consistent with ulcerative colitis. Stool studies as above
notable for C diff infection, remaining stool studies pending at
the time of discharge. She was started on IV methylprednisone
and transitioned to oral prednisone after ~48 hours. CRP
initially elevated to 72.2, peaked at 96, and improved to 55 at
the time of discharge. Patient also with marked improvement in
symptoms following treatment with steroids/vanc. Patient
declined DVT ppx during admission despite understanding of risks
and benefits - that she is particularly high risk for DVT given
h/o UC. Patient discharged on PO prednisone taper (40 mg x 10
days, then 30 mg x 10 days, then 20 mg x 10 days, then 10 mg x
10 days). She was given a prescription for omeprazole
(prescribed previously by outpatient providers) given prednisone
taper. Home balsalazide held during admission per GI, restarted
at discharge.
# C diff infection:
Found to be C diff positive on admission, likely community
acquired. Treated with PO vancomycin 125mg q6hrs, ___, which
she will continue for 14d course through ___.
# Bipolar Disorder:
Continued home dextroamphetamine-amphetamine, divalproex, and
mirtazapine
TRANSITIONAL ISSUES:
====================
[ ] Patient discharged on PO prednisone 40 mg x 10 days, then 30
mg x 10 days, then 20 mg x 10 days, then 10 mg x 10 days.
[ ] Continue PO Vancomycin 125mg q6hrs through ___.
[ ] Provided Rx for omeprazole, previously prescribed by
outpatient providers but patient unable to fill. F/U with
outpatient providers, including PCP and GI, to determine
requisite course.
[ ] Stool Cx pending at discharge. F/U with outpatient providers
for these results.
[ ] F/U pending pathology, CMV staining. F/U with GI for these
results. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Codeine / Percocet / Neomycin / Darvocet-N 100
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
___: cardiac angiography with DES x2 to LAD
History of Present Illness:
Ms. ___ is an ___ year old woman with T2DM (on insulin), HTN,
HLD, newly diagnosed AF (not on anticoagulation), who presented
from ___ (assisted living ___) at 6am with 2
hours of chest pressure, EMS EKG with ST elevations in
precordial leads and associated ST depressions in inferior
leads, urgently taken to cath lab.
Patient reports that this AM she woke up around 6am and felt
"funny." She checked her sugar, which was normal. She then
developed substernal pain with radiation to the back and R
shoulder. She had no associated SOB, DOE, heart palpitations or
diaphoresis. At her facility they attributed her symptoms to
anxiety and gave her Ativan. However, after eating some
breakfast she became nauseous and vomited her breakfast. EMS was
then called, who upon arrival got an EKG which showed STE in the
precordial leads and called a pre-hospital code STEMI.
In cath lab, found to have 3 vessel coronary artery disease. Two
drug-eluting stents placed in the LAD. She was not ticagrelor
preloaded due to nausea and instead loaded with cangrelor then
received 180mg ticagrelor after PCI.
Upon arrival to the floor, patient reports feeling very anxious
and tired. She denies any chest pain, SOB, DOE, lightheadedness,
dizziness, palpitations, nausea or vomiting.
Past Medical History:
Depression
Diabetes
HTN
HLD
Hypothyroidism
Osteoporosis
DJD
Hx GIB with GAVE and H.pylori
Hx Bacterial Overgrowth Syndrome
Hx Colonic Adenoma
Hx Zoster
Hx TAH
Hx CCY
Hx L Leg Squamous Cell Ca s/p Resection
Transitional Cell Carcinoma of the Bladder s/p Removal at
___
___ History:
___
Family History:
Mother with stroke and type 2 DM
Sister with stroke
Brother with brain cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 97.9 BP 152/70 HR 85 RR 18 O2 SAT 99% RA
GENERAL: Elderly, frail woman, anxious, lying comfortably in
bed, alert and awake, speaking in full sentences, in NAD.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple, unable to appreciate JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decreased breath sounds
at bases; no crackles, wheezes or rhonchi.
ABDOMEN: +BS, soft, NTND, no rebound or guarding.
EXTREMITIES: WWP, trace edema of ankles, no clubbing or
cyanosis.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
========================
Tele: no events
VS: T 98.0 BP 152/60 (100s/50-60) HR 63 (50-60) O2 SAT 96% RA
GENERAL: Elderly, frail woman, anxious, lying comfortably in
bed, alert and awake, speaking in full sentences, in NAD.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple, unable to appreciate JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decreased breath sounds
at bases; no crackles, wheezes or rhonchi.
ABDOMEN: +BS, soft, NTND, no rebound or guarding.
EXTREMITIES: WWP, trace edema of ankles, no clubbing or
cyanosis.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
===============
___ 10:27AM BLOOD WBC-10.9* RBC-3.20* Hgb-10.2* Hct-29.0*
MCV-91 MCH-31.9 MCHC-35.2 RDW-12.8 RDWSD-42.6 Plt ___
___ 10:27AM BLOOD ___
___ 10:27AM BLOOD Glucose-205* UreaN-9 Creat-1.0 Na-137
K-2.7* Cl-104 HCO3-18* AnGap-18
___ 10:27AM BLOOD cTropnT-0.05*
___ 10:27AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.6
NOTABLE LABS:
=============
___ 10:27AM BLOOD cTropnT-0.05*
___ 09:51PM BLOOD cTropnT-0.60*
___ 05:00AM BLOOD cTropnT-0.51*
___ 10:27AM BLOOD UreaN-9 Creat-1.0
___ 09:51PM BLOOD UreaN-8 Creat-1.0
___ 05:00AM BLOOD UreaN-7 Creat-1.1
___ 05:00AM BLOOD UreaN-12 Creat-1.3*
___ 05:30AM BLOOD UreaN-16 Creat-1.4*
___ 04:55AM BLOOD UreaN-15 Creat-1.2*
___ 10:27AM BLOOD ___
___ 05:00AM BLOOD ___ PTT-27.3 ___
___ 05:30AM BLOOD ___
___ 04:55AM BLOOD ___
DISCHARGE LABS:
================
___ 04:55AM BLOOD ___
___ 04:55AM BLOOD Glucose-149* UreaN-15 Creat-1.2* Na-134
K-4.0 Cl-101 HCO3-21* AnGap-16
___ 04:55AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.9
IMAGING:
=========
___ Imaging CHEST (PORTABLE AP)
New opacities in the left lower lobe worrisome for pneumonia.
___ Angiography:
Coronary Anatomy
Dominance: Right
-LMCA: The LMCA tapered to 30% distally.
-LAD: The LAD had an ostial hazy 30% plaque. The small high D1
had a tubular ostial 50% stenosis. The mid LAD tapered to 85%
between D1 and the large D2. D2 had a proximal hazy 30% plaque,
a mid hazy 25% plaque and distal tortuousity and a terminal
bifurcation. The mid LAD had an eccentric tubular 60% stenosis
with TIMI 2 pulsatile flow beyond.
-LCX: The CX gave off a modest caliber very high OM1. OM2 had a
broad bend. The AV groove CX was small with an 80% stenosis
supplying a tortuous LPL1 with TIMI 2 flow and a tiny LPL2.
-RCA: The RCA had a mid 60% stenosis. The RPDA was a large,
branching vessel, as was the large RPL that extended well up the
LV.
Impressions:
1. Three vessel coronary artery disease.
2. Low left ventricular end-diastolic pressure at entry.
3. Successful primary PCI with deployment of 2 Synergy
drug-eluting stents in the mid LAD with estimated D2B of 25
minutes.
___ TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is an apical left ventricular aneurysm. Overall
left ventricular systolic function is moderately depressed
(LVEF= 35 %) secondary to extensive severe apical hypokinesis
with focal akinesis. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BusPIRone 11.25 mg PO BID
2. Simethicone 125 mg PO QID:PRN gas
3. BusPIRone 7.5 mg PO QHS
4. Polyethylene Glycol 17 g PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. FLUoxetine 40 mg PO DAILY
7. Acidophilus (Lactobacillus acidophilus) oral DAILY
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
9. Senna 17.2 mg PO QHS:PRN constipation
10. LORazepam 0.5 mg PO TID:PRN anxiety
11. Pantoprazole 40 mg PO Q24H
12. Pravastatin 80 mg PO QPM
13. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
14. Docusate Sodium 100 mg PO BID:PRN constipation
15. amLODIPine 5 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Diltiazem Extended-Release 120 mg PO DAILY
18. Levothyroxine Sodium 50 mcg PO DAILY
19. Calcium Carbonate 500 mg PO BID
20. GlipiZIDE XL 10 mg PO QAM
21. GlipiZIDE XL 5 mg PO QPM:PRN if ___ is >200 at dinner
22. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL)
subcutaneous 30 units daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet
Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. DULoxetine 30 mg PO DAILY
RX *duloxetine 30 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Warfarin 2.5 mg PO DAILY16
Please take according to your ___ clinic
instructions.
8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
9. Acidophilus (Lactobacillus acidophilus) oral DAILY
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
11. BusPIRone 11.25 mg PO BID
12. BusPIRone 7.5 mg PO QHS
13. Calcium Carbonate 500 mg PO BID
14. Docusate Sodium 100 mg PO BID:PRN constipation
15. GlipiZIDE XL 10 mg PO QAM
16. GlipiZIDE XL 5 mg PO QPM:PRN if ___ is >200 at dinner
17. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL)
subcutaneous 30 units daily
18. Levothyroxine Sodium 50 mcg PO DAILY
19. LORazepam 0.5 mg PO TID:PRN anxiety
20. Ondansetron 8 mg PO Q8H:PRN nausea
21. Pantoprazole 40 mg PO Q24H
22. Senna 17.2 mg PO QHS:PRN constipation
23. Simethicone 125 mg PO QID:PRN gas
24. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
S-T segment elevation myocardial infarction
LV apical aneurysm
Ischemic cardiomyopathy with reduced ejection fraction
Coronary artery disease
SECONDARY DIAGNOSES:
=====================
Atrial fibrillation
Depression
Anxiety
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with atypical pleuritic chest pain// Evaluate
for mediastinal widening, pericardial effusion
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Cardiac size is top normal. New opacity in the left lower lobe is worrisome
for pneumonia.. There is no pneumothorax or pleural effusion.
IMPRESSION:
New opacities in the left lower lobe worrisome for pneumonia.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: STEMI
Diagnosed with Chest pain, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Ms. ___ is an ___ year old woman with T2DM (on insulin), HTN,
HLD, newly diagnosed AF (not on anticoagulation), who presented
from ___ (assisted living facility) with 2 hours
of chest pressure, EMS EKG with ST elevations in precordial
leads and associated ST depressions in inferior leads, urgently
taken to cath lab, now s/p 2 DES to LAD.
#STEMI:
#CAD:
#LV apical aneurysm:
Patient without prior history of CAD. Presented with chest pain,
found in EMS EKG to have ST elevations in precordial leads and
associated ST depressions in inferior leads, and urgently taken
to cath lab. On cardiac angiography, found to have 3 vessel
disease with 2 DES to LAD. Given heparin bolus and loaded with
cangrelor. She was started on ASA 81mg daily and metoprolol
12.5mg q6h. Her pravastatin was changed to atorvastatin 80mg
daily. She then underwent TTE which showed reduced EF 35%,
severe apical hypokinesis with focal akinesis, and LV apical
aneurysm. She was started on coumadin for LV thrombus ppx. Given
need for anticoagulation for apical aneurysm, patient's
antiplatelet agent was switched from ticagrelor to clopidogrel.
During ___, she was noted to be bradycardic to the ___ and
her metoprolol was decreased to 12.5mg BID. She was then
transitioned to metoprolol succinate 25mg daily. When her
creatinine recovered, she was started on lisinopril 5mg daily
and her amlodipine was discontinued.
#Acute ischemic cardiomyopathy with reduced EF:
As above, patient's post-MI TTE with new reduced EF 35%, severe
apical hypokinesis with focal akinesis, and LV apical aneurysm.
As above, she was started on metoprolol and high-dose statin.
She was also started on anticoagulation with Coumadin.
Lisinopril 2.5mg daily was started, but discontinued after 1
dose due to post-cath ___. She was started on lisinopril 5mg
daily once her post-cath ___ improved. She had minimal ectopy on
telemetry and therefore did not receive a lifevest. Plan for
repeat TTE in 8 weeks to reassess LVEF.
#Atrial fibrillation:
Newly diagnosed during admission in ___. Rate controlled with
diltiazem ER 120mg. Not placed on anticoagulation at that time
despite CHADS-Vasc score 5 due to concern for age and fall risk.
Her diltiazem was d/c'd post-MI and she was started on
metoprolol (as above). She was also started on Coumadin for LV
apical aneurysm.
___:
Patient with increase in creatinine from baseline 1.0 to 1.3
after catheterization. Initially had been started on lisinopril,
which was d/c'd after bump in creatinine. When her creatinine
improved, she was started on lisinopril 5mg daily.
#Depression
#Anxiety:
Patient with noted anxiety during admission. Her outpatient
psychiatrist recommended discontinuing fluoxetine and starting
duloxetine 30mg daily instead.
TRANSITIONAL ISSUES:
=====================
#Medication changes:
- stopped diltiazem
- started metoprolol succinate 25mg daily
- stopped pravastatin
- started atorvastatin 80mg qPM
- started aspirin 81mg daily
- started clopidogrel 75mg daily
- started warfarin 2.5mg daily (to be adjusted per
___ clinic)
- started lisinopril 5mg daily
- stopped amlodipine
- stopped fluoxetine
- started duloxetine 30mg daily
[] post-STEMI TTE with newly reduced EF 35%. Not given LifeVest
as she had very minimal ectopy on telemetry. Please obtain TTE
in 8 weeks (___) to check for recovery of LVEF. If
continues to be depressed, consider ICD placement.
[] Patient with episodes of bradycardia to ___ with ___.
Metoprolol decreased from 12.5mg q6 to 12.5mg q8. She was then
transitioned to metoprolol succinate 25mg daily. Please continue
to monitor HR and adjust metoprolol dosage as clinically
indicated.
[] Patient started on Coumadin, ASA, and Plavix for LV apical
aneurysm s/p PCI for STEMI. Please monitor for bleeding.
[] Check Chem 7 on ___ to check creatinine and
lytes while on lisinopril.
[] Check INR on ___ and adjust warfarin dose as
needed.
[] Consider starting spironolactone as outpatient given low EF
and insulin-dependent diabetes.
# CODE: Full (confirmed)
# CONTACT: HCP: daughter ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute cholecystitis
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy
History of Present Illness:
___ w/ central sleep apnea who is presenting here to the ED
for a <1 day hx of epigastric pain that has not improved. He
says he was in his usual state of health when he developed
epigastric pain around 7:30 pm last night. He notes having eaten
clam chowder for lunch around 1:30pm. He has also had several
episodes of n/v, and denies any other sx; ROS is otherwise
negative except as noted before. He says he has never had
similar sx before. Labs show WBC 11.0, LFTs wnl, and a CT A/P
was obtained which showed distended gallbladder w/
hyperenhancing wall, some pericholecystic fluid, and 3 cm
gallstone at the GB neck. We were consulted for further
management. RUQ U/S was requested and pending. Of note he is
visiting from ___.
Past Medical History:
Central sleep apnea
Social History:
___
Family History:
Fam Hx: grandmother w/ gallstones
Physical Exam:
Admission Physical Exam:
VS - 98.7 57 124/73 18 99% RA
Gen - NAD
CV - bradycardic
Pulm - non-labored breathing, no resp distress, satting
adequately on RA
Abd - soft, nondistended, mild epigastric ttp, severe RUQ ttp w/
guarding and mild rebound
Discharge Physical Exam
VS- T 97.6, BP 90/55, HR 48, RR 18, O2 Sat 98% (RA)
Gen- Awake, alert, NAD
CV- +RRR, +S1/S2, no RMG
Pulm- Normal WOB, +CTAB, no wheezes or crackles
Abd- Soft, non-distended, non-TTP; +normoactive BS x 4
quadrants; no rebound or guarding; lap incision sites c/d/I
Pertinent Results:
___ 12:15AM BLOOD WBC-11.0* RBC-4.48* Hgb-14.4 Hct-42.0
MCV-94 MCH-32.1* MCHC-34.3 RDW-12.4 RDWSD-42.9 Plt ___
___ 12:15AM BLOOD Neuts-86.3* Lymphs-8.9* Monos-3.6*
Eos-0.3* Baso-0.5 Im ___ AbsNeut-9.49* AbsLymp-0.98*
AbsMono-0.40 AbsEos-0.03* AbsBaso-0.06
___ 12:15AM BLOOD ___
___ 12:15AM BLOOD Plt ___
___ 12:15AM BLOOD Glucose-125* UreaN-18 Creat-0.9 Na-138
K-3.9 Cl-102 HCO3-23 AnGap-13
___ 12:15AM BLOOD ALT-12 AST-24 AlkPhos-109 TotBili-0.5
___ 12:15AM BLOOD Lipase-54
___ 12:15AM BLOOD Albumin-4.2
___ 06:45AM BLOOD Lactate-3.7*
___ 02:40PM BLOOD Lactate-2.7*
___ 08:12PM BLOOD Lactate-4.0*
___ 03:45AM BLOOD Lactate-1.0
___ 04:52AM BLOOD WBC-6.4 RBC-3.62* Hgb-11.5* Hct-35.1*
MCV-97 MCH-31.8 MCHC-32.8 RDW-12.9 RDWSD-45.6 Plt ___
___ 04:52AM BLOOD Glucose-83 UreaN-11 Creat-1.0 Na-142
K-3.8 Cl-106 HCO3-26 AnGap-10
___ 02:00PM BLOOD ALT-68* AST-96* AlkPhos-133* TotBili-0.9
___ 04:52AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.7
CT Abd/Pelvis with Contrast (___)
The liver demonstrates homogenous attenuation throughout. Mild
periportal edema. There is no evidence of focal lesions. There
is no evidence
of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is
distended, measuring 10.5 x 4 cm with ___nd a
3 cm gallstone
at the neck. Surrounding hepatic hyperemia is likely reactive.
No evidence
of perforation.
IMPRESSION: Findings suggest acute calculous cholecystitis.
RUQ Ultrasound (___)
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the
liver is smooth. There is no focal liver mass. The main portal
vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 7 mm
GALLBLADDER: Again seen is a 3 cm obstructive gallstone at the
gallbladder
neck. The gallbladder is distended with associated gallbladder
wall
thickening.
PANCREAS: The imaged portion of the pancreas appears within
normal limits,
without masses or pancreatic ductal dilation, with portions of
the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 13.7 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 12.4 cm
IMPRESSION: Findings suggest acute calculus cholecystitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 1600 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
3. Polyethylene Glycol 17 g PO DAILY
4. Gabapentin 1600 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with acute abdominal pain and
nauseaNO_PO contrast// ? acute process
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 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 6.9 s, 54.6 cm; CTDIvol = 16.2 mGy (Body) DLP = 884.2
mGy-cm.
Total DLP (Body) = 893 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Mild bibasilar atelectasis. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Mild
periportal edema. There is no evidence of focal lesions. There is no evidence
of intrahepatic or extrahepatic biliary dilatation. The gallbladder is
distended, measuring 10.5 x 4 cm with 3 mm thickened wall and a 3 cm gallstone
at the neck. Surrounding hepatic hyperemia is likely reactive. No evidence
of perforation.
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 demonstrate normal nephrogram. Multiple peripelvic cysts
are noted in the left kidney. Additionally, there are multiple simple renal
cysts in the bilateral kidneys, largest measuring up to 3.2 cm in the inferior
pole of the left kidney. There are parapelvic cysts in the left kidney.
There is no evidence of suspicious solid renal lesions or hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostatomegaly.
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 os1seous lesions or acute fracture.
Mild degenerative changes of the thoracolumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Findings suggest acute calculous cholecystitis.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with abd pain and acute cholecystitis// further eval
of acute cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis with contrast dated ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 7 mm
GALLBLADDER: Again seen is a 3 cm obstructive gallstone at the gallbladder
neck. The gallbladder is distended with associated gallbladder wall
thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 13.7 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 12.4 cm
IMPRESSION:
Findings suggest acute calculus cholecystitis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Diarrhea
Diagnosed with Acute cholecystitis, Dyspnea, unspecified, Right upper quadrant pain, Epigastric pain
temperature: 98.0
heartrate: 54.0
resprate: 16.0
o2sat: 100.0
sbp: 114.0
dbp: 89.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ was evaluated by the Acute Care Surgery team in the ED
on ___ as described in the HPI. Admission CT abdomen/pelvis
and RUQ ultrasound both demonstrated acute calculous
cholecystitis. He was admitted on ___ under the Acute Care
Surgery service for management of his acute cholecystitis. He
was taken to the operating room and underwent a laparoscopic
cholecystectomy on HD 1. Please see operative report for details
of this procedure. He tolerated the procedure well and was
extubated upon completion. Of note, he voided prior to his
surgery, but when a Foley catheter was placed for the procedure,
he had a post-void residual of greater than 400 CC. He was
subsequently taken to the PACU for recovery.
After a brief, uneventful stay in the PACU, the patient arrived
on the floor tolerating a clear liquid diet, on IV fluids, and
with scheduled acetaminophen/toradol and PRN oxycodone for pain
control. He was hemodynamically stable. His vital signs were
routinely monitored and he remained afebrile and hemodynamically
stable. Post-operative labs were notable for elevated lactate to
4.0, which was attributably to likely dehydration. He was
initially given IV fluids postoperatively, as well as a 1000 CC
fluid bolus with improvement in his lactate to 1.0. His
maintenance IV fluids were discontinued when he was tolerating
PO intake. His diet was advanced during the afternoon of POD 0
from clear liquids to regular, which he tolerated without
abdominal pain, nausea, or vomiting. He was voiding adequate
amounts of urine without difficulty. Given his high post-void
residual in the OR, we sent a UA, which was unremarkable.
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. His pain level was routinely assessed and
well controlled at discharge with an oral regimen as needed.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. He was voiding appropriately, and on questioning
reported urinary frequency prior to this hospitalization. He was
instructed to mention this to his PCP at follow up for further
work up and possible intervention. 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. He was instructed to follow
up with his PCP in ___ in ___ weeks. If necessary, his PCP
may refer his to Urology or General Surgery as needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
red dye
Attending: ___.
Chief Complaint:
Motor vehicle crash; seizure
Major Surgical or Invasive Procedure:
___ Intubation (at outside hospital)
History of Present Illness:
The patient is a ___ man with a history of prior stroke
who presents to the ED as a transfer from an outside hospital
after a motor vehicle crash and possible seizure.
He was apparently last seen by his wife at around 10 AM today.
He left the house to run some errands. When she had not heard
from him for several hours, she tried calling his cell phone,
but was answered by a nurse at ___.
Documentation from ___ states that he "was driving
erratically on the highway, at several cars in the sign [sic].
He parked at ___ then had a seizure in the car. He has
not been mentating normally since that time. He is violent and
thrashing around in bed." It may be the case that he had a
seizure while being transported by EMS, but this is not clearly
documented. While at ___, he had initial vitals notable
for a heart rate of 130 and a respiratory rate of 26. It is
unclear if there was ongoing seizure activity or if he was
encephalopathic, but he received a total of 6 mg of lorazepam, 2
L normal saline, 1 g of Keppra at 11:25 AM. He was intubated for
airway protection and started on a propofol drip. By report, he
may have received a dose of phenytoin, but this is not
documented in the ___ records. He was then transferred to
___. Of note, hand off to the ED also reported
temperature of 95 degrees while at ___.
On my arrival, he is intubated and unable to provide any further
history. In speaking to his wife, she does report that he may
have had a similar episode about ___ years ago, wherein he was
driving and then caused a car accident for unclear reasons. He
was amnestic of the event. She tells me he was started on a
medicine, which may have been a seizure medicine, for a month
but then it was stopped. Otherwise, he has no definite history
of seizure. He does have a history of stroke in ___, which
apparently left him with a slight degree of left-sided weakness
and sensory changes, as well as a shortened temper and
occasional angry outbursts.
Unable to obtain review of systems due to mental status.
Past Medical History:
Stroke, ___
Aortic regurgitation, unclear history of valve replacement
___ esophagus
BPH
Congestive heart failure
GERD
Heart murmur
Thrombocytopenia
Hearing loss since childhood, possibly with some sort of implant
in place
Social History:
___
Family History:
Unknown
Physical Exam:
General: older male sitting in chair, NAD
HEENT:NC/AT, no scleral icterus noted
CV: warm and well perfused
Lungs: breathing comfortably on room air
Abdomen: non distended
Ext: No ___ edema.
Skin: no rashes or lesions noted.
Neuro:
MS- awake and alert, sitting up in chair, oriented to hospital,
can't say name of hospital, oriented to ___. Following axial
and appendicular commands
CN- R 0.5mm larger than L, booth briskly reactive, EOMI with
nystagmus bilaterally that extinguishes, decreased activation of
right face, sensation intact V1-V3, VFF to finger wiggle, tongue
midline, very hard of hearing
Sensory- withdraws to noxious throughout
Motor: no tremor or pronator drift, normal bulk and tone
throughout, moving extremities spontaneously antigravity
Sensory: intact to light touch.
DTR:
Bi Tri ___ Pat Ach
L 2 1 1 2 1
R 0 1 1 2 1
Plantar response was extensor bilaterally
Coordination: no dystmetria on FNF
Pertinent Results:
ADMISSION LABS
==============
___ 04:45PM BLOOD WBC-15.4* RBC-4.30* Hgb-13.7 Hct-41.8
MCV-97 MCH-31.9 MCHC-32.8 RDW-12.8 RDWSD-45.2 Plt ___
___ 04:45PM BLOOD ___ PTT-26.3 ___
___ 04:45PM BLOOD Glucose-154* UreaN-13 Creat-1.0 Na-137
K-4.0 Cl-105 HCO3-21* AnGap-11
___ 04:45PM BLOOD ALT-31 AST-42* AlkPhos-58 TotBili-0.9
___ 04:45PM BLOOD Lipase-20
___ 04:45PM BLOOD cTropnT-<0.01
___ 04:45PM BLOOD Albumin-3.3* Calcium-7.5* Phos-2.8 Mg-1.6
___ 05:00PM URINE Color-Straw Appear-Clear Sp ___
___ 05:00PM URINE Blood-LG* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:00PM URINE RBC-41* WBC-2 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 05:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
PERTINENT LABS
==============
___ 06:00PM BLOOD D-Dimer-3513*
___ 11:45PM BLOOD %HbA1c-5.6 eAG-114
___ 11:45PM BLOOD Triglyc-65 HDL-61 CHOL/HD-1.7 LDLcalc-32
___ 04:45PM BLOOD Phenyto-18.7
IMAGING
=======
CT HEAD/CTA HEAD & NECK ___
1. No acute intracranial abnormality.
2. Occlusion of the left vertebral artery from its origin to the
V2 segment where it is reconstituted. Occlusion of the right
vertebral artery at C2-3, with reconstitution distally at C1.
Both vertebral arteries receive collateral supply from
paraspinal arteries, and patent to the basilar origin. Findings
are age-indeterminate, although appearance and collateral
vessels suggest chronic findings, acute occlusion not excluded.
3. Patent bilateral cervical carotid arteries. Calcified plaque
at the
carotid bulbs and extracranial ICAs causes 30% left extracranial
ICA luminal narrowing by NASCET criteria. No significant right
ICA luminal narrowing by NASCET criteria.
4. 1-2 mm right intracranial ICA infundibulum. Mild luminal
narrowing,
cavernous and paraclinoid intracranial ICAs, due to calcified
plaque.
Remainder of the circle of ___ is widely patent. No
aneurysm, additional stenosis, or occlusion.
5. Medial right occipital encephalomalacia, likely sequela of
remote right PCA territory infarction.
6. Small chronic lacunar infarcts, bilateral thalami, right
basal ganglia.
7. Mild changes of chronic white matter microangiopathy.
8. Moderate sinus disease, involving ethmoid air cells,
maxillary sinuses,
with air-fluid levels.
9. Incidental findings include bilateral layering small
nonhemorrhagic pleural effusions; prominent and numerous
cervical and upper mediastinal lymph nodes, nonspecific,
possibly reactive; moderate biapical paraseptal and
centrilobular emphysema.
TTE ___
Well-seated, normally functioning aortic bioprosthesis. Mildly
reduced left
ventricular systolic function consistent with single vessel
coronary artery disease. Mild mitral regurgitation. Borderline
pulmonary hypertension.
CTA CHEST ___
1. No evidence of main or segmental pulmonary arterial embolus.
Evaluation of sub segmental pulmonary artery sub limited by
severe motion artifact.
2. Small left and small to moderate right-sided pleural effusion
with adjacent atelectasis. These are more pronounced compared
to most recent outside hospital imaging.
3. Mild opacification of the right lower lobe bronchi may
represent retained secretions or aspiration. No convincing
evidence of pneumonia at this stage.
MICROBIOLOGY
============
URINE CULTURE (Final ___: NO GROWTH.
TEE ___
There is moderate spontaneous echo contrast in the body of the
left atrium and in the left atrial appendage. A small, mobile
0.3x0.6cm echodensity attached to the wall of the the distal
left atrial appendage is seen, representing a probable left
atrial appendage thrombus (seen best on 60 degree view of clip
5, and clip 9). An aortic valve bioprosthesis is present. The
prosthesis is well seated with normal leaflet motion. No masses
or vegetations are seen on the aortic valve. No abscess is seen.
There is trace aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve. No abscess
is seen. There is physiologic mitral regurgitation. Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be UNDERestimated.
IMPRESSION: Moderate spontaneous echo contrast in the left
atrium and left atrial appendage with probable small thrombus in
the left atrial appendage. Well-seated aortic valve
bioprosthesis with normal leaflet motion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 20 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Cetirizine 10 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Lisinopril 5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO/NG BID
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 40 mg PO BID
4. LevETIRAcetam 750 mg PO BID
5. Metoprolol Tartrate 150 mg PO BID
6. Thiamine 100 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Cetirizine 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
History of stroke
Heart failure with preserved EF
Left atrial thrombus
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: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with ng tube placement// confirm position
Contact name: ___: ___
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 05:42.
IMPRESSION:
There has been interval replacement of the nasogastric tube which terminates
in the body of the stomach. The endotracheal tube is been removed. Otherwise,
no significant interval change compared to study from earlier today.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with ___ y/o male s/p MVC, possible seizure, now
hypothermia intubated on arrival, OSH imaging shows questionable aspirations
bilateral pleural effusions// assess for PE
TECHNIQUE: Multi detector CT pulmonary angiogram
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 32.4 cm; CTDIvol = 9.2 mGy (Body) DLP = 297.8
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 30.0 mGy (Body) DLP =
15.0 mGy-cm.
Total DLP (Body) = 314 mGy-cm.
COMPARISON: Outside hospital CT done ___
FINDINGS:
The study is degraded by severe motion artifact.
NECK, THORACIC INLET, AXILLAE, CHEST WALL: No suspicious thyroid lesions.
Subcentimeter axillary lymph nodes. Bilateral gynecomastia.
UPPER ABDOMEN: Feeding tube in situ in the stomach. No subdiaphragmatic
pathology.
MEDIASTINUM: Subcentimeter mediastinal lymph nodes.
HILA: Subcentimeter hilar lymph nodes.
HEART and PERICARDIUM: Evidence of prior aortic valve replacement.
Cardiomegaly. No substantial pericardial effusion.
PLEURA: Small left and small to moderate simple right pleural effusions.
These are increased in size compared to prior imaging.
LUNG:
-PARENCHYMA: Motion artifact obscures the pulmonary parenchyma for fine
interstitial changes and small pulmonary nodules. Enhancing bibasal
atelectasis in association with the pleural effusions. Associated mild
opacification of the right lower lobe bronchi may represent retained
secretions or aspirate. No convincing evidence of pneumonia.
-AIRWAYS: The central airways are patent.
-VESSELS: The pulmonary arteries not dilated. No filling defects to suggest
pulmonary emboli. There is a single apparent subsegmental pulmonary arterial
filling defect (series 301, image 61), but this is most likely artifactual.
No right heart strain.
CHEST CAGE: Prior sternotomy and prior left posterior thoracotomy. No
suspicious bony lesions.
IMPRESSION:
1. No evidence of main or segmental pulmonary arterial embolus. Evaluation of
sub segmental pulmonary artery sub limited by severe motion artifact.
2. Small left and small to moderate right-sided pleural effusion with adjacent
atelectasis. These are more pronounced compared to most recent outside
hospital imaging.
3. Mild opacification of the right lower lobe bronchi may represent retained
secretions or aspiration. No convincing evidence of pneumonia at this stage.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with past medical history of stroke in ___,
aortic regurg s/p bioprosthetic valve replacement ___, CHF unknown EF, found
seizing in parked car with preceding erratic driving, presented with slight
hypothermia intubated on arrival, now s/p extubation with EEG negative for
seizure// interval change interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Previous mild pulmonary edema has improved. Small bilateral pleural effusions
moderate cardiomegaly remain. No pneumothorax.
Left PIC line ends in the right atrium, as before. Nasogastric drainage tube
ends in the midportion of a nondistended stomach.
Radiology Report
INDICATION: New left PICC.
TECHNIQUE: Frontal chest radiograph.
COMPARISON: Chest CT from ___.
FINDINGS:
A left PICC terminates at the cavoatrial junction. An nasogastric tube
terminates at the stomach. Small bilateral pleural effusions are present.
There is central pulmonary vascular congestion with mild interstitial edema.
A cardiac valve and intact sternal wires are unchanged in configuration.
IMPRESSION:
1. Left PICC terminating at the cavoatrial junction.
2. Central pulmonary vascular congestion with mild interstitial edema. Small
bilateral pleural effusions.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:28 am, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with seizure, asp pna, pulm edema// eval pna and
edema
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph dated ___
FINDINGS:
7 median sternotomy wires are intact and unchanged in configuration from
prior. Patient is status post aortic valve replacement. Right PICC line
terminates at the right atrium.
Lung volumes are low bilaterally, exaggerating pulmonary vasculature. There
is minimally worsened mild pulmonary edema. Interval resolution of right
pleural effusion. Small left pleural effusion is unchanged. No pneumothorax.
Moderate cardiomegaly is unchanged.
IMPRESSION:
1. Minimally worsened mild pulmonary edema.
2. Interval resolution of right pleural effusion. Small left pleural
effusion is unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with COPD. Dyspneic// Eval for new
edema/consolidation
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph dated ___
FINDINGS:
The left PICC line terminates at the cavoatrial junction. 7 mediastinal wires
are intact and unchanged in configuration. Patient is status post aortic
valve replacement.
Lung volumes are low bilaterally. Progressive now mild-to-moderate pulmonary
edema. Recurrence of small right pleural effusion. Small left effusion is
unchanged. No pneumothorax. Mediastinal silhouette is stable. Moderate
cardiomegaly is unchanged.
IMPRESSION:
Progressive now mild-to-moderate pulmonary edema. Recurrence of small right
pleural effusion. Small left effusion is unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with seizure// Please evaluate lung fields
Please evaluate lung fields
IMPRESSION:
Left PICC line tip is at the proximal right atrium and should be pulled back
at least 2 cm. Heart size is enlarged. Vascular congestion has progressed
now with interstitial pulmonary edema associated with bilateral pleural
effusions. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with seizure// assess for pulmonary edema
IMPRESSION:
In comparison with the study of ___, the patient has taken a slightly
better inspiration. In cardiomediastinal silhouette and mild elevation of
pulmonary venous pressure are stable. Small bilateral pleural effusions with
underlying compressive atelectasis are again seen.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with new seizure// Eval for mass
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Coronal MPRAGE imaging was
performed and re-formatted in axial orientations. Coronal T2 sequences
through the hippocampal formations performed.
COMPARISON: CTA head and neck ___.
FINDINGS:
Encephalomalacia of the right occipital lobe is seen with susceptibility,
likely due to an old hemorrhagic infarct. The encephalomalacia extends along
the posteromedial right temporal lobe and hippocampus (series 11, image 9;
series 12, image 44). Other microhemorrhagic foci are seen in the right
frontal and occipital lobes. There is no evidence of new infarction, mass
effect, masses or midline shift.
The ventricles and sulci are prominent, consistent with global cerebral volume
loss. Confluent periventricular T2 hyperintensities are most consistent with
chronic microvascular angiopathy. No focal cortical dysplasia or gray matter
heterotopia. Subcentimeter old lacunar infarcts are seen in bilateral deep
gray nuclei. The hippocampi are symmetric in size, signal and morphology.
There is no abnormal enhancement after contrast administration. The
visualized intracranial flow voids are preserved. The dural venous sinuses
are patent.
IMPRESSION:
1. No acute infarct or intracranial hemorrhage. No abnormal enhancement or
masses.
2. Right PCA territory infarct with encephalomalacia of the right occipital
lobe extending to the right posteromedial temporal lobe and hippocampus.
Hemosiderin staining of the right occipital lobe noted.
3. No evidence of focal cortical dysplasia or gray matter heterotopia.
4. Chronic microvascular angiopathy changes and additional findings as
described above.
Radiology Report
INDICATION: Trauma.
TECHNIQUE: Single supine portable view of the chest.
COMPARISON: Chest CT from earlier the same day at 23:57.
FINDINGS:
ET tube tip is 2.5 cm from the carina. Enteric tube passes below the field of
view, side-port past the GE junction. Mild cardiac enlargement is similar
compared to the CT. Mediastinal contours are unremarkable. Atelectasis and
layering effusions better seen on prior chest CT. No displaced fractures.
IMPRESSION:
ET tube tip 2.5 cm from the carina.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK.
INDICATION: ___ with seizure, paralysis// basilar stroke?
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain after the
intravenous administration of 55 mL of Omnipaque 350 nonionic contrast.
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 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 32.4 mGy (Body) DLP =
16.2 mGy-cm.
3) Spiral Acquisition 4.9 s, 38.2 cm; CTDIvol = 15.2 mGy (Body) DLP = 582.1
mGy-cm.
Total DLP (Body) = 598 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Unenhanced head CT from outside facility dated ___
performed at 11:47.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is encephalomalacia in the medial right occipital lobe, likely sequelae
of remote PCA territory infarction. Small hypodensities in the region of the
right basal ganglia likely reflect chronic lacunar infarcts, also involving
the bilateral thalami.
No evidence of recent infarction. No evidence of hemorrhage, extra-axial
collection, or intracranial mass effect.
The ventricles and sulci are normal in caliber and configuration.
Ill-defined periventricular white matter hypodensity is nonspecific but
compatible with mild changes of chronic white matter microangiopathy.
No evidence of a displaced calvarial fracture. There is moderate ethmoid air
cell mucosal thickening. There is layering fluid in the left more than right
maxillary sinus. Sphenoid, frontal sinuses are clear. There is an
endotracheal and enteric tube noted in the oropharynx and nasopharynx, along
with nasopharyngeal secretions. Aside from bilateral lens extraction, the
globes and orbits are within normal limits.
CTA HEAD:
Left dominant vertebral artery, a normal variant. Diminutive but patent right
vertebral artery. Widely patent basilar artery. Conventional bilateral PCA
anatomy. Patent bilateral posterior cerebral arteries with normal distal
runoff. The posterior communicating arteries are not well seen, either
diminutive or absent.
1-2 mm laterally projecting outpouching arising from the right cavernous
intracranial ICA (3:228), likely a small infundibulum. There is calcified
plaque affecting the cavernous and paraclinoid intracranial ICAs bilaterally,
causing areas of mild luminal narrowing, right worse than left.
Otherwise, the remaining portions of the bilateral intracranial internal
carotid arteries and the bilateral anterior and middle cerebral arteries are
patent with normal distal runoff.
No additional stenosis no aneurysm. No large vessel occlusion.
Major dural venous sinuses are not well opacified or assessed on this study.
CTA NECK:
The right vertebral artery is diminutive, likely a combination of congenital
hypoplasia and superimposed atherosclerosis. The vessel is occluded at the
level of C2-3 level, however is reconstituted by paraspinal collaterals at the
C1 level, distal to this remaining patent to the basilar origin.
The left vertebral artery is occluded beginning at its origin extending to the
proximal V2 segment, where it is apparently reconstituted by collateral flow
(3:110). Just distal to this, the artery lumen is severely stenosed, near
occluded (03:23), in the subsequently demonstrates patency distal to this,
albeit with mild background luminal narrowing (03:40). The artery distal this
demonstrates an irregular lumen caliber with areas of up to moderate luminal
narrowing, worst at the V2-V3 junction (3:87), however remains patent.
Paraspinal collaterals reconstitute the left vertebral artery at the C1 level,
as on the right (3:164).
There is calcified plaque at the right carotid bulb and proximal intracranial
ICA, not causing luminal narrowing by NASCET criteria. There is bulky
calcified plaque at the left carotid bulb and proximal extracranial left ICA,
causing 30% luminal narrowing by NASCET criteria (451:1). The remaining
components of the bilateral cervical carotid arteries appear widely patent.
Mild calcification of the aortic arch. Arch branch vessels are grossly patent
and within normal limits.
OTHER:
Endotracheal tube is seen in situ with tip terminating in the midthoracic
trachea, appropriate position. Enteric tube is seen in the lumen of the
esophagus. Median sternotomy wires are noted. Scattered multilevel cervical
lymph nodes are increased in number but did not appear individually enlarged,
likely reactive. Prominent veins are noted in the neck bilaterally, not
opacified or delineated on this study. No aggressive focal osseous lesions.
Scattered upper mediastinal lymph nodes are increased in number and prominent,
for example measuring up to 1.6 by 1.2 cm at the high right paratracheal
station (03:52). There are small bilateral layering, left larger than right
nonhemorrhagic pleural effusions with adjacent relaxation atelectasis of the
dependent pulmonary parenchyma. Moderate biapical paraseptal and
centrilobular emphysema. No suspicious pulmonary.
IMPRESSION:
1. No acute intracranial abnormality.
2. Occlusion of the left vertebral artery from its origin to the V2 segment
where it is reconstituted. Occlusion of the right vertebral artery at C2-3,
with reconstitution distally at C1. Both vertebral arteries receive
collateral supply from paraspinal arteries, and patent to the basilar origin.
Findings are age-indeterminate, although appearance and collateral vessels
suggest chronic findings, acute occlusion not excluded.
3. Patent bilateral cervical carotid arteries. Calcified plaque at the
carotid bulbs and extracranial ICAs causes 30% left extracranial ICA luminal
narrowing by NASCET criteria. No significant right ICA luminal narrowing by
NASCET criteria.
4. 1-2 mm right intracranial ICA infundibulum. Mild luminal narrowing,
cavernous and paraclinoid intracranial ICAs, due to calcified plaque.
Remainder of the circle of ___ is widely patent. No aneurysm, additional
stenosis, or occlusion.
5. Medial right occipital encephalomalacia, likely sequela of remote right PCA
territory infarction.
6. Small chronic lacunar infarcts, bilateral thalami, right basal ganglia.
7. Mild changes of chronic white matter microangiopathy.
8. Moderate sinus disease, involving ethmoid air cells, maxillary sinuses,
with air-fluid levels.
9. Incidental findings include bilateral layering small nonhemorrhagic pleural
effusions; prominent and numerous cervical and upper mediastinal lymph nodes,
nonspecific, possibly reactive; moderate biapical paraseptal and centrilobular
emphysema. Other incidental findings, as above.
Radiology Report
INDICATION: ___ year old man with seizure, pleural effusion// Eval for
interval change in effusion
COMPARISON: Radiographs from ___
IMPRESSION:
Support lines and tubes are unchanged in position. Heart size is upper limits
of normal. There is a left retrocardiac opacity, stable. There is again seen
mild pulmonary edema. There are lower lung volumes than previous. There are
no pneumothoraces
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: MVC, Seizure, Transfer
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus, Car driver injured in collision w car in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ett
level of acuity: 1.0 | ___ y/o male with a past medical history of stroke in ___,
aortic regurg s/p bioprosthetic valve replacement ___, HFpEF,
found seizing in parked car with preceding erratic driving,
presented with slight hypothermia (95 degrees at OSH), intubated
on arrival to outside hospital. Transferred to ___ for cvEEG,
which was negative for seizure. Course complicated by tenuous
respiratory status ___ COPD, aspiration PNA), and paroxysmal
atrial fibrillation with RVR.
#Seizure
#Altered Mental Status
At OSH, received a total of 6 mg of lorazepam, 2L normal saline,
1 g of Keppra, and started on a propofol drip. By report, he may
have received a dose of phenytoin at OSH, not clearly
documented, though phenytoin level on arrival to ___ was 18.7.
Unclear trigger for seizure. Meningitis was considered so
empiric coverage with vancomycin, ampicillin, acyclovir was
initiated, though was discontinued after he rapidly improved on
arrival to ___. LP therefore deferred. Continuous EEG showed
diffuse background slowing and disorganization, no seizures or
epileptiform discharges. Initiated keppra 750 mg BID, which he
tolerated well.
#Acute respiratory insufficiency
#Aspiration PNA
#COPD exacerbation
#Pleural effusions:
Intubated as above for airway protection in setting of concern
for seizure. Extubated ___ with continued respiratory distress
(wheezing, accessory muscle use, shortness of breath). Etiology
likely multifactorial due to pleural effusions (including fluid
collection above hemithorax- nonsurgical, aspiration PNA, and
reactive airway disease (h/o smoking). CTA negative for PE. He
was diuresed with Lasix, as high as 40mg IV, with modest
benefit. Respiratory status improved with initiation of high
dose IV steroids x5 days (___) and unasyn x7 days
(___) for COPD/aspiration pneumonia.
#Paroxysmal atrial fibrillation with RVR:
Placed on dilt gtt initially, which was weaned with uptitration
of home metoprolol with good effect. However, despite high doses
of Metoprolol, heart rate remained elevated to the 130s. He was
therefore given a bolus + 48 hour infusion of Amiodarone, with
some improvement in his heart rate. Switched home rivaroxaban to
apixaban per discussion with outpatient cardiologist to reduce
bleeding risk. On the floor, cardiology consulted for additional
recs, recommended TEE and potential cardioversion. On TEE,
however, patient found to have a left atrial thrombus, so
cardioversion was aborted. Plan for 4 weeks of uninterrupted
anticoagulation, followed by cardioversion. This was
communicated with his outpatient cardiologist Dr. ___.
#Heart failure
Diuresed with 40mg IV BID to good effect, discharge dry weight
was 52.4kg. Discharge diuretic dose will be 40mg PO BID.
#ETOH use disorder:
Per wife, he does not drink, though records from the outside
hospital indicate 3 or more alcoholic beverages per night. He
was given a phenobarb load x1 on admission. Initiated thiamine,
folic acid repletion.
#History of stroke:
Transitioned to apixaban as above. Continued home atorvastatin.
#Thrombocytopenia:
Likely due to splenic sequestration in setting of chronic ETOH
use.
#HTN:
Held home lisinopril.
#History of aortic valve replacement:
TTE with well seated and normally functioning valve. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Headache, Ataxia, Delirium
Major Surgical or Invasive Procedure:
IJ Central Venous Catheter Placement - ___
Dobhoff Placement - ___
Endotracheal Intubation and Mechanical Ventilation ___
Bronchoscopy ___
History of Present Illness:
Primary Care Physician: ___ (___)
CHIEF COMPLAINT: Headache, Delirium, Ataxia
HISTORY OF PRESENT ILLNESS:
___, a ___ yo M PMHx AIDS (PCP ___ ___, didnt
complete treatment, recently started on ART, CD4 39 ___,
active crystal meth use, and history of syphilis, who left AMA
on ___ after an admission for headache, presents to ED
with headache/ataxia. The patient reportedly followed up with
___ Health after discharge where he started HAART. He cannot
recall the name, but believes that there are 3 different
medications. He reports that his headaches that caused his
admission previously had improved, but a few days prior to
admission, he started developing ___ frontal headaches that was
made worse with sounds. He also reports that he sometimes has
difficulty finding the right words. He denies taking any
medications for his headaches. He reports that he last snort
crystal meth 1 week ago and has not injected it for >6 months.
As per report, he was having difficulty walking as well which
prompted his family to bring him in. He denies any fevers,
chills, nausea, vomiting, abdominal pain, diarrhea, cough,
shortness or breath, DOE, chest pain.
On the previous admission for headache, he was found to have
fever/tachycardia, epididymitis/orchitis (G/C negative),
negative headache workup, and a cavitary lung lesion (AFB
negative x3, PCP negative, prior positive Quantiferon Gold®).
Per ___ documentation, he had a headache to 1.5 weeks prior
to presentation but presented to clinic without delirium/ataxia
on ___.
In the ED initial vitals were: 98.9 ___ 18 97% RA. Labs
were notable for CBC 6.8. Chem 7 notable for hyponatremia to
128. LFTs unremrkable. Serum tox negative, but urine tox
positive for ampehtamines. lactate 2.7. Patient underwent CT
head that showed new scattered hypodensities in the bilateral
basal ganglia, thalami, left temporal lobe, and cerbellum. It
also showed diffuse atrophy. CTA did not show dissection.
Neurology was consulted in the ED and believed that because of
his significant involvement of the cerebellum with some
indication of increased pressure in the posterior fossa, a
lumbar puncture could not be safely performed and LP was
deferred. ID was consulted and recommended broad spectrum
coverage with acyclovir, vancomycin, ceftriaxone, PCP ___
(atovaquone ppx). Patient was given acyclovir 750mg, 2L NS,
Ceftriaxone 2gm. Vital signs on transfer: 99 84 128/71 16 RA.
On CC7, patient is intermittently somnolent but oriented,
somnolent and confused with difficulty following even simple
commands, and agitated pull lines out.
ROS: Per HPI, review of systems otherwise limited by somnolence.
Past Medical History:
HIV (recently started on unknown HAART with most recent CD4 of
22 in ___ and 39 in ___ diagnosed in ___)
Pneumocystis Pneumonia ___ at ___ confirmed,
admitted to ICU, no intubation), incomplete treatment due to
leaving AMA
Syphilis treated ___
MRSA Abscess of Right Buttock ___
Chronic Hepatitis B (since resolved, HBcAb and HbsAb positive
but HBsAg negative)
- Eczema
- IVDU and Crystal Meth Use
- ?Bipolar Disorder (per ___ records)
Social History:
___
Family History:
Noncontributory in past and unable to be obtained due to altered
mental status this admission
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
==================================
Vitals - 97.9 134/84 62 18 94%RA
GENERAL: NAD, restless in bed, speaking in full sentences,
falling asleep between questions, but easily arousable.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, No appreciable
oral lesions
NECK: nontender supple neck, no LAD
CARDIAC: RRR, I/VI SEM at ___, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, warm
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, sensation intact throughout, Mild
dysmetria on finger to nose R>L
SKIN: warm and well perfused, multiple erythematous papules
throughout back
DISCHARGE PHYSICAL EXAMINATION:
==================================
Vitals: 98.3, ___, ___, 96-98% on RA, ___
Pain, Ins 470, Outs BRP
General: NAD, middle-aged male in bed watching ___ street,
very bored
HEENT: Sclera anicteric, MMM, some small scattered yellow
globules on tongue but no white plaques or growth, poor
dentition
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended without fluid wave,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNIII-XII intact, alert and oriented x3, fluent speech
speaking in complete sentences, no signs of facial droop, ___ UE
and ___ strength, sensation intact throughout, very mild R>L
upper extremity dysmetria, gait exam normal
Pertinent Results:
ADMISSION LABS:
============================
___ 05:00PM BLOOD WBC-6.8# RBC-4.88 Hgb-14.2 Hct-41.3
MCV-85 MCH-29.1 MCHC-34.4 RDW-14.1 Plt ___
___ 05:00PM BLOOD Neuts-78.9* Lymphs-15.9* Monos-3.8
Eos-0.9 Baso-0.4
___ 05:13PM BLOOD ___ PTT-32.4 ___
___ 05:00PM BLOOD Glucose-168* UreaN-16 Creat-0.7 Na-128*
K-3.8 Cl-92* HCO3-23 AnGap-17
___ 05:00PM BLOOD ALT-20 AST-17 AlkPhos-107 TotBili-0.3
___ 05:00PM BLOOD Lipase-75*
___ 05:00PM BLOOD Albumin-4.6 Calcium-9.6 Phos-3.8 Mg-1.9
___ 04:42AM BLOOD Triglyc-149
___ 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:12PM BLOOD Lactate-2.7*
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 04:00PM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
___ 04:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-POS mthdone-NEG
Serum Cryptococcal Antigen Negative
MICROBIOLOGY:
==================
___ SPUTUM ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY
___ SPUTUM ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-PENDING; Respiratory Viral Antigen Screen-FINAL
INPATIENT
___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {STAPH AUREUS COAG +, YEAST}; LEGIONELLA
CULTURE-PRELIMINARY; POTASSIUM HYDROXIDE PREPARATION-FINAL;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST}; NOCARDIA
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; VIRAL CULTURE: R/O
CYTOMEGALOVIRUS-PRELIMINARY; CYTOMEGALOVIRUS EARLY ANTIGEN TEST
(SHELL VIAL METHOD)-PENDING INPATIENT
___ Staph aureus Screen Staph aureus Screen-FINAL {STAPH
AUREUS COAG +} INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ SEROLOGY/BLOOD RPR w/check for Prozone-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-FINAL EMERGENCY
WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
OTHER PERTINENT LABS:
==========================
___ 12:15AM BLOOD WBC-8.6 RBC-4.89 Hgb-14.2 Hct-40.7 MCV-83
MCH-29.1 MCHC-35.0 RDW-14.5 Plt ___
___ 04:31AM BLOOD WBC-8.7 RBC-4.19* Hgb-12.4* Hct-35.8*
MCV-85 MCH-29.5 MCHC-34.5 RDW-14.4 Plt ___
___ 04:18AM BLOOD WBC-8.2 RBC-4.07* Hgb-12.5* Hct-35.0*
MCV-86 MCH-30.8 MCHC-35.8* RDW-14.3 Plt ___
___ 02:23AM BLOOD WBC-6.9 RBC-3.78* Hgb-11.3* Hct-31.9*
MCV-84 MCH-29.8 MCHC-35.3* RDW-14.7 Plt ___
___ 12:01AM BLOOD Glucose-148* UreaN-21* Creat-0.8 Na-138
K-4.1 Cl-109* HCO3-19* AnGap-14
___ 04:18AM BLOOD Glucose-148* UreaN-21* Creat-0.9 Na-140
K-4.0 Cl-109* HCO3-20* AnGap-15
___ 03:00PM BLOOD Glucose-128* UreaN-23* Creat-0.7 Na-140
K-3.9 Cl-111* HCO3-21* AnGap-12
___ 02:23AM BLOOD Glucose-129* UreaN-24* Creat-0.9 Na-141
K-4.0 Cl-111* HCO3-19* AnGap-15
___ 02:23AM BLOOD ___ PTT-25.2 ___
___ 02:23AM BLOOD Calcium-8.6 Phos-2.3* Mg-2.4
___ 04:31AM BLOOD Osmolal-275
___ 12:41PM BLOOD ___ Temp-37.5 pO2-62* pCO2-35
pH-7.37 calTCO2-21 Base XS--3 Intubat-INTUBATED
STUDIES:
================
CT Head noncontrast ___ = New scattered hypodensities in the
bilateral basal ganglia, thalami, left temporal lobe, and
cerebellum. The etiology is unknown, though these could
represent posterior reversible encephalopathy syndrome, HIV
associated encephalitis, vasculitis, embolic phenomenon, or
potentially infection such as toxoplasmosis. Further evaluation
with a contrast enhanced MRI is recommended. Diffuse atrophy,
which is out of proportion for a patient of this age, and may
relate to HIV.
CTA Head ___ = No conclusion, dissection, vessel wall
irregularity, stenosis, or aneurysm greater than 3 mm. Reformats
a are pending. The known hypodensities in the brain are better
assessed on the recent noncontrast CT of the head. Mild sinus
disease. No cervical lymphadenopathy. Mild emphysema.
CXR: Minimal bibasilar patchy opacities, likely atelectasis.
___ TTE:
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild global left
ventricular hypokinesis. Quantitative (biplane) LVEF = 43 %.
Right ventricular chamber size and free wall motion are normal.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are mildly thickened (?#). The aortic
valve is not well seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. IMPRESSION: Suboptimal image quality. No
vegetations or masses seen (best excluded by TEE); mild global
LV hypokinesis
___ MRI Head with and without Contrast
Multiple ring and solid enhancing lesions in the supratentorial
and
infratentorial white matter and within the bilateral basal
ganglia and bowel MRI. Differential diagnosis for these findings
is broad and includes opportunistic infections such as
toxoplasmosis, fungal disease, bacterial abscess, CNS lymphoma,
and less likely metastatic disease.
___: CXR
In comparison with the study of ___, the right IJ catheter
has been pulled out by the patient. Dobbhoff tube is no longer
present. Continued enlargement of the cardiac silhouette with
pulmonary edema.
EKG ___ = NSR, QTc 416
CXR Portable ___ = In comparison with the study of ___,
there is again some enlargement of the cardiac silhouette with
mild indistinctness of pulmonary vessels raising the possibility
of some elevated pulmonary venous pressure. No evidence of acute
focal pneumonia.
CT-Chest ___ = Interval resolution of multiple opacities seen
on the prior chest CT from ___ including the 6 mm
cavitary lesion in the right upper lobe which is no longer
identified. Bibasilar opacities are likely atelectasis. No
pleural effusions or pneumothorax (prelim).
MRI Brain ___ = Decrease in size of the enhancing lesion seen
previously in the supra and infratentorial brain. Surrounding
edema has also decreased. Multiple enhancing lesions are still
identified. Followup as clinically indicated.
DISCHARGE LABS:
Aspergillus Galactomannan Negative
Beta-D-Glucan 100 (borderline positive)
___ Bronchoscopy CMV Early Antigen Positive
___ 06:05AM BLOOD WBC-5.6 RBC-4.69 Hgb-13.9* Hct-39.0*
MCV-83 MCH-29.7 MCHC-35.8* RDW-15.1 Plt ___
___ 06:05AM BLOOD Glucose-97 UreaN-23* Creat-1.0 Na-130*
K-4.3 Cl-96 HCO3-21* AnGap-17
___ 07:28PM BLOOD Calcium-9.5 Phos-3.6 Mg-2.2
___ 12:41PM BLOOD Lactate-0.8
___ 12:41PM BLOOD freeCa-1.12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Darunavir 800 mg PO DAILY
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. RiTONAvir 100 mg PO DAILY
4. Azithromycin 1200 mg PO 1X/WEEK (SA)
5. Nystatin 500,000 UNIT PO BID
6. Atovaquone Suspension 1500 mg PO DAILY
Discharge Medications:
1. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 6 Weeks
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*72 Tablet Refills:*0
3. Azithromycin 1200 mg PO 1X/WEEK (SA)
4. Darunavir 800 mg PO DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. RiTONAvir 100 mg PO DAILY
7. Nystatin 500,000 UNIT PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Central Nervous System Toxoplasmosis complicated by delirium and
ataxia
SECONDARY:
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
HIV/AIDS
Cavitary Lung Lesion (resolved)
Acute Kidney Injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with HIV, malaise
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Heart size appears mildly enlarged but similar. Mediastinal and hilar contours
are unremarkable. Pulmonary vasculature is normal. Minimal patchy opacities
are noted in the lung bases. No focal consolidation, pleural effusion or
pneumothorax is evident. There are mild degenerative changes in the upper
lumbar spine. No acute osseous abnormality is visualized.
IMPRESSION:
Minimal bibasilar patchy opacities, likely atelectasis.
Radiology Report
EXAMINATION:
CT HEAD W/O CONTRAST
INDICATION: History of HIV with a worsening headache. Evaluate for a mass.
TECHNIQUE: Contiguous axial images of the brain were obtained without the
administration of IV contrast. Coronal and sagittal as well as thin
bone-algorithm reconstructed images were obtained.
DOSE: DLP: 891.93 mGy-cm;
CTDIvol: 55.33 mGy.
COMPARISON: CT of the head from ___.
FINDINGS:
Since the prior exam, there are new hypodensities in the bilateral basal
ganglia and thalami, more prominent on the right than the left. There is also
a new hypodensity in the left external capsule and in the periphery of the
left temporal lobe in the subcortical white matter (2, 14 and 10). Both lobes
of the cerebellum are heterogeneous with diffuse ill-defined hypodensities.
There is no hemorrhage. No significant mass effect is noted surrounding the
new hypodensities. The ventricles and sulci are prominent for the patient's
age. The basal cisterns are patent.
No fracture is identified. There is mild mucosal thickening in the ethmoidal
air cells. The remainder of the paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The soft tissues and orbits are unremarkable.
IMPRESSION:
1. New scattered hypodensities in the bilateral basal ganglia, thalami, left
temporal lobe, and cerebellum. The etiology is unknown, though these could
represent posterior reversible encephalopathy syndrome, HIV associated
encephalitis, vasculitis, embolic phenomenon, or potentially infection such as
toxoplasmosis. Further evaluation with a contrast enhanced MRI is recommended.
2. Diffuse atrophy, which is out of proportion for a patient of this age, and
may relate to HIV.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with abnormal head CT // please assess for septic
emboli
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
brain during infusion of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated. This report is based on interpretation of all
of these images.
DOSE: DLP: 1517.56 mGy-cm; CTDI: 79.06 mGy
COMPARISON: Noncontrast 15:42 CT head ___
FINDINGS:
HEAD CTA:
The vertebral arteries are normal; the right vertebral artery is dominant. The
basilar artery, superior cerebellar, and posterior cerebral arteries are
normal. The intracranial internal carotid arteries are normal. The middle
cerebral arteries are normal. The anterior cerebral arteries are normal. The
anterior communicating artery region is normal. There is no evidence of
aneurysm, stenosis or occlusion. The major dural venous sinuses are patent.
Ventricles, sulci, and cisterns are age-appropriate. Hypodensities described
on CT from earlier the same day are not well evaluated on this study optimized
for evaluation of the vasculature. No definite parenchymal enhancement is
identified within the limitations.
There is mucosal thickening of the maxillary sinuses.
Sphenoid sinus has 2 septations, the minor left inserts on the left carotid
groove.
There are periapical lucencies surrounding multiple maxillary teeth.
The mastoid air cells and tympanic cavities are clear. The orbits are normal.
NECK CTA:
There is mild calcification of the aortic arch. There is 3 vessel aortic arch
anatomy.
The included subclavian artery and cervical vertebral arteries on both sides
are patent, without focal flow-limiting stenosis or occlusion.
Right vertebral artery is dominant.
The common, internal, and external carotid arteries are patent.
There is no internal carotid artery stenosis by NASCET criteria.
CT NECK:
Mildly prominent adenoids and palatine tonsils, with mild fullness in the foci
of ___ on both sides.
Multiple small nodes in both sides of the neck, some of which are mildly
prominent, however not abnormally enlarged by size criteria.
No obvious intraluminal mass in the aerodigestive tract.
The submandibular, parotid, and thyroid glands are normal.
No lymphadenopathy is identified.
The included lungs are clear with minimal emphysematous changes.
There is mild degenerative disc and facet and uncovertebral joint disease of
the cervical spine.
IMPRESSION:
1. No stenosis, occlusion, or aneurysm of the major intracranial and
extracranial arterial circulation.
2. Parenchymal hypodensities described on CT head from earlier the same day
are not well visualized on this study optimized for evaluation of the
vasculature. No definite parenchymal enhancement is identified,however, this
study is optimized for evaluation of the vasculature rather than the brain
parenchyma.
3. Maxillary periodontal disease and mild maxillary sinus mucosal thickening.
Other details as above.
Radiology Report
EXAMINATION: MRI head without and with intravenous contrast
INDICATION: ___ year old man with PMH HIV/AIDS p/w headache and new head CT
findings. // better characterization of posterior fossa given CT findings
TECHNIQUE: MRI of the head was attempted. The patient was unable to remain
still within the scanner. Only localizer and sagittal T1 sequence were
obtained. The study was then terminated. No intravenous contrast was
administered.
COMPARISON: CTA head ___, noncontrast CT head ___
FINDINGS:
The patient was unable to remain still within the magnet and the study was
terminated following acquisition of only localizer and sagittal T1 sequences.
There are T1 hypointense areas in the left temporal lobe, bilateral basal
ganglia, and bilateral cerebellar hemispheres. These areas of signal
abnormality correspond to hypodensities seen on recent noncontrast CT head
from ___.
However, these are not adequately assessed on the present incomplete study.
Inferior aspect of the fourth ventricle/obex is not well seen-? Related to
adjacent cerebellar edema
Hypointense marrow signal in particular in the cervical spine, occipital bones
and in the clivus.
IMPRESSION:
Only limited MR ___ and sagittal T1 images were obtained only as the patient
could not remain still within the scanner.
1. Foci of abnormal signal in the left temporal lobe, bilateral basal ganglia,
and bilateral cerebellar hemispheres. Complete MRI of the brain without and
with intravenous contrast is recommended for further evaluation when the
patient is clinically suitable.
2. Hypointense marrow signal in particular in the cervical spine, occipital
bones and in the clivus.
Inadequately assessed on the present incomplete MRI study.
Correlate clinically and with hematology labs for anemia, systemic disease,
myeloproliferative or infiltrative disorders, etc.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HIV, h/o PCP, intubated // please confirm
ET tube position please confirm ET tube position
IMPRESSION:
In comparison with the study of ___, there is obliquity of the patient at
somewhat obscures detail. There is been placement of an endotracheal tube
with its tip approximately 6 cm above the carina. Nasogastric tube extends at
least to the mid stomach were crosses the lower margin of the image.
There has been development of increased opacification at the left base with
poor definition of the hemidiaphragm, this is consistent with volume loss in
the left lower lobe and pleural effusion.
No evidence of vascular congestion.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with HIV/AIDS, h/o syphilis, multifocal
hypodensities on CT head, also c/f intracranial hypertension // please
characterize lesions, ?e/o hypotension
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations
COMPARISON: Prior head CT dated ___ Prior MRI of the head dated ___.
FINDINGS:
The ventricles and sulci are normal in caliber and configuration. There are
multiple ring-enhancing and solid enhancing T2/FLAIR lesions in the bilateral
cerebral hemispheres with the largest lesions noted in the corona radiata of
the left frontal lobe, bilateral basal ganglia and thalami, bilateral temporal
lobes. There are also enhancing T2/FLAIR hyperintense lesions in the
bilateral cerebellar hemispheres and cerebellar vermis as well as within the
midbrain. There is local mass effect with sulcal effacement noted within
these regions. Several of these lesions demonstrate slow diffusion. There is
no definite leptomeningeal enhancement noted. Vascular flow voids are
preserved. There is minimal mucosal thickening within the ethmoid air cells
and left greater than right maxillary sinuses. The mastoid air cells are
grossly clear.
Inflammatory changes including post-contrast enhancement is noted adjacent to
the bilateral temporomandibular joints.
Diffuse T1 hypointensity is again noted in the marrow of the cervical spine
similar to prior study.
IMPRESSION:
Multiple ring and solid enhancing lesions in the supratentorial and
infratentorial white matter and within the bilateral basal ganglia and bowel
MRI. Differential diagnosis for these findings is broad and includes
opportunistic infections such as toxoplasmosis, fungal disease, bacterial
abscess, CNS lymphoma, and less likely metastatic disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with NG tube placed. // Confirm NG placement.
Confirm NG placement.
IMPRESSION:
In comparison with the earlier study of this date, the tip of the nasogastric
tube is in the lower portion of the stomach. Endotracheal tube is unchanged.
Continued opacification at the left base consistent with volume loss in the
left lower lobe and pleural effusion. Indistinctness of pulmonary vessels is
consistent with elevated pulmonary venous pressure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with possible PNA, toxo, lymphoma. // Comparison
to previous.
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Cardiomegaly and widening mediastinum are stable. Mild vascular congestion,
bibasilar atelectasis larger on the left side and a small left effusion are
grossly unchanged. Lines and tubes are in standard position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CVL just placed. // Confirm RIJ placement
in SVC/cavoatrial jxn.
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed 3 hours earlier
IMPRESSION:
Right supraclavicular catheter tip is in the proximal right atrium. Can be
withdrawn couple of cm for more standard position. There is no pneumothorax.
No other interval change from prior study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cerebral toxoplasmosis who needs dobhoff
placement. // multiple films please to confirm dobhoff placement
multiple films please to confirm dobhoff placement
IMPRESSION:
In comparison with the earlier study of this day, there has been placement of
a Dobbhoff tube that extends just beyond the level of the esophagogastric
junction. Little change in the appearance of the heart and lungs.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man who tugged on his IJ, now removed. // assess
interval change assess interval change
IMPRESSION:
In comparison with the study of ___, the right IJ catheter has been pulled
out by the patient. Dobbhoff tube is no longer present. Continued enlargement
of the cardiac silhouette with pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with AIDS on aspiration precautions and cough //
Evaluate for pneumonia Evaluate for pneumonia
IMPRESSION:
In comparison with the study of ___, there is again some enlargement of
the cardiac silhouette with mild indistinctness of pulmonary vessels raising
the possibility of some elevated pulmonary venous pressure. No evidence of
acute focal pneumonia.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with AIDS and presumptive CNS Toxoplasmosis,
ataxia/delirium has significantly improved on treatment // Ensure
improvement/resolution of ring-enhancing lesions
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
COMPARISON: ___.
FINDINGS:
Again multiple enhancing lesions are identified in the supra and
infratentorial brain involving both cerebral hemispheres, brain stem and both
cerebellar hemispheres. Compared to the prior study, the size of the enhancing
lesions has considerably decreased with decreasing surrounding edema. Multiple
enhancing lesions are still visualized bilaterally. Some of the previously
seen lesions are not perceptible on the current study. The mass effect on the
fourth ventricle has decreased. There is no hydrocephalus or midline shift.
There are no acute infarcts.
IMPRESSION:
Decrease in size of the enhancing lesion seen previously in the supra and
infratentorial brain. Surrounding edema has also decreased. Multiple
enhancing lesions are still identified. Followup as clinically indicated.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with HIV/AIDS, preexisting cavitary lesion //
Per IP to determine status of cavitary lesion pre-bronchoscopy
TECHNIQUE: Multi detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. All images were reviewed.
DOSE: DLP: 360.21 mGy-cm.
COMPARISON: CT chest ___.
FINDINGS:
The thyroid is normal. 7 mm left thoracic inlet lymph node (02:10) previously
measured 10 mm and no longer enhances. Axillary, mediastinal and hilar lymph
nodes are not enlarged. Aorta and pulmonary arteries are normal size.
Cardiomegaly is increased compared to CT ___. There is no coronary
artery calcification.
Central airways are patent to the subsegmental level. Previously described
cavitary lesion in the right upper lobe measuring 6 mm in greatest dimension
has significantly decreased in size currently measuring 3 x 1 mm with
resolution of surrounding wall thickening. Although detailed evaluation of
lung parenchyma is limited by respiratory motion, previously seen areas of
linear and focal opacity scattered throughout the lungs have resolved.
Bibasilar ground-glass opacities are diffuse. There is no pleural effusion.
There is no osseous lytic or blastic lesion concerning for malignancy or
infection. There are mild degenerative changes of the thoracic spine including
multiple levels of Schmorl's nodes.
11 x 10 mm left adrenal nodule is similar to CT ___ but
incompletely characterized. This study is not designed for subdiaphragmatic
diagnosis but shows no other abnormality in the imaged portions of the
suboptimally enhanced organs in the upper abdomen.
IMPRESSION:
1. Effectively treated right upper lobe cavitary lesion and scattered
opacities described on CT ___.
2. Bibasilar ground-glass opacities in the setting of cardiomegaly suggest
pulmonary edema which may be followed with conventional chest radiographs.
3. Small adrenal nodule is likely an adenoma, but this needs to confirmed with
non-contrast CT imaging on any subsequent Chest or Abd CT.
RECOMMENDATION(S): Small adrenal nodule is likely an adenoma, but this needs
to confirmed with non-contrast CT imaging on any subsequent Chest or Abd CT.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Headache, Slurred speech, Vomiting
Diagnosed with ALTERED MENTAL STATUS
temperature: 98.9
heartrate: 103.0
resprate: 18.0
o2sat: 97.0
sbp: 153.0
dbp: 100.0
level of pain: 7
level of acuity: 2.0 | ___, a ___ yo M PMHx AIDS (only known OI PCP ___ ___
and did not complete tx, recently started on HAART, most recent
CD4 39 on ___ ___, actively smoking crystal
meth, syphilis, and who left AMA on ___ after an admission
for headache and represented to the ___ ED on ___ with
headache and AMS. He is now s/p intubation for MRI showing
multiple ring enhancing lesions concerning for toxo vs. CNS
lymphoma, and 6d MICU stay c/b SIADH and agitation, during which
he was transitioned to empiric treatment for toxo. LP was not
performed initially due to concern of cerebral edema with high
risk of herniation. He self-extubated in MICU and was
transferred to floor for continued treatment. He continued to
improve (and therefore did not require lumbar puncture or brain
biopsy), his mental status returned to baseline, his ataxia
resolved, ___ cleared patient to go home, his lung lesions noted
previously resolved.
# Central Nervous System Toxoplasmosis (presumed): Patient with
history of HIV/AIDS presented with ___ days of headache, ___
days of ataxia, and 1 day of delirium and CT-Head showing
multiple hypodensities in bilateral basal ganglia, thalami, left
temporal lobe, and cerebellum. Initial differential included
drug intoxication (positive amphetamines but wouldn't explain
ataxia), toxic-metabolic disease (Na 128 but otherwise normal),
cryptococcal disease (negative serum antigen), toxoplasmosis,
meningitis (HSV, TB), neurosyphilis, PML, CNS fungal disease,
septic emboli, CNS ___, PRES (by imaging, no significant
hypertension or relevant drug exposures), vasculitis, and
HIV-associated encephalitis (possibly superimposed on
HIV-associated neurocognitive dysfunction/atrophy). Neurology
Consult wanted MRI Brain but did not want lumbar puncture due to
concern of posterior fossa edema and thus increased risk of
herniation. Infectious Disease Consult wanted cryptococcal
antigen and initially wanted many CSF labs (also started
initially on vancomycin/ceftriaxone/ampicillin/acyclovir at
meningitic dosing). Patient initially had poor
concentration/judgement but this worsened to disorientation and
severe agitated delirium requiring 4-point restraints (patient
still managed to slip out, jump out of bed, and immediately
strike head against wall). Team attempted twice to obtain MRI
on main hospital floor (once within hours of arrival without
sedation which failed, a second time shortly before ICU transfer
with 4mg of lorazepam also failed). Due to need for MRI Brain
to determine clinical course, continued worsening of patient's
encephalopathy, and by Neurology/ID recommendation, patient was
transferred to MICU for MRI, Bronchoscopy, and potentially LP
and Brain Biopsy. MRI Brain showed multiple ring and solid
enhancing lesions in basal ganglia and
supratentorial/infratentorial white matter most concerning for
toxoplasmosis, CNS lymphoma, and less likely
fungal/bacterial/metastatic disease. Given concerns regarding
herniation from LP and invasiveness of brain biopsy (as well as
known Toxoplasmosis IgG), patient was started on empiric course
of pyrimethamine/sulfadiazine/leucovorin starting ___ along with
a single day of dexamethasone and levetiracetam for seizure
prophylaxis. Patient had history of sulfonamide allergy and so
underwent desensitization (without incident). Neurosurgery was
consulted for possibility of brain biopsy. After patient
self-extubated in ICU and was stable, he was transferred back to
the hospital floor. Due to overall stability and dramatic
improvement in focal neurological deficits by ___, patient did
not receive LP or brain biopsy (improvement at that time no
longer felt to be dexamethasone-related). His regimen was
subsequently changed to TMP-SMZ 2tabs BID on ___ with continued
improvement (total 6 week course, improved compliance). His
ataxia resolved completely (with mild residual upper extremity
dysmetria), his confusion cleared completely, and ___ cleared
patient to go home. HCP noted that patient had repeated
exposures to an outdoor cat and cleaned after the cat despite
being repeatedly warn by doctors and family not to. Repeat MRI
on ___ demonstrated dramatic improvement in the CNS lesions and
patient was discharged (taxi'd to ___ to receive
prepackaged TMP-SMZ and levetiracetam).
# Delirium/Agitation: Noted on admission, likely secondary to
CNS Toxoplasmosis versus contributions from amphetamine usage
versus possibly bipolar syndrome. Made admission MRI Brain
impossible without intubation/sedation. In ICU, patient
self-D/Cd central line, endotracheal tube, and innumerable
peripheral IVs. Currently somnolent with antipsychotics and
tolerating PO. Then Code Purpled on ___ in early morning
wanting to leave AMA but was redirected without force and with
quetiapine/lorazepam. Of note, last hospitalization at ___
ended with AMA discharge. On 5:00 on ___, Code Purple was
called since patient was bored and wanted to go home; received
25mg PO Quetiapine. At 6:30 again Code Purpled. Nightfloat
attempted to redirect but patient went out of room into hallway,
was unable to state consequences of leaving, and received
lorazepam 1mg, and was peacefully brought back to his room. At
8:00, he Code Purpled a ___ time, made it to the ___ elevator,
assaulted the PGY2, and had to be escorted back to room by
security. Later in the day he was less agitated with sister/HCP
present. Quetiapine was replaced with olazapine due to concern
of effect on ART. Late ___, he Code Purpled for a ___ time
but was easily redirected back into his room; given lorazepam
1mg PO x1. His quetiapine was changed to olanzapine due to
concern of ART interaction. His QTc was in low 400s and so
daily EKG monitoring was stopped due to stability. As of
___, he demonstrated some impulsivity but understood the
consequences of leaving and was fully oriented. Physical
Therapy consult felt that the patient had no acute ___ needs.
Since ___, patient was calm and no attempted to leave AMA.
Speech and Swallow recommended aspiration diet but liberalized
over the course of his hospital stay. for the remainder of his
inpatient stay, he was stable on olanzapine 5mg and trazodone
50mg. He was oriented and was able to understand the nature of
his condition and treatments and consequences of noncompliance
and was discharged to home without any psychiatric medication.
# SIADH / Hyponatremia: Noted to have Na 120s on admission with
Urine Na 100s that worsened with IV normal saline in ED. Likely
in setting of active CNS process, though lung process is also
possible given recent chest findings. Na has since returned to
140+, from 128 on admission, with hypertonic saline. ___ have
been a component of hypovolemia (since patient was not eating in
final days prior to hospitalization) and SIADH may improve with
improvement in brain lesions. Down to low 130s on ___ and
beyond despite fluid restriction but patient overall
asymptomatic.
# HIV/AIDS: Patient with a long history of HIV/AIDS (unclear if
acquired from MSM or IVDU) for as well as thrush and PCP ___
(did not complete treatment) recently started on ART ___,
not previously did to concerns of noncompliance) On ___, his
CD4 count was 39 and his viral load was ~250,000. On a visit on
___, his VL was 984 (notions of medication noncompliance but
VL would suggest otherwise). His outpatient regimen of
Emtricitabine-Tenofovir 200-300mg PO Daily, Ritonavir 100mg PO
Daily, Darunivir 800mg PO Daily,
Azithromycin/Atovaquone/Nystatin was continued as inpatient
aside from atovaquone (replaced with toxoplasmosis treatment).
Of note, patient did not receive TMP-SMZ due to recorded
sulfonamide allergy (no issues with desensitization during ICU
stay) which may have resulted in poor coverage of toxoplasmosis.
# Leukopenia: Patient with HIV/AIDS with previously normal WBC
noted to be leukopenic on ___ having recently been started on
Toxoplasmosis treatment. No neutropenia on ___ and WBC normal
on ___ and beyond.
# History of Crystal Meth Use and IVDU: Patient had allegedly
stopped IVDU 6 months prior to presentation and crystal
methaphetamine several days prior to presentation (positive
urine toxicology). After the acute phase of his
hospitalization, patient was noted to be somewhat somnolent
possibly secondary to methamphetamine withdrawal. Patient was
counseled to abstain from recreational drug use.
# Right Upper Lobe Cavitary Lesion and Ground Glass Opacities:
Lung findings (6mm cavitary lesion) noted on prior imaging with
patient no-showing numerous outpatient bronchoscopies. Overall
unclear etiology given lack of fever/chills/cough, positive IGRA
but negative AFBx3 in ___. Bronchoscopy with bronchoalveolar
lavage on ___ (while intubated in ICU) by Interventional
Pulmonology grew late CMV Early Antigen Positive and later
pansensitive Staphylococcus aureus but Infectious Disease was
not concerned given lack of CXR findings and change in symptoms.
Patient was initially on Contact/Airborne precautions but these
were discontinued once patient was in ICU. Repeat CT-Chest on
___ showed interval resolution of all lung pathology.
Differential on discharge includes viral pneumonia versus
incidentally treated PCP ___ (with evidence on BAL) versus
unclear etiology.
# ___: Most likely pre-renal or contrast-induced, given contrast
for CT angiography on ___ oliguria during MICU stay. Cr has
since returned to baseline. Nephrology was consulted in ICU for
assistance with ___ and SIADH but signed off in ICU given
normalization of renal function. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o HCV cirrhosis s/p OLT ___ who presents with chest
discomfort and ___. Patient states that yesterday (___) he
developed sharp pleuritic type chest pain that was worse with
deep inspiration. He has never had pain like this before. Pain
did not travel. It persisted for at least one day and prompted
him to present to outside hospital. There an EKG was negative
for acute ischemia and initial troponin was reported as
indeterminate near his baseline. Due to elevated creatinine,
patient was unable to undergo CTA and was transferred here.
Patient with history of liver transplant ___ years ago and
infected hardware in the left knee that has been removed several
months ago while he waits for a new knee repair. Currently
anticoagulated with Coumadin for history of PE and atrial
fibrillation. Patient states he does not remember what his prior
PE felt like. In the ED his CP resolved. On arrival to the floor
he complained only of right Knee pain for which he receives high
doses of narcotics at his rehab. He reports pain is ___
currently compared to ___ yesterday, but he will not beable to
sleep with this level of pain.
In the ED, initial vitals were:
98.2 67 123/68 19 99% 2L Nasal Cannula
- Labs were significant for
CBC
5.5 9.7 199
28.6
N:70.5 L:22.1 M:7.1 E:0 Bas:0.___.0 PTT: 37.1 INR: 3.4
Trop-T: 0.13
Chem 7
131 94 72
------------<125
4.4 26 2.2
ALT: 25 AP: 129 Tbili: 0.8 Alb: 3.0
AST: 12
- Imaging revealed
OSH CXR was without consolidation
ECG was Afib with RBBB stable from ___
-The patient was given
0.5 mg IV dilaudid x 1
Vitals prior to transfer were:
97.8 66 136/68 18 98% RA
Upon arrival to the floor,
T 97.8 BP 92/50 p 61 R 18 98% On RA
REVIEW OF SYSTEMS:
(+) Per HPI Of not he has not urinated in 12 hours
(-) Chest paint resolved in ED Denies fever, chills, night
sweats, recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel habits. No dysuria.
Past Medical History:
1. Hep C Cirrhosis s/p transplant at ___ on ___
-- Discharged from ___, presented to ___ 8 weeks post op for
prolonged hosp stay complicated by encephalopathy (due to
cyclosporine and tacrolimus), transient ischemic attack,
neutropenia, thrombocytopenia, mild acute rejection, acute
kidney injury, hypertension (cyclosporine related), recurrent c.
difficile infection, and lower extremity edema
-- ___: portal vein thrombus with found incidental PE. U/S
of ___ negative for DVT. No anticoag at that time d/t bleeding
risk.
-- ___: Pt admitted to OSH with left ___ DV (fem-pop).
Preceded by episode of imobility from hospitalization for
pneumonia. Pt started on coumadin since this time with INR goal
___.
-- ___: left DVT in the setting of seemingly on
therapeutic anticoagulation with coumadin
-- BM suppression posttransplant: ___ BM Aspirate dyspoiesis
with myeloid and erythroid lineages along with megakaryocytic
hyperplasia
-- Posttransplant skin cancer: scalp lesion/squamous cell
carcinoma, R distal dorsal arm/squamous cell carcinoma, L
chest/basal cell carcinoma (s/p MOHs)
-- pseudogout, knee aspiration, s/p steroid injection
-- ___ edema, started lasix ___
2. H/O Esophageal varices, PVT prior to transplant: Most recent
BI records with ___ EGD without varicies
3. AVNRT s/p ablation in ___
4. Atrial fibrillation: failed CV immed post-tx, on coumadin
5. Melanoma status post excision in 1980s
6. Septic meningitis in ___
7. Osteoarthritis in the knees status post arthroscopy and left
knee replacement c/b septic joint on abx in ___.
8. Aphthous stomatitis
9. Asthma
10. GERD
11. High tibial osteotomy
12. s/p bilaterally cataract extraction
13. s/p Appendectomy
14. C. diff several times (4x) in ___ prior to transplant
15. History of CMV viremia.
16. History of acute rejection of a liver transplant.
Social History:
___
Family History:
The patient's father had bilateral lower extremity amputations
but had no clots prior to the surgery. There is no history of
VTE in the family. There is no history of miscarriages in the
family either.
Physical Exam:
ADMISSION EXAM:
================
Vitals: T 97.8 BP 92/50 p 61 R 18 98% On RA
General: Alert, oriented, mildly distraught regarding right knee
pain
HEENT: Sclera anicteric, dry oropharynx, EOMI
Neck: Supple
CV: Regular rate and rhythm, ___ SEM at apex
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: obese, soft,
Ext: Cool, pitting edema to sacrum bilaterally, R knee non ttp
but tender to flexion/extension and varous/valgus stress
Neuro: A+Ox3 ___ motor exam limited ___ pain
DISCHARGE EXAM:
================
Vitals: T 97.5, HR 81, BP 179/95, RR 22, SaO2 99% RA
General: Alert, oriented, NAD, chronically ill-appearing
HEENT: Sclera anicteric, oropharynx wnl, MMM, EOMI
Neck: Supple, no JVD
CV: Irregular rhythm, normal rate, no murmurs
Lungs: Limited exam, clear to auscultation anteriorly
Abdomen: +BS, obese, soft, nontender, nondistended
Ext: WWP, ___ pitting edema bilaterally, compression dressings
in place. L knee in brace.
Neuro: Oriented to self, place, and year (not day or month), no
asterixis, ___ motor exam limited ___ pain, sensation to light
touch intact
Pertinent Results:
ADMISSION LABS:
================
___ 12:20AM BLOOD WBC-5.5 RBC-3.23* Hgb-9.7* Hct-28.6*
MCV-89 MCH-30.2 MCHC-34.1 RDW-16.3* Plt ___
___ 12:20AM BLOOD Neuts-70.5* ___ Monos-7.1 Eos-0
Baso-0.2
___ 12:20AM BLOOD ___ PTT-37.1* ___
___ 12:20AM BLOOD Plt ___
___ 12:20AM BLOOD Glucose-125* UreaN-72* Creat-2.2* Na-131*
K-4.4 Cl-94* HCO3-26 AnGap-15
___ 12:20AM BLOOD ALT-25 AST-12 AlkPhos-129 TotBili-0.8
___ 12:20AM BLOOD CK-MB-1 cTropnT-0.13*
___ 05:40AM BLOOD CK-MB-1 cTropnT-0.14*
___ 09:45AM BLOOD CK-MB-2 cTropnT-0.15*
___ 12:20AM BLOOD Albumin-3.0*
___ 05:40AM BLOOD Albumin-3.0* Calcium-9.1 Phos-4.1 Mg-1.6
___ 05:40AM BLOOD Osmolal-300
___ 05:40AM BLOOD Cyclspr-80*
___ 02:46PM URINE Color-LtAmb Appear-SlHazy Sp ___
___ 02:46PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 02:46PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 02:46PM URINE CastHy-8*
___ 02:46PM URINE Mucous-OCC
___ 02:46PM URINE Hours-RANDOM Creat-139 Na-15 K-63 Cl-<10
___ 02:46PM URINE Osmolal-369
OTHER PERTINENT LABS:
======================
___ 05:45AM BLOOD Cyclspr-157
___ 08:00AM BLOOD Cyclspr-114
___ 05:35AM BLOOD Cyclspr-140
___ 08:55AM BLOOD Cyclspr-339
___ 04:47AM BLOOD Cyclspr-77*
___ 05:40AM BLOOD Cyclspr-86*
___ 05:24AM BLOOD Cyclspr-81*
___ 06:40AM BLOOD Cyclspr-82*
DISCHARGE LABS:
================
___ 05:40AM BLOOD WBC-4.5 RBC-3.08* Hgb-9.1* Hct-27.4*
MCV-89 MCH-29.5 MCHC-33.1 RDW-15.6* Plt ___
___ 05:40AM BLOOD ___ PTT-36.1 ___
___ 05:40AM BLOOD Glucose-121* UreaN-57* Creat-2.1* Na-130*
K-4.3 Cl-91* HCO3-33* AnGap-10
___ 05:40AM BLOOD ALT-12 AST-9 AlkPhos-133* TotBili-0.8
___ 05:40AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.7
MICROBIOLOGY:
==============
___ 11:48 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 16 R
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---- =>16 R
___ 2:46 pm URINE Source: Catheter.
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
=========
TTE (___):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
There is no ventricular septal defect. 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. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___,
the degree of MR seen has decreased. AS is not appreciated.
CXR (___):
There is a right-sided PICC line terminating in the mid SVC.
Patient rotation contributes to exaggeration of the cardiac
size, which is likely normal. Segmental atelectasis is noted,
particular in the right lung, although there does appear to be
new pulmonary edema superimposed on this. There may be small
tiny effusions. There is no pneumothorax.
Renal U/S (___):
IMPRESSION:
1. No evidence of hydronephrosis.
2. Extremely limited Doppler evaluation due to technically
limited study,
demonstrating both kidneys to be vascularized. No further
Dopp;er analysis could be obtained.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atovaquone Suspension 1500 mg PO DAILY
3. Bisacodyl ___AILY:PRN constipation
4. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
5. Fluoxetine 20 mg PO DAILY
6. Gabapentin 200 mg PO TID
7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
8. Losartan Potassium 25 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. Ranitidine 75 mg PO BID:PRN heartburn
11. Senna 17.2 mg PO QHS
12. Vitamin D ___ UNIT PO DAILY
13. Warfarin 2.5 mg PO DAILY16
14. Lactulose 30 mL PO TID
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
BID
17. Ferrous Sulfate 325 mg PO DAILY
18. Polyethylene Glycol 17 g PO EVERY OTHER DAY
19. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
20. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atovaquone Suspension 1500 mg PO DAILY
3. Bisacodyl ___AILY:PRN constipation
4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluoxetine 20 mg PO DAILY
7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth q6h prn Disp #*10
Tablet Refills:*0
8. Lactulose 30 mL PO QID
9. Omeprazole 40 mg PO BID
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Polyethylene Glycol 17 g PO EVERY OTHER DAY
12. Ranitidine 75 mg PO BID:PRN heartburn
13. Senna 17.2 mg PO QHS
14. Vitamin D ___ UNIT PO DAILY
15. Warfarin 1 mg PO DAILY16
16. Amlodipine 5 mg PO DAILY
17. Torsemide 40 mg PO DAILY
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
BID
20. OxyCONTIN (oxyCODONE) 10 mg oral Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
Acute on chronic kidney disease
SECONDARY DIAGNOSES:
=====================
Hypertension
Catheter-associated urinary tract infection
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: RENAL U.S WITH DOPPLERS.
INDICATION: ___ y/o male with HCV cirrhosis ___ years s/p OLT; h/o DVT and PE on
coumadin; found to have ___ worsening despite IVF and foley placement** please
obtain with dopplers **.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Comparison is made to abdominal CT from ___.
FINDINGS:
Limited evaluation due to technically difficult study as patient was unable to
breath hold.
The right kidney measures 10.9 cm. The left kidney measures 9.5 cm. There is
no hydronephrosis, stones, or suspicious masses bilaterally. Multiple simple
cyst are present, as seen on prior abdominal CTs. The largest cysts measure
2.1 x 2.0 x 1.4 cm in the right upper pole and 2.7 x 3.0 x 2.9 cm in the left
midpole. Normal cortical echogenicity and corticomedullary differentiation are
seen bilaterally.
DOPPLERS:
Extremely limited Doppler evaluation due to technical factors, adequate blood
flow is seen entering and exiting both kidneys. Intrarenal arteries unable to
be assessed.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Extremely limited Doppler evaluation due to technically limited study,
demonstrating both kidneys to be vascularized. No further Dopp;er analysis
could be obtained.
Radiology Report
INDICATION: ___ year old man with new R PICC // Evaluate new R single-lumen
Power PICC 51cm ___ ___ Contact name: ___: ___
TECHNIQUE: AP view of the chest
COMPARISON: ___
FINDINGS:
There is a right-sided PICC line terminating in the mid SVC. Patient rotation
contributes to exaggeration of the cardiac size, which is likely normal.
Segmental atelectasis is noted, particular in the right lung, although there
does appear to be new pulmonary edema superimposed on this. There may be small
tiny effusions. There is no pneumothorax.
IMPRESSION:
Right-sided PICC line terminating in the mid SVC.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.2
heartrate: 67.0
resprate: 19.0
o2sat: 99.0
sbp: 123.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ gentleman with HCV cirrhosis ___ years
s/p OLD and h/o DVT and PE (on Coumadin) who was transferred
from an OSH with chest pain, which resolved on admission, but
found to have supratherapeutic INR and ___.
# Acute on chronic kidney disease: Cr up to 2.2 on admission
from baseline of 1.4-1.5. Cr rose to 2.7 after albumin/IVF
boluses. Muddy brown casts were seen on urine sediment. Per
renal, multiple hypotensive episodes and bradycardia likely
resulted in ATN. Patient's creatinine slowly improved after
starting diuretics. Cr on discharge was 2.1. Kidney function
is expected to recover with time.
# Anasarca: Patient was grossly anasarcic after being volume
resuscitated with albumin for hypotension. TTE was largely
unchanged. Patient was diuresed with 40-80 mg IV Lasix/day and
his edema improved. He was discharged on torsemide 40 mg po
daily.
# Hepatitis C cirrhosis s/p OLT: Transplanted in ___, on
cyclosporine 75 mg q12h. MMF was stopped in clinic in
___ and LFTs remained normal. HCV VL 342,000 IU/mL on
___. Last biopsy was performed at previous admission
revealed Grade ___ inflammation, no acute cellular rejection, no
steatosis or ballooning, and stage ___ fibrosis. Atovaquone
was continued for prophylaxis. Cyclosporine was decreased to 50
mg q12h and levels were monitored.
# Supratherapeutic INR: Patient's Coumadin was held on
admission for supratherapeutic INR. He received vitamin K for
INR 5.2 and INR then became subtherapeutic. Warfarin was
restarted with a heparin gtt until INR became therapeutic. INR
became supratherapeutic again and Coumadin dose was adjusted.
INR on discharge was 3.6. He was discharged on Coumadin 1 mg
daily.
# Hypertension: Patient was initially hypotensive and losartan
and diuretics were held. He received an albumin bolus with
improvement in his blood pressure. He then became hypertensive
during the latter part of his hospitalization (SBP up to
170/180s). Losartan continued to be held given ___. Patient
was started on amlodipine 5 mg daily, which can be uptitrated as
needed.
# Prior left knee infection s/p hardware removal in ___:
Patient has chronic pain related to his previous knee
infection/hardware removal. He also has shallow venous stasis
ulcers on bilateral lower extremities. Patient's orthopedic
surgeon plans to replace his knee hardware once his ulcers have
healed and his leg swelling has resolved. Patient's pain was
well-controlled on home Oxycontin and po Dilaudid. He became
confused after receiving IV Dilaudid, so this was avoided.
# Catheter-associated UTI: Initial urine culture was negative.
Repeat urine culture after catheter was placed grew >100,000
Klebsiella sensitive to ceftriaxone. Foley was exchanged and
patient completed a 7 day course of ceftriaxone. Foley was
removed prior to discharge.
# Chest Pain: Patient had chest pain at OSH, which resolved on
admission here. No ischemic changes on EKG and three sets of
cardiac enzymes were negative. Considered PE, especially given
h/o prior PE, but patient had been therapeutic on Coumadin. CTA
was deferred given ___.
# Atrial fibrillation/pauses: Not on agents for rate or rhythm
control. During last admission (___), patient was
bradycardic at night with ___ second pauses seen on telemetry.
Patient continued to have pauses with HR ___, though rates
improved to ___ without intervention. It is unclear if these
pauses are contributing to hypotensive episodes. Patient is
followed by Dr. ___ have further outpatient EP
evaluation if warranted.
# Hyponatremia: Na persistently low (as low as 130s), which is
chronic per review of prior discharge summaries. Hyponatremia
neither responded to nor worsened with albumin or diuretics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Increased right leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of unprovoked left
carotid dissection, left MCA stroke with hemicraniectomy and
bilateral pulmonary emboli in ___,
residual right sided weakness and aphasia, and right hip
fracture in ___ who presented with 5 days of increased RLE
weakness. He had been at ___ and ___
following his right hip fracture hospitalization and was
improving and had been discharged home. Shortly after returning
home, he began having increased right leg weakness. He had been
on warfarin from ___ until ___ for prior stroke and
immobility (risk factor), then was stopped by hematology. He was
on prophylactic Lovenox when he was discharged in ___ after
his hip fracture, which was discontinued when he left rehab in
late ___.
Past Medical History:
THROMBOEMBOLIC STROKE
CAROTID DISSECTION
PNEUMATOSIS
CEREBRAL VENOUS ACCIDENT
STROKE
APHASIA
RIGHT HIP FRACTURE
PULMONARY EMBOLI
Social History:
___
___ History:
esophageal cancer
Physical Exam:
VITALS: Afebrile and vital signs within normal limits
GENERAL: Alert and in no apparent distress, laying in bed, calm,
conversant
EYES: Anicteric, PERRL
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. MMM.
CV: Heart regular, no murmur, no S3, no S4.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored on room air.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No Foley
EXT: Mild RLE edema, no LLE edema, right leg warmer than left
leg
SKIN: No rashes or ulcerations noted. Small area of erythema on
right inner wrist, no rash on palm.
NEURO: Alert, oriented, aphasic but able to answer questions,
face symmetric, ___ RLE strength, cannot move RUE except for
weak hand grip, ___ strength in LUE/LLE
PSYCH: pleasant, appropriate affect
Pertinent Results:
Ultrasound on ___ showed "1. Occlusive deep venous thrombosis
of the right common femoral, femoral, popliteal, gastrocnemius,
posterior tibial, and peroneal veins, extending down to at least
the level of the ankle. 2. No deep venous thrombosis of the left
lower extremity."
On admission:
___ 11:53PM WBC-8.9 RBC-4.83 HGB-14.0 HCT-43.2 MCV-89
MCH-29.0 MCHC-32.4 RDW-12.6 RDWSD-41.4
___ 11:53PM PLT COUNT-211
___ 11:53PM GLUCOSE-84 UREA N-8 CREAT-1.0 SODIUM-138
POTASSIUM-6.2* CHLORIDE-95* TOTAL CO2-29 ANION GAP-14
___ 11:58PM LACTATE-1.5 K+-4.5
___ 04:57AM ___ PTT-27.1 ___
On discharge:
___ 07:10AM BLOOD WBC-9.1 RBC-4.42* Hgb-12.8* Hct-39.8*
MCV-90 MCH-29.0 MCHC-32.2 RDW-12.3 RDWSD-40.6 Plt ___
___ 07:12AM BLOOD ___
___ 06:10AM BLOOD Glucose-114* UreaN-13 Creat-0.9 Na-142
K-4.2 Cl-99 HCO3-28 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Atorvastatin 10 mg PO QPM
3. Baclofen 30 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. FLUoxetine 60 mg PO DAILY
6. Nortriptyline 100 mg PO QHS
7. Omeprazole 20 mg PO DAILY
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
9. Tamsulosin 0.8 mg PO QHS
10. Polyethylene Glycol 17 g PO DAILY
11. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
12. TraZODone ___ mg PO QHS:PRN Insomnia
13. Aspirin 81 mg PO DAILY
14. melatonin 3 mg oral QHS
15. Senna 8.6 mg PO DAILY
16. Gabapentin 100 mg PO TID
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
2. Warfarin 5 mg PO QPM
3. Nortriptyline 150 mg PO QHS
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Baclofen 30 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. FLUoxetine 60 mg PO DAILY
10. Gabapentin 100 mg PO TID
11. melatonin 3 mg oral QHS
12. Omeprazole 20 mg PO DAILY
13. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 8.6 mg PO DAILY
16. Tamsulosin 0.8 mg PO QHS
17. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
18. TraZODone ___ mg PO QHS:PRN Insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right lower extremity deep vein thrombosis
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: BILAT LOWER EXT VEINS
INDICATION: ___ with right leg warmth// assess for dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Prior lower extremity Doppler from ___
FINDINGS:
There is echogenic thrombus with lack of compressibility and minimal to no
demonstrable color Doppler flow throughout the right common femoral, femoral,
popliteal, gastrocnemius, posterior tibial, and peroneal veins, extending down
to at least the level of ankle, consistent with occlusive deep venous
thrombosis. There is normal compressibility, flow, and augmentation of the
left common femoral, femoral, and popliteal veins. Normal color flow
demonstrated in the tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
1. Occlusive deep venous thrombosis of the right common femoral, femoral,
popliteal, gastrocnemius, posterior tibial, and peroneal veins, extending down
to at least the level of the ankle.
2. No deep venous thrombosis of the left lower extremity.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Weakness
temperature: 98.8
heartrate: 91.0
resprate: 16.0
o2sat: 95.0
sbp: 129.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ male with history of unprovoked left
carotid dissection, left MCA stroke with hemicraniectomy and
bilateral pulmonary emboli in ___, residual right sided
weakness and aphasia, and right hip fracture in ___ who
presented with 5 days of increased RLE weakness and was found to
have extensive right leg DVT. He had been on warfarin from ___
until ___ for prior stroke and immobility, then was stopped
by hematology. He was on prophylactic Lovenox when he was
discharged in ___ after his hip fracture, which was
discontinued when he left rehab in late ___.
Ultrasound on ___ showed "1. Occlusive deep venous thrombosis
of the right common femoral, femoral, popliteal, gastrocnemius,
posterior tibial, and peroneal veins, extending down to at least
the level of the ankle. 2. No deep venous thrombosis of the left
lower extremity." He was started on a heparin drip and then
transitioned to Lovenox 1 mg/kg BID. He was started on warfarin
5mg QHS on ___. He had mild RLE pain. His INR was 2.4 on
___, the day of discharge.
Hematology was consulted and recommended having 2 therapeutic
INR values 24 hours apart before discontinuing Lovenox. He will
need at least 3 months of therapeutic anticoagulation.
When he was admitted he also had a non-contrast CT head that
showed no acute intracranial findings and stable chronic
infarcts. Neurology was consulted and will arrange outpatient
follow-up. He had no new neurologic changes on exam.
He also had frequent headaches that he described as unilateral
and associated with lacrimation and rhinorrhea, lasting minutes
to hours. He felt these were like cluster headaches he had in
the past. He has not had success with finding pain relief
previously, but he and his wife wanted to try increasing the
nortriptyline, as they felt this had partially helpful in the
past. This was increased to 150mg QHS.
He was evaluated by ___ and OT, who both recommended rehab. He
was discharged to ___ on ___.
Check if applies: [ X ] Mr. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was greater
than 30 minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Plavix
Attending: ___.
Chief Complaint:
Painful, cool right lower extremity
Major Surgical or Invasive Procedure:
___: Right lower extremity angiogram, angiojet w/ 60mg tPA,
Right SFA stent, R SFA stent PTA
History of Present Illness:
___ with history of CAD, peripheral vascular disease s/p recent
RLE angiogram, SFA stenting and peroneal angioplasty for a cool,
painful RLE now presenting with similar symptoms. The patient
had been discharged after a course noted only for
pseuodoaneurysm development of the left groin after his right
SFA stenting and angioplasty. This was treated with manual
compression, with resolution. The patient was continued on his
aspirin and ticagrelor therapy and discharged home in good
condition with strong dopplerable distal signals.
The patient now returns with pain and coolness of the foot since
the afternoon several hours ago. The patient was accompanied by
his son, who noted that his RLE was 'cool up to the knee.' The
patient otherwise maintained intact sensory and motor function.
Given the likely acute nature of onset, the patient was brought
___, whereupon he underwent a venous ultra-sound
of the extremity and initiated on heparin drip after a single
bolus. He was then transferred to ___ for further management.
The patient reports intermittent paresthesias with sensations of
'electric shocks' to his toes. His symptoms are similar to that
which brought him to ___ in his initial hospitalization. He
denies fevers, chills, chest pain or dyspnea; denies
palpitations or recent arrythmias. He has noticed an improvement
in his symptoms since heparinization.
Past Medical History:
PMH: AAA, HLD, asbestosis, CAD s/p CABG ___, HTN, duputyren's
contracture, PAD, elevated LFT's, EtOH dependence
PSH: CABGx4, L SFA stent ___, L SFA stent PTA and re-stenting,
diagnostic RLE angiogram (___), repeat RLE angiogram, SFA
stent x2/angioplasty peroneal art. (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
VS:98.3 88 131/73 18 98%RA
General: in no acute distress, pleasant, cooperative with exam.
HEENT: sclera anicteric, mucus membranes moist, nares clear,
trachea at midline
CV: regular rate, rhythm. No appreciable murmurs, rubs, gallops
Pulm: clear to auscultation bilaterally
Abd: scaphoid, non-tender, non-distended.
MSK:
Right foot cooler than left but without discoloration. Patient
has overall pale complexion, with otherwise unchanged appearance
of his extremities since discharge. Motor and sensory exam are
both intact; able to evert/invert at ankle, and
dorsi/plantar-flex. No thrill appreciated at either groin
fem pop dp pt
R p dopp triphasic monophasic venous
L p p p d
Neuro: alert, oriented to person, place, time
On discharge:
VS: 98.0, 88, 149/73, 18, 100% RA
Gen: NAD, AAOx3, pleasant
CV: RRR no m/r/g
Pulm: CTAB, no w/r/r
Abd: Soft, NT/ND
L groin: dressing in place c/d/i. Patient has L groin
non-pulsatile bulge ~2x2 cm, consistent with previous exam. Per
patient, has not expanded, and firm area is non-fluctuant to
palpation. Consistent with ultrasound imaging.
Pulses:
Fem Pop DP ___
Right P P D D
Left P P P D
Pertinent Results:
___ 11:55PM BLOOD WBC-10.6 RBC-3.50* Hgb-10.3* Hct-31.7*
MCV-91 MCH-29.4 MCHC-32.4 RDW-14.3 Plt ___
___ 08:05AM BLOOD WBC-9.2 RBC-3.41* Hgb-10.0* Hct-30.7*
MCV-90 MCH-29.4 MCHC-32.6 RDW-14.2 Plt ___
___ 03:13AM BLOOD WBC-12.6* RBC-3.65* Hgb-10.4* Hct-33.2*
MCV-91 MCH-28.4 MCHC-31.3 RDW-14.3 Plt ___
___ 11:55PM BLOOD Glucose-103* UreaN-18 Creat-0.9 Na-137
K-4.5 Cl-105 HCO3-21* AnGap-16
___ 08:05AM BLOOD Glucose-92 UreaN-15 Creat-0.8 Na-138
K-4.4 Cl-107 HCO3-24 AnGap-11
___ 03:13AM BLOOD Glucose-106* UreaN-15 Creat-0.9 Na-136
K-4.2 Cl-105 HCO3-20* AnGap-15
Medications on Admission:
lisinopril 10 daily, Crestor 40 daily, ASA 81', ticagrelor 90
bid, oxycodone 5 q4h prn, clobetasol
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Rosuvastatin Calcium 40 mg PO DAILY
3. TiCAGRELOR 90 mg PO BID
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral arterial disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: Right lower extremity arterial duplex.
REASON: Status post right SFA stent and right peroneal angioplasty.
FINDINGS: Duplex was performed of the right lower extremity arterial system.
Peak velocities in centimeters per second from proximal to distal are as
follows: Common femoral 40, SFA 28, SFA stent ___, 22, 26. The stent then
occludes in the distal thigh and the above-knee segment. The peroneal artery
is reconstituted and patent with velocities ranging from 18-25 cm/sec.
The left groin was also examined. The common femoral artery is patent as is
the vein. There is no evidence of pseudoaneurysm or AV fistula. A hematoma
is seen measuring 0.6 x 2.2 x 2.9 cm.
IMPRESSION: Occlusion of the distal right SFA stent. No evidence of left
groin pseudoaneurysm or AV fistula.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: COLD FOOT
Diagnosed with CIRCULATORY DISEASE NEC
temperature: 98.3
heartrate: 88.0
resprate: 18.0
o2sat: 98.0
sbp: 131.0
dbp: 73.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ was admitted to the Vascualar Surgery service with
HPI as stated above. including recent placement of 2 left SFA
stents and peroneal angioplasty. He underwent duplex which
noted no flow through the distal stent.
He went back to the OR on ___ for occluded right distal
superficial
femoral artery stent and underwent Right lower extremity
imaging, AngioJet thrombectomy, stenting of distal SFA, and
balloon angioplasty of proximal superficial femoral artery
stent; for full details please see the dictated operative
report.
He tolerated the procedure well and went to the PACU and then to
the floor on good condition. He was maintained on a heparin
drip as well as his home aspirin and ticagrelor overnight, and
his activity and diet were advanced on POD#1. He was normalized
on his home meds and the heparin drip was discontinued; he
voided without catheter.
On the afternoon of POD#1 that patient was felt to be
progressing well and appropriate for discharge. He will
continue his home anticoagulation and resume all other home meds
upon discharge. He is discharged to home on the afternoon of
POD#1, ___, in good condition and with appropriate
instructions, information, and plans to follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / adhesive tape / Cephalexin / Percocet
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o woman with PMHx EtOH cirrhosis c/b esophageal varicies
(last EGD ___ and ascites, HTN, HLD and AS s/p bioprosthetic
AVR in ___ (last TTE ___, mean AV gradient 24) presenting
with SOB. She states that she last felt in her USOH in ___.
At that time she was able to walk her dogs ___ mile, 8 times per
day. Since then, she has noted progressive DOE; currently she is
only able to walk 20 feet before needing to stop and rest. She
denies any recent CP or pedal edema. For the past 36 hours she
has noted orthopnea, which is new for her and some PND. She is
not sure if she has gained weight recently. She denies personal
history of CAD, CHF or MI, though she has a very strong family
history of early CAD. She denies syncope and states she has
never had exertional CP before.
.
Initial VS in the ED:
T 96.9 HR 61 BP 125/41 RR 18 O2 Sat 95% RA
Labs were notable for BNP 5230, trop <0.01, normal CBC, normal
lytes. CXR showed moderate pulmonary edema, b/l pleural
effusions L>R, and cardiomegaly, which is new compared to study
dated ___. She was given Lasix 80mg IV x1 and admitted to
medicine. She received Lasix 80mg IV in the ED at 01:15, to
which she had put out 400cc of urine on arrival to the floor at
02:45.
.
On the floor, initial VS were:
T 98 BP 115/57 HR 65 RR 18 O2 Sat 95% 2L (88% RA)
Past Medical History:
Aortic stenosis
Hypertension
Hypercholesterolemia
Asthma
Gastroesophageal Reflux Disease
s/p r. Total Hip Replacement ___
s/p Tonsillectomy
Social History:
___
Family History:
father died during CEA. Mom had RA. No FH of liver problems,
diabetes, emphysema.
Physical Exam:
ADMISSION Physical Exam:
T 98.2 BP 125-128/57-66 HR 56-65 RR 18 O2 Sat 94% 2L
General: Obese woman in NAD, RR increases with talking
HEENT: EOMI, NCAT, MMM
Neck: JVP to the ear at 45 degrees
CV: III/VI late peaking systolic murmur best heard at the RUSB
radiating to the bilateral carotids. Normal S2, no audible
S3/S4.
Lungs: Bibasilar crackles to midway up back, diminished BS, no
increased WOB, no wheezes or rhonchi.
Abdomen: Obese, NTND, NABS, no r/r/g
Ext: WWP, no c/c/e
Neuro: A/Ox3, CN II-XII intact, no asterexis, non focal
Skin: No impairments
DISCHARGE Physical Exam:
T 98.0 BP 90-135/34-54 52-67 20 95%RA I:O ___ Wt
189->186.4lbs
General: Pleasant woman in NAD, appears well
HEENT: EOMI, NCAT, MMM
Neck: No JVD
CV: III/VI late peaking systolic murmur best heard at the RUSB
radiating to the bilateral carotids. Normal S2, no audible
S3/S4.
Lungs: Good air movement, no increased WOB, no wheezes or
rhonchi.
Abdomen: Obese, NTND, NABS, no r/r/g
Ext: WWP, no c/c/e
Neuro: A/Ox3, CN II-XII intact, no asterexis, non focal
Pertinent Results:
ADMISSION:
___ 07:30PM BLOOD WBC-7.0 RBC-4.03* Hgb-12.5 Hct-38.3
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.9 Plt ___
___ 07:30PM BLOOD Neuts-67.5 ___ Monos-4.6 Eos-4.4*
Baso-0.8
___ 11:20AM BLOOD ___ PTT-34.0 ___
___ 07:30PM BLOOD Glucose-153* UreaN-13 Creat-0.9 Na-135
K-3.7 Cl-97 HCO3-28 AnGap-14
___ 07:30PM BLOOD cTropnT-<0.01 proBNP-5230*
___ 07:30PM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
DISCHARGE:
___ 06:16AM BLOOD WBC-5.6 RBC-3.77* Hgb-11.6* Hct-36.1
MCV-96 MCH-30.7 MCHC-32.1 RDW-13.7 Plt ___
___ 06:05AM BLOOD Glucose-119* UreaN-14 Creat-0.8 Na-138
K-3.6 Cl-96 HCO3-32 AnGap-14
___ 06:45AM BLOOD ALT-23 AST-32 LD(LDH)-214 AlkPhos-80
TotBili-0.6
___ 06:05AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1
___ 06:05AM BLOOD AFP-2.6
IMAGING:
TTE (___):
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). 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. A bioprosthetic aortic valve
prosthesis is present. The aortic prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. Trace 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.
.
TTE: ___
IMPRESSION: Suboptimal image quality. Well-seated bioprosthetic
aortic valve with markedly increased transaortic gradient in the
setting of only mild aortic regurgitation (may be underestimated
secondary to shadowing). Visually, the valve appears more
pliable than would be suggested by mean gradient, but no good
quality short axis images are available for review. Preserved
global biventricular systolic function. Increased left
ventricular filling pressure. At least mild mitral
regurgitation. Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the transaortic mean gradient has markedly increased from 24
mmHg to 68 mmHg. The severity of aortic regurgitation has
increased. Moderate pulmonary artery systolic hypertension is
new. Hyperdynamic left ventricular systolic function is no
longer appreciated.
If clinically indicated, a transesophageal echocardiogram may be
considered to better assess the aortic valve bioprosthesis and
severity of aortic regurgitation.
TEE: ___
Mild spontaneous echo contrast but no thrombus is seen in the
left atrial appendage. No spontaneous echo contrast or thrombus
is seen in the body of the left atrium or the body of the right
atrium/right atrial appendage. Left atrial appendage ejection
velocity is borderline reduced (0.22 m/s). No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is mild elevation of pulmonary artery
pressures. Simple atheroma are seen in the aortic arch and
descending thoracic aorta. A well-seated bioprosthetic aortic
valve prosthesis is present with thickened/relatively immobile
leaflets. Moderate aortic regurgitation is seen. There is simple
atheroma in the aortic arch and descending aorta 33cm from the
incisors. No masses or vegetations are seen on the aortic valve.
Moderate (2+) aortic regurgitation is seen. The mitral leaflets
are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: Well-seated bioprosthetic aortic valve with
restricted leaflet motion. Moderate aortic regurgitation. Normal
left ventricular systolic function. Mild-moderate mitral
regurgitation. Moderate tricuspid regurgitation. Mild pulmonary
artery hypertension. Spontaneous echo contrast but no thrombus
in the ___.
.
CXR (___): Moderate pulmonary edema, b/l pleural effusions
L>R, and cardiomegaly, which is new compared to study dated
___.
RUQ U/S ___
IMPRESSION:
1. Nodular hepatic contour with a coarsened echotexture
consistent with
history of cirrhosis.
2. 8 mm hypoechoic nodule in segment ___ ___s poorly
defined larger
isoechoic lesion in segment 4A which are suspicious for ___.
Recommend
further evaluation with MRI or multiphasic liver CT.
3. Cholelithiasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO Q6H PRN anxiety
2. Citalopram 40 mg PO DAILY
3. Nadolol 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Spironolactone 100 mg PO DAILY
6. Furosemide 80 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Cetirizine *NF* 10 mg Oral daily
9. 20 mg Other daily
10. Vitamin D ___ UNIT PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
Discharge Medications:
1. ALPRAZolam 0.5 mg PO Q6H PRN anxiety
2. Cetirizine *NF* 10 mg Oral daily
3. Citalopram 20 mg PO DAILY
RX *citalopram 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Furosemide 120 mg PO DAILY
RX *furosemide 40 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
7. Nadolol 20 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Spironolactone 100 mg PO DAILY
10. Mupirocin Nasal Ointment 2% 1 Appl NU BID Duration: 5 Days
RX *mupirocin calcium [Bactroban Nasal] 2 % 1 application
topically twice a day Disp #*1 Unit Refills:*0
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
12. Multivitamins 1 TAB PO DAILY
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Critical Aortic Stenosis
Acute Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: History of alcoholic cirrhosis for preop evaluation for AVR,
question ___.
TECHNIQUE: Abdominal ultrasound.
COMPARISON: Abdominal ultrasound from ___.
FINDINGS:
The liver has a nodular contour and is coarsened with increased echogenicity
consistent with the history of cirrhosis. An 8 x 4 mm hypoechoic irregularly
marginated nodule is present in segment ___ of the liver. There is a larger
but more ill-defined isoechoic lesion in segment 4A which is suspicious for a
mass. There is no intra or extrahepatic biliary dilatation and the common
bile duct meaures 4 mm. The portal vein is patent with normal hepatopetal
flow. Multiple gallstones are identified as seen previously, but there is no
evidence of gallbladder wall thickening or pericholecystic fluid to suggest
cholecystitis. Limited views of the pancreatic body appear unremarkable. The
head and tail are obscured by bowel gas. The right kidney measures 11.1 cm
and the left 10.8 cm. There is no evidence of hydronephrosis or concerning
lesions. The spleen is not enlarged measuring 10.6 cm. The visualized aorta
and IVC are unremarkable. There is no evidence of ascites.
IMPRESSION:
1. Nodular hepatic contour with a coarsened echotexture consistent with
history of cirrhosis.
2. 8 mm hypoechoic nodule in segment ___ as well as poorly defined larger
isoechoic lesion in segment 4A which are suspicious for ___. Recommend
further evaluation with MRI or multiphasic liver CT.
3. Cholelithiasis.
These findings were discussed with Dr. ___ by Dr. ___ telephone
at 4:45 pm on ___.
Radiology Report
HISTORY: ETOH cirrhosis and mass found on ultrasound. Evaluate liver for
query hepatocellular carcinoma.
TECHNIQUE: Multiplanar T1 and T2 weighted imaging was obtained on a 1.5 T
magnet, including dynamic 3D imaging obtained prior to, during and subsequent
to the intravenous administration of 0.1 mmol/kg of Gadavist (8 ml).
COMPARISON: Ultrasound ___.
FINDINGS:
The liver is of normal signal on T2 weighted imaging, it has a nodular contour
with hypertrophy of the left lobe and a right posterior hepatic notch
compatible with cirrhosis. There is signal drop-off on out of phase imaging
when compared to in phase T1 weighted imaging compatible with fatty
deposition. Multiple foci of blooming artifact are seen within the liver on
in phase imaging compatible with cirrhotic nodules. Post administration of
contrast there are linear persistent enhancing areas consistent with confluent
fibrosis. There are no suspicious enhancing lesions within the liver. In
particular, no lesions are seen to correlate with the suspicious areas
identified on the recent ultrasound. There is conventional hepatic arterial
anatomy. The portal and hepatic venous systems are patent. No intra or
extrahepatic biliary dilatation. Gallstones noted within the gallbladder, no
evidence of cholecystitis.
The spleen is not enlarged. Incidental note is made of a 1.6 cm accessory
spleen. No significant intra-abdominal varices. There is a trace amount of
ascites adjacent to the liver.
The pancreas is of normal signal and morphology. No focal pancreatic lesion.
The pancreatic duct is of normal caliber. No adrenal lesion. The kidneys
enhance symmetrically. No focal renal lesion. No hydronephrosis.
No upper abdominal or retroperitoneal lymphadenopathy. The visualized small
large bowel are within normal limits.
Normal marrow signal within the visualized skeletal system. There are
bilateral pleural effusions with associated bibasilar atelectasis.
IMPRESSION:
1. Background cirrhosis without imaging features of portal hypertension.
2. No suspicious lesions within the liver, in particular no lesions to
correlate with the suspicious areas seen on the recent ultrasound. A
follow-up ultrasound is advised in 3 months to ensure stability/ resolution of
these findings.
3. Fatty deposition within the liver.
4. Cholelithiasis.
5. Bilateral pleural effusions with associated bibasilar atelectasis
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SOB
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSION NOS
temperature: 96.9
heartrate: 61.0
resprate: 18.0
o2sat: 95.0
sbp: 125.0
dbp: 41.0
level of pain: 0
level of acuity: 3.0 | ___ y/o woman with PMHx EtOH cirrhosis c/b esophageal varicies
and ascites, HTN, HLD and AS s/p bioprosthetic AVR in ___
(previous TTE ___, mean AV gradient 24) presenting with CHF
___ aortic stenosis.
.
Active Problems:
# Decompensated aortic stenosis with acute CHF: Pt s/p AVR in
___ for AS with bioprosthetic valve and has had good functional
capacity. Orthopnea, cardiomegaly, hypoxia and pulmonary edema
in the setting of progressive decline in functional capacity and
elevated BNP is consistent with acute decompensated CHF. TTE
showed normal EF with concern for increased gradient in aortic
valve, concerning for symptomatic AS with TEE confirming
non-working AVR. She denies CP or syncope. She was seen by
cardiology who recommended cardiac surgery eval for redo AVR.
Patient currently at or near dry weight. Functional capacity
increased from walking 10ft on presentation to 5 laps around the
nursing station on d/c. Low Na diet. Switched to PO Lasix 120mg
with strict instructions for patient to weight herself every
morning as critical AS is pre-load dependent and do not want to
dry her out too much. Patient will return to AS clinic on ___.
Hepatology deemed her low risk for surgery.
# EtOH Cirrhosis: Due to longstanding EtOH use. Currently well
compensated. ___ Class A. MELD 7. RUQ showed mass
suspicious for HCC, AFP 2.6. MRI read did not pick up any mass
and after speaking to radiologist confirmed that sometimes there
can be a "fake out" with U/s. Did recommend f/u ultrasound in 3
months. Continued home Spironolactone, Nadolol. EGD without any
significant changes from previous.
Chronic Problems:
# GERD: Patient reports heart burn for 2-days that lasts about
30min. Had not mentioned this previously because didn't think a
big deal. Not worse with exercising. Pt on Pantoprazole at home
for GERD. Likely non-cardiac. EKG no acute changes. Encourage
sitting upright after meals. Continue Protonix
.
# Anxiety: Continue home Alprazolam |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pleural effusion
Major Surgical or Invasive Procedure:
Bilateral chest tubes by Interventional Pulmonology ___
History of Present Illness:
Ms. ___ is a pleasant ___ w/ HTN, DL, T2DM, CAD s/p
CABG ___ admitted ___ for nausea and found to have
new AML who p/w orthopnea. No F/C, no cough, no N/V, no chest
pain. She is a poor historian and unable to provide more
history.
She went to OSH where CT and CXR revealed pleural effusions,
moderately sized. She was transferred to ___ for continuity of
care. She was seen in the ED by IP who noted sig dyspnea and
placed b/l chest tubes, fluid studies c/w CHF. She felt sig
improved. On arrival to ___, she noted no dyspnea.
Past Medical History:
DM2
HTN
HLD
CAD s/p ?CABG ___
GERD
Social History:
___
Family History:
per ___ Medical record
Parents died in their ___, unknown cause
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 98.0 PO 104 / 62 86 20 92 Ra
General: NAD, Resting in bed comfortably asleep, arousable to
voice
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 No MRG, JVD to the madible
PULM: CTAB on anterolateral fields, faint b/l crackles b/l
lateral fields, No respiratory distress, b/l chest tubes in
place
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, 2+ b/l ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: Generalized weakness
PSYCH: Pleasant and cooperative but does not contribute much in
regards to history
ACCESS: PIV
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 821)
Temp: 98.1 (Tm 98.5), BP: 157/68 (145-172/51-88), HR: 81
(81-94), RR: 20 (___), O2 sat: 98% (96-98), O2 delivery: RA,
Wt: 102.5 lb/46.49 kg
General: elderly woman lying in bed, appears comfortable and in
NAD
HEENT: MMM, no OP lesions.
CV: RRR, NL S1 S2 no S3 S4. No MRG
PULM: unlabored breathing, diminished breath sounds bilaterally
ABD: BS+, soft, NTND, no rebound or guarding
LIMBS: WWP, 1+ b/l dependent lower extremity edema to thighs
SKIN: No notable rashes on trunk nor extremities
NEURO: Generalized weakness
Pertinent Results:
ADMISSION LABS
================
___ 08:00AM BLOOD WBC-9.2 RBC-3.19* Hgb-9.9* Hct-30.6*
MCV-96 MCH-31.0 MCHC-32.4 RDW-18.4* RDWSD-63.7* Plt ___
___ 08:00AM BLOOD Neuts-66.9 Lymphs-11.1* Monos-10.7
Eos-5.7 Baso-1.1* Im ___ AbsNeut-6.17* AbsLymp-1.02*
AbsMono-0.98* AbsEos-0.52 AbsBaso-0.10*
___ 08:00AM BLOOD Glucose-103* UreaN-10 Creat-0.9 Na-135
K-7.3* Cl-108 HCO3-19* AnGap-8*
___ 01:45PM BLOOD Albumin-2.4* Calcium-8.8 Phos-3.9 Mg-1.6
___ 08:00AM BLOOD ALT-6 AST-53* LD(LDH)-894* AlkPhos-98
TotBili-0.4
___ 08:00AM BLOOD proBNP-___*
___ 08:00AM BLOOD cTropnT-0.03*
___ 01:45PM BLOOD CK-MB-2 cTropnT-0.03*
___ 08:37AM BLOOD ___ pO2-58* pCO2-36 pH-7.39
calTCO2-23 Base XS--2
___ 08:37AM BLOOD Lactate-0.6
DISCHARGE LABS
================
___ 06:45AM BLOOD WBC-7.1 RBC-2.73* Hgb-8.7* Hct-26.6*
MCV-97 MCH-31.9 MCHC-32.7 RDW-18.8* RDWSD-66.3* Plt Ct-96*
___ 06:45AM BLOOD Glucose-99 UreaN-15 Creat-1.3* Na-139
K-4.1 Cl-104 HCO3-22 AnGap-13
___ 06:45AM BLOOD ALT-<5 AST-10 LD(LDH)-258* AlkPhos-87
TotBili-0.2
___ 06:45AM BLOOD Albumin-2.1* Calcium-8.4 Phos-3.9 Mg-2.1
MICRO
=========
___ 3:20 pm PLEURAL FLUID PLEURAL FLUID RIGHT SIDE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
Reported to and read back by ___ ___
1:10PM.
PROPIONIBACTERIUM ACNES.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
___ 3:21 pm PLEURAL FLUID PLEURAL FLUID LEFT SIDE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 12:41 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 12:30 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal 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.
___ 12:52 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 1:04 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:18 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:40 pm BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending): No growth to date.
___ 7:45 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
URINE
=========
Urine Sediment: ___ RBC, and ___ WBC per high powered field; no
casts of any kind noted; many calcium phosphate crystals
appreciated, including triple phosphate.
PLEURAL FLUID CYTOLOGY
=======================
___ CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: PLEURAL FLUID, left side
DIAGNOSIS:
Pleural fluid, left:
NEGATIVE FOR MALIGNANT CELLS.
- Mesothelial cells, lymphocytes, and histiocytes.
___ CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: PLEURAL FLUID, right side
DIAGNOSIS:
Pleural fluid, right:
NEGATIVE FOR MALIGNANT CELLS.
- Mesothelial cells, lymphocytes, and histiocytes.
IMAGING
==========
___ CXR
IMPRESSION:
Status post placement of bibasilar chest tubes with near
complete resolution
of previously demonstrated bilateral pleural effusions. Minimal
residual
atelectasis in the lung bases. No pneumothorax.
___ TTE
CONCLUSION:
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with a
normal cavity size. Overall left ventricular systolic function
is mildly depressed secondary to inferior
posterior hypokinesis. The visually estimated left ventricular
ejection fraction is 45%. There is no
resting left ventricular outflow tract gradient. Normal right
ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender.
The aortic arch diameter is normal with a normal descending
aorta diameter. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. There
is mild to moderate [___] aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear
structurally normal. There is mild [1+] tricuspid regurgitation.
There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior TTE (images reviewed) of ___,
there is no obvious change, but the
suboptimal image quality of the studies precludes definitive
comparison.
___ CXR
IMPRESSION:
Compared to chest radiographs ___.
Small right pleural effusion and mild bibasilar atelectasis are
new. No
pneumothorax. Upper lungs clear. Heart size normal.
___ NCHCT
IMPRESSION:
1. No evidence acute intracranial abnormality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with with PMH of AML found to have recurrent
bilateral pleural effusions s/p bilateral chest tube placement ___// Eval
for tube placement and pneumothorax.
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: Chest CT ___ from outside institution, chest radiograph
___ from outside institution
FINDINGS:
Status post median sternotomy and CABG. Interval placement of bibasilar chest
tubes with near complete resolution of previously demonstrated bilateral
pleural effusions. No pneumothorax. Minimal streaky atelectasis in the lung
bases. Cardiac, mediastinal and hilar contours are unchanged. Pulmonary
vasculature is not engorged. No acute osseous abnormality. Contrast material
is seen within diverticula in the left upper quadrant of the abdomen.
IMPRESSION:
Status post placement of bibasilar chest tubes with near complete resolution
of previously demonstrated bilateral pleural effusions. Minimal residual
atelectasis in the lung bases. No pneumothorax.
Radiology Report
INDICATION: ___ year old woman with b/l pleural effusions// eval b/l chest
tubes
COMPARISON: Radiographs from ___
IMPRESSION:
Mediastinal wires and bilateral pleural pigtail catheters are again seen.
Cardiomediastinal silhouette is within normal limits. There are no focal
consolidations, pleural effusion, or pulmonary edema. There are no
pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ w/ HTN, DL, T2DM, CAD s/p CABG ___ admitted
___ nausea and found to have new AML c/b pleural effusions
s/pthoractensis ___ confirming lymphocytic transudative fluid, whopresented
to OSH with acute onset dyspnea, transferred to BIDMCafter being found to have
recurrent b/l moderate sized pleuraleffusions, clinically improved s/p b/l CTs
(d/c'd ___, more lethargic this morning, decreased breath sounds// ?pleural
effusions ?pleural effusions
IMPRESSION:
Compared to chest radiographs ___.
Small right pleural effusion and mild bibasilar atelectasis are new. No
pneumothorax. Upper lungs clear. Heart size normal.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ w/ HTN, DL, T2DM, CAD s/p CABG ___ admitted ___
for nausea and found to have new AML c/b pleural effusions (lymphocytic
transudative fluid on thoracentesis), who presented to OSH with acute onset
dyspnea, transferred to ___ after being found to have recurrent b/l moderate
sized pleural effusions, now clinically improved s/p b/l CTs, course
complicated by ___ and worsening lethargy. Difficult to arouse, refuses to
participate in exam, ?intracranial bleed, chronic subdural hematoma.//
?subdural hematoma
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 45.3 mGy (Head) DLP =
684.4 mGy-cm.
Total DLP (Head) = 684 mGy-cm.
COMPARISON: Multiple CT head evaluations dated ___. MR head dated ___.
FINDINGS:
There is no evidence of large territory infarction,hemorrhage,edema, or mass.
Encephalomalacia is again demonstrated at the left parietal lobe. Left
greater than right bilateral chronic cerebellar infarcts are again
demonstrated. The ventricles and sulci are grossly stable in size and
configuration. Mild hypodensities within the periventricular and subcortical
white matter are nonspecific but likely sequela of chronic microvascular
angiopathy.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits demonstrate postoperative changes related to bilateral
lens replacements.
IMPRESSION:
1. No evidence acute intracranial abnormality.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Leukemia, now with some no less since.
COMPARISON: ___.
FINDINGS:
Patient is status post sternotomy. Cardiac, mediastinal and hilar contours
appear stable. Hazy new opacities at each lung base suggest small, newly
apparent, layering bilateral pleural effusions. No pneumothorax. Clear
lungs.
IMPRESSION:
Suspected small pleural effusions, otherwise unchanged.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Pleural effusion, Transfer
Diagnosed with Pleural effusion, not elsewhere classified
temperature: 98.4
heartrate: 101.0
resprate: 22.0
o2sat: 96.0
sbp: 180.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY
=================
Ms. ___ is a ___ year-old woman with AML (now in
ongoing Complete Response following Decitabine/Venetoclax x 3
cycles), who was admitted on ___ with recurrent pleural
effusions secondary to acute on chronic Congestive Heart Failure
exacerbation (resolved following bilateral chest tubes), Acute
Kidney Injury (Cr improved to 1.3 on discharge, peak 2.0), and
failure to thrive.
TRANSITIONAL ISSUES
===================
[] Please refer patient to establish Primary Care and Cardiology
(any provider) follow up at ___ as she wishes to receive
all her care there
[] Metformin was held given labile renal function, consider
restarting if patient improves and PO tolerance is improved
[] Home olanzapine was also held given lethargy during
admission, can restart PRN
[] f/u Cr and diuretic dosing within the next 2 weeks: pt has a
history of nephrotic syndrome, with significant variability in
the serum creatinine over the past several months from
0.9-2.4mg/dL.
[] f/u dyspnea and pulmonary exam: pt may need titration of home
diuretic and hypertension medications to prevent reaccumulation
of pleural effusions.
[] f/u BP, medication adherence: pt with labile BPs, can have
SBPs up to 180s when refusing PO amlodipine and metoprolol.
ACUTE ISSUES
==============
# Bilateral pleural effusions
# Dyspnea
Presented from home with recurrent bilateral pleural effusions
and dyspnea x3-4 days. Labs consistent with transudative pleural
effusion, most likely ___ acute on chronic CHF. S/p bilateral
chest tube placement by IP on ___ with resolution of dyspnea,
removed ___. Diuresis held intermittently in setting of ___, as
below. Discharged on torsemide 20mg PO QD per nephrology
recommendations to help prevent reaccumulation of pleural
effusions.
# Acute on Chronic HFmrEF
Presented with elevated BNP, b/l pleural effusions, ___,
elevated JVD, consistent with acute heart failure. Dyspnea
improved after chest tube placement. No clear precipitant of her
CHF though her home medications did not previously include a
daily diuretic. EKG w/o acute ischemic changes and she denied
chest pain so less likely ACS. ___ TTE without significant
change from prior. She has a history of nephrotic syndrome for
which she required on the last admission 80-160mg IV Lasix
boluses. S/p IV diuresis, appeared euvolemic at time of
discharge. Continued home metoprolol.
# Failure to thrive
# Malnutrition
# Lethargy
Pt noted to have 40 pound weight loss on admission (~120lb)
compared to last documented weight 1 month prior (~160lb). Bed
weight accuracy limited and possible contribution of weight from
edema during last admission, however pt likely has lost
significant weight related to insufficient PO. Very poor PO
intake during this admission. Diet liberalized and supplements
provided per Nutrition. Pt was also noted to be often somnolent,
although arousable. ___ be related to generalized weakness and
failure to thrive. NCHCT negative for intracranial bleed. Per
discussion with social work, patient, and family, patient tends
to do much better when at home where she has an extensive
support network and home services.
# AML
Diagnosed during last admission, now in ongoing Complete
Response following Decitabine/Venetoclax x 3 cycles. Continued
home acyclovir. Per discussion with Dr. ___ on ___, pt will
follow up with Dr. ___ in ___ for further AML care.
# ___
# Nephrotic syndrome
Pt has a history of nephrotic syndrome, Cr bumped 1.5 to 2.0 on
___, likely ___ IV Lasix. Diuresis was held and ___ resolved.
Renal spun urine, no casts, many calcium phosphate crystals
including triple phosphate. Discharge Cr 1.3.
# Leukocytosis
# P. acnes in pleural fluid
WBC 9.2 -> 19.6 on ___ with left shift (86% PMNs), downtrended
to normal without antibiotic treatment. Flu negative in the ED.
CXR without evidence of consolidation. Pt endorsed cough and
transient sore throat, no abd pain or diarrhea, dysuria. BCx,
UCx neg. Reassuringly she remained afebrile and HDS. ___
anaerobic pleural fluid with P. acnes, likely contaminant. BCx
were negative throughout admission.
# HTN
Per chart review, during her last admission SBPs often up to
180s, home losartan 25mg QD was changed to amlodipine 10mg QD
due to labile renal function. On amlodipine 10mg QD she had SBPs
130s-160s, regimen not uptitrated further because of labile SBPs
sometimes dipping to ___. Continued home amlodipine and
metoprolol, in addition to PO hydralazine 25mg q6h prn for
SBP>160. Pt often refusing PO medications.
CHRONIC ISSUES
==============
# Delirium
Patient has a history of hypoactive delirium inpatient.
Continued delirium precautions during this admission.
Discontinued home olanzapine given occasional lethargy.
# Stage II Pressure ulcers
Pt noted to have two stage 2 pressure injuries on admission.
Continued wound care with mepilexes.
# CAD: cont metoprlol
# T2DM: held home metformin, discontinued ISS as has not been
requiring insulin
# DL: not on statin
# GERD: cont famotidine, protonix
# OA: cont lidocaine patch
CORE MEASURES
=============
#CODE: full code, presumed
#CONTACT: Name of health care proxy: ___
___: Daughter
Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: ___ y.o woman with history of
dementia, hypertension who presents from her nursing home with
acutely altered mental status. Per corollary history from EMS,
the patient was last seen normal the evening before, but this
morning was acutely altered with at one point 3 minutes of
decorticate posturing with no incontinence. She also was
tachycardiac as well to 160 with hypertension to 210/100. There
was also an unconfirmed report that the patient had a urinary
tract infection. Fingerstick glucose was normal at 132, and
there was no report of a fall or trauma to the head.
.
In the ED, initial VS were: 97.2 ___ 2L
Patient was given 2L NS, ativan and zyprexa for agitation.
Vitals on transfer were hr 109 160/98 20 100% on RA
.
Review of systems:
Unable to obtain
.
Past Medical History:
Dementia
Hypertension
Glaucoma
Blindness
Anemia
B12 deficiency
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
Vitals: 98.8 170/84 92 20 97% on RA
General: Eyes closed, in 2 point restraints, in no acute
distress.
HEENT: Sclera anicteric, MMM, oropharynx clear. Pupils
constricted and minimally reactive to light. Arcuate senensis on
right eye.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
ejection murmur at ___. Does not radiate to carotids
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: unable to cooperate, but grossly non-focal.
Pertinent Results:
Laboratory Findings:
___ 10:20AM BLOOD WBC-7.5# RBC-3.89* Hgb-11.4* Hct-33.5*
MCV-86 MCH-29.3 MCHC-34.0 RDW-12.5 Plt ___
___ 10:20AM BLOOD Neuts-88.8* Lymphs-8.7* Monos-2.2 Eos-0.1
Baso-0.1
___ 10:20AM BLOOD ___ PTT-24.4 ___
___ 07:25AM BLOOD WBC-4.0 RBC-3.97* Hgb-11.4* Hct-33.7*
MCV-85 MCH-28.7 MCHC-33.8 RDW-12.6 Plt ___
___ 10:20AM BLOOD Glucose-108* UreaN-10 Creat-0.7 Na-134
K-3.4 Cl-99 HCO3-24 AnGap-14
___ 07:25AM BLOOD Glucose-91 UreaN-5* Creat-0.6 Na-135
K-3.1* Cl-103 HCO3-24 AnGap-11
___ 10:20AM BLOOD ALT-15 AST-24 AlkPhos-76 TotBili-0.2
___ 07:25AM BLOOD CK(CPK)-325*
___ 10:20AM BLOOD Lipase-47
___ 10:20AM BLOOD cTropnT-<0.01
___ 07:25AM BLOOD CK-MB-4 cTropnT-0.01
___ 10:20AM BLOOD Calcium-8.9 Phos-2.2* Mg-1.9
___ 07:25AM BLOOD Calcium-9.2 Mg-2.0
___ 10:38AM BLOOD Lactate-3.4*
___ 11:14PM BLOOD Lactate-1.1
___ 11:20AM URINE Color-Straw Appear-Clear Sp ___
___ 11:20AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 11:20AM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
.
MICROBIOLOGY:
Blood Culture ___ pending
Urine Culture ___ pending
.
IMAGING:
EEG ___: This is an abnormal portable EEG due to the presence
of
generalized slowing indicative of deep midline dysfunction, and
left
greater than right temporal slowing indicative of subcortical
dysfunction in these regions. Although the bifrontal activity
appeared
at times to be sharply contoured: however no clear spike and
wave
discharges or electrographic seizures were seen.
.
NCHCT ___: FINDINGS: There is no evidence of acute
intracranial hemorrhage, edema, mass effect, or territorial
infarction. There is mild prominence of the ventricles and sulci
consistent with age-related atrophy. There is confluent
periventricular white matter hypodensity consistent with chronic
small vessel ischemic disease. The visualized paranasal sinuses
are clear. There is opacification of the mastoid air cells on
the left, stable from prior study and may represent chronic
inflammation. Osseous structures are intact.
IMPRESSION: No acute intracranial process.
.
CXR ___: FINDINGS: Single supine AP portable view of the chest
was obtained. Per radiology technologist, the exam was done
supine as the patient was uncooperative. No focal consolidation,
pleural effusion, or evidence of pneumothorax is seen. The
patient is rotated to the left. The calcified mediastinal lymph
nodes are again noted. The cardiac silhouette is not enlarged.
The aorta is calcified and tortuous.
IMPRESSION: No acute cardiopulmonary process. Apparent mild
elevation of the left hemidiaphragm may relate to patient
positioning.
Medications on Admission:
amlodipine 7.5mg daily
citalopram 10mg daily
exelon 4.6mg patch 1 patch daily
latanoprost 0.005% 1 drop once daily
brimoidine 0.15% 1 drop twice daily
colace 100mg twice daily
dorzolamide timilol 2%-0.5% 1 drop right eye twice daily
senna 8.6mg qhs
artificial tears
ducolax suppository 10mg dailyprn
fleet enema 1 daily
trazodone 25mg prn
tylenol ___ q4-6h prn
vitamin D 50,000 q weds
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Exelon 4.6 mg/24 hour Patch 24 hr Sig: One (1) Transdermal
once a day.
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day).
6. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic BID (2 times a day): to right eye.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Artificial Tears Drops Sig: ___ Ophthalmic once a day as
needed for dry eyes.
10. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
11. Fleet Enema ___ gram/118 mL Enema Sig: One (1) Rectal once
a day as needed for constipation.
12. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
13. Vitamin D 5,000 unit Tablet Sig: One (1) Tablet PO once a
week.
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
15. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
16. diclofenac sodium 1 % Gel Sig: One (1) Topical once a day
as needed for pain: to use topically for arthritis pain.
Disp:*60 grams* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute delerium, unclear cause
Dementia
HTN
Blindness
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with altered mental status, question acute
intracranial process.
COMPARISON: CT head without contrast from ___.
TECHNIQUE: Contiguous axial images were obtained through the brain without
the administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass
effect, or territorial infarction. There is mild prominence of the ventricles
and sulci consistent with age-related atrophy. There is confluent
periventricular white matter hypodensity consistent with chronic small vessel
ischemic disease. The visualized paranasal sinuses are clear. There is
opacification of the mastoid air cells on the left, stable from prior study
and may represent chronic inflammation. Osseous structures are intact.
IMPRESSION: No acute intracranial process.
Radiology Report
EXAM: Chest single supine AP portable view.
CLINICAL INFORMATION: Altered mental status.
___.
FINDINGS: Single supine AP portable view of the chest was obtained. Per
radiology technologist, the exam was done supine as the patient was
uncooperative. No focal consolidation, pleural effusion, or evidence of
pneumothorax is seen. The patient is rotated to the left. The calcified
mediastinal lymph nodes are again noted. The cardiac silhouette is not
enlarged. The aorta is calcified and tortuous.
IMPRESSION: No acute cardiopulmonary process. Apparent mild elevation of the
left hemidiaphragm may relate to patient positioning.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: CHANGE MS/SVT
Diagnosed with ALTERED MENTAL STATUS , SCHIZOPHRENIA NOS-UNSPEC, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
temperature: 97.2
heartrate: 160.0
resprate: 16.0
o2sat: 97.0
sbp: 210.0
dbp: 138.0
level of pain: 13
level of acuity: 1.0 | ___ year old woman with history of dementia, hypertension who
presents to the hospital with with an acute encephalopathy which
spontaneously resolved.
.
# Acute encephalopathy (toxic-metabolic) - During this
admission, there was no clear predisposing etiology for her
change in mental status. Per history there was a
supraventricular tachycardia during her acute event, however we
have no ECG record of this. During this admission, she underwent
an EEG that showed no evidence of seizures. Her bloodwork was
unremarkable and did not reveal any metabolic derangement. An
infectious workup including chest Xray and urinalysis were
unremarkable; blood and urine cultures had not growth, but were
still pending at the time of discharge. A CT head was also
unremarkable and the patient had no significant focal findings
on neurologic exam to support a stroke. She was monitored on
telemetry and ruled out for an ischemic cardiac event with 2
sets of negative cardiac enzymes. She did have a slightly
elevated lactate on admission, which resolved with
administration of IVF, suggesting the patient may have been
dehydrated. In the emergency room she received ativan and
zyprexa for agitation and was sleepy overnight. In the morning,
she appeared to have returned to her baseline mental status; she
was oriented and cooperative and requested to return home to her
nursing home.
.
# Tachycardia - The patient had an EKG showing normal sinus
rhythm on admission. She was monitored on telemetry and had
several episodes of non-sustained sinus tachycardia, which were
asymptomatic.
.
# Hypertension - The patient was significantly hypertensive
during this admission. Her amlodipine was increased to 10mg
daily, and she was started on metoprolol 12.5 mg twice daily.
.
# Glaucoma - continued home meds.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Zyprexa
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Blood transfusion ___
History of Present Illness:
___ h/o metastatic pancreatic cancer receiving palliative FOLFOX
who presents with dyspnea on exertion. She reports two weeks of
worsening dyspnea on exertion. This became significant worse on
___ and ___. She states that she now cannot walk from
one room to another without feeling very short of breath. She
felt some chest pain last week, which is now resolved. She also
notes intermittent nausea and vomiting. She is overall very
fatigued. She has had diarrhea recently which is not black or
bloody and was C. diff negative. She was recently set up for
home IVF.
On arrival to the floor, patient reports feeling tired. She
denies fevers/chills, night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbness, cough, hemoptysis,
chest pain, palpitations, abdominal pain, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: as above otherwise 10point ROS negative
Past Medical History:
PAST ONCOLOGIC HISTORY:
Pancreatic cancer stage IV
- ___ Presented with 5 weeks of left buttock pain in the
setting of prior back surgery that did not respond to
conservative medical treatment.
- ___ Spine MR showed signal abnormalities/bony lesions
in sacrum and ilium.
- ___ Bone scan showed abnormal areas of activity in the
sacrum and approximately T5 concerning, both concerning for
metastatic disease. CT abdomen pelvis that day showed 20 x 34 mm
mass within the pancreas at the junction of body and tail c/f
adenocarcinoma. CT suggested left sacral involvement and
possibly L4 involvement. CT chest showed small lung nodules.
- ___ EUS showed a 2.6 cm X 2.1 cm ill-defined mass in
body of pancreas with suspicious for vascular invasion by the
mass. Pancreatic mass biopsy and FNA demonstrated
adenocarcinoma.
- ___ Biopsy of sacrum showed metastatic adenocarcinoma.
- ___ C1D1 Gemcitabine NAB paclitaxel
- ___ C2D1 Gemcitabine NAB paclitaxel
- ___ C3D1 Gemcitabine NAB paclitaxel
- ___ C4D1 Gemcitabine NAB paclitaxel
- ___ C5D1 Gemcitabine NAB paclitaxel
- ___ C6D1 Gemcitabine NAB paclitaxel
- ___ C7D1 Gemcitabine NAB paclitaxel
- ___ C8D1 Gemcitabine NAB paclitaxel
- ___ C9D1 Gemcitabine NAB paclitaxel
- ___ C1D1 FOLFIRINOX
- ___ C2D1 FOLFIRINOX
- ___ C3D1 FOLFIRINOX
- ___ C4D1 FOLFIRINOX
- ___ C5D1 FOLFIRINOX
- ___ C6D1 FOLFIRINOX
- ___ C7D1 FOLFIRINOX
- ___ C1D1 FOLFIRI
- ___ C2D1 FOLFIRI
- ___ C3D1 FOLFIRI
- ___ C4D1 FOLFIRI
- ___ C5D1 FOLFIRI
- ___ C6D1 FOLFIRI
- ___ Consent for ___ ___ the COMBAT Bioline trial
- ___ C1D1 BL8040 1.25 mg/kg loading week 1 D1,2,3,4,5
followed by MWF dosing with pembrolizumab 200 mg D8
- ___ C2D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ CT torso showed stable disease
- ___ C3D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ C4D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ C5D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ Reconsent for ___ ___, signed for data
collection and tissue banking but not optional biopsy
- ___ CT torso showed stable disease by RECIST criteria
with some increased in bone mets by size but not new lesions.
- ___ C6D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ C7D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ C8D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ CT torso showed stable disease by RECIST criteria,
but increased size of bone mets, no new disease
- ___ C9D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ Start XRT to symptomatic bone mets
- ___ Complete XRT with 20 Gy to T2-5 and 20 to the
sacrum
- ___ CT for abdominal pain showed increase in adnexal
mass -unclear if metastatic disease or not
- ___ C10D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ Held therapy, admitted for symptomatic progression
of pelvic mass
- ___ Underwent resection of the enlarging symptomatic
pelvic mass
- ___ CT torso shows increase in size of pancreatic mass
- ___ C1D1 FOLFOX7 (LV @ 200 ___ cytopenias) +
Neulasta
- ___: C1D15 FOLFOX + Neulasta
- ___ - ___: Admitted for nausea/vomiting/abdominal pain.
CT a/p without new process and MRI head normal
- ___: Celiac plexus neurolysis
OTHER PAST MEDICAL HISTORY:
- Anal Fissure
- Neuropathy
Social History:
___
Family History:
Maternal aunt with ovarian cancer at ___. Paternal grandmother
with colon cancer.
Physical Exam:
-Vitals: reviewed
-General: NAD, laying comfortably in bed
-HENT: atraumatic, normocephalic, moist mucus membranes
-Eyes: PERRL, EOMi
-Cardiovascular: RRR, no murmur
-Pulmonary: clear b/l, no wheeze
-GI: Soft, nontender, nondistended, bowel sounds present
-GU: no foley, no CVA/suprapubic tenderness
-MSK: No pedal edema, no joint swelling
-Skin: No rashes, ulcerations, or jaundice
-Neuro: no focal neurological deficits, CN ___ grossly intact
-Psychiatric: appropriate mood and affect
Discharge Exam:
-General: NAD, laying comfortably in bed
-HENT: atraumatic, normocephalic, moist mucus membranes
-Eyes: PERRL, EOMi
-Cardiovascular: RRR, no murmur
-Pulmonary: clear b/l, no wheeze
-GI: Soft, nontender, nondistended, bowel sounds present
-GU: no foley, no CVA/suprapubic tenderness
-MSK: No pedal edema, no joint swelling
-Skin: No rashes, ulcerations, or jaundice
-Neuro: no focal neurological deficits, CN ___ grossly intact
-Psychiatric: appropriate mood and affect
Pertinent Results:
ADMISSION LABS
___ 04:41PM BLOOD WBC-8.3 RBC-2.30* Hgb-7.4* Hct-22.4*
MCV-97 MCH-32.2* MCHC-33.0 RDW-19.9* RDWSD-70.0* Plt Ct-83*
___ 04:41PM BLOOD Neuts-81* Bands-7* Lymphs-7* Monos-5
Eos-0 Baso-0 ___ Myelos-0 NRBC-2* AbsNeut-7.30*
AbsLymp-0.58* AbsMono-0.42 AbsEos-0.00* AbsBaso-0.00*
___ 05:24PM BLOOD ___ PTT-24.6* ___
___ 04:41PM BLOOD Glucose-126* UreaN-10 Creat-0.4 Na-140
K-4.1 Cl-105 HCO3-20* AnGap-15
___ 04:41PM BLOOD ALT-14 AST-16 AlkPhos-294* TotBili-0.2
___ 04:41PM BLOOD Albumin-4.0 Calcium-8.3* Phos-1.5* Mg-2.1
___ 04:41PM BLOOD cTropnT-<0.01
___ 04:41PM BLOOD proBNP-75
DISCHARGE LABS
___ 05:02AM BLOOD WBC-6.0 RBC-2.36* Hgb-7.4* Hct-22.0*
MCV-93 MCH-31.4 MCHC-33.6 RDW-20.9* RDWSD-68.5* Plt Ct-65*
___ 05:02AM BLOOD Glucose-115* UreaN-5* Creat-0.3* Na-141
K-3.3* Cl-107 HCO3-22 AnGap-12
IMAGING
-CTA CHEST ___:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. New ___ opacification in the superior segment of the
left lower lobe, likely small airways infection, with slightly
increased airway wall thickening.
3. Persistent small left pleural effusion and slightly
increased left lower lobe perifissural atelectasis.
4. Multiple bilateral perifissural nodules are similar to the
prior exam, and metastases are not excluded.
5. Multiple osseous sclerotic metastases again noted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon ___ CAP PO QIDWMHS
2. Docusate Sodium 200 mg PO BID
3. Milk of Magnesia 30 mL PO DAILY:PRN constipation
4. Omeprazole 20 mg PO BID
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. Bisacodyl 5 mg PO DAILY:PRN constipation
9. LORazepam 1 mg PO QHS:PRN insomnia/anxiety/nausea
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
11. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
12. Dexamethasone 2 mg PO AS DIRECTED WITH CHEMOTHERAPY
13. LOPERamide 2 mg PO QID:PRN diarrhea
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 5 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
2. Bisacodyl 5 mg PO DAILY:PRN constipation
3. Creon ___ CAP PO QIDWMHS
4. Dexamethasone 2 mg PO AS DIRECTED WITH CHEMOTHERAPY
5. Docusate Sodium 200 mg PO BID
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. LORazepam 1 mg PO QHS:PRN insomnia/anxiety/nausea
8. Milk of Magnesia 30 mL PO DAILY:PRN constipation
9. Omeprazole 20 mg PO BID
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
14. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Symptomatic anemia
Pneumonia
Pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ with worsening dyspnea, pancreatic cancer. Assess for
pulmonary embolism.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 9.1 mGy (Body) DLP = 4.6
mGy-cm.
2) Spiral Acquisition 3.8 s, 29.8 cm; CTDIvol = 10.6 mGy (Body) DLP = 315.3
mGy-cm.
Total DLP (Body) = 320 mGy-cm.
COMPARISON: Chest CT of ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect concerning for pulmonary embolism. The main and
right pulmonary arteries are normal in caliber, and there is no evidence of
right heart strain.
Port-A-Cath tip terminates in the right atrium.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. Trace left pleural effusion is
unchanged since the prior study.
Previously described left lower lobe perifissural atelectasis is again noted,
now larger in appearance, spanning 2.3 cm (3:126) with the associated
perifissural nodule similar appearance. Additional multiple left perifissural
nodules measure up to 0.6 cm on the current study (3:92). There is a new area
of ___ opacification in the superior segment of the left lower lobe
(3:81), with increased bronchial wall thickening. Several perifissural
micronodules along the right minor fissure are unchanged. The airways are
patent to the subsegmental level.
Limited images of the upper abdomen are notable for splenomegaly and a
partially imaged venous shunt in the region of the splenic hilum. Known
pancreatic cancer is only partially imaged and was better characterized on the
CT from ___.
Several sclerotic osseous metastases again noted, most predominantly involving
the T3 and T4 vertebral bodies and lamina, the superior left aspect of the T5
vertebral body, and in the ribs, as seen on the prior staging CT.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. New ___ opacification in the superior segment of the left lower
lobe, likely small airways infection, with slightly increased airway wall
thickening.
3. Persistent small left pleural effusion and slightly increased left lower
lobe perifissural atelectasis.
4. Multiple bilateral perifissural nodules are similar to the prior exam, and
metastases are not excluded.
5. Multiple osseous sclerotic metastases again noted.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Acute bronchitis, unspecified, Dyspnea, unspecified
temperature: 98.2
heartrate: 106.0
resprate: 17.0
o2sat: 100.0
sbp: 132.0
dbp: 76.0
level of pain: 5
level of acuity: 2.0 | ___ h/o metastatic pancreatic cancer receiving palliative FOLFOX
who presents with dyspnea on exertion and weakness found to have
anemia and pneumonia.
1. Acute on chronic normocytic anemia and thrombocytopenia
-s/p chemotherapy ___ with subsequent nadir as likely cause
of anemia. She essentially has pancytopenia with
thrombocytopenia and a relative leukopenia (drop in WBC from
30.8 ___ s/p Neulasta to 7.8 today). Transfused 1Unit PRBC ___
with improvement in hemoglobin to 7.4 to 7.6. Fecal occult
testing was negative. She noted improvement of her SOB even
prior to transfusion and felt better and requested to be
discharged home for further management as an outpatient
2. Community Acquired Pneumonia
-Potential small airway infection noted on CT. She has been
afebrile this admission. Was treated with a 5 day course of
levofloxacin that will continue through ___.
3. DOE and weakness
-Likely in setting of symptomatic anemia although potentially
mulficatorial in setting of pneumonia and poor PO intake. No PE
on CTA chest. She reported improvement in her SOB and symptoms
even prior to transfusion.
CHRONIC MEDICAL PROBLEMS
1. Metastatic pancreatitic cancer: Most recent treatment ___
with FOLFOX w/ Neulasta support. Continue oxycodone and
pancreatic supplementation.
2. Nausea/vomiting: Seems to be a side effect of chemotherapy on
antiemetics not currently an issue.
3. GERD: continue omeprazole
4. Opioid-induced constipation: continue bowel regimen
5. Hypophosphatemia: replete and monitor
>30 minutes spent on discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
___
aortogram, b/l limb religning, perclose
History of Present Illness:
___ with Hx SBR and AAA s/p repair x 2 (___) c/b graft
infection on chronic suppressive antibiotics, presenting with
recurrent GI bleed and concern for aorto-enteric fistula.
She has a history of an open AAA in ___ c/b infection requiring
explant and re-do in ___ due to graft infection, and the
patient remains on chronic suppressive cefixime and levaquin. Of
note, the patient required an urgent femoral thrombectomy after
her ___ operation in ___ for loss of pulses in her right leg.
She has already been admitted twice for GIB ___ and
___ She presented again two days ago with BRBPR and a Hct
of 26. She was transferred to the FICU for hemodynamic
instability but had not required any pressors. A push
enteroscopy on ___ was negative. CTA on ___ showed no active
extravasation but tagged pRBC scan also on ___ showed brisk
bleeding from the small bowel, most likely the duodenum. She has
required 5 units of pRBC in the last 48 hours. Her Hct this
morning was 30.
Currently denies abdominal pain, SOB or chest pain. Has no Hx of
previous GI bleed. Last BRBPR was 500 cc at 3 AM today. She was
provisionally suspected to have an aorto-enteric fistula, given
her history and the proximity of her
bowel and aorta on imaging. She was typed and crossed for 1-
units of PRBCs and it was decided to take her to the OR
emergently for aortogram & attempted endovascular repair,
possible conversion to open.
Past Medical History:
PMH -
1. AAA repair x 2 ___ both at ___) c/b chronic graft
infection on suppressive abx
2. HLD
3. HTN
4. Diverticulosis
5. GERD
PSH -
1. open AAA x 2 w aorto bi-iliac stent graft ___ both at
___)
2. right femoral thrombectomy
3. TAH-BSO for DUB c/b SBO s/p LOA and SBR (2in of TI)
4. CCY
5. Right total hip replacement
6. Appendectomy
7. SBR/LOA for ___ in ___
Social History:
___
Family History:
NC
No history of colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Tmax: 36.7 °C (98.1 °F)
Tcurrent: 36.7 °C (98.1 °F)
HR: 82 (74 - 82) bpm
BP: 148/46(69) {115/46(63) - 148/47(69)} mmHg
RR: 20 (15 - 20) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
General - Patient is pale appearing, in NAD
HEENT - PERRLA, EOMI, sclera pale, dry MM
Neck - Supple, No JVD
CV - Tachycardic but regular
Lung - CTAB
Abdomen - Soft, NT/ND, maroon/bloody stool in diaper
GU - (-) foley
Extremities - No edema
DISCHARGE PHYSICAL EXAM:
98.3, 71, 106/54, 18, 97% RA
Gen: NAD, AAOx3, pleasant
HEENT: Right CVL site is s/p CVL removal, c/d/i
CV: RRR no m/r/g
Pulm: CTAB no w/r/r
Abd: Soft, NT/ND, +bruising from heparin injections
Groin: puncture sites c/d/i, no bleeding, no evidence of
hematoma
Ext: Warm and well-perfused, motor and sensory intact. Patient
ambulates with minimal assistance.
LUE PICC is in place.
Pulses: Fem Pop DP ___
Left: P P P D
Right: P P D D
Pertinent Results:
ADMISSION LABS:
___ 06:58PM ___ PTT-23.0* ___
___ 06:58PM PLT COUNT-171
___ 06:58PM NEUTS-78.1* LYMPHS-16.2* MONOS-5.0 EOS-0.2
BASOS-0.4
___ 06:58PM WBC-10.5# RBC-3.90* HGB-11.0* HCT-34.0*
MCV-87 MCH-28.3 MCHC-32.5 RDW-15.8*
___ 06:58PM GLUCOSE-96 UREA N-14 CREAT-0.9 SODIUM-140
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14
___ 08:45AM HCT-29.2*
___ 05:45PM PLT COUNT-148*
___ 05:45PM WBC-5.9 RBC-3.35* HGB-9.4* HCT-29.1* MCV-87
MCH-28.2 MCHC-32.4 RDW-16.0*
IMAGING:
___ CT Abdomen/Pelvis
IMPRESSION:
1. No active extravasation of contrast to suggest a source of
bleed within the
small bowel or colon on this examination. Colonic
diverticulosis. Colonic
anastomosis as described above.
2. Aorto bi-iliac graft. Dilated portion of the left common
iliac artery
consistent with arterial anastomosis. Narrowing of the right
common iliac
artery, however it remains patent.
3. 11 mm left renal hyperdense enhancing lesion which is
concerning for an
underlying renal neoplasm and could be assessed by MRI.
4. 1.8 cm cystic lesion within the body of the pancreas may
represent
intraductal papillary mucinous neoplasm (IPMN), which may be
re-assessed at
the time of MRI for left kidney.
Tagged RBC scan ___
Intermittent, brisk GI bleeding in the small bowel, likely
starting
in the duodenum.
CXR ___ - PRELIMINARY
Right IJ with tip terminating in the upper SVC. The proximal
catheter
contains a possible kink, correlate with catheter function. No
pneumothorax or
other acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Levofloxacin 500 mg PO Q24H
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Lorazepam 0.5 mg PO BID:PRN anxiety
5. Omeprazole 20 mg PO DAILY
6. ceFIXime 400 mg ORAL DAILY
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 grams IV once a day Disp #*42 Vial
Refills:*0
2. Citalopram 40 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Lorazepam 0.5 mg PO BID:PRN anxiety
6. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
7. Metoprolol Tartrate 12.5 mg PO TID
Follow up with your primary care doctor in the next week to
adjust this medicine as needed
RX *metoprolol tartrate 25 mg One-half tablet(s) by mouth every
eight (8) hours Disp #*40 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q6H:PRN fever
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*126 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aorto-enteric fistula
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 abdomen/pelvis
INDICATION: History of lower GI bleed with large bloody bowel movement,
hypotensive, blood coming out of rectum. Please evalute for source of bleed.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis with
following intravenous administration of 150cc of Omnipaque. Coronal and
sagittal reformations were performed.
DOSE: DLP: 680.2 mGy-cm.
COMPARISON: No previous examinations available for comparison on comparisons
previous CT pelvis from ___.
FINDINGS:
ABDOMEN:
There is a 1 cm lung cyst within the right lower lobe (6:1). There is a 4 mm
calcified granuloma within the right lower lobe. There are minimal atelectatic
changes at the lung bases.
There is a right renal cortical atrophy and scarring from prior
infection/ischemia. There is an 11 mm left renal hyperdense enhancing lesion
which is concerning for an underlying renal neoplasm. There is a 1.8 x 0.8 cm
cystic lesion within the body of the pancreas (6:32) which may represent an
intraductal papillary mucinous neoplasm (IPMN). There has been prior
cholecystectomy. There is a 9 mm accessory spleen. The liver, adrenal glands
and spleen appear unremarkable.
There is no definite contrast extravasation to suggest a source of bleed with
the small bowel or colon on this examination. There is colonic diverticulosis
without diverticulitis. There are anastomotic sutures noted within the
proximal transverse colon. There is no retroperitoneal or intra-abdominal
lymphadenopathy. There is a small 1.6 cm fat-containing area in the anterior
abdominal soft tissues, which may be related to a fat-containing umbilical
hernia.
There is severe atherosclerosis of the abdominal aorta and iliac arteries.
There is an aorto bi-iliac graft in place with several surgical clips noted
surrounding the distal abdominal aorta/common iliac arteries. There is a
dilated portion of the left common iliac artery consistent with arterial
anastomosis. There is narrowing of the right common iliac artery, however it
remains patent (6:60).
PELVIS:
Assessment of the pelvis is limited by artifact from the right total hip
arthroplasty. There has been prior hysterectomy. The bladder appears
unremarkable.
OSSEOUS STRUCTURES:
There is a benign appearing predominantly sclerotic lesion within the right
iliac bone. There are no suspicious lytic or sclerotic bone lesions. There has
been right total hip arthroplasty. There are mild degenerative changes of the
lower thoracic and lumbar spine.
IMPRESSION:
1. No active extravasation of contrast to suggest a source of bleed within the
small bowel or colon on this examination. Colonic diverticulosis. Colonic
anastomosis as described above.
2. Aorto bi-iliac graft. Dilated portion of the left common iliac artery
consistent with arterial anastomosis. Narrowing of the right common iliac
artery, however it remains patent.
3. 11 mm left renal hyperdense enhancing lesion which is concerning for an
underlying renal neoplasm and could be assessed by MRI.
4. 1.8 cm cystic lesion within the body of the pancreas may represent
intraductal papillary mucinous neoplasm (IPMN), which may be re-assessed at
the time of MRI for left kidney.
NOTIFICATION: Findings discussed with Dr. ___ at 11AM on ___, 30 minutes after discovery of the findings.
Radiology Report
HISTORY: Right IJ catheter.
FINDINGS: No previous images. Right IJ sheath extends to the upper SVC.
There is a prominent kink at the level of the skin insertion, which could be
degrading catheter function.
No evidence of acute pneumonia, vascular congestion, pleural effusion, or
pneumothorax.
Radiology Report
HISTORY: Line placements.
FINDINGS: In comparison with study of ___, there has been placement of an
endotracheal tube with its tip approximately 5 cm above the carina. Right IJ
sheath is in good position. Nasogastric tube extends only to the lower
esophagus. This information was telephoned to Dr. ___.
There are lower lung volumes. There is obscuration of the most medial portion
of the left hemidiaphragm. This most likely reflects an area of atelectasis.
However, in the appropriate clinical setting, supervening pneumonia would have
to be considered. The right lung is clear.
Radiology Report
INDICATION: History of aorto-enteric fistula, intubated. Please evaluate NG
tube position.
COMPARISONS: Chest radiograph from ___.
TECHNIQUE: Single AP portable supine radiograph of the chest.
FINDINGS: There is an enteric tube which extends below the diaphragm. The ET
tube terminates approximately 5 cm above the carina. There is a right-sided
IJ which terminates in the upper SVC. Small bilateral pleural effusions are
persistent. There is mild perihilar vascular congestion; otherwise, the
cardiomediastinal contours are stable. There is no evidence of a
pneumothorax. The visualized osseous structures are unremarkable.
IMPRESSION:
NG tube extends below the diaphragm with the tip out of view of the stomach.
Radiology Report
PORTABLE CHEST FILM, ___ AT 5:41
CLINICAL INDICATION: ___ with aortoenteric fistula, possible bowel
perforation, question free air.
Comparison to prior study dated ___.
Portable AP upright chest film ___ at 5:41 is submitted.
IMPRESSION:
1. Right internal jugular introducer remains in place with its tip in the
proximal SVC. The endotracheal tube continues to have its tip approximately
4.5 cm above the carina. A nasogastric tube is seen coursing below the
diaphragm with the tip not identified. Lungs appear well inflated without
evidence of focal airspace consolidation, pulmonary edema, or pneumothorax.
Overall cardiac and mediastinal contours are unchanged with calcification of
the aortic knob consistent with atherosclerosis. There is no evidence of free
intraperitoneal air or pleural effusions. No pneumothorax.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with PICC. // Pt had a left picc,47cm Contact
name: ___: ___
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph on ___.
FINDINGS:
A left-sided PICC is seen terminating in the lower SVC and is in appropriate
position. There is been interval removal of a right internal jugular
introducer, nasogastric tube and endotracheal tube.
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. There is minimal atelectasis at the left
base as well as linear atelectasis and scarring at the right juxta hilar
region. No pleural effusion or pneumothorax is seen. There are no acute
osseous abnormalities.
IMPRESSION:
Left-sided PICC seen terminating in the lower SVC .
Bibasilar linear atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BRBPR, Transfer
Diagnosed with GASTROINTEST HEMORR NOS, OTHER MALAISE AND FATIGUE, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.4
heartrate: 76.0
resprate: 18.0
o2sat: 98.0
sbp: 112.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | Hospital course prior to Vascular Surgery involvement:
___ y/o F with PMH of of AAA s/p repair x 2 (___) c/b
aortic graft infection on chronic suppressive antibiotics and
diverticulosis who presented with GI bleeding.
ACTIVE ISSUES
# Bleeding per rectum: Source localized to duodenum, which
could represent ulcer or vascular lesion within the GI tract.
Also, there was high concern by Surgery for the possibility of
aorto-enteric fistula given h/o AAA s/p repair with aortic graft
infection. There was no bleeding GI lesion evident on recent
endoscopy ___. Colonoscopy on ___ showed internal
hemorrhoids, a polyp in the ascending colon, and no evidence of
recent or current bleeding. Push enteroscopy on ___ showed a
___ tear with no bleeding in the gastroesophageal
junction. She was transferred to the medical ICU for
hematochezia and presyncopal symptoms on ___ as per HPI. Urgent
CTA abd/pelvis was negative for extravasation of blood. She
underwent capsule endoscopy. A trauma line was placed in the
RIJ. She became hypotensive in the afternoon to SBP ___ and
received 1L LR. Tagged RBC was positive for blood in the ___
portion of the duodenum. Hct dropped from 30 to 21. She received
3U pRBC, ___, and calcium repletion overnight for Hct down to
21. She had multiple episodes of hematochezia overnight and
remained hemodynamically stable. Hct responded well to three
units pRBCs which suggested that bleeding had at least
temporarily stopped. GI anticipated repeat endoscopy in the
morning to look at duodenum more closely, but per Surg it would
not change their management due to strong concern for fistula.
She was transferred to the ___ to be under the
management of Vascular Surgery.
CHRONIC ISSUES
# Aortic graft infection: The patient is on chronic antibiotics
since ___. As cefixime is non-formulary, antibiotic was
chanaged to cefpodoxime 400 mg PO QD at time of admission.
# GERD: Continued home omeprazole.
# Anxiety: She was continued on home citalopram and lorazepam.
She was written for IV lorazepam on ___ due to escalating
anxiety due to medical problems and NPO status.
TRANSITIONAL ISSUES
#CTA revealed small renal neoplasm and pancreatic cyst which
need MRI evaluation.
#F/u capsule endoscopy results.
Hospital course after time of initialy Vascular Surgery
involvement:
Ms. ___ was admitted to the Vascular Surgery service with
HPI as stated above and went to the OR emergently for the
above-listed procedure. During the procedure, she required 7
units of PRBCs and 4 units of FFP. Post-operatively her crit
was found to be 38.9; she had a brief episode of hypotension to
the ___ post-op but recovered and repeat crit was found to be
36.
Overnight into POD#1 she had three bloody maroon bowel movements
and persistent melena. Her hematocrits, measured serially,
drifted to 33, but she remained stable and was transferred to
the VICU the following day. There, repeat crits were stable in
the low ___, and it was decided to advance her diet. The
following day, POD#3, she was considered safe to bear weight and
got up with physical therapy; she became briefly orthostatic to
the ___ but was entirely asymptomatic and recovered. PO intake
was encouraged and she got up again later and did well.
Also on POD#3, ID was consulted and recommended not less than 6
weeks of PO metronidazole and IV ceftriaxone. These were
initiated in the inpatient setting. The patient received a
left-sided PICC line to continue receiving IV antibiotics in the
outpatient setting. On the same day, her foley came out and she
voided.
She tolerated a regular diet and her pain was well controlled on
POD#4, she ambulated well with minimal assistance, and she was
determined to be safe for discharge to home with services. She
will continue to receive daily ceftriaxone infusion through her
PICC. She will take daily aspirin for anticoagulation and oral
metronidazole for infection prophylaxis. She has follow-up
arranged with ID and with vascular surgery. She is discharged
to home on POD#4 with all appropriate information, warnings,
prescriptions, and follow-up. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
Therapeutic Paracentesis ___
Diagnostic Paracentesis ___
History of Present Illness:
Patient is a ___ woman w/newly diagnosed cirrhosis who
presents with jaundice, right upper quadrant pain, and right leg
swelling. Patient was referred to the ED by her provider for
deterioration in performance status and concern for increased
abdominal swelling. Patient states that she feels weak, and
complains of sharp intermittent right upper quadrant pain.
Pertinent negatives include: chest pain, shortness of breath,
lower extremity pain/rash, dizziness, lightheadedness, fainting
episodes, injury, trauma, fall, coughing, hemoptysis, or bloody
stool.
Past Medical History:
-CIRRHOSIS
-TONSILLECTOMY
Social History:
___
Family History:
Mother - diabetes ___, hypothyroidism
Father - cardiac issues, prostate cancer
Sister - asthma
Physical ___:
ADMISSION PHYSICAL EXAM
===========================
VITALS: Temp 97.7, HR 98, BP 146/75, RR 18 99% RA
GENERAL: Alert, oriented, no acute distress, calm, conversative
HEENT: Oropharynx clear, mild scleral icterus
NECK: supple, no signs of trauma
LUNGS: Clear to auscultation bilaterally, no wheezes/crackles
CV: Regular rate and rhythm, normal S1 S2, no murmurs
ABD: soft, non-tender, distended, no rebound tenderness or
guarding, ascites appear to be present
EXT: Warm, well perfused, mild edema
SKIN: Jaundice
NEURO: Alert and oriented
DISCHARGE PHYSICAL EXAM
===========================
VITALS: Temp 98.2 BP 102/68 HR 109 RR 16 95%RA
GENERAL: Thin Caucasian woman, jaundiced. Temporal wasting. In
NAD. AAOx3. Able to recite DOWB backwards.
HEENT: Sclerae slightly icteric. MMM.
NECK: JVD < 10 cm at 90 degrees
HEART: Slightly irregular rhythm with regular rate, normal
S1/S2,
no M/R/G.
LUNGS: Clear to auscultation anteriorly.
ABDOMEN: normal bowel sounds. Abdomen is moderately
protuberant and soft. + fluid wave, bulging flanks. Slight
increase in distention when compared to exam ___.
EXTREMITIES: Warm and well perfused. trace ___ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact. A&O x3. Moving all four
extremities with purpose. No asterixis noted.
SKIN: No excoriations or lesions, no rashes
Pertinent Results:
ADMISSION LABS
==============
___ 12:55PM BLOOD WBC-4.4 RBC-2.58* Hgb-9.0* Hct-27.0*
MCV-105* MCH-34.9* MCHC-33.3 RDW-15.5 RDWSD-58.9* Plt ___
___ 12:55PM BLOOD Neuts-33.7* ___ Monos-18.6*
Eos-4.1 Baso-0.5 Im ___ AbsNeut-1.49* AbsLymp-1.89
AbsMono-0.82* AbsEos-0.18 AbsBaso-0.02
___ 12:55PM BLOOD Plt ___
___ 12:55PM BLOOD Glucose-156* UreaN-6 Creat-0.8 Na-137
K-2.9* Cl-96 HCO3-27 AnGap-14
___ 12:55PM BLOOD ALT-28 AST-81* AlkPhos-120* TotBili-4.5*
___ 12:55PM BLOOD Albumin-2.8* Calcium-8.7 Phos-2.8 Mg-1.4*
___ 11:32PM BLOOD Lactate-2.5*
___ 12:20AM URINE Color-Orange* Appear-Hazy* Sp ___
___ 12:20AM URINE CastHy-13*
___ 12:20AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln-4* pH-6.5 Leuks-NEG
NOTABLE LABS
=============
___ 03:43PM ASCITES TNC-77* RBC-97* Polys-2* Lymphs-25*
___ Mesothe-3* Macroph-70* Other-0
___ 06:00PM ASCITES TNC-58* RBC-252* Polys-4* Lymphs-35*
Monos-20* Macroph-41*
___ 03:43PM ASCITES TotPro-1.2 Glucose-148
___ 06:00PM ASCITES TotPro-1.3 Albumin-0.6
___ 12:55PM BLOOD ALT-28 AST-81* AlkPhos-120* TotBili-4.5*
___ 06:01AM BLOOD ALT-17 AST-41* AlkPhos-95 TotBili-3.5*
___ 06:21AM BLOOD ALT-17 AST-41* AlkPhos-86 TotBili-3.4*
___ 06:31AM BLOOD ALT-16 AST-38 LD(LDH)-204 AlkPhos-105
TotBili-2.4*
___ 06:14AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 04:29AM BLOOD Ethanol-NEG Acetmnp-NEG Tricycl-NEG
DISCHARGE LABS
==============
___ 06:31AM BLOOD WBC-5.6 RBC-2.33* Hgb-8.2* Hct-24.4*
MCV-105* MCH-35.2* MCHC-33.6 RDW-14.2 RDWSD-54.2* Plt ___
___ 06:31AM BLOOD ALT-16 AST-38 LD(LDH)-204 AlkPhos-105
TotBili-2.4*
___ 06:31AM BLOOD Albumin-2.5* Calcium-8.4 Phos-3.2 Mg-1.6'
MICROBIOLOGY & PATHOLOGY
=========================
__________________________________________________________
___ 6:00 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
__________________________________________________________
___ 6:00 pm PERITONEAL FLUID PERITONEAL FLUID.
Hematology/Chemistry specimen, possibly contaminated.
INTERPRET RESULTS WITH CAUTION.
**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.
__________________________________________________________
___ 12:20 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
THIS IS A CORRECTED REPORT ___ @ 11:45 AM.
Reported to and read back by ___ MD, (___)
___ @
13:18.
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
PREVIOUSLY REPORTED AS GRAM NEGATIVE ROD(S) ___ @
11:12 AM.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 11:43 pm
BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:53 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:43 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH
IMAGING
======
EGD ___
"Normal duodenum. Tortuous lower esophagus with sharp turn into
stomach. As the therapeutic endoscope was passed through the
lower esophagus blood was noticed and upon examination a shallow
mucosal laceration was noted. There did not appear to be
underlying or nearby varices. The bleeding was observed and
slowed and stopped without intervention. Due to this, the
planned NJ tube was not placed at this time. Scar tissue
consistent with previous banding was seen in the lower
esophagus. Hiatal hernia. Nodular erythema in the antrum."
TTE ___
"Mitral and tricuspid valve prolapse with late systolic mitral
and tricuspid regurgitation.
Normal biventricular systolic function. EF 65%"
CXR ___
"Small to moderate left pleural effusion with mild pulmonary
vascular
congestion. Bibasilar airspace opacities, more pronounced on
the left, could
reflect atelectasis, though infection or aspiration is not
excluded in the
correct clinical setting."
Lower Extremity Vein Study ___
"1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Subcutaneous edema without drainable fluid collection
identified."
Liver/Gallbladder US ___
"1. No cholelithiasis or sonographic evidence of cholecystitis.
2. Cirrhotic liver with large volume ascites.
3. Patent portal vein. No intrahepatic biliary dilation."
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Furosemide 20 mg PO ONCE
2. Spironolactone 50 mg PO DAILY
3. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO DAILY Duration: 2 Days
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidocare] 4 % QAM Disp #*30 Patch Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth Daily Disp #*30 Capsule
Refills:*0
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*60
Tablet Refills:*0
5. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 1 suspension(s) by mouth four times
a day Disp #*1 Package Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth Daily
Disp #*1 Tablet Refills:*0
7. Furosemide 20 mg PO DAILY
8. Spironolactone 50 mg PO DAILY
Discharge Disposition:
___ With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
==========
Cirrosis
Anemia
Hypertension
Hypoxia
Enterococcus bacteriuria
SECONDARY
==========
Alcohol use disorder
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: ___ year old woman with new cirrhosis w possible acute
decompensation// pulmonary edema or pleural effusion
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: None.
FINDINGS:
Cardiac silhouette size is mildly enlarged. The aorta is unfolded.
Mediastinal and hilar contours are unremarkable. There is mild crowding of
bronchovascular structures. A small to moderate left pleural effusion is
demonstrated along with ill-defined opacities in the lung bases. No
pneumothorax. No acute osseous abnormalities detected.
IMPRESSION:
Small to moderate left pleural effusion with mild pulmonary vascular
congestion. Bibasilar airspace opacities, more pronounced on the left, could
reflect atelectasis, though infection or aspiration is not excluded in the
correct clinical setting.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with cirrhosis and unilateral lower leg swelling
presenting with acute decompensation and RUQ sharp pain.// gallbladder
pathology potential DVT in the right lower extremity
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None available in PACs at the time of interpretation.
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. In
the right hepatic lobe, a lobulated anechoic cyst measures 1.8 x 1.6 x 1.7 cm.
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. The gallbladder is distended
with wall thickening most likely reflecting third-spacing due to underlying
liver disease. Sonographic ___ sign was negative.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 10.4 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No cholelithiasis or sonographic evidence of cholecystitis.
2. Cirrhotic liver with large volume ascites.
3. Patent portal vein. No intrahepatic biliary dilation.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with cirrhosis and unilateral lower leg swelling
presenting with acute decompensation and RUQ sharp pain.// gallbladder
pathology potential DVT in the right lower extremity
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. Prominent subcutaneous
edema without drainable fluid collection identified.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. Subcutaneous edema without drainable fluid collection identified.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Jaundice, R Leg swelling
Diagnosed with Acute and subacute hepatic failure without coma, Hyperkalemia, Unspecified jaundice, Chest pain, unspecified
temperature: 97.7
heartrate: 98.0
resprate: 18.0
o2sat: 99.0
sbp: 146.0
dbp: 75.0
level of pain: 4
level of acuity: 2.0 | Ms. ___ is a ___ woman w/newly diagnosed cirrhosis who
presented with jaundice, right upper quadrant pain, and right
leg swelling in the setting of hypotension and large volume
ascites. She was found to have hypoxia with evidence of pleural
effusions on CXR in the ED. She was transferred to the MICU for
hypotension and suspected shock. However, she was negative for
SBP based on diagnostic paracentesis and never required pressors
in the ICU. She was initially hypoxic to 91% on room air; CXR
notable for RLE atelectasis, likely compression from large
volume ascites. Oxygen requirement resolved after therapeutic
paracentesis as below
# Cirrhosis
# Ascite.
# Alcoholic Hepatits.
Newly diagnosed cirrhosis in the outpatient setting, presumed
___ alcohol use, though final workup is still pending.
Decompensated by ascites this hospital stay. Elevated
ferritin:TIBC ratio (1:1), possibly suggestive of iron
overload/hemochromatosis as a contributor, though important to
note that with alcoholic hepatitis, ferritin is expectedly
elevated. Pt endorses a moderate history of EtOH use in the past
(3 drinks per day per her report)., though brother thinks she is
drinking significantly more than this. No evidence of PVT on
RUQUS ___. Underwent paracentesis with removal of 6 L fluid on
___ resultant improvement in subjective dyspnea as well as
hypoxia as below. TTE echocardiogram (___) showed Mitral and
tricuspid valve prolapse with late systolic mitral and tricuspid
regurgitation but normal biventricular systolic function.
Patient was resumed on ___ spironolactone 50 mg daily as well
as furosemide 20 mg daily. Though ascites did slowly increase
over the course of her hospital stay, she did not require repeat
therapeutic paracentesis during her stay here. Patient was
followed by nutrition consul. Due to downtrending MDF and GIB on
___, steroids were not used in treatment of patient's alcoholic
hepatitis. Dobhoff tube placement was attempted on ___ via EGD
that was complicated by laceration as below. Due to downtrending
discriminative function, Dobbhoff tube placement and tube feeds
were ultimately not started though risks and benefits
conversation with patient was had regarding concern for
malnutrition and need for at least ___ kcal/day intake.
#Hypotension
# Asymptomatic Bateruria.
In the ED the patient's BP went from 146/75 to 94/53 suggesting
shock. Differential diagnosis included infection (SBP), systemic
vasodilation ___ liver disease, medication effect or other
infectious source. No evidence evidence of infection on
diagnostic or therapeutic paracentesis on ___ and ___
respectively. Blood cultures with no growth. Chest x-ray with no
evidence of pneumonia. Urine with growth of enterococcus species
___. This was deemed an asymptomatic bacteriuria as patient had
no signs or symptoms of urinary tract. It was not treated. She
notea that
she and her family have always had low blood pressure
# Esophageal Laceration. Patient underwent EGD on ___ for
scheduled Dobhoff tube placement and suffered an esophageal
laceration. She was initially treated for an upper GI bleed with
IV pantoprazole 40 mg Q12H, IV ceftriaxone and octreotide. She
had no signs of repeat bleed and remained hemodynamically stable
with stable hemoglobin. Diet was advanced to a regular diet over
the course of a 24 hour period. She was discharged on oral
pantoprazole 40 mg Q12H and 7 days of oral antibiotic
prophylaxis as below.
# Anemia
# Thrombocytopenia. Likely a chronic issue secondary to her
cirrhosis. No acute management.
# Hypoxia (resolved). Patient initially required up to 2 L O2
via NC. CXR revealed pulmonary vascular congestion and L sided
effusion, likely related to cirrhosis and volume overload as
below. Resolved with therapeutic paracentesis as above.
Transitional Issues
===============
- Code status: Patient states that she would not want
interventions done "if
there were no point." However, she does feel frustrated that she
continues to get asked about code status questions in the
hospital. This conversation should be continued in the
outpatient setting.
- She should have follow up iron studies in ___ months given
elevated ferritin and TIBC
- Antibiotics: She should remain on antibiotics for a total of 7
days after her GI bleed on ___ (start date ___ | projected end
date ___
- Consider increase of diuretics as an outpatient
- Patient suffered an esophageal laceration during EGD. She was
intially managed on IV PPI, octreotide and IV ceftriaxone and
de-escalated to p.o. pantoprazole every 12 hours and
ciprofloxacin p.o. for prophylaxis as above. Please reassess the
need for PPI in the outpatient setting.
- Diuretic: Spironolcatone 50 mg/Lasix 20 mg. ___ uptitrate in
outpatient setting as tolerated
- Please repeat chem10 one week after discharge to monitor for
electrolyte stability on current diuretic regimen
- Continue sucralfate for 9 days after discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Codeine / Betadine Viscous Gauze
Attending: ___
Chief Complaint:
HMED Admission Note
.
CC: jaundice
.
Major Surgical or Invasive Procedure:
___ ERCP
History of Present Illness:
___ year old M presenting with jaundice. Pt with very complex
past medical history, best outlined in recent visit with Dr
___ in ___. Pt with UC/chrons diagnosed at age ___ which
has been quiescent and has not needed medications. Also with
history of autoimmune disorders including thyroiditis s/p
thyroidectomy, type 1DM, ITP, and likely autoimmune leukopenia.
Pt also with achalasia s/p myotomy. In addition he has
hemoptysis from lung granulomas of uncertain etiology. Resected
specimens negative for mycobacteria.
Pt has had issues with cholestasis/choledocholithiasis for the
past ___ years. In early ___, he had an obstructing stone in
the distal cbd for which he underwent ERCP with improvement in
his LFT's. Liver biopsy showed cholestasis with periportal
inflammation. Subsequetntly in ___ he developed gangrenous
cholecystitis and underwent CCY. Around that time he had a
repeat ERCP which showed stricture at hilum with negative
brushings. He had subsequent imaging and discussion in tumor
board with the thought that his stricture is likely benign.
Pt doing well until about a week ago when his wife noticed
worsening jaundice. She contacted Dr ___ recommended
he come to the ER. ERCP team and liver team consulted prior to
pt arriving to help work up his worsening jaundice. Pt denies
abdominal pain, fevers, chills, itching. He has been taking
vicodin for pain control but taking less than 3grams per day of
tylenol. He does not drink. No other new meds. Labs done on
arrival today show a bilirubin of 22 and alk phos of 886.
ROS: 10 ppint ROS negative except as noted above
Past Medical History:
Diabetes type 1
Thyroiditis s/p thyroidectomy
Migraines
ITP
Ulcerative colitis/Crohn's
COPD
HTN
HL
degenerative disk disease
granulomatous lung disease NOS
s/p thoroidectomy ___
s/p ___ myotomy age ___
s/p lung granuloma resection ___
s/p ERCP ___ for choledocholithiasis
s/p cholecystectomy ___
Social History:
___
Family History:
Mother: ___ aneurysm
Father: CAD
Children: epilepsy, ___'s thyroiditis
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vitals: 97.1 127/69 70 18 100%RA
Gen: NAD, sitting in bed, markedly jaundiced
HEENT: sclearl icterus, moist mm
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, nontender, nondistended
Ext: no edema
Neuro: alert and oriented x 3, no asterixis
Discharge:
o: 97.9 134/69 92 ___
Yesterday I/Os: 1680/1325U/380 first 8 hours, then capped in AM
Overnight I/O: ___ /capped drain
General: Improving jaundice; siting in chair eating breakfast
HEENT: EOMI, exopthalmus, +scleral icterus
CV: RRR, +II/VI SEM
Lungs: CTAB
Abdomen: Soft, distended but nontender, PTC drain continues in
place, capped.
Neuro: CN, motor, and sensation grossly intact. Gait normal. No
asterixis.
Pertinent Results:
ADMISSION LABS:
===================
___ 12:05AM BLOOD WBC-4.0 RBC-3.76* Hgb-12.2* Hct-36.1*
MCV-96# MCH-32.3* MCHC-33.7 RDW-17.4* Plt ___
___ 12:05AM BLOOD Neuts-60.3 ___ Monos-13.0*
Eos-0.2 Baso-0.3
___ 12:05AM BLOOD ___ PTT-38.4* ___
___ 12:05AM BLOOD Glucose-345* UreaN-18 Creat-0.4* Na-123*
K-3.1* Cl-84* HCO3-23 AnGap-19
___ 12:05AM BLOOD ALT-86* AST-149* AlkPhos-886*
TotBili-28.6*
___ 12:05AM BLOOD Albumin-3.3*
___ 12:05AM BLOOD Lipase-7
.
IMAGING:
================
___ ERCP
Impression:
A plastic stent placed in the biliary duct was found in the
major papilla. This was removed with a snare.
Evidence of a widely patent previous sphincterotomy was noted in
the major papilla.
Cannulation of the biliary duct was successful and deep with a
balloon using a free-hand technique.
A stricture was seen at the common hepatic duct with
intra-hepatic duct pruning. Contrast drainage from the biliary
tree was delayed.
Findings are compatible with PSC.
Spyglass cholangioscopy was performed. The CHD stricture was
identified. The wall appeared nodular with adherent mucus to the
wall.
No visual components of malignancy such as exophytic lesions,
ulcerations, or raised lesions were noted within the duct.
Active drainage of pus from the proximal biliary tree was noted
with water flushes.
The CBD wall was normal appearing on spy exam.
Cytology samples were obtained for cytology and FISH using a
brush in the common hepatic duct.
No stricture dilation or stent placement was indicated as there
was no residual contrast seen in the biliary tree and given the
higher risk of developing cholangitis with history of PSC.
DIAGNOSIS:
BRUSHING, LEFT HEPATIC DUCT:
POSITIVE FOR MALIGNANT CELLS.
Consistent with adenocarcinoma.
ECHO:
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 30 cm from the
incisors. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No 2D echocardiographic evidence of endocarditis.
Final Report
INDICATION: Left/common hepatic duct cholangiocarcinoma with
biliary
stricture.
COMPARISON: PTC ___, CTA abdomen ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology
fellow) and
Dr. ___ radiology attending) performed the
procedure. The
attending, Dr. ___ was present and supervising throughout
the procedure.
ANESTHESIA: Moderate sedation was provided by administrating
divided doses of
300mcg of fentanyl and 6 mg of midazolam throughout the total
intra-service
time of 1 hr 25 min during which the patient's hemodynamic
parameters were
continuously monitored by an independent trained radiology
nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the
access site.
MEDICATIONS: Fentanyl and midazolam. 4 mg Zofran.
CONTRAST: 45 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 14.2 meds, 252 mGy
PROCEDURE:
1. Over-the-wire cholangiogram through existing left
percutaneous transhepatic
biliary drainage catheter.
2. Placement of 8 x 80 mm biliary stent.
3. 6 mm balloon dilatation of biliary stent.
4. Placement of 3 fiducials in the left hepatic lobe.
5. Needle aspiration of a left hepatic subcapsular biloma.
6. Placement of a 10 ___ left anchor drain.
PROCEDURE DETAILS: Following the discussion of the risks,
benefits and
alternatives to the procedure, written informed consent was
obtained from the
patient. The patient was then brought to the angiography suite
and placed
supine on the exam table. A pre-procedure time-out was performed
per ___
protocol. The right/mid abdomen was prepped and draped in the
usual sterile
fashion.
Initial scout images showed biliary drain in the appropriate
position. The
left tube was injected with dilute contrast. The images were
stored on PACS.
Following the subcutaneous injection of 1% lidocaine and
instillation of
lidocaine jelly into the skin site, the left catheter was cut
and ___
wire was advanced through the catheter into the duodenum. A 7
___ sheath
was placed over the wire and a pull back cholangiogram was
performed and
demonstrated biliary stricture at the left hepatic duct and
left/common
hepatic duct junction. The ___ was exchanged for an Amplatz
wire. A
measuring catheter was placed through the stricture and into the
duodenum to
assess the required length of the stent. An 8 x 80 mm wall stent
was placed
into the left hepatic duct through the common bile duct and into
the duodenum.
A cholangiogram was performed and demonstrated adequate flow of
contrast. To
further stabilize the stent and expand it, proximal dilation was
performed
using a 6 x 40 mm balloon. Another cholangiogram was obtained
and demonstrated
adequate flow with adequate drainage of left bile ducts.
Attention was turned to fiducials placement. Liver ultrasound
was performed
and demonstrated an incidental fluid collection with septation
anterior to the
liver and posterior to the abdominal wall measuring 6 cm in
maximal dimension.
Using a Cook needle under ultrasound guidance, the collection
was accessed and
biliary fluid was aspirated . The fluid compoment was
completely aspirated
via a ___ Accustick sheath and sent for culture and analysis. The
sheath was
removed and dressing was applied. Then, 3 fiducials were placed
around the
left hepatic duct lesion by advancing the 19G brachystar needle
through the
biliary sheath, avoiding a capsular puncture.
The biliary sheath was removed and a 10 ___ percutaneous
transhepatic
biliary anchor catheter was advanced into the left hepatic duct
proximal to
the stent. The wire and inner stiffener were removed, the
catheter was
flushed, the catheter was attached to a bag and sterile
dressings were
applied.
The patient tolerated the procedure well and there were no
immediate
post-procedure complications.
FINDINGS:
1. Left percutaneous transhepatic biliary drainage catheter in
situ.
2. Cholangiogram showing left hepatic/common hepatic duct
junction stricture.
3. Adequate contrast flow through the left hepatic duct and into
the duodenum
after metallic stenting.
4. Incidental finding of a 6cm biloma anterior to the left
hepatic capsule,
decreased in size post drainage. .
IMPRESSION:
1. Stenting of left hepatic duct to duodenum with adequate
contrast flow.
2. Placement of 3 left hepatic fiducials.
3. Drainage of an incidentally found new 6 cm biloma anterior
to left hepatic
lobe.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___ ___ 5:45 ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ursodiol 500 mg PO BID
2. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Cyclobenzaprine 10 mg PO HS
4. Levothyroxine Sodium 225 mcg PO DAILY
5. Atenolol 75 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Atorvastatin 10 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation bid
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheeze
12. Fluticasone Propionate NASAL 1 SPRY NU BID
13. Zolpidem Tartrate 10 mg PO HS
14. Lorazepam 1 mg PO HS:PRN anxiety
15. Hydrocodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN
headache
16. Fentanyl Patch 100 mcg/h TD Q48H
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Levothyroxine Sodium 225 mcg PO DAILY
4. Lorazepam 1 mg PO Q6H:PRN anxiety
5. Ursodiol 500 mg PO BID
6. Lactulose 30 mL PO DAILY
RX *lactulose [Enulose] 10 gram/15 mL 30 ml by mouth three times
a day Refills:*5
7. Linezolid ___ mg PO Q12H
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
8. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth Q6H:PRN Disp #*90
Tablet Refills:*0
9. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Furosemide 20 mg PO DAILY
13. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheeze
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation bid
15. TraZODone 100 mg PO HS:PRN insomnia
RX *trazodone 100 mg 1 tablet(s) by mouth QHS:PRN Disp #*30
Tablet Refills:*0
16. Outpatient Lab Work
LFTs, CBC, CHEM 10.
Forward results to Dr. ___ #: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholangiocarcinoma
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 fevers and GPC bacteremia, udnergoing
infectious w/u, ?pna // ?pna ?pna
COMPARISON: Comparison to ___ at 16 50
FINDINGS:
PA and lateral views of the chest ___ at 15 22 were submitted.
IMPRESSION:
The left hemidiaphragm remains elevated. The patient is status post left
upper lung surgery with stable postsurgical changes in the left hemithorax.
Patchy opacities seen at the medial right lung base which may reflect an area
of atelectasis, although pneumonia should also be considered. Clinical
correlation is advised. No pneumothorax. No pulmonary edema. Relatively low
lung volumes. No large effusions.
Radiology Report
INDICATION: Left/common hepatic duct cholangiocarcinoma with biliary
stricture.
COMPARISON: ___ ___, CTA abdomen ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and
Dr. ___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
300mcg of fentanyl and 6 mg of midazolam throughout the total intra-service
time of 1 hr 25 min during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl and midazolam. 4 mg Zofran.
CONTRAST: 45 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 14.2 meds, 252 mGy
PROCEDURE:
1. Over-the-wire cholangiogram through existing left percutaneous transhepatic
biliary drainage catheter.
2. Placement of 8 x 80 mm biliary stent.
3. 6 mm balloon dilatation of biliary stent.
4. Placement of 3 fiducials in the left hepatic lobe.
5. Needle aspiration of a left hepatic subcapsular biloma.
6. Placement of a 10 ___ left anchor drain.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right/mid abdomen was prepped and draped in the usual sterile
fashion.
Initial scout images showed biliary drain in the appropriate position. The
left tube was injected with dilute contrast. The images were stored on PACS.
Following the subcutaneous injection of 1% lidocaine and instillation of
lidocaine jelly into the skin site, the left catheter was cut and ___
wire was advanced through the catheter into the duodenum. A 7 ___ sheath
was placed over the wire and a pull back cholangiogram was performed and
demonstrated biliary stricture at the left hepatic duct and left/common
hepatic duct junction. The ___ was exchanged for an Amplatz wire. A
measuring catheter was placed through the stricture and into the duodenum to
assess the required length of the stent. An 8 x 80 mm wall stent was placed
into the left hepatic duct through the common bile duct and into the duodenum.
A cholangiogram was performed and demonstrated adequate flow of contrast. To
further stabilize the stent and expand it, proximal dilation was performed
using a 6 x 40 mm balloon. Another cholangiogram was obtained and demonstrated
adequate flow with adequate drainage of left bile ducts.
Attention was turned to fiducials placement. Liver ultrasound was performed
and demonstrated an incidental fluid collection with septation anterior to the
liver and posterior to the abdominal wall measuring 6 cm in maximal dimension.
Using a Cook needle under ultrasound guidance, the collection was accessed and
biliary fluid was aspirated . The fluid compoment was completely aspirated
via a ___ Accustick sheath and sent for culture and analysis. The sheath was
removed and dressing was applied. Then, 3 fiducials were placed around the
left hepatic duct lesion by advancing the 19G brachystar needle through the
biliary sheath, avoiding a capsular puncture.
The biliary sheath was removed and a 10 ___ percutaneous transhepatic
biliary anchor catheter was advanced into the left hepatic duct proximal to
the stent. The wire and inner stiffener were removed, the catheter was
flushed, the catheter was attached to a bag and sterile dressings were
applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Left percutaneous transhepatic biliary drainage catheter in situ.
2. Cholangiogram showing left hepatic/common hepatic duct junction stricture.
3. Adequate contrast flow through the left hepatic duct and into the duodenum
after metallic stenting.
4. Incidental finding of a 6cm biloma anterior to the left hepatic capsule,
decreased in size post drainage. .
IMPRESSION:
1. Stenting of left hepatic duct to duodenum with adequate contrast flow.
2. Placement of 3 left hepatic fiducials.
3. Drainage of an incidentally found new 6 cm biloma anterior to left hepatic
lobe.
Radiology Report
INDICATION: History of granulomatous disease now presenting with
decompensated liver disease undergoing transplant evaluation. Evaluate for
cardiopulmonary abnormalities.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
Left hemidiaphragm remains elevated from at least ___. Patient is
status post right upper lung surgery and the resulting "neo-fissure" is again
visualized. There is no pleural effusion, pneumothorax or focal airspace
consolidation. Heart is normal size. The mediastinal and hilar structures are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ year old man with possible PSC, decompensated liver disease
undergoing liver transplant workup // please evaluate vasculature for liver
transplant protocol
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. 3D reformations were generated on a separate workstation
DOSE: DLP: 1021 mGy-cm (abdomen and pelvis.
IV Contrast: 150 mL Omnipaque injected at a rate of 4 cc/sec
COMPARISON: Reference MR abdomen dated ___
FINDINGS:
LOWER CHEST:
Suture material is noted in the left lower lobe. There is elevation of the
left hemidiaphragm. There is no evidence of pleural or pericardial effusion.
There is a small hiatal hernia.
ABDOMEN:
HEPATOBILIARY: The liver has a dysmorphic appearance with architectural
distortion. There is moderate intrahepatic biliary dilatation. No focal liver
lesions are identified. The patient is status post cholecystectomy. There is
a small amount of ascites.
PANCREAS: The pancreas is atrophic, without evidence of focal lesions or
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: There is splenomegaly. An accessory spleen is noted.
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 stones, focal renal lesions or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Visualized loops of small large bowel are normal in
caliber.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal wall is within normal
limits.
Arterial Vasculature:
1. Celiac trunk
1. Stenosis: No
2. Aneurysm: No
2. Common hepatic artery
1. Conventional anatomy: Yes
2. Replaced/accessory right hepatic artery: No
3. Replaced/accessory left hepatic artery: No
4. Stenosis: No
5. Aneurysm: No
Portal venous system:
1. Main portal vein patent: Yes
2. Main portal vein thrombosis: No
3. Main portal vein cavernous transformation: No
4. Superior mesenteric vein patent: Yes
5. Splenic vein patent: Yes
Hepatic veins:
1. Accessory hepatic veins (>=4mm): No
Liver masses concerning for HCC: No
Liver volume: Pending 3D reformations.
IMPRESSION:
1. Hepatic architectural distortion and biliary dilatation consistent with
history of PSC. No focal liver lesions.
2. Patent hepatic vasculature with conventional hepatic arterial anatomy.
3. Sequela of portal hypertension including ascites and splenomegaly.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with likely cholangiocarcinoma, without pulmonary
symptoms, requires imaging for staging // please evaluate for e/o metastatic
disease in chest, for staging cholangiocarcinoma please evaluate for e/o
metastatic disease in chest, for sta
TECHNIQUE: Volumetric, multidetector CT of the chest was performed with
intravenous contrast administration. Images are presented for display in the
axial plane at 5 mm and 1.25 mm collimation. A series of multiplanar
reformation images are also submitted for review.
Total exam DLP: 713 mGy-cm.
COMPARISON: Outside chest CT from ___.
FINDINGS:
The thyroid has been surgically removed. No significant axillary, mediastinal
or hilar lymphadenopathy is detected. There is diffuse thickening of the
esophageal wall with fluid extending to the level of the thoracic esophagus.
The esophagus is also dilated. The thoracic aorta is normal in caliber with a
typical 3 vessel takeoff from the arch. The pulmonary arterial trunk is
normal in caliber. The heart is mildly enlarged. There is a small amount of
pericardial effusion. There is a moderate sized hiatal hernia.
The tracheobronchial tree is normal to the subsegmental levels. The airways
are normal in caliber. Within the pulmonary parenchyma, there is no
interstitial abnormality. Surgical sutures are seen in left upper and lower
lobe. There is mild bibasilar atelectasis. No focal consolidation, pleural
effusion or pneumothorax is present. There are no suspicious opacities,
masses or pleural abnormalities.
No blastic or lytic lesion suspicious for malignancy is present.
Although the study is not tailored for evaluation of subdiaphragmatic
structures, within the upper abdomen, there is re- demonstration of moderate
intrahepatic biliary dilation. Surgical clips are seen in the right upper
quadrant, likely related to prior cholecystectomy. The spleen is enlarged and
note is made of an accessory spleen. Please refer to most recent abdominal
examination from ___ for a complete report on additional
findings.
IMPRESSION:
1. No evidence of intrathoracic malignancy.
2. Postsurgical changes seen in the left lung. Mild bibasilar atelectasis.
3. Dilated esophagus with diffuse esophageal wall thickening and fluid
extending to the level of the thoracic esophagus, in keeping with known
history of achalasia.
Radiology Report
INDICATION: ___ year old man with PSC and CHD stricture w/cytology suggestive
of adenocarcinoma, with persistent hyperbilirubinemia // Please place PTC for
decompression of CHD stricture.
COMPARISON: Comparison is made to ct abdomen performed ___ and
mri abdomen performed ___
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow), Dr
___ resident,) and Dr. ___ radiology
attending) performed the procedure. The attending, Dr. ___ was present and
supervising throughout the procedure.
ANESTHESIA: General anesthesia was administered by the anesthesiology
department.
MEDICATIONS: 1 g ceftriaxone.
CONTRAST: 60 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 25.4 min, for 58 mGy
PROCEDURE:
1. Targeted transabdominal ultrasound.
2. Ultrasound guided left percutaneous transhepatic bile duct access.
3. Left cholangiogram
4. Brushings and forceps biopsy of common hepatic duct stricture x 2
5. Brushings and forceps biopsy of left main hepatic duct stricture x 2
6. ___ left internal/external biliary drain placement.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits, and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. The left abdomen
was prepped and draped in the usual sterile fashion.
Under ultrasound guidance, a 21G Cook needle was advanced into mildly dilated
leftbiliary system. Images of the access were stored on PACS. Once return of
bilious fluid was identified, a Nitinol wire was advanced under fluoroscopic
guidance into the proximal left hepatic duct. A skin ___ was made over the
needle and the needle was removed over the wire. An Accustick set was advanced
over the wire and the inner stiffener was withdrawn. A contrast injection was
performed to confirm biliary position and anatomy. The Nitinol wire was
exchanged for a Glidewire which was eventually advanced into the common bile
duct using a Kumpe catheter. The glidewire was exchanged for an Amplatz wire.
A ___ sheath was advanced over the wire into the biliary system. A pull-back
cholangiogram was performed with findings as detailed below.
A ___ wire was passed along side the Amplatz through the 6 ___ sheath
into the fourth portion of the duodenum. The sheath was removed and re-
advanced over the ___ wire alone into the distal CBD. The wire was
withdrawn and a Celebrity Cytology brush was advanced into the sheath. Both
the sheath and Cytology Brush were withdrawn to the level of the common
hepatic duct stenosis. Two brushing samples were obtained from this region and
placed in Cytolyte. Next, a radial jaw forceps biopsy device was advanced
through the sheath to the level of the common hepatic duct stenosis. Tissue
samples were obtained and placed in formalin.
The sheath was a then withdrawn to the level of the left hepatic duct
stenosis. Agian a Celebrity Cytology brush was advanced into the sheath. Both
the sheath and Cytology Brush were withdrawn to the level of the common
hepatic duct stenosis. Two brushing samples were obtained from this region and
placed in Cytolyte. Next, radial jaw forceps biopsy device was advanced
through the sheath to the level of the common hepatic duct stenosis. Tissue
samples were obtained and placed in formalin.
The catheters and sheath were removed. A modified ___ internal external
biliary catheter was advanced, the wire and inner stiffener were removed and
the pigtail was formed. Contrast injection confirmed appropriate position. The
catheter was flushed with saline, secured with stay sutures to the skin and
sterile dressings were applied. The catheter was attached to a bag.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Pull-back cholangiogram demonstrating significant stenosis in the common
hepatic duct just beyond the hilar confluence as well as a smaller stricture
in the left main hepatic duct just proximal to the hilar confluence. The left
biliary system as well as the a proximal central anterior right system were
significantly dilated with areas of intermittent strictures consistent with
known primary sclerosing cholangitis.
2. Successful placement of a left 10 ___ internal-external biliary drain.
IMPRESSION:
1. Successful placement of the left ___ internal-external biliary drain.
2. Uncomplicated biopsy of common hepatic and left main biliary duct stenoses.
Results pending.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with JAUNDICE NOS, DIABETES UNCOMPL JUVEN, LONG-TERM (CURRENT) USE OF INSULIN, HYPOTHYROIDISM NOS
temperature: 98.0
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 56.0
level of pain: 0
level of acuity: 3.0 | ASSESSMENT/PLAN: ___ with PSC Child's B MELD 16, UC/Crohn's,
autoimmune thyroiditis, achalasia, ITP, DMI who presented for
evaluation of jaundice, found to have stricture of common
hepatic duct now confirmed to be cholangioCA after 2 biopsies
and FISH studies. Patient developed VRE and Dapto resistent SIRS
after stent placement through the stricutre caused by the
cholangiocarinoma. Last positive blood cultures was ___. After
biopsy results, pt was not longer a candidate for tranplant at
this institution; however, ___ in ___ will
perform. Pt was given that option, however, declined and wanted
to move forward with chem and radiation here. In prepartion for
treatment, a metal biliary stent replaced the plastic one and
three fiducial markers were placed for raditation treatment. Pt
started and discharged on 2 week course of Linezolid ___ BID
since first negative Bcx--with stop date ___. He is to follow
up with rad onc, heme one, liver clinic, and ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is an ___ M with h/o tobacco abuse, COPD who presents
to the ___ ED with vertigo starting very early this morning.
Last evening the patient was in his usual state prior to going
to bed for the evening. He had gotten up to use the bathroom and
did so without difficulty. When he laid back down, he had the
sudden onset of room spinning dizziness. It improved somewhat
with sitting up right on the edge of the bed, but continued for
about 30 minutes before abating. He was then able to stand and,
though cautious, walk steadily. He went back to bed at about
4am. This morning, the patient got up to use the restroom and
was feeling ok. While in the bathroom he leaned forward and
again felt very dizzy. He fell, but did not strike his head or
lose consciousness. He laid there for a bit and continued to
feel dizzy. EMS was called and he was brought to the ED. Now in
the ED, he states that he is asymptomatic when sitting with his
head up, but symptoms return every time he tilts his head
downward. He has never had vertigo before.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Basal cell carcinoma
Hearing loss
Inguinal hernia
Schwannoma
Tobacco abuse
Prostate cancer
Depression
Social History:
___
Family History:
Noncontributory
Physical Exam:
Vitals:
99.2 100 149/84 36 100% Nasal Cannula
GEN: Awake, cooperative, NAD.
HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx
NECK: Supple
RESP: slight SOB with exertion
CV: RRR
ABD: soft, NT/ND
EXT: No edema, no cyanosis
SKIN: no rashes or lesions noted.
NEURO EXAM:
MS:
Alert, oriented x 3.
Able to relate history without difficulty.
Attentive.
Language is fluent with intact repetition and comprehension.
Normal prosody.
There were no paraphasic errors.
Speech was not dysarthric.
Pt was able to name both high and low frequency objects.
Able to follow both midline and appendicular commands.
Good knowledge of current events.
No evidence of apraxia or neglect.
CN:
II:
PERRLA 3 to 2mm and brisk.
VFF to confrontation.
III, IV, VI: EOMI, a few beats of torsional nystagmus to R with
extreme gaze in all directions. Normal saccades.
V: Sensation intact to LT.
VII: Facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally. Inconclusive
HIT, possible single corrective saccade with head turning left
to right (undershoot), but this is not seen consistently.
IX, X: Palate rise symmetric.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue protrudes midline.
Motor:
Normal bulk, tone throughout. No pronator drift bilaterally.
No adventitious movements. No asterixis.
Delt Bic Tri WrE FE IO IP Quad Ham TA ___
L ___ ___ 5 5 ___ 5
R ___ ___ 5 5 ___ 5
Sensory: No deficits to light touch. No extinction to DSS.
Slight stocking distribution decrease to sensation up to ankles.
Decreased proprioception at toes bilatearlly
Reflexes:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Toes equivocal (withdrawal)
Coordination:
No intention tremor, no dysdiadochokinesia noted. No dysmetria
on FNF or HKS bilaterally.
Gait:
Stance is wide based, falls backward upon placing feet closer
together with eyes open. Remainder of gait exam aborted.
On discharge: exam is unchanged
Pertinent Results:
___ 02:40PM BLOOD WBC-15.1*# RBC-4.67 Hgb-14.4 Hct-43.0
MCV-92 MCH-30.8 MCHC-33.5 RDW-13.1 RDWSD-43.9 Plt ___
___ 06:15AM BLOOD WBC-10.6* RBC-4.24* Hgb-13.3* Hct-39.0*
MCV-92 MCH-31.4 MCHC-34.1 RDW-13.1 RDWSD-43.8 Plt ___
___ 02:40PM BLOOD Neuts-88.4* Lymphs-5.2* Monos-5.7
Eos-0.1* Baso-0.3 Im ___ AbsNeut-13.36*# AbsLymp-0.79*
AbsMono-0.86* AbsEos-0.02* AbsBaso-0.05
___ 02:40PM BLOOD ___ PTT-40.6* ___
___ 06:15AM BLOOD Glucose-99 UreaN-18 Creat-0.9 Na-142
K-4.1 Cl-108 HCO3-21* AnGap-17
___ 06:15AM BLOOD CK(CPK)-400*
___ 02:40PM BLOOD ALT-26 AST-33 AlkPhos-81 TotBili-1.2
___ 06:15AM BLOOD CK-MB-6 cTropnT-<0.01
___ 06:15AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.0 Cholest-PND
CXR: Streaky opacity in the lingula concerning for pneumonia.
CTA head/neck: pending
MRI brain: No acute infarcts identified. Moderate cortical
brain atrophy seen.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
2. Vitamin D 1000 UNIT PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
5. Azithromycin 250 mg PO Q24H Duration: 3 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
6. Outpatient Physical Therapy
___ rehab
Discharge Disposition:
Home
Discharge Diagnosis:
peripheral vertigo
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro: no truncal ataxia, very unsteady on his feet and falls
backwards. CN exam benign, motor exam ___ throughout. No
nystagmus. Inconclusive HIT.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with dizziness // eval for acute process
COMPARISON: ___ and ___.
FINDINGS:
AP upright and lateral views of the chest provided. The lungs appear
hyperinflated with upper lobe lucency compatible with known emphysema.
Streaky opacity in the region of the lingula could represent an early
pneumonia. Otherwise the lungs are clear. No large effusion or pneumothorax.
The heart size remains within normal limits. The mediastinal contour is
normal. Bony structures are intact.
IMPRESSION:
Streaky opacity in the lingula concerning for pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with dizziness // eval for acute process
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: None available.
FINDINGS:
Please note the study is mildly degraded by motion. There is no evidence of
acute territorial infarction, hemorrhage, edema, or large mass.
Periventricular and subcortical white matter hypodensities are nonspecific,
but likely represent chronic small vessel ischemic disease. Prominence of the
ventricles and sulci is suggestive of involutional changes. Multiple
arachnoid granulation pits are seen scalloping the inner table of the
calvarium. There is a lucent lesion of the right frontal bone involving both
the inner and outer table with well-defined margins (03:47) which could
represent an atypical arachnoid granulation pit though this is unclear. The
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
orbits are unremarkable.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial process.
3. Possible atypical arachnoid granulation pit in the right frontal bone which
can be further characterized by nonemergent MRI.
RECOMMENDATION(S): Consider nonemergent bone scan or MRI to further assess.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: ___ year-old male with history of dizziness. Evaluate for
aneurysm or stenosis.
TECHNIQUE: Rapid axial imaging was performed through the neck and brain
during the uneventful infusion of 70 mL of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered and segmented images
were then generated on a dedicated workstation. This report is based on
interpretation of all of these images.
DOSE: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7
mGy-cm.
4) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
5) Spiral Acquisition 5.0 s, 39.4 cm; CTDIvol = 31.7 mGy (Head) DLP =
1,251.3 mGy-cm.
Total DLP (Head) = 1,276 mGy-cm.
COMPARISON: ___ Noncontrast head CT
FINDINGS:
CTA HEAD:
There is atherosclerotic calcification in the bilateral cavernous and supra
clinoid internal carotid arteries. There are bilateral fetal type origin of
the posterior cerebral arteries. Otherwise, the vessels of the circle of
___ and their principal intracranial branches appear normal with no
evidence of stenosis,occlusion or aneurysm. The dural venous sinuses are
patent.
CTA NECK: There is atherosclerosis of the aortic arch. The left vertebral
artery arises directly off of the aorta. Atherosclerosis of the bilateral
carotid bulbs is seen. There is less than 50% stenosis of the origin of the
left internal common carotid artery. Bilateral fetal style PCA's are seen.
There is a dominant right vertebral artery.
OTHER: There is biapical centrilobular emphysema. The lytic right frontal
calvarial lesion is again seen, thinning of the inner and outer table. There
are multilevel degenerative changes throughout the cervical spine.
Nonobstructive calcifications in the left parotid gland is identified.
IMPRESSION:
1. No evidence of aneurysm greater than 3 mm, dissection, vascular
malformation, or significant luminal narrowing.
2. Less than 50% stenosis at the origin of the left internal common carotid
artery.
3. Lytic right frontal calvarial lesion for which a bone scan can be acquired
further evaluation.
RECOMMENDATION(S): Bone scan to evaluate the calvarial lesion.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with vertigo, gait instability // stroke?
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images .
COMPARISON: CT angiography of ___.
FINDINGS:
There is no acute infarct identified. Moderate brain atrophy is seen
predominantly affecting the cord thecal sulci. Mild to moderate changes of
small vessel disease seen. There is no evidence of micro hemorrhages.
Suprasellar and craniocervical regions are unremarkable. Vascular flow voids
are maintained.
IMPRESSION:
No acute infarcts identified. Moderate cortical brain atrophy seen.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, s/p Fall
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, VERTIGO/DIZZINESS
temperature: 99.2
heartrate: 100.0
resprate: 36.0
o2sat: 100.0
sbp: 149.0
dbp: 84.0
level of pain: 0
level of acuity: 1.0 | ___ is an ___ M with h/o tobacco abuse, COPD who presents
to the ___ ED with vertigo starting very early this morning.
Symptoms have been somewhat fluctuating in intensity, but
relatively continuous and brought on more severely with bending
the head downward. His exam is notable only for gait
instability. There are no other clear signs of cerebellar
dysfunction. HIT is inconclusive. Given gait instability and
continuing vertigo, admitted for and MRI of his head. MRI
negative for stroke, evaluated by ___ who recommended outpatient
___ rehab.
Also found a pneumonia on CXR in the ED, given levaquin once,
started on Z-pak for a 5 day course to be finished as
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of
recurrent parastomal hernia related SBO, CKD stage V, CAD s/p
MI,
atrial fibrillation, chronic diastolic heart failure, severe AS
s/p TAVR, complete heart block s/p PPM, bladder cancer s/p
cystectomy and ileal conduit with urostomy, prostate cancer s/p
radical prostatectomy who presents as transfer from ___ for SBO on ___.
The patient had developed 3 days of nausea, nonbloody vomiting,
and abdominal pain. The abdominal pain is crampy, sometimes
sharp, comes in waves, similar to prior SBO presentation, and in
the lower quadrants, nonradiating. He is currently passing
flatus
and has improved overall symptoms since NGT placement (800 cc
gastric output) at BID-N ED. His last bowel movement was 3 days
ago.
He has never had the SBO operated on in the past, but it has
been
a recurrent problem (most recently hospitalized and discharged
___, and ___ with conservative management).
At BID-N ED a CT was obtained which showed bowel obstruction
(similar appearance to ___ with two transition points
associated with right parastomal hernia. He was transferred to
___ ED for his medical complexity.
Past Medical History:
- Recurrent parastomal hernia related SBO
- CKD stage V
- CAD s/p MI
- Atrial fibrillation
- Chronic diastolic heart failure
- severe AS s/p TAVR
- complete heart block s/p PPM
- bladder cancer s/p cystectomy and ileal conduit with urostomy
- prostate cancer s/p radical prostatectomy
- iron deficiency anemia
- h/o GI bleed
- h/o perforated gastric ulcer
Social History:
___
Family History:
Father with history of alcoholism. Mother passed of MI.
Physical Exam:
ADMISSION 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 irregularly irregular, systolic murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen with urostomy bag in position on LLQ which is full
with red wine colored urine. Abdomen is mildly tender without
palpation. Not distended, BS are heard, there is reducible
ventral and parastomal hernia present.
GU: No CVAT
MSK: Neck supple, moves all extremities
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
DISCHARGE EXAM:
***
Pertinent Results:
___ IMAGING:
==================
CT ABDOMEN AND PELVIS WITHOUT CONTRAST
1. Small-bowel obstruction with similar degree of severe
proximal small bowel dilation when compared to ___. Two
separate transition points are noted in the right/midline
parastomal
hernia (series 2, image 56, 55).
2. Short-term stability of 4 mm right lower lobe pulmonary
nodule.
3. Right lower quadrant ileal conduit in place with
resolution of right sided hydronephrosis seen on ___.
ADMISSION LABS:
===============
___ 03:40PM BLOOD WBC-9.4 RBC-2.78* Hgb-8.2* Hct-25.8*
MCV-93 MCH-29.5 MCHC-31.8* RDW-17.0* RDWSD-57.5* Plt ___
___ 03:40PM BLOOD Neuts-77.1* Lymphs-10.2* Monos-10.4
Eos-1.4 Baso-0.4 Im ___ AbsNeut-7.26* AbsLymp-0.96*
AbsMono-0.98* AbsEos-0.13 AbsBaso-0.04
___ 03:40PM BLOOD ___
___ 03:40PM BLOOD Glucose-74 UreaN-92* Creat-3.8* Na-146
K-5.5* Cl-108 HCO3-24 AnGap-14
___ 03:40PM BLOOD ALT-17 AST-13 AlkPhos-108 TotBili-0.4
___ 03:40PM BLOOD Albumin-2.7* Calcium-7.5* Phos-5.3*
Mg-1.0*
MICRO:
=====
___ URINE URINE CULTURE-FINAL
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ URINE URINE CULTURE-PRELIMINARY {KLEBSIELLA
OXYTOCA} INPATIENT
URINE CULTURE (Preliminary):
KLEBSIELLA OXYTOCA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>___ R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ IMAGING:
==============
AXR portable ___:
IMPRESSION:
Gas distention of multiple loops of small and large bowel, with
air and stool in the rectum.
Clinical correlation for ileus is recommended.
DISCHARGE LABS:
(Pt frequently refused labs; last available labs from ___ 12:50PM BLOOD WBC-10.0 RBC-2.94* Hgb-8.7* Hct-28.3*
MCV-96 MCH-29.6 MCHC-30.7* RDW-16.5* RDWSD-58.5* Plt ___
___ 12:50PM BLOOD Glucose-106* UreaN-90* Creat-3.3* Na-146
K-5.1 Cl-110* HCO3-23 AnGap-13
___ 12:50PM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8
___ 07:15AM BLOOD ALT-10 AST-12 AlkPhos-111 TotBili-0.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Calcitriol 0.25 mcg PO DAILY
3. Calcium Acetate 1334 mg PO TID W/MEALS
4. Epogen (epoetin alfa) 20,000 unit/mL injection q14 days
5. Ferrous Sulfate 650 mg PO DAILY
6. HydrALAZINE 10 mg PO TID
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Sodium Bicarbonate ___ mg PO TID
11. Torsemide 20 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Ondansetron ODT 4 mg PO TID W/MEALS nausea
3. Senna 8.6 mg PO BID Constipation - First Line
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 0.25 mcg PO DAILY
6. Calcium Acetate 1334 mg PO TID W/MEALS
7. Epogen (epoetin alfa) 20,000 unit/mL injection q14 days
8. Ferrous Sulfate 650 mg PO DAILY
9. HydrALAZINE 10 mg PO TID
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Sodium Bicarbonate ___ mg PO TID
14. Torsemide 20 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Small bowel obstruction
Acute on chronic kidney disease
Klebsiella urinary tract infection
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: ___ year old man with SBO, eval for change in SBO// ?interval
change in SBO
TECHNIQUE: Portable supine and upright abdominal radiographs were obtained.
COMPARISON: None
FINDINGS:
There are multiple dilated loops of small and large bowel, without air-fluid
levels. Air and stool is seen in the rectum.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Pacemaker leads are partially visualized in the right ventricle.
IMPRESSION:
Gas distention of multiple loops of small and large bowel, with air and stool
in the rectum.
Clinical correlation for ileus is recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, SBO, Transfer
Diagnosed with Other partial intestinal obstruction
temperature: 97.2
heartrate: 70.0
resprate: 16.0
o2sat: 98.0
sbp: 142.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ male with history of recurrent
parastomal hernia related SBO, CKD stage V, CAD s/p MI, atrial
fibrillation, chronic diastolic heart failure, severe AS s/p
TAVR, complete heart block s/p PPM, bladder cancer
s/p cystectomy and ileal conduit with urostomy, prostate cancer
s/p radical prostatectomy who presents as transfer from
___ for SBO on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
transfer for c/f acute leukemia found to have high grade B cell
lymphoma
Major Surgical or Invasive Procedure:
bone marrow biopsy ___
History of Present Illness:
HPI: History obtained from son and ___ note, as pt has been
having worsening mental status per son.
Per ___ note by ___ MD
___ old female with pneumonia and found to have wbc 92,0000
transferred from ___. She was overall healthy aside from
some back pain, but reports about ___ weeks of worsening
illness,
both weakness/SOB/fevers and worsening buttock/low back pain
with
bilateral burning leg pain. This pain is different from in past.
In ___, she was given CTX, azithromycin, and 850cc NS, and
transferred. On transfer, she appears fatigued and unwell,
reports ongoing leg
pain. She denies chest pain, abdominal pain. She has no
hematological history. No relevant family hx.
ROS +spitting up blood for 3 weeks "
To this history, her son reiterates that she has been having
back
and leg pain, like knives or electric shocks in her legs,
worsening over the last ___ weeks. He adds that she started
having streaking hemoptysis about a week ago. She has had poor
appetite for one week as well.
He reports, after some reflection, that he has noticed a change
in her mental status over the course of the last week. He says
that she normally is able to care for her self, but is now
confused sometimes.
Son cannot remember the name of ___ PCP or what, if any,
medications she is taking. He reports she went to her PCP last
week and was given three medications. In terms of her PMH, he
knows that she has had eye surgery and takes eye drops.
Past Medical History:
- glaucoma
- TKR
Social History:
___
Family History:
could not obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 99.4 103 / 61 HR 100 28 94 3 LNC
Gen: asleep
HEENT: No icterus. MMM.
NECK: supple without jugular venous distension
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. ___ low pitched SEM RLSB
LUNGS: No incr WOB. On 3L NC. Scant scattered wheezes, with RML
crackles.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: mostly asleep. Responsive to son in ___. Son is
reporting pt is forgetful
LINES: PIV
DISCHARGE PHYSICAL EXAM:
Vitals: Temp: 98.6 PO BP: 131/68 HR: 81 RR: 16 O2 sat 100% O2
Gen: lying in bed
HEENT: No icterus. MMM.
NECK: supple without jugular venous distension
LYMPH: No cervical or supraclav LAD
CV: tachycardia regular. Normal S1,S2. ___ low pitched SEM RLSB
LUNGS: No incr WOB. On RA. Scant scattered wheezes.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: ___ strength throughout. Pt able to stand. Alert.
Orientation not tested.
LINES: PICC
Pertinent Results:
ADMISSION LABS
___ 01:20AM BLOOD WBC-95.9* RBC-2.91* Hgb-8.2* Hct-26.4*
MCV-91 MCH-28.2 MCHC-31.1* RDW-14.3 RDWSD-47.0* Plt Ct-5*
___ 01:20AM BLOOD Neuts-0 Bands-0 Lymphs-7* Monos-1* Eos-0
Baso-0 Atyps-1* ___ Myelos-0 Blasts-91* Other-0
AbsNeut-0.00* AbsLymp-7.67* AbsMono-0.96* AbsEos-0.00*
AbsBaso-0.00*
___ 01:20AM BLOOD ___ PTT-25.3 ___
___ 01:20AM BLOOD ___ 01:20AM BLOOD Glucose-118* UreaN-15 Creat-0.7 Na-143
K-3.6 Cl-102 HCO3-25 AnGap-16
___ 07:55AM BLOOD Calcium-8.9 Phos-4.9* Mg-1.6 UricAcd-6.6*
___ 01:20AM BLOOD Hapto-55
___ 05:46PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
PERTINENT LABS
___ 06:00
QUANTIFERON-TB GOLD
Test Result Reference
Range/Units
QUANTIFERON(R)-TB GOLD POSITIVE A NEGATIVE
*******************
PERTINENT IMAGING
*******************
TTE ___ at 2:08:02 ___:
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>65%). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
No valvular pathology or pathologic flow identified.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
CTA CHEST Study Date of ___ 3:20 AM
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral peribronchovascular opacification, concentrated in
the right
upper and lower lobes, is consistent with multifocal pneumonia.
3. Main pulmonary artery dilatation up to 3.5 cm is suggestive
but not
diagnostic of pulmonary arterial hypertension.
CT HEAD W/O CONTRAST Study Date of ___ 2:27 ___
IMPRESSION:
1. Three areas of hemorrhage, with a subdural hematoma involving
the left
frontoparietal lobe and measuring 1.7 x 1.2 cm, associated with
sulci
effacement and significant edema without frank uncal herniation.
5 mm left to right shift of normally midline structures.
2. Subdural hematoma in the left frontal lobe measuring 5 x 2
mm.
3. Hemorrhage along the left tentorium.
CT HEAD W/O CONTRAST Study Date of ___ 9:38 AM
IMPRESSION:
1. Left hemisphere subdural hematoma without evidence of new
hemorrhage.
2. Overall unchanged effacement of sulci without increase in
mass effect.
CT HEAD W/O CONTRAST Study Date of ___ 8:45 AM
IMPRESSION:
1. Evolution of left hemispheric subdural hematoma without
evidence of new
hemorrhage.
2. Slight improvement in mass effect when compared to the study
from ___.
DISCHARGE LABS:
___ 12:00AM BLOOD WBC-3.0*# RBC-2.81* Hgb-8.4* Hct-25.4*
MCV-90 MCH-29.9 MCHC-33.1 RDW-13.4 RDWSD-44.8 Plt Ct-32*
___ 12:00AM BLOOD Neuts-68 Bands-2 Lymphs-17* Monos-7 Eos-0
Baso-0 Atyps-4* ___ Myelos-2* NRBC-3* AbsNeut-2.10
AbsLymp-0.63* AbsMono-0.21 AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Glucose-109* UreaN-13 Creat-0.6 Na-142
K-4.3 Cl-101 HCO3-27 AnGap-14
___ 12:00AM BLOOD ALT-22 AST-14 LD(LDH)-339* AlkPhos-98
TotBili-0.5
___ 12:00AM BLOOD Albumin-3.6 Calcium-8.5 Phos-4.1 Mg-2.1
UricAcd-2.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tear Ointment 1 Appl BOTH EYES PRN ___ eyes
Discharge Medications:
1. Acyclovir 400 mg PO TID
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*3
2. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
4. Isoniazid ___ mg PO DAILY
RX *isoniazid ___ mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
5. LaMIVudine 100 mg PO DAILY
RX *lamivudine 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
6. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % 1 patch every AM Disp #*30 Patch
Refills:*0
7. Ondansetron ODT 8 mg PO ASDIR
RX *ondansetron 8 mg 1 tablet(s) by mouth TID prn Disp #*30
Tablet Refills:*3
8. Pyridoxine 50 mg PO DAILY
RX *pyridoxine (vitamin B6) 50 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*3
9. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth @hs Disp #*30 Tablet
Refills:*0
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*3
11. Topiramate (Topamax) 25 mg PO BID
RX *topiramate [Topamax] 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
12. TraMADol ___ mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth every 8 hours as
needed Disp #*30 Tablet Refills:*0
13. Artificial Tear Ointment 1 Appl BOTH EYES PRN ___ eyes
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
lymphoma
atrial tachycardia
subdural hemorrhage
indolent TB
hep B
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with back pain, with new SOB, elevated ddimer//
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 = 6.1 mGy (Body) DLP = 3.0
mGy-cm.
2) Spiral Acquisition 4.0 s, 31.6 cm; CTDIvol = 14.6 mGy (Body) DLP = 460.4
mGy-cm.
Total DLP (Body) = 463 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental level without filling defect to indicate a pulmonary embolus. Main
pulmonary artery diameter is elevated at 3.5 cm. The thoracic aorta is normal
in caliber without evidence of dissection or intramural hematoma. Heart size
is top normal. There are no significant coronary artery or valvular
calcifications. Small pericardial fluid is within physiologic limits.
AXILLA, HILA, AND MEDIASTINUM: Borderline mediastinal and right hilar lymph
nodes are likely reactive from pneumonia. No axillary lymphadenopathy is
present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Respiratory motion limits detailed evaluation. There are
multiple scattered areas of bilateral peribronchovascular opacification,
concentrated in the right upper and lower lobes, compatible with multifocal
pneumonia. The airways are patent to the segmental bronchi bilaterally.
BASE OF NECK: The imaged thyroid is unremarkable.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral peribronchovascular opacification, concentrated in the right
upper and lower lobes, is consistent with multifocal pneumonia.
3. Main pulmonary artery dilatation up to 3.5 cm is suggestive but not
diagnostic of pulmonary arterial hypertension.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with new R PICC// 46 cm R brachial DL PICC-
___ ___ Contact name: ___: ___
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: CTA chest ___.
FINDINGS:
There has been placement of a right-sided PICC terminating in the right atrium
and should be retracted by 5 cm. Lung volumes are extremely low accentuating
the cardiac silhouette. Heart size is likely top normal. Low lung volumes
accentuate the cardiac silhouette and pulmonary vasculature. However, there
appear to be multifocal opacities throughout bilateral lung fields, as seen on
the same-day CT examination. There is no large effusion or pneumothorax.
IMPRESSION:
Right PICC should be retracted by 5 cm. Multifocal pulmonary opacities as
seen on the same-day CT examination consistent with multifocal pneumonia.
NOTIFICATION: The findings were discussed with ___, by ___
___, M.D. on the telephone on ___ at 4:55 pm, 2 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with AML and distal RLE pain, eval for DVT//
eval 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.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with hypoxemia// pulmonary edema
TECHNIQUE: Portable frontal view of the chest
COMPARISON: ___
IMPRESSION:
There is little changed compared the prior examination. Right PICC is
unchanged. Lung volumes remain low. There remains mild cardiomegaly and
unfolding of the thoracic aorta. The areas of increased opacity in the
bilateral lung fields correspond to the consolidations as seen on the prior
CT, consistent with multifocal pneumonia, though these findings do not appear
worsened. There may be some superimposed pulmonary vascular congestion and
mild edema. There is no large effusion or pneumothorax.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with PICC// evaluate placement of PICC
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___
IMPRESSION:
Right PICC terminates in the right atrium, and could be retracted by 2-3 cm
for more ideal positioning. Otherwise no change. Lung volumes remain low.
Cardiomediastinal silhouette is unchanged. There is no gross consolidation.
There is no large effusion or pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old woman with thrombocytopenia and throbbing headache.
Please evaluate for intracranial bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.6 s, 19.6 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,021.9 mGy-cm.
Total DLP (Head) = 1,022 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a convex area of high attenuation overlying the left frontal lobe
with slight extension into the left parietal lobe measuring approximately 1.7
x 1.2 cm, consistent with a subdural hematoma. There is effacement of the
sulci and mass effect demonstrating left to right shift of the normally
midline structures of approximately 5 mm. There is significant edema but no
frank evidence of uncal herniation is noted.
There is an additional area high attenuation consistent with a subdural
hematoma in the left frontal lobe measuring approximately 5 x 2 mm.
An area of hemorrhage is also noted along the left tentorium.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. There is mild
opacification of the mastoid air cells bilateral. The visualized portion of
the orbits are unremarkable.
IMPRESSION:
1. Three areas of hemorrhage, with a subdural hematoma involving the left
frontoparietal lobe and measuring 1.7 x 1.2 cm, associated with sulci
effacement and significant edema without frank uncal herniation. 5 mm left to
right shift of normally midline structures.
2. Subdural hematoma in the left frontal lobe measuring 5 x 2 mm.
3. Hemorrhage along the left tentorium.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:16 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT of the abdomen and pelvis:
INDICATION: ___ year old woman with lymphoma, thrombocytopenia/anemia c/o
bleeding, eval for bleed, disease in abdomen/pelvis// ___ year old woman with
lymphoma, thrombocytopenia/anemia c/o bleeding, eval for bleed, disease in
abdomen/pelvis
TECHNIQUE: Multiplanar CT images of the abdomen pelvis are obtained after
administration of oral intravenous contrast material.
COMPARISON: No prior imaging studies were available for comparison.
FINDINGS:
Lung bases: Is included and show bilateral pleural effusion, greater on the
right than on the left. Minimal subsegmental atelectasis is also identified.
No suspicious pulmonary nodules are seen.
Abdomen: The liver and spleen are normal in size. No focal hepatic lesions
are present. The gallbladder, pancreas, both adrenals, and kidneys are
unremarkable. There is no evidence for hydronephrosis or nephrolithiasis.
There is no retroperitoneal mesenteric lymphadenopathy.
The there is normal caliber of the small and large bowel loops. No evidence
for focal abnormalities. No evidence for obstruction.
Pelvis: The urinary bladder is well distended and does not show any gross
abnormalities. The uterus and necks are normal in size for the age of the
patient. There is no pelvic lymphadenopathy.
Review of the images in bone window does not show any suspicious bony lesions.
IMPRESSION:
1. Small bilateral pleural effusions. 2. No lymphadenopathy in the abdomen
or pelvis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with ICH. Please eval for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.5 s, 21.5 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,120.5 mGy-cm.
Total DLP (Head) = 1,121 mGy-cm.
COMPARISON: CT study from ___.
FINDINGS:
Again noted is a left hemisphere subdural hematoma with isolated areas of high
attenuation involving the anterior left frontal lobe, laterally in the left
frontoparietal area, and the left tentorium. There is no evidence of a new
hemorrhage. Again noted is effacement of the sulci, largely unchanged when
compare to the study from the prior day. There is no worsening of the mass
effect, again with a mild left to right shift of the normally midline
structures noted.
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 mastoid cells. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Left hemisphere subdural hematoma without evidence of new hemorrhage.
2. Overall unchanged effacement of sulci without increase in mass effect.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with active cancer with c/f LUE clot// LUE
clot- please eval L arm
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: ___
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with leukemia and PNA, now recovered
clinically// baseline CXR for treatment for presumed latent TB baseline
CXR for treatment for presumed latent TB
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild cardiomegaly and vascular congestion of the mediastinum and right hilus
are chronic. Previous right upper lobe pneumonia has resolved. Lungs are
essentially clear. No appreciable pleural abnormality.
Right PIC line ends in the upper right atrium, as before.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with known ICH. Please evaluate for interval
change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
Total DLP (Head) = 856 mGy-cm.
COMPARISON: CT head from ___ and ___.
FINDINGS:
There is a evolution of the known left hemispheric subdural hematoma without
evidence of new hemorrhage. The overall size of the hematoma is unchanged.
There continues to be effacement of the left hemispheric sulci. There is a
slight improvement in the mass effect when compared to the most recent study
(___).
There is no evidence of infarction,new hemorrhage,or mass.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. Evolution of left hemispheric subdural hematoma without evidence of new
hemorrhage.
2. Slight improvement in mass effect when compared to the study from ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with known ICH. Please evaluate for interval
change// evaluate ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: Head CT ___
FINDINGS:
Left hemispheric mixed density subacute on chronic subdural hematoma,,
measuring 0.9 cm in maximum thickness, similar to prior. More prominent
mildly hyperdense component along the posterior margin of left parietal lobe.
Slightly increased high density components within collection, consistent with
interval hemorrhage. Small left tentorial subdural hematoma, similar compared
with ___. Minimal midline shift, stable. Mild-to-moderate
chronic small vessel ischemic changes. There is no evidence of
infarction,edema,or mass. The ventricles and sulci are normal in size and
configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
Mixed density subacute on chronic left hemispheric subdural hematoma, with
small volume of interval hemorrhage since ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Cough, Dyspnea on exertion, Fever, Transfer
Diagnosed with Pneumonia, unspecified organism, Non-Hodgkin lymphoma, unspecified, unspecified site, Dyspnea, unspecified
temperature: 98.3
heartrate: 94.0
resprate: 16.0
o2sat: 97.0
sbp: 122.0
dbp: 72.0
level of pain: 2
level of acuity: 2.0 | This is an ___ originally presenting with 3 weeks of back pain,
forgetfulness and hemoptysis found to have high grade B cell
lymphoma now s/p 1C of mini CHOP.
#High grade B cell lymphoma: with peripheral/bone marrow
involvement at diagnosis. initiated C1 mini CHOP per primary
attending recommendations (multiple comorbities/age limited use
of EPOCH)
CycloPHOSPHAMIDE 720 mg IV Day 1. (___)
(750 mg/m2 - dose reduced by 47% to 400 mg/m2)
Reason for dose reduction: mini-CHOP, elderly
DOXOrubicin 45 mg IV Day 1. (___)
(50 mg/m2 - dose reduced by 50% to 25 mg/m2)
Reason for dose reduction: mini-CHOP, elderly
VinCRIStine (Oncovin) 1 mg * IV Day 1. (___)
(1.4 mg/m2 [cap at 2 mg] - dose reduced by 50% to 1 mg)
Reason for dose reduction: mini-CHOP, elderly
PredniSONE 100 mg PO Q24H Duration: 5 Doses
Give on Days, 2, 3, 4 and 5.
Filgrastim-sndz 480 mcg SC DAILY until ___ recovery, plan to
d/c once ___ >1000, D/C ___ prior to discharge
- Transfuse for Hgb < 7 and plt < 50 fibrinogen < 150 in
setting
of SDH--less frequent due to count recovery
- give low dose Rituxan 100mg IV once only on ___ (high risk of
reaction due to circulating disease, age, comorbities) pre-med
appropriately and do not escalate per primary attending
recs--tolerated well
-plan for POC placement prior to next cycle of mini CHOP--need
to schedule outpatient
-will f/u in clinic every other day for possible plt transfusion
and will see Dr. ___ on ___
# Subdural Hematoma
Discovered on ___ ___omplained of headache.
Neurosurgery
as immediately consulted, who recommended rescanning the next AM
and ppx Keppra 500 mg BID. Will follow with interval scans.
- last repeated ___ and reviewed with Dr ___
25mg BID to prevent seizures and plt threshold >50K
- repeat NCHCT for any new neurologic symptoms
- Transfuse for plts < 50
- SBP < 160
- see neuro surg notes for further recommendations
# Sinus tachycardia - evaluated by cardiology--will f/u
outpatient as well
- tapered off short acting meto (patient has been responding to
IV diltiazem over meto )
- Change short acting diltiazem 30 mg q6h to 120mg daily long
acting starting ___, increased to 180mg in setting of low grade
tachycardia over weekend of ___
-monitor rate/symptoms, last EKG NSR ___
# Fever
# Multifocal PNA
resolution.
- Continue cefepime until count recovery (___), d/c
with ANC >900 on ___
# AMS: waxes/wanes
Differential diagnosis includes delirium, toxic metabolic
encepholopathy, dementia, EtOH withdrawal, leukostasis. Will
continue to monitor closely. Psychiatry has evaluated, suspect a
combination cultural factors, educational factors, baseline
argumentative personality, with overlying significant delirium.
-continues Seroquel @hs, rec while receiving steroids and could
consider peeling off when off, will continue for now while
inhouse for long period of time and re-introducing high dose
steroids every ___ weeks with chemo regimen.
# Unclear ___
Records from PCP office suggest pt was in good health with only
___ knee replacement and glaucoma surgery prior to this
hospitalization.
# EtOH use disorder
Son reports daily EtOH use, concerning for alcohol use disorder.
Unknown history of seizures. s/p CIWA protocol. Pt has not
required diazepam.
# Hep B core Ab positivity: Will continue lamivudine
# latent TB : +quant gold, to treat per ID. on INH/B6
# FEN: Gentle IVF/ Replete PRN/ Regular low-bacteria diet
# ACCESS: ___--line care outpatient due to frequent
transfusions
# PROPHYLAXIS:
-Bowel: senna, colace
-DVT: none indicated, thrombocytopenic
-viral: acyclovir
-fungal: fluc while neutropenic, d/c on discharge
-PCP: bactrim
# CODE: Presumed Full
# DISPO: home with 24hr supervision confirmed with son and
grand-daughter with multiple services in place--see case
management note |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male who presents with approximately one week
history of malaise, and abdominal pain. He describes the pain as
sharp, non-radiating and constant ___. Located periumblical and
epigastric area mainly. Started about one week ago and is not
associated with food or drinking. Not associated with long
periods of fasting either. No nausea/vomiting. He has had no
previous episodes of this. He has a hx of a perforated gastric
ulcer and underwent a subtotal gastrectomy in ___ complicated
by peritonitis and CVA with right hemiparesis. He has had
chronic diarrhea since the surgery with no recent change in
bowel habits. Does not know if he has been given NSAIDs at ___
___ where he resides.
In the ED, initial vital signs were: T98.3 102 179/91 16 97% RA
- Exam notable for: TTP over epigastric region
- EKG-SR 85 LAD/NI, no prior
- Labs were notable for: WBC 13 (83%N), Hb 10.4, plt 396, BUN/Cr
___
- bl cx sent
- CTA abd with extensive inflammatory changes and complex fluid
in the right upper quadrant just lateral to the proximal
duodenum is most consistent with a severe duodenitis. A small
underlying rupture cannot be completely excluded, though there
is no free air or evidence of extravasated oral contrast.
- Patient was given: 1L NS, Cipro/flagyl
- The patient has been able to tolerate po without issue, no
diarrhea, no lactate, no peritoneal signs. No free air.
- On Transfer Vitals were: 98.2 98 134/83 16 96% RA
On the floor, he is comfortable. He states he felt better after
he received antibiotucs in the ED.
Vital were: 97.6 160/80 ___ RR20 99%ra wt 74.7kg
Past Medical History:
HTN
Perforated gastric ulcer s/p subtotal ___
CVA with residual right-sided weakness -___
Hypothyroidism
Social History:
___
Family History:
Brother with diabetes
Physical Exam:
Admissions Physical:
=============
Vitals: 97.6 160/80 ___ RR20 99%ra wt 74.7kg
GENERAL: Alert and oriented x 3. NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical:
============
Pertinent Results:
Admissions Labs:
===========
___ 12:20PM BLOOD WBC-13.0* RBC-3.66* Hgb-10.4* Hct-31.6*
MCV-86 MCH-28.3 MCHC-32.8 RDW-15.1 Plt ___
___ 12:20PM BLOOD Neuts-83.0* Lymphs-12.7* Monos-3.9
Eos-0.2 Baso-0.1
___ 12:20PM BLOOD Glucose-116* UreaN-19 Creat-1.3* Na-142
K-3.8 Cl-99 HCO3-28 AnGap-19
___ 12:20PM BLOOD ALT-14 AST-15 AlkPhos-143* TotBili-0.2
___ 12:20PM BLOOD Albumin-3.8 Calcium-9.5 Phos-2.5* Mg-2.0
Discharge Labs:
==========
Pertinent Imaging:
===========
- CT abd:
1. Extensive inflammatory changes and complex fluid in the right
upper
quadrant just lateral to the proximal duodenum, with areas
appearing confluent
with the duodenal wall, is most consistent with severe
duodenitis. No free
air or extraluminal oral contrast to suggest frank perforation.
No organized
fluid collections are present. Etiologies for these findings
include infected
ulcer, a postoperative injury, or an inflammatory neoplasm.
Correlate with
surgical history. Endoscopy is recommended following resolution
of acute
condition as underlying mass cannot be excluded.
2. The gallbladder lies adjacent to this process, but appears
intact and
non-distended, and is not felt to be the source.
3. Nonspecific mild bile duct prominence which may be
age-related.
4. Colonic diverticulosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 12.5 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Levothyroxine Sodium 12.5 mcg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Gabapentin 100 mg PO BID
8. Acetaminophen 650 mg PO TID
9. Calcium Carbonate 1000 mg PO QHS:PRN dyspepsia
10. Mirtazapine 15 mg PO QHS
11. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
12. Hydrocortisone Cream 1% 1 Appl TP BID:PRN inflammation
13. Guaifenesin 10 mL PO Q6H:PRN cough
14. Fleet Enema ___AILY:PRN constipation not relieved
by dulcolax
15. Milk of Magnesia 30 mL PO Q6H:PRN dyspepsia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 1000 mg PO QHS:PRN dyspepsia
3. Gabapentin 100 mg PO BID
4. Guaifenesin 10 mL PO Q6H:PRN cough
5. Levothyroxine Sodium 12.5 mcg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. Milk of Magnesia 30 mL PO Q6H:PRN dyspepsia
8. Mirtazapine 15 mg PO QHS
9. Vitamin D ___ UNIT PO DAILY
10. Acetaminophen 650 mg PO TID
11. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
12. Fleet Enema ___AILY:PRN constipation not relieved
by dulcolax
13. Furosemide 20 mg PO DAILY
14. Hydrocortisone Cream 1% 1 Appl TP BID:PRN inflammation
15. Omeprazole 20 mg PO BID
16. Sucralfate 1 gm PO QID Duration: 14 Days
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*52 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Duodenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Epigastric pain. Per the ED dashboard, the patient has a history
of a perforated pyloric ulcer, status post subtotal gastrectomy in ___. This was complicated by peritonitis and abscess formation. Evaluate for
obstruction or internal hernia.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: DLP: 734.47 mGy-cm.
IV Contrast: 130 mL Omnipaque.
COMPARISON: None.
FINDINGS:
LOWER CHEST:
There is minimal scarring at the right base. The bases of the lungs are
otherwise clear without a nodule, consolidation, or pleural effusion. The base
of the heart is normal in size. There is no pericardial effusion. Incidentally
noted is a tiny left Bochdalek hernia (2, 18).
ABDOMEN:
The liver is normal in shape and contour. There are no focal hepatic lesions.
The portal veins are patent. There is minimal and intrahepatic biliary duct
dilation in the left lobe of the liver. The common bile duct is dilated to 14
mm (601b, 25). It gradually tapers down into the head of the pancreas. There
is no evidence of a filling defect or mass.
The patient is status post a subtotal gastrectomy. An anastomosis is noted in
the left anterior abdomen (2, 22). There is no stranding or free fluid near
the anastomosis.
Anterior to the gallbladder and just lateral to the proximal duodenum is a
focus of ill-defined soft tissue stranding and inflammation which measures
approximately 5.9 x 2.7 x 5.1 cm (601B, 16 and 2, 28). The inflammation
extends superiorly along the anterior abdominal wall and is present anterior
to the liver (2, 17). There is no evidence of inflammation or abscess
formation within the hepatic parenchyma. Along the most inferior aspect of
this stranding is slightly-organized complex fluid (2, 30). No walled-off
discrete collection is present. This inflammatory process appears to be
contiguous with the lateral wall of the proximal duodenum (602b, 36), and in
some areas the wall appears indistinct. The findings are concerning for
severe duodenitis. There is no free air or extravasated oral contrast. While
this abnormality is intimately associated with the collapsed gallbladder, the
gallbladder wall itself appears intact series ___, image 31 through 34).
Additionally, the posterior aspect of the gallbladder wall is normal without
stranding. No gallstones are identified.
The distal duodenum and remainder of the small bowel are normal in course and
caliber. There is no evidence of obstruction or focal inflammatory changes.
The abdominal vasculature is normal in caliber with mild atherosclerotic
calcifications. There is no periportal, retroperitoneal, or mesenteric
lymphadenopathy.
The spleen and pancreas are normal. There is no evidence of pancreatic mass or
pancreatic duct dilation. The bilateral adrenal glands and kidneys are normal.
There are no renal lesions, hydronephrosis, or pyelonephritis. The kidneys
enhance and excrete contrast symmetrically.
PELVIS:
There is diverticulosis of the sigmoid colon without evidence of
diverticulitis. The remainder of the large bowel is normal. While the right
side of the transverse colon sits immediately inferior to the abnormal
inflammation in the right upper quadrant, the wall of the transverse colon
appears grossly normal without secondary inflammatory changes. No diverticuli
are noted in the transverse colon. The appendix is normal. The bladder is
distended, though within normal limits. The prostate is normal in size with
several coarse calcifications centrally. There is no pelvic or inguinal
lymphadenopathy.
OSSEOUS STRUCTURES AND SOFT TISSUES:
There are no concerning lytic or sclerotic osseous lesions. A focal 7 mm
lucency in L2 (602b, 43) has no aggressive features, and may be connected to
the underline endplate, thus representing a Schmorl's node. No acute fracture
is identified. Mild anterolisthesis of L4 on L5 is noted. Straightening of the
normal lumbar lordosis is likely positional. Moderate degenerative changes are
noted in the thoracic spine.
IMPRESSION:
1. Extensive inflammatory changes and complex fluid in the right upper
quadrant just lateral to the proximal duodenum, with areas appearing confluent
with the duodenal wall, is most consistent with severe duodenitis. No free
air or extraluminal oral contrast to suggest frank perforation. No organized
fluid collections are present. Etiologies for these findings include infected
ulcer, a postoperative injury, or an inflammatory neoplasm. Correlate with
surgical history. Endoscopy is recommended following resolution of acute
condition as underlying mass cannot be excluded.
2. The gallbladder lies adjacent to this process, but appears intact and
non-distended, and is not felt to be the source.
3. Nonspecific mild bile duct prominence which may be age-related.
4. Colonic diverticulosis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Epigastric pain
Diagnosed with ABDOMINAL PAIN EPIGASTRIC
temperature: 98.3
heartrate: 102.0
resprate: 16.0
o2sat: 97.0
sbp: 179.0
dbp: 91.0
level of pain: 5
level of acuity: 3.0 | ___ y/o gentleman with PMH of HTN and gastric ulcer presenting
with abdominal pain found to have duodenitis.
#Abdominal pain/duodenitis: The patient presented to the
hospital with abdominal pain, malaise, nausea, and vomiting for
one week. CT Abdomen/Pelvis in the ED shows finding consistent
with severe duodenitis. No obvious free air but small underlying
rupture cannot be excluded; reassured by no evidence of perf on
imaging though. Given the acute inflammation, there was no role
for endoscopy on this admission. The patient was initially
started on IV cipro/flagyl, IV pantoprazole, and was made NPO.
His pain significantly improved overnight. According to the
___ stewardship team, there is no definitive role
for antibiotics in the treatment of duodenitis and thus his
antibiotics were discontinued on his second hospital day (___)
without clinical deterioration. His abdominal exam remained
benign without evidence of peritonitis. The patient's diet was
advanced without issue. He did have some mild abdominal pain on
his ___ hospital day for which he was started on sucralfate with
good response (total course 14 days ending ___. He was
discharged home with resumption of home services. The patient
should have an endoscopy after resolution of acute inflammation
(> approximately 6 weeks).
#HTN: Stable while admitted. Home metoprolol was continued.
#Hypothyroidism: Stable while admitted. Home levothyroxine was
continued.
Transitional Issues:
- DNR, ok to intubate
- The patient should have an upper endoscopy in > 6 weeks or
when acute inflammation resolves
- The patient should follow up with his PCP upon discharge
- Stool h. pylori and h. pylori antibody test pending at
discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
dobutamine
Attending: ___.
Chief Complaint:
Hypotension, Pre-syncope
Major Surgical or Invasive Procedure:
___ - Implant of Heartmate III LVAD, removal of Right
axillary impella 5.0.
___ - Re-exploration of Right axillary incision,
evacuation of small hematoma, repositioning of Impella.
___ - Right axillary cutdown, Impella 5.0 placement.
History of Present Illness:
Mr. ___ is a ___ year-old-man with past medical history of
stage D HFrEF on dobutmaine s/p elective single chamber ICD
placement ___, coronary artery disease status post stent to
RCA, OSA and T2DM who was admitted after episode of dizziness
and hypotension.
He was seen in cardiology clinic for routine follow-up after his
ospitalization at ___ ___ for hypotension during
this admission he was mildly hypovolemic but ultimately was
started on dobutatmine 5mcg/kg/hr. He had previously undergone
elective single lead ICD placement for primary prevention during
a ___ his prior admission before then was for PCI to
his RCA in ___. His appointment was uneventful and he
continued his day, looking for an apartment in ___ with
his family.
Very shortly after lunch, when he was getting out of the car he
felt profoundly dizzy. No loss of consciousness, no fall or
headstrike. This eventually resolved with rest however they
decided to go to his parents home. There they checked his blood
pressure which was 80/60, a neighbor who is a nurse checked ___
manual BP and found to be 60/palp. An ambulance was called and
he went to ___ where he received 500cc fluid and was
transferred to ___. He notes no chest pain, no increased
dyspnea, he has been taking torsemide 30mg daily with good urine
output and in fact weight is done 109 kg to 106 kg. He cannot
recall any palpitations. He has not had any problem with his ICD
or any shocks since implantation.
Past Medical History:
Asthma
Atrial Fibrillation
Congestive Heart Failure, chronic systolic
Coronary Artery Disease
Diabetes Mellitus Type II
Diverticulosis
Gastroesophageal Reflux Disease
Obstructive Sleep Apnea on BiPAP
Small Bowel Obstruction with diverting ostomy
Surgical History:
Divertying ostomy due to small bowel obstruction
Social History:
___
Family History:
___ positive for CAD. Cousin with recent stent. Niece with PE on
coumadin. No known family history of bleeding diathesis or
coagulopathy.
Physical Exam:
ADMISSION PHYSICAL EXAM
===============================
VS: ___ 2328 Temp: 98.7 PO BP: 100/62 HR: 109 RR: 20 O2
sat:
97% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ weight:
106kg (last discharge weight: 239 lbs)
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD, JVP ___ no hepatojugular reflux
CV: RRR, S1/S2, II/VI systolic murmurs at RLSB. No gallops, or
rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema, +axillary sweat,
capillary refill <2 seconds, no skin tenting
PULSES: 2+ radial and DP pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
ACCESS: Right arm, non-heparin dependent PICC site c/d/i
DISCHARGE PHYSICAL EXAM
===============================
___ ___ 97.9 Intermediate Care: Doppler Pressure: 78 CVP:
speed: 5600, flow: 5.2, PI: 3.7, power: 4.6 Dyspnea: 0 RASS: 0
Pain Score: ___
General: sitting in bed. appears comfortable, no apparent
distress
CV: HM3 hum, S1
NECK: JVP 12cm +HJR
PULM: Lungs CTA
CHEST: dressing is clean/dry/intact with no surrounding
erythema,
tenderness to palpation, drainage, swelling
BACK: dressing is clean/dry/intact with no surrounding erythema,
tenderness to palpation, drainage, swelling
ABD: soft, nontender, nondistended
EXT: legs are warm, arms are warm, no pitting edema
Pertinent Results:
ADMISSION LABS
=================================
___ 07:35PM BLOOD WBC-11.2* RBC-4.43* Hgb-13.0* Hct-37.7*
MCV-85 MCH-29.3 MCHC-34.5 RDW-15.6* RDWSD-48.0* Plt ___
___ 07:35PM BLOOD Neuts-55.8 ___ Monos-8.7 Eos-9.1*
Baso-0.6 Im ___ AbsNeut-6.21* AbsLymp-2.83 AbsMono-0.97*
AbsEos-1.02* AbsBaso-0.07
___ 07:35PM BLOOD Plt ___
___ 07:35PM BLOOD Glucose-125* UreaN-17 Creat-0.9 Na-137
K-3.9 Cl-98 HCO3-20* AnGap-19*
___ 03:41AM BLOOD ALT-20 AST-20 CK(CPK)-76 AlkPhos-90
TotBili-0.6
___ 07:35PM BLOOD proBNP-425*
___ 07:35PM BLOOD Calcium-8.9 Phos-4.1 Mg-1.5*
___ 07:53AM BLOOD Hgb-11.6* calcHCT-35 O2 Sat-54
___ 07:39PM BLOOD Lactate-1.6
RELEVANT IMAGING
=================================
CXR ___
Heart is moderately enlarged. Left chest wall single lead
pacing device is again noted. The lungs are clear without
consolidation, effusion or edema. Right PICC is seen with tip
in the lower SVC, better demonstrated on the lateral view. No
acute osseous abnormalities.
RHC ___. No oxymetric evidence of significant left-to-right shunting.
2. Depressed cardiac index despite dobutamine.
3. Right ventricular diastolic heart failure.
4. Markedly elevated mean PCW consistent with severe left
ventricular diastolic heart failure.
5. Severe pulmonary hypertension.
CXR ___
The patient now carries an intra-aortic balloon pump, an
external pacemaker and the Swan-Ganz catheter. All devices are
in correct position. The tip of the intra-aortic balloon pump
is 1 mm be low the upper most part of the aortic arch. Low lung
volumes. Moderate cardiomegaly without pulmonary edema. No
pleural effusions. No pneumothorax.
TTE ___
Suboptimal image quality. Well seated HeartMate III LVAD cannula
in the apical left ventricle with mild mitral regurgitation and
opening of the aortic valve on every beat. Moderately dilated
and hypokinetic left ventricle. Normal right ventricular size
with moderately decreased function. Moderate tricuspid
regurgitation.
CTA Chest ___: Filling defects consistent with
thrombi/emboli seen in the right subclavian
and in the right internal jugular vein.
LVAD in appropriate positioning.
Large left pleural effusion, not hemorrhagic, causing
compressive atelectasis
in the left lower lobe and lingula and mild pulmonary edema in
the left upper
lobe.
___ ECHO:
The left ventricle has a moderately increased/dilated cavity.
Overall left ventricular systolic function is severely
depressed. Mildly dilated right ventricular cavity with mild
global free wall hypokinesis.
IMPRESSION:
RAMP ECHO:
5600 rpm: LVEDD 6.2 cm, septum midline, AoV opening every beat,
mild MR, RV 4.6cm, trace AR, ___ TR
5700 rpm: LVEDD 6.6cm, septum midline, mild MR, trace AR, AoV
partially opening q1-2 beats, RV 4.8 cm, PASP 28
5800 rpm: LVEDD 6.2 cm, septum midline to slightly towards L,
AoV opens partially q1-2 beats, mild MR, trace AR, ___ TR, RV
4.9cm, pASP 29
Given increased RV size and worsening TR with increased speed,
final speed was set at original speed of 5700rpm (despite AoV
opening every beat).
FINDINGS:
LEFT VENTRICLE (LV): Moderate cavity dilation. SEVERELY
depressed ejection fraction.
RIGHT VENTRICLE (RV): Mild cavity enlargement. Mild global free
wall hypokinesis.
CT Chest ___:
Status post left-sided chest tube placement.
Decrease in volume of the left pleural effusion which is now
small volume and
partially loculated.
Trace right pleural effusion is unchanged.
No interval change in the cardiomegaly and small mediastinal
lymph nodes. An
LVAD and left-sided pacemaker are unchanged.
Lack of intravenous contrast limits evaluation. No pneumothorax
RELEVANT MICRO
=================================
___ BLOOD CULTURE
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPHYLOCOCCUS HOMINIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 2 S
___ BLOOD CULTURE
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 2 S
RELEVANT LABS
=================================
___ 12:25PM BLOOD calTIBC-229* Ferritn-860* TRF-176*
___ 04:04AM BLOOD %HbA1c-8.5* eAG-197*
___ 02:05AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
___ 02:05AM BLOOD HIV Ab-NEG
___ 02:05AM BLOOD HCV Ab-NEG
___ 06:25AM BLOOD WBC-8.6 RBC-2.77* Hgb-7.6* Hct-23.6*
MCV-85 MCH-27.4 MCHC-32.2 RDW-17.8* RDWSD-55.4* Plt ___
___ 12:23PM BLOOD ___ PTT-31.4 ___
___ 06:25AM BLOOD Glucose-136* UreaN-18 Creat-0.7 Na-136
K-3.8 Cl-93* HCO3-32 AnGap-11
___ 12:23PM BLOOD LD(LDH)-629*
___ 06:25AM BLOOD ALT-20 AST-34 LD(LDH)-606* AlkPhos-99
TotBili-0.7
___ 06:25AM BLOOD Albumin-3.1* Calcium-8.2* Phos-3.9 Mg-1.7
___ 12:23PM BLOOD CRP-66.6*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Losartan Potassium 125 mg PO DAILY
6. Magnesium Oxide 400 mg PO DAILY
7. Sertraline 100 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9. Torsemide 30 mg PO DAILY
10. TraZODone 100 mg PO QHS:PRN insomnia
11. DOBUTamine 5 mcg/kg/min IV DRIP INFUSION
12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
13. Multivitamins W/minerals 1 TAB PO DAILY
14. glimepiride 4 mg oral BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth three times a day Disp #*180 Tablet
Refills:*0
2. Captopril 25 mg PO TID
RX *captopril 25 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
3. Digoxin 0.25 mg PO DAILY
RX *digoxin 250 mcg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
6. Glargine 12 Units Breakfast
Glargine 14 Units Bedtime
Humalog 19 Units Breakfast
Humalog 16 Units Lunch
Humalog 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 12 Units before BKFT; 14 Units before BED; Disp
#*10 Syringe Refills:*1
RX *insulin lispro [Humalog KwikPen Insulin] 200 unit/mL (3 mL)
AS DIR 19U with breakfast, 16U with lunch, 14U with dinner Disp
#*10 Syringe Refills:*1
RX *insulin syringe-needle U-100 31 gauge X ___ Please use with
pens for insulin administration Disp #*5 Package Refills:*2
7. Ipratropium Bromide MDI 2 PUFF IH QID:PRN SOB
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 puffs
IH four times a day Disp #*1 Inhaler Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % Please apply one patch once daily
Disp #*30 Patch Refills:*0
9. LORazepam 0.5 mg PO Q8H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) mg by mouth every
eight (8) hours Disp #*15 Tablet Refills:*0
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
11. OxyCODONE SR (OxyconTIN) 10 mg PO DAILY
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
12. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
13. Senna 8.6-17.2 mg PO QHS:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
14. Sildenafil 20 mg PO TID
RX *sildenafil (antihypertensive) 20 mg 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
15. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
16. 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
17. Torsemide 20 mg PO DAILY
Total daily dose should be 120mg once daily.
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
18. Warfarin 8 mg PO DAILY16
RX *warfarin 4 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
19. Aspirin 162 mg PO DAILY
RX *aspirin 81 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
20. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
21. Torsemide 120 mg PO DAILY
RX *torsemide 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
22. TraZODone 50 mg PO QHS:PRN Insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
23. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puff IH twice
a day Disp #*1 Inhaler Refills:*0
24. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
25. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
26. Sertraline 100 mg PO DAILY
RX *sertraline 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Congestive Heart Failure, chronic systolic
Coronary Artery Disease
Anemia
Blood stream infection
Leukocytosis
Epistaxis
Hyponatremia
Delirium
Secondary Diagnosis:
Asthma
Atrial Fibrillation
Diabetes Mellitus Type II
Diverticulosis
Gastroesophageal Reflux Disease
Obstructive Sleep Apnea on BiPAP
Small Bowel Obstruction with diverting ostomy
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema
Followup Instructions:
___
Radiology Report
INDICATION: ___ with hx of HFrEF 25% presents with dyspnea and
hypotension// SOB r/o pulm edema
TECHNIQUE: Frontal and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Heart is moderately enlarged. Left chest wall single lead pacing device is
again noted. The lungs are clear without consolidation, effusion or edema.
Right PICC is seen with tip in the lower SVC, better demonstrated on the
lateral view. No acute osseous abnormalities.
IMPRESSION:
Cardiomegaly without superimposed acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with cardiogenic shock s/p balloon pump, now with fever//
pneumonia/ pulm edema? pneumonia/ pulm edema?
IMPRESSION:
Comparison to ___. The patient now carries an intra-aortic balloon
pump, an external pacemaker and the Swan-Ganz catheter. All devices are in
correct position. The tip of the intra-aortic balloon pump is 1 mm be low the
upper most part of the aortic arch. Low lung volumes. Moderate cardiomegaly
without pulmonary edema. No pleural effusions. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p aortic balloon pump// interval change? interval
change?
IMPRESSION:
Comparison to ___. No relevant change is noted. The position of
the intra-aortic balloon pump is stable, with the tip of the pump projecting
over the aortic knob. The position of the pacemaker lead and of the Swan-Ganz
catheter as well as of the right PICC line are stable. Mild pulmonary edema
is present. No pleural effusions. No pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HFrEF, IABP in place// evaluate for IABP
placement evaluate for IABP placement
IMPRESSION:
Comparison to ___. All monitoring and support devices are in
stable position. In particular, the intra-aortic balloon pump is unchanged.
The tip continues to project over the aortic knob. Stable position of the
Swan-Ganz catheter and of the pacemaker leads. Moderate cardiomegaly persists
in unchanged manner. No pulmonary edema. No pneumothorax. No pleural
effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HFrEF, IABP in place// evaluate for IABP
placement evaluate for IABP placement
IMPRESSION:
Comparison to ___. The tip of the intra-aortic balloon pump
continues to project over the aortic knob. Moderate cardiomegaly persists.
No pulmonary edema.
Radiology Report
INDICATION: ___ s/p intra-aortic balloon pump// balloon pump position
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Lungs are low volume with mild interstitial edema. Moderate cardiomegaly is
again seen. Left-sided pacemaker is also unchanged. Intra-aortic balloon
pump remains in place. No pneumothorax is seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IABP// IABP placement IABP placement
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild cardiomegaly has improved, interstitial edema has resolved. Lungs are
clear and there is no pleural effusion.
Intra-aortic balloon pump in standard placement. Transvenous right
ventricular pacer defibrillator lead tip projects over the right ventricular
apex.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ s/p intubation// ETT placement
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
New ETT, 5.5 cm distant from the carina.
New LVAD device, overlying the left ventricle.
Single lead ICD projects over the right ventricle.
Swan-Ganz tip ends in right main pulmonary artery.
Moderate cardiomegaly, stable.
Lung volumes are lower and right hilum is more prominent now, likely due to
positioning changes.
No pleural effusions.
IMPRESSION:
New ET tube and LVAD since ___, both appropriately placed. No evidence
of complications.
Unchanged appearance of remaining cardiopulmonary support devices.
No significant interval change of lung and cardiac appearances.
Radiology Report
EXAMINATION: CHEST RADIOGRAPH
INDICATION: ___ w/ CHF s/p impella placement// interval change
TECHNIQUE: Portable AP chest
COMPARISON: Multiple prior chest radiographs, most recent from ___
at 13:34.
FINDINGS:
Endotracheal tube tip terminates approximately 7 cm above the carina. There
has been interval removal of an intra-aortic balloon pump. The remaining
cardiopulmonary support devices are in unchanged position.
Lung volumes remain low, exaggerating the cardiomediastinal silhouettes. No
new focal consolidations or pleural abnormality. Mild pulmonary vascular
congestion persists.
IMPRESSION:
1. Endotracheal tube tip terminates approximately 7 cm above the carina, for
which advancement of 2 cm may be considered.
2. Low lung volumes and persistent mild pulmonary vascular congestion.
3. No new focal consolidations or pleural abnormality.
Radiology Report
INDICATION: ___ s/p Impella// interval change?
COMPARISON: Radiographs from ___
IMPRESSION:
Tip of the Swan-Ganz pattern has been pulled back approximately 3 cm and now
projects over the midline of the spine. Endotracheal tube has been removed.
There is a persistent left-sided pacemaker. There is mild prominence of the
left heart. There is no focal consolidation, pulmonary edema, or large
pleural effusions. There are no pneumothoraces
Radiology Report
EXAMINATION: BILAT UP EXT VEINS US
INDICATION: ___ s/p TEE with incidentally discovered possible clot of IJ//
DVT?- BILATERAL INTERNAL JUGULAR VEIN assessment please
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: None.
FINDINGS:
The examination is technically limited by decreased penetration as a result of
bandages over the areas of concern. Within the limitation of the study, there
is normal flow with respiratory variation in the bilateral subclavian veins.
There is peripheral, nonocclusive, hyperechoic material along the right
internal jugular vein consistent with a subacute or chronic thrombus. There
is a line within the left internal jugular without definite evidence of
thrombus. The left internal jugular and bilateral axillary veins are patent,
show normal color flow and compressibility.
The bilateral brachial, basilic, and cephalic veins are patent, compressible
and show normal color flow and augmentation.
IMPRESSION:
The study is technically limited as discussed above. There is a peripheral
nonocclusive thrombus within the right internal jugular vein that is likely
subacute or chronic.
Otherwise, there is no evidence of deep vein thrombosis in the other deep
veins of the bilateral upper extremities.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:19 pm, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old man with impella// impella placement
COMPARISON: Radiographs from ___
IMPRESSION:
Support lines and tubes are unchanged in position. Cardiomediastinal
silhouette is within normal limits. There are no focal consolidations,
pleural effusion, or pulmonary edema. There are no pneumothoraces.
Radiology Report
INDICATION: ___ s/p intubation in OR// ETT and OG tube placement
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette
is stable. Left-sided pacemaker is unchanged. And Impella device is in
place. No pneumothorax is seen
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with impella placement// evaluate for placement
of impella evaluate for placement of impella
IMPRESSION:
Impella devise is in place. Swan-Ganz catheter is in place. Pacemaker
defibrillator lead is in place. Overall the position of the devices is
stable.
NG tube has been discontinued.
There is interval improvement in pulmonary edema with no vascular congestion
or pulmonary edema currently seen. No appreciable pleural effusion. No
pneumothorax.
Radiology Report
EXAMINATION: CHEST U.S.
INDICATION: ___ year old man with impella in place, expanding chest wall
hematoma.// evaluate for size of hematoma
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right chest wall overlying Impella implant.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right chest wall demonstrate a 4.9 x 3.4 x 2.5 cm hypoechoic collection,
approximately 1.4 cm from the skin surface. No internal vascular flow is
seen..
IMPRESSION:
4.9 x 3.4 x 2.5 cm collection in the subcutaneous tissue of the right chest
wall overlying Impella. No internal vascular flow seen. Differential
diagnosis includes hematoma, seroma, superinfection is not excluded.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p impella placement// interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged. Continued enlargement of the cardiac silhouette without
appreciable vascular congestion, pleural effusion, or acute focal pneumonia.
Radiology Report
INDICATION: ___ s/p Impella// interval change
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
The left-sided pacemaker and the heart meet devices are unchanged in position.
The Swan-Ganz catheter is also unchanged. Lungs continue to be low volume.
Moderate cardiomegaly is unchanged. There is no pleural effusion. No
pneumothorax is seen
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p impella placement// interval change? interval
change?
IMPRESSION:
Swan-Ganz catheter tip is at the level of the right ventricular outflow tract.
Impella devise and pacemaker leads are in unchanged position. Cardiomegaly is
unchanged. There is no pulmonary edema. There is no appreciable pleural
effusion or pneumothorax.
Radiology Report
INDICATION: ___ year old man with HFrEF, impella in place// evaluate for
placement of swan, impella
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Support lines and tubes are unchanged. Left-sided pacemaker is stable. There
is moderate cardiomegaly. There is mild interstitial edema. There are no
pleural effusions. No pneumothorax is seen
Radiology Report
INDICATION: ___ year old man with HFrEF s/p impella placement.// Impella
placement
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Lungs are low volume with mild interstitial prominence. Moderate cardiomegaly
is unchanged. Left-sided pacemaker and ventricular assist device are in
place. There are no pleural effusions. No pneumothorax is seen
cardiomediastinal silhouette is stable
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p Impella placement// impella positioning impella
positioning
IMPRESSION:
Comparison to ___. No relevant change is noted. Stable position
of the ventricular assist device and of the pacemaker. Moderate cardiomegaly
persists. No pulmonary edema. No pleural effusions. No pneumonia.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old man with HFrEF with impella in place with previous
non occlusive clot visualized in right IJ, repeat exam needed prior to swan
placement// SPECIFICALLY TO EVALUTE for evidence of right IJ clot seen on
previous US on ___
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: Upper extremity venous ultrasound ___
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The right internal jugular vein contains a small amount of nonocclusive
thrombus, decreased in size to previous ultrasound. The right subclavian vein
is patent with no evidence thrombus.
IMPRESSION:
A small amount of nonocclusive deep vein thrombus is re-demonstrated within
the right internal jugular vein, and is decreased compared to prior
ultrasound.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ PMHx HFrEF (EF 25%) on home dobutamine s/p ICD placement
(___), mixed ischemic/ non-ischemic CMP, CAD s/p DES x2 to RCA (___),
OSA, and T2DM who was initially admitted to ___ after episode of dizziness
and hypotension, later discovered to have hypereosinophila ___ dobutamine.
Initial plan was for nitroprusside challenge in CCU to assess for reversible
pulmonary vascular resistance, though by ___ AM was decompensating and so
urgently went to cath lab for balloon pump placement. Transferred to CCU for
further monitoring, ideally with plan for LVAD next week as bridge to
transplant.Interval change in pulmonary congestion
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate to severe cardiomegaly is stable. Right trans subclavian Impella
device unchanged in position, extending to the floor of the left ventricle.
Transvenous right ventricular pacer defibrillator lead also stable. Pulmonary
vasculature is mildly engorged, but there is no frank pulmonary edema. No
pneumothorax or pleural effusion.
Radiology Report
INDICATION: ___ year old man with impella// evaluate impella
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Left-sided pacemaker is unchanged. Left IJ sheath has been removed.
Cardiomediastinal silhouette is stable. A right sided Impella device is seen
projected over the heart. Lungs are low volume with mild pulmonary vascular
congestion. There is no pleural effusion. No pneumothorax is seen
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man s/p LVAD placement. Please ___ at
___ with abnormalities.// FAST TRACK EXTUBATION CARDIAC SURGERY, ?line
placement, r/o PTX/Effusion Contact name: ___: ___
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recently ordered today.
FINDINGS:
Status post midline sternotomy with intact wires for LVAD placement with
expected mild mediastinal bleeding and small pneumomediastinum.
ET tube appropriately placed, 4 cm distant from the carina.
Esophageal feeding tube ends well into the stomach.
New Swan-Ganz catheter with tip overlying main pulmonary artery.
Unchanged position of the left ICD with intact lead overlying right ventricle.
Low lung volumes bilaterally with no significant pleural effusions or
pneumothorax.
Heart size is top normal.
IMPRESSION:
Stable postoperative appearance with expected mild mediastinal bleeding and a
small pneumomediastinum.
Newly placed monitoring devices.
Lung volumes are low but otherwise clear.
Radiology Report
INDICATION: ___ year old man with s/p lvad// hypoxia
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Support lines and tubes including left-sided pacemaker and ventricular assist
device are unchanged. There is new parenchymal opacity in the right upper
lobe which could represent edema or pneumonia. Cardiomediastinal silhouette
is stable. There are small bilateral effusions left greater than right. No
pneumothorax is seen
Radiology Report
INDICATION: ___ year old man s/p VAD with bronch// eval for collapse
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The supporting lines and tubes are unchanged. Retrocardiac opacities are
similar to prior and likely reflect atelectasis. The right lung is clear with
interval re-expansion of the right upper lobe. There is no pneumothorax. No
right pleural effusion. The size of the cardiac silhouette is unchanged.
Unchanged pneumomediastinum.
IMPRESSION:
Increased aeration of the right upper lobe. Otherwise no significant interval
change since prior
Radiology Report
INDICATION: ___ year old man with s/p vad// s/p vad with rul collapse s/p
bronch ___
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Support lines and tubes unchanged. Cardiomediastinal silhouette is stable.
There is no pleural effusion. No pneumothorax is seen. Pulmonary edema is
stable.
Radiology Report
INDICATION: ___ year old man with hypoxia// ___ year old man with hypoxia
TECHNIQUE: AP portable chest radiograph
COMPARISON: Multiple prior radiographs most recently dated ___
IMPRESSION:
The tip of a right transjugular Swan-Ganz catheter projects over the right
pulmonary artery. The endotracheal and gastric tubes have been removed. A
left chest tube and mediastinal drain are noted. Skin staples project over the
right axilla.
Retrocardiac opacities likely reflect atelectasis and small volume pleural
fluid. There is mild pulmonary edema. No pneumothorax or right
consolidation. The size of the cardiac silhouette is enlarged but unchanged.
Radiology Report
INDICATION: ___ year old man with LVAD// follow up effusion/edema
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Cardiomediastinal silhouette is stable. Pulmonary edema has worsened.
Left-sided pacemaker and ventricular assist device are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p LVAD// eval infiltrate/ LVAD lines
IMPRESSION:
In comparison with the study of ___, there are slightly improved lung
volumes. Cardiac silhouette remains substantially enlarged, though there is
minimal if any vascular congestion. Retrocardiac opacification is consistent
with volume loss in the left lower lobe and pleural fluid.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p LVAD// eval LVAD
IMPRESSION:
In comparison with the study of ___, there is further improvement in
lung volumes. Monitoring and support devices are essentially unchanged. The
any vascular congestion is minimal. Retrocardiac opacification is again
consistent with volume loss in left lower lobe and probable small pleural
effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p LVAD-epicardial wires/ CTs DCd// eval
for hemothorax/ PTX-post pull
IMPRESSION:
In comparison with the study of earlier in this date, the chest tubes have
been removed and there is no evidence of pneumothorax. A lower lung volumes
with stable enlargement of the cardiac silhouette. Increasing opacification
is seen in the left hemithorax. Some of this could represent asymmetric
pulmonary edema with pleural fluid and basilar atelectasis. However, in the
appropriate clinical setting the, superimposed aspiration/pneumonia would have
to be considered.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p LVAD// eval for pleural effusions
IMPRESSION:
In comparison with the study of ___, the monitoring and support
devices are stable, as is the overall appearance of the heart and lungs.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with Right PICC// Right PICC 49cm, ___ ___
Contact name: ___: ___
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 10:45.
FINDINGS:
There has been interval placement of a right upper extremity PICC which
terminates in the right atrium. Retraction by 2 cm is recommended for optimal
positioning at the cavoatrial junction. The right IJ Swan-Ganz catheter has
been removed. The vascular sheath is still in place. Otherwise, no
significant interval change.
IMPRESSION:
1. Interval placement of a right upper extremity PICC which terminates in the
right atrium. Retraction by 2 cm is recommended for optimal positioning at
the cavoatrial junction.
2. Interval removal of the Swan-Ganz catheter.
3. Otherwise, no significant interval change from earlier today.
Radiology Report
INDICATION: ___ year old man s/p LVAD// ___ year old man s/p LVAD
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Left-sided pacemaker and ventricular assist device are unchanged. Right-sided
PICC line projects to the cavoatrial junction. Right IJ sheath has been
removed. Cardiomediastinal silhouette is stable. Small bilateral effusions
left greater than right are stable. Pulmonary edema has minimally improved.
No pneumothorax is seen
Radiology Report
EXAMINATION: AP portable chest radiograph
INDICATION: ___ year old man with as above// s/p LVAD implant evaluate for
interval change
TECHNIQUE: AP portable chest radiograph
COMPARISON: Prior chest radiograph dated ___ as well as multiple
prior studies dating back to ___.
FINDINGS:
A left pectoral single lead pacemaker is unchanged with a lead terminating in
the right ventricle. The left ventricular assist device is unchanged. A
right-sided PICC line terminates in the low SVC. There is no pneumothorax.
There is no evidence of pneumonia. There has been minimal interval
improvement in now mild pulmonary edema on the left. There is a small left
pleural effusion, improved from prior. The right lung remains grossly clear.
Cardiomediastinal silhouette is unchanged.
IMPRESSION:
Interval improvement in now mild pulmonary edema on the left and a small left
pleural effusion. There is no pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with LVAD, R pleural effusion// interval change
interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate left pleural effusion is enlarging, with equivalent enlargement of
left lower lobe atelectasis maintaining the mediastinum in the midline.
Moderate enlargement of cardiac silhouette has not changed. Right lung shows
a mild increase in pulmonary vascular congestion but no edema as yet and no
right pleural effusion. No pneumothorax.
Right PIC line ends in the mid to low SVC. Transvenous right ventricular
pacer lead unchanged in standard position. LVAD also grossly unchanged.
Radiology Report
INDICATION: ___ year old man with L pleural effusion// post L thoracentesis
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Moderate cardiomegaly is unchanged. Pulmonary edema has improved. Small left
pleural effusion is stable. Ventricular assist device and left-sided
pacemaker are also unchanged. Right-sided PICC line projects to the
cavoatrial junction. No pneumothorax is seen. Cardiomediastinal silhouette
is stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with rising leukocytosis, worsening SOB, recent
___ for effusion.// Any new consolidation? PTX? Any new consolidation?
PTX?
IMPRESSION:
Right PICC line tip is at the level of lower SVC. LVAD is in place. No
pneumothorax. No pleural effusion increase. No pulmonary edema.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old man with R picc, had R sided impella earlier in
admission, some left arm pain that is worning.// DVT in RUE?
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: Upper extremity ultrasound dated ___.
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.
A right basilic PICC is visualized.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p LVAD, persistent white count, back pain// new
consolidation, reaccumulated effusion?
IMPRESSION:
In comparison with study of ___, a the monitoring support devices are
unchanged. There is increasing opacification at the left base, consistent
with a combination of reaccumulating pleural effusion and volume loss in the
retrocardiac region. Continued enlargement of the cardiac silhouette with
moderate pulmonary vascular congestion.
Radiology Report
EXAMINATION: Chest CTA
INDICATION: ___ year old man with CHF admitted with cardiogenic shock, course
c/b CoNS bacteremia now s/p abx, impella placed for 2 weeks, now s/p Heartmate
III LVAD. Has had a L bloody pleural effusion that was tapped and not thought
to be hemorrhagic (thought ___ cardiac surgery), but has now reaccumulated
with Hgb that hasn't bumped appropriately to transfusion. Concern might be
slow ooze?He has also had persistent R shoulder pain and rising LDH in the
setting of 2 weeks of impella in R axilla. Could there be thrombosis or other
architectural distortion causing his symptoms? Could there be R hemidiaphragm
irritation
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 2.0 s, 31.7 cm; CTDIvol = 5.4 mGy (Body) DLP = 171.1
mGy-cm.
2) Spiral Acquisition 2.6 s, 34.9 cm; CTDIvol = 15.2 mGy (Body) DLP = 529.3
mGy-cm.
3) Spiral Acquisition 2.6 s, 34.9 cm; CTDIvol = 15.2 mGy (Body) DLP = 529.8
mGy-cm.
Total DLP (Body) = 1,230 mGy-cm.
COMPARISON: Prior chest CT dated ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. Mild
atherosclerotic calcifications of the coronary arteries. Stent between the
ascending aorta this in left ventricle apex, HeartMate III type LVAD.
Small filling defects (301:13 and 17) in the right subclavian artery.
Right central venous line with tip terminating in the right atrium.
A small filling defect is also found in the right internal jugular vein.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
Numerous small mediastinal lymph nodes seen throughout all stations, not
enlarged by size criteria. The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. Large left pleural effusion,
nonhemorrhagic, causing compressive atelectasis of the lingula and right lower
lobe..
Ground-glass opacity left upper lobe, likely edema. The airways are patent to
the subsegmental level.
Limited images of the upper abdomen are unremarkable.
Intact sternotomy wires. No lytic or blastic osseous lesion suspicious for
malignancy is identified.
IMPRESSION:
Filling defects consistent with thrombi/emboli seen in the right subclavian
and in the right internal jugular vein.
LVAD in appropriate positioning.
Large left pleural effusion, not hemorrhagic, causing compressive atelectasis
in the left lower lobe and lingula and mild pulmonary edema in the left upper
lobe.
NOTIFICATION: The findings were discussed with Dr ___, M.D.
by ___, M.D. on the telephone on ___ at 8:17 pm, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with left recurrent pleural effusion,
macroscopically c/f hemothorax// chest tube placement Contact name: ___,
___: ___
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs and CT, most recently ___.
FINDINGS:
Stable low lung volumes.
Stable position of right-sided PICC line and LVAD.
New left-sided chest tube with tip obscured by part of the LVAD.
No pneumothorax.
Left lower lobe collapse.
Lungs are otherwise clear with mild vascular congestion.
Stable cardiac and mediastinal silhouettes.
IMPRESSION:
New left-sided chest tube with tip obscured by part of the LVAD but apparently
in the left costophrenic angle.
Radiology Report
INDICATION: ___ year old man with LVAD s/p chestube for L pleural effusion.//
daily XR for ptx eval of interval change in effusion
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Left-sided pacemaker ventricular assist device are unchanged. Right-sided
PICC line projects to the cavoatrial junction. Moderate cardiomegaly is
unchanged. Small left pleural effusion stable. There is mild pulmonary
vascular congestion. No pneumothorax is seen
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with non-ischemic cardiomyopathy s/p LVAD with
recurrent pulmonary effusion, s/p thoracentesis ___ with 2L removed//
obtaining CT for baseline image, patient will be followed in ___ clinic
obtaining CT for baseline image, patient will be followed in
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions. Axial sagittal and coronal images were acquired.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: To a prior study done on ___
FINDINGS:
THORACIC INLET: The there is some stable stranding in the right
supraclavicular lymph nodes right-sided PICC line projects to the cavoatrial
junction. Left-sided pacemaker is unchanged
BREAST AND AXILLA : There are no enlarged axillary lymph nodes
MEDIASTINUM: There is stable small mediastinal lymph nodes. There is moderate
cardiomegaly. LVAD is in place. There is moderate coronary artery
calcification.
PLEURA: Left pleural effusion has decreased in volume post thoracentesis.
Small right pleural effusion is unchanged.
LUNG: There is subsegmental atelectasis in the right lung base and left lower
lobe. A left-sided pigtail catheter is in place.
BONES AND CHEST WALL : Review of bones shows evidence of median sternotomy.
UPPER ABDOMEN: Limited sections through the upper abdomen shows no adrenal
masses.
IMPRESSION:
Status post left-sided chest tube placement.
Decrease in volume of the left pleural effusion which is now small volume and
partially loculated.
Trace right pleural effusion is unchanged.
No interval change in the cardiomegaly and small mediastinal lymph nodes. An
LVAD and left-sided pacemaker are unchanged.
Lack of intravenous contrast limits evaluation. No pneumothorax
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chest tube removed evening of ___//
residual effusion, ptx residual effusion, ptx
IMPRESSION:
Compared to chest radiographs ___ through ___.
Elevated left hemidiaphragm, left lower lobe collapse, small to moderate left
pleural effusion all long-standing. Right lung clear. Stable large
cardiomediastinal silhouette.
LVAD device unchanged in position.
Transvenous pace maker defibrillator lead projects over the right ventricular
apex. The right PIC line ends in the low SVC as before.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with hemothorax s/p chest tube, now removed, but
with dec breath sounds drop again in hgb// interval reaccumulation of
effusion?
IMPRESSION:
In comparison with the study of ___, the there is no evidence of
appreciable pneumothorax following chest tube removal. Little change in the
appearance of the heart and lungs and the monitoring and support devices.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Hypotension
Diagnosed with Heart failure, unspecified, Hypotension, unspecified, Syncope and collapse, Dizziness and giddiness
temperature: 97.8
heartrate: 102.0
resprate: 18.0
o2sat: 96.0
sbp: 98.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year-old-man with PMHx of mixed
ischemic/non-ischemic cardiomyopathy (LVEF 25%) s/p elective
single chamber ICD placement ___, CAD s/p DES to RCA
___, OSA and T2DM who was admitted after episode of dizziness
and hypotension thought to be secondary to over diuresis. While
admitted the patient was transitioned from dobutamine to
milrinone because of eosinophilia. A RHC was completed that
showed poor CI and high PVR. The patient did not improve on
inotropes, and it was felt he needed mechanical support. He was
transferred to the CCU and a balloon pump was inserted while
awaiting LVAD placement. On ___ his IABP was removed and
replaced with impella 5.0 to bridge to LVAD, which was placed on
___. His course was complicated for a CoNS blood stream
infection, for which he received 4 weeks of IV antibiotics,
anemia, for which he received multiple pRBC transfusions, and a
challenging anticoagulation course.
# CORONARIES: R-dominant; LMCA, LAD, LCx without flow limiting
disease, DES to RCA ___
# PUMP: EF 25%
# RHYTHM: Sinus
ACTIVE ISSUES
=============
# Mixed ischemic/non-ischemic HFrEF (Stage D, EF 25%) Patient
admitted for hypotension/presyncope, but found to have
eosinophilia thought to be secondary to dobutamine. Patient was
transitioned to milrinone, then to digoxin and sildenafil.
Patient worsened to the point that he needed mechanical support
in the CCU w/ a balloon pump while awaiting LVAD, which was
placed on ___. The IABP was removed and replaced with
impella to bridge to LVAD, which was placed on ___ (of note,
impella graft was left in). He was then transferred to the floor
where he stabilized on a PO Torsemide regimen. He was initially
on milrinone for right ventricular support, but was able to
transition to sildenafil and digoxin. Physical therapy worked
with him extensively to improve his strength and he and his
family members received LVAD training. He had some challenges
with anticoagulation, which are detailed below. His course was
also complicated by persistently low hemoglobin, continued fluid
reaccumulation, a blood clot in his arm, and a major life event. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Called at home about abnormal sodium noted on pre-op labs
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
___ with decompensated NASH cirrhosis (ascites, jaundice), AAA
with planned repair this week, had pre-op labs drawn showing Na
117. Surgery was cancelled and pt advised to go to ED.
.
First diagnosis with ascites/cirrhosis in ___. Patient
noted to have hyponatremia in the past with adjustment of
diuretics. On ___ had Na 124.
.
In the ED, initial vs were: 97.2 81 ___ 100%ra. Pt was
give 1L NS and started on ___ L while in ED. While there, he
denied symptoms, pain, CP, SOB, n/v, any changes to BM or
urinary outpt. Abdomen noted to be distended and firm to
palpation, lungs clear.
Vitals before transfer: 97.9, 110/71, 82, 16, 99% RA.
.
On the floor, complains of hunger, but otherwise feels well.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-Decompensated Cirrhosis with ascites
-hyponatremia
-Bilateral cataract repair.
-Incisional hernia repair.
-History of sigmoid resection over ___ years ago due to
diverticulitis.
-Diabetes, currently on metformin.
-Hypertension.
-Hypovitmanosis D
-AAA which measured 5.2 cm in ___
Social History:
___
Family History:
Negative for liver disease or liver cancer. No GI cancer in his
family.
Physical Exam:
Adm PE:
97.9, 110/71, 82, 16, 99% RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly. fluid wave
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
.
D/c PE:
VS: 97.9 103/65 66 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: AAOx3, CN II-XII intact, str ___ b/l.
Skin: Multiple purpuric areas
Pertinent Results:
Adm labs:
___ 12:05PM BLOOD WBC-8.0 RBC-3.80* Hgb-12.5* Hct-35.6*
MCV-94 MCH-32.9* MCHC-35.1* RDW-14.5 Plt Ct-92*
___ 12:05PM BLOOD Neuts-83* Bands-0 Lymphs-5* Monos-9 Eos-0
Baso-0 ___ Metas-1* Myelos-1* Plasma-1*
___ 12:05PM BLOOD ___ PTT-41.6* ___
___ 12:05PM BLOOD UreaN-20 Creat-0.9 Na-117* K-5.5* Cl-82*
HCO3-26 AnGap-15
___ 06:30AM BLOOD ALT-47* AST-57* AlkPhos-137* TotBili-5.1*
___ 05:25PM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8
.
Hyponatremia w/u:
___ 06:03AM BLOOD Cortsol-9.0
___ 06:30AM BLOOD TSH-2.8
.
Fibrinogen:
___ 11:20AM BLOOD Fibrino-75*
___ 06:20AM BLOOD Fibrino-64*
___ 05:30AM BLOOD Fibrino-50*
___ 05:50AM BLOOD Fibrino-61*
.
ASCITES:
___ 12:00AM ASCITES WBC-325* RBC-5475* Polys-11* Lymphs-48*
Monos-24* Mesothe-2* Macroph-15*
___ 12:00AM ASCITES TotPro-0.7 Albumin-LESS THAN
Cultures: NO GROWTH AT DISCHARGE
.
Reports:
___ U/s: 1. Cirrhotic liver without concerning focal liver
lesion. No bile duct dilation.
2. Main portal vein patent with a normal waveform.
.
Discharge labs:
___ 05:35AM BLOOD WBC-3.3* RBC-2.95* Hgb-9.7* Hct-28.0*
MCV-95 MCH-32.8* MCHC-34.5 RDW-15.7* Plt Ct-48*
___ 05:35AM BLOOD ___ PTT-52.2* ___
___ 05:35AM BLOOD Glucose-134* UreaN-12 Creat-0.6 Na-126*
K-3.9 Cl-94* HCO3-25 AnGap-11
___ 05:35AM BLOOD ALT-27 AST-40 AlkPhos-98 TotBili-4.5*
___ 05:35AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.7
Medications on Admission:
atenolol 50 mg a day
vitamin D2 50K
furosemide 40 mg a day
metformin 1000 twice a day
spironolactone 100 mg once a day
vitamin C
aspirin 81 mg a day
vitamin B12.
Discharge Medications:
1. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week: For 12 weeks.
2. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
3. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for Dry skin: Apply to
areas of bruised and/or dry skin.
Disp:*1 tub* Refills:*2*
5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO 1X/WEEK
(___).
Disp:*15 Tablet(s)* Refills:*0*
10. tolvaptan 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
Please have AST, ALT, Alk Phos, Total bilirubin, a full
chemistry panel, and CBC with Differential on ___
and have the results called in to ___, MD
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Decompensated Cirrhosis
Hyponatremia
AAA
.
Secondary:
Diabetes, type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with abdominal aortic
aneurysm before repair.
PA and lateral upright chest radiographs were reviewed in comparison to CT of
the abdomen from ___.
Heart size is normal. Mediastinum is normal. Lungs are essentially clear.
Old rib fracture on the right is noted involving eighth right rib. There is
no pleural effusion or pneumothorax.
Radiology Report
INDICATION: ___ male with ascites.
COMPARISON: ___.
RIGHT UPPER QUADRANT ULTRASOUND: The liver is heterogeneous, nodular and
shrunken in contour compatible with history of cirrhosis. An anechoic 1.2 x
1.2 x 1.2 cm cyst in the right lobe of the liver is unchanged. There is no
focal liver lesion of concern. There is no intra- or extra-hepatic bile duct
dilation and the common bile duct measures 2 mm. The main portal vein is
patent with hepatopetal flow. Spleen is enlarged at 14.7 cm. There is a
small amount of ascites.
IMPRESSION:
1. Cirrhotic liver without concerning focal liver lesion. No bile duct
dilation.
2. Main portal vein patent with a normal waveform.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNORMAL LABS
Diagnosed with HYPOSMOLALITY/HYPONATREMIA, DIABETES UNCOMPL ADULT
temperature: 97.2
heartrate: 81.0
resprate: 16.0
o2sat: 100.0
sbp: 110.0
dbp: 75.0
level of pain: 0
level of acuity: 3.0 | Summary: ___ M with decompensated cirrhosis with ascites and
varices, admitted for hyponatremia noted prior to planned AAA
repair, with SBP diagnosed on ___.
.
# Hyponatremia - No symptoms. Initially managed with fluid
restriction and holding of lasix/spironolactone. Tolvaptan was
later initiated, and the patient demonstrated a good response,
with peak Na of 132 (levels were trended carefully to ensure
sodium did not correct too rapidly). Lasix/spironolactone were
restarted. After tolvaptan was stopped, the patient's sodium
decreased to 126. Subsequently, this was restarted prior to
discharge. The patient was instructed to follow-up with his
primary care doctor, and to obtain basic labwork shortly after
discharge to monitor sodium levels closely.
.
# SBP: Initial diagnostic paracentesis was negative. however,
the cultures grew coagulase negative staph in very low numbers,
raising suspician for contamination. The patient had a repeat
paracentesis (with 3L of fluid removed), which was positive for
SBP. This infection may have been the precipitant of his
hyponatremia, however it was suspected that the coag negative
staph was likely an unrelated contaminant. He completed a 5 day
course of Ceftriaxone 2g on ___, with Albumin given on D1 and
D3. Ciprofloxacin was initated for prophylaxis upon discharge.
.
# Pancytopenia, low fibrinogen, and coagulopathy: Likely
related to low-grade DIC from infection or liver failure, or a
combination of the two. He had no evidence of bleeding, with
the exception of during peripheral lab draws. Aspirin was held,
and the patient was instructed to follow-up with his primary
doctor regarding whether to restart this medicine. His CBC,
Fibrinogen, and coags were stable or improving at the time of
discharge.
.
# Decompensated cirrhosis - Likely secondary to NASH. history of
grade 1 varices, ascites, and SBP; no history of encephalopathy.
Diuretics were restarted after initially being held. Nadolol
was added with resting HR in ___ (atenolol was stopped).
.
# T2DM: Treated with metformin at home. His blood sugars were
elevated this admission, and the patient was instructed to
follow-up closely with his primary doctor regarding additional
treatment options.
.
# HTN: Started nadolol in lieu of atenolol as above.
.
# Vitamins: Continued Vitamin B12, Vitamin C. Vitamin D weekly
at home.
.
# Primary prophylaxis: Holding aspirin for now, to follow-up
with PCP.
.
========== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Worst headache of my life
Major Surgical or Invasive Procedure:
LP attempted, unsuccessful
History of Present Illness:
___ yoF with h/o HTN, asthma, and recent rotator cuff surgery on
___ who presents with severe headache and dizziness.
Reports waking up yesterday morning with a severe frontal
headache. Accompanied by dizziness, worse with standing/walking.
+ photosensitivity. Also had onset of left sided non-pleuritic
chest pain that was sharp and did not radiate. CP not
positional. Had nausea but no vomiting. Had recent rotator cuff
surgery and shoulder pain was also worse. Took a Percocet with
mild improvement in her HA. Recently started lisinopril 10mg po
daily (3 days ago) for poorly controlled blood pressure. Denies
any weakness, numbness, shortness of breath. Dizziness is a
lightheaded sensation, not vertigo. When symptoms began, seen by
outpatient physical therapist who took BP which was reportedly
SBP 180. Also endorsed some palpitations during this time. Does
have a neighbor with acute viral gastroenteritis symptoms.
In the ED, initial vitals were 98.2 94 137/80 16 100%RA. ECG
showed sinus rhythm with LAD, nonspecific ST changes.
Orthostatics were negative. Guaiac negative. Head CT without
acute process. CTA showed no evidence of PE. LP was attempted by
4 people (including ED attending) and could not be performed.
Currently, she reports feeling mildly improved but still with
headache. Was able to ambulate to the bathroom without
substantial dizziness.
Past Medical History:
Anemia
Tension headaches
HTN
Asthma
S/p hysterectomy
Talipes planovalgus, congenital - post surgery
Elevated glucose
Social History:
___
Family History:
Father had colon cancer, mother died of MI in her ___.
Physical Exam:
ADMISSION:
VS - 98.4 159/94 81 18 100%RA 79.7kg
GENERAL - well-appearing female in NAD, comfortable, appropriate
although with a somewhat flat affect
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no nuchal rigidity
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, CP not
reproducible
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
DISCHARGE:
VS 98.5, 130/90, 84, 18, 100RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD. no neck stiffness or c spine
tenderness.
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION:
___ 04:40PM BLOOD WBC-4.0 RBC-3.69* Hgb-10.9* Hct-31.8*
MCV-86 MCH-29.6 MCHC-34.3 RDW-14.9 Plt ___
___ 04:40PM BLOOD Neuts-51.5 Lymphs-43.9* Monos-3.6 Eos-0.6
Baso-0.3
___ 07:26PM BLOOD ___ PTT-34.9 ___
___ 04:40PM BLOOD Glucose-113* UreaN-13 Creat-0.9 Na-142
K-3.8 Cl-107 HCO3-23 AnGap-16
___ 04:40PM BLOOD cTropnT-<0.01
___ 06:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:30AM BLOOD CK(CPK)-129
___ 06:30AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.1
DISCHARGE:
___ 06:30AM BLOOD WBC-3.3* RBC-3.82* Hgb-11.0* Hct-33.4*
MCV-88 MCH-28.7 MCHC-32.8 RDW-15.0 Plt ___
___ 06:30AM BLOOD ___ PTT-34.8 ___
___ 06:30AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-141
K-4.1 Cl-108 HCO3-22 AnGap-15
PERTINENT MICRO: none
PERTINENT IMAGING:
___ CTA chest: No acute process in the chest. Specifically,
no evidence of pulmonary embolism.
___ CT head: No acute intracranial process.
___ ECG: NSR with rate 88, normal axis, short PR, no ST
changes
___ BRAIN MRI: no signs of SAH. final read pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Ibuprofen 800 mg PO DAILY:PRN pain
3. Mirtazapine 22.5 mg PO QAM
4. Mirtazapine 45 mg PO HS
5. BuPROPion (Sustained Release) 300 mg PO QAM
6. Estradiol Transdermal Patch *NF* (estradiol) 0.25 mg/24hr
Transdermal weekly
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheeze
8. Clotrimazole Cream 1 Appl TP BID
9. Hydrochlorothiazide 25 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Differin *NF* (adapalene) 0.1 % Topical qhs
12. Clindamycin 1 Appl TP BID
13. econazole *NF* 1 % Topical BID
14. Loratadine *NF* 10 mg Oral daily
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheeze
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Mirtazapine 22.5 mg PO QAM
7. Mirtazapine 45 mg PO HS
8. Acetaminophen 650 mg PO Q6H:PRN pain, fever
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*40 Tablet Refills:*0
9. Clindamycin 1 Appl TP BID
10. Clotrimazole Cream 1 Appl TP BID
11. Differin *NF* (adapalene) 0.1 % Topical qhs
12. econazole *NF* 1 % Topical BID
13. Estradiol Transdermal Patch *NF* (estradiol) 0.25 mg/24hr
Transdermal weekly
14. Loratadine *NF* 10 mg Oral daily
15. Ibuprofen 400-600 mg PO DAILY:PRN shoulder pain
RX *ibuprofen 200 mg ___ tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine
Secondary diagnoses:
hypertension
asthma
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Acute onset frontal headache and presyncope. Evaluate for
subarachnoid hemorrhage.
COMPARISON: None.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material. Multiplanar reformats were
performed.
FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of
normally midline structures, hydrocephalus, or acute large vascular
territorial infarction. The imaged portions of the orbits are unremarkable.
The visualized aspects of the paranasal sinuses and mastoid air cells are well
aerated. No suspicious lytic or blastic lesions are identified.
IMPRESSION: No acute intracranial process.
Radiology Report
INDICATION: Sharp chest pain. Presyncope. Evaluate for pulmonary embolism.
COMPARISON: None.
TECHNIQUE: MDCT axial images were acquired through the chest during
administration of 100 cc of intravenous contrast material. Multiplanar
reformations were performed.
CHEST CT: There is no evidence of pulmonary embolism to the subsegmental
levels bilaterally. The thoracic aorta is unremarkable. There are no
pathologically enlarged mediastinal, hilar, or axillary lymph nodes. The
visualized portion of the thyroid gland is unremarkable. The heart is normal
in size. There is biapical pleuroparenchymal thickening/scarring. Mild
bronchiectasis is seen in the bilateral lower lobes, right middle lobe, and
right upper lobe. Minimal focal bronchiectasis is seen in the left upper lobe
(3:24). There is also minimal scarring with possible associated
bronchiectasis more inferiorly in the left upper lobe (3:40). There is no
focal consolidation. No pleural or pericardial effusion is seen. The airways
are patent to the subsegmental levels bilaterally.
The visualized portion of the upper abdomen is unremarkable.
BONE WINDOW: No suspicious lytic or blastic lesions are identified.
IMPRESSION: No acute process in the chest. Specifically, no evidence of
pulmonary embolism.
Radiology Report
MR HEAD NEURO WITHOUT CONTRAST, ___
HISTORY: Severe headaches and dizziness. Is there evidence of hemorrhage?
Sagittal imaging was performed with short TR, short TE spin echo technique.
Axial imaging was performed with diffusion, FLAIR, long TR, long TE fast spin
echo, and gradient echo technique. No contrast was administered.
Comparison to a head CT of ___.
FINDINGS: The study is normal. There is no evidence of hemorrhage, edema,
masses, mass effect, or infarction. The ventricles and sulci are normal in
caliber and configuration.
Incidentally noted is a mucous retention cyst in the right maxillary sinus.
CONCLUSION: Right maxillary sinus mucous retention cyst. Otherwise, normal
study.
Gender: F
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: DIZZINESS
Diagnosed with HEADACHE, CHEST PAIN NOS
temperature: 98.2
heartrate: 94.0
resprate: 16.0
o2sat: 100.0
sbp: 137.0
dbp: 80.0
level of pain: 10
level of acuity: 3.0 | ___ yoF with h/o HTN, asthma, and recent rotator cuff surgery on
___ who presents with severe headache and dizziness.
#Headache: Thought to be due to ___ initially based on
presentation. Multiple failed attempts at LP. No signs of acute
bleed on head CT or brain MR. ___ the following morning.
Seen by neuro, who felt this to be most consistent with
migraine. Pt educated on migraine triggers and recommended HA
log.
# Dizziness: Resolved following AM. Likely component of
headache.
# Chest pain: CTA negative for PE. Troponins negative x2, no EKG
changes. Resolved the following AM. Likely anxiety or GERD.
Unlikely ACS.
# HTN: continued home HCTZ and lisinopril
# Anemia: At recent baseline. no signs of bleeding. Did not
receive transfusions.
# Depression: continued ome meds. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Elevated transaminases, acute on chronic renal failure
Major Surgical or Invasive Procedure:
Liver biopsy
ERCP
History of Present Illness:
Mr. ___ is a ___ gentleman with hepatitis C
cirrhosis s/p orthotopic liver transplantation ___. His
post-transplant course has been complicated by recurrent HCV,
acute cellular rejection, and stage I fibrosis. He was admitted
from liver clinic today with hyperkalemia, acute-on-chronic
renal insufficiency (Cr 1.9 from recent discharge Cr of 1.5),
and transaminitis, which was concerning for acute rejection vs.
recurrent HCV.
Of note, Mr. ___ has had several biopsies positive for mild
acute cellular rejection this fall. He was recently admitted for
mild acute cellular rejection from ___ to ___. During
this stay, he his immunosuppression regimen was changed from
sirolimus to tacrolimus and he was dosed with IV steroids. He
had a repeat biopsy on ___ which showed mild acute cellular
rejection and recurrent HCV. He also developed acute kidney
injury, which was attributed to tacrolimus, though he continued
to make urine normally and had no electrolyte abnormalities.
In the ED, initial vitals were 97.8 79 113/74 18 100% RA. Mr.
___ reported feeling very well, and had no symptoms aside
from chronic mild RUQ pain and bilateral lower extremity edema,
which has been present since prior admission. A RUQ ultrasound
showed little change in comparison to the prior study, with no
ductal dilatation, patent hepatic vasculature, and stable
restrictive indices. Patient was admitted to the Hepatorenal
service for further management.
Upon arrival to the floor, vital signs were: 97.1, 120/78, 90,
18, 96% RA. Patient denied any symptoms beyond swelling in his
bilateral lower extremities and mild constipation. He
specifically denied fever, chills, nausea, vomiting, cough,
shortness of breath, dysuria, and abdominal pain.
Past Medical History:
Summary of events since liver transplant.
___: Liver transplant
-ERCP ___: bile leak from the biliary anastomosis noted.
Stent placed.
-ERCP ___: a stricture at biliary anastomosis is dilated
with stent placed.
-Renal Failure ___ (creatinine up to 3.2) attributed to
Tacrolimus -> changed to Sirolimus ___ -> creatinine
steadily improved to 0.9-1.1
-Small Bowel Obstruction requiring laparotomy ___
___:
-LFTs rising
-biopsy shows no rejection but possible hepC recurrence
-ERCP ___ shows improvement in anastomotic stricture.
Biliary sludge extracted. Old stents removed without any new
ones placed.
___:
-LFTs still elevated
-biopsy (again) shows no rejection but possible hepC
___:
-LFTs stable ___ ALT/AST/Tbili)
-biopsy shows no rejection, likely recurrent hepC with grade 1
inflammation, stage 0 fibrosis
___:
-LFTs trending up
-biopsy shows recurrent hepC with grade 1 inflammation, stage 0
fibrosis
-no changes in management
___:
-LFTs stably elevated
-biopsy shows recurrent hepC with grade 2 inflammation, stage
___ fibrosis
-no changes in management
___:
-LFTs rising
-biopsy is indeterminate for rejection, plus recurrent hepC with
grade 2 inflammation, stage 1 fibrosis
-Sirolimus goal increased to ___ and LFTs subsequently
improved.
___:
-LFTs rising
-biopsy shows mild-moderate acute cellular rejection, grade 2
inflammation, stage 1 fibrosis
-Sirolimus increased 1mg BID-> 2.5mg BID, MMF 500 BID -> 1500
___:
-LFTs still elevated
-biopsy shows mild acute cellular rejection + recurrent hepC +
bile ductular proliferation with associated neutrophils which
raises the possibility of bile duct obstruction, ischemia or
ascending cholangitis.
-ERCP on ___ with mild stenosis at the anastamosis, which was
dilated and then stented open with 2 plastic stents.
-Sirolimus back down to 2mg BID, MMF 500 BID
___:
-LFTs stably elevated
-biopsy shows mild acute cellular rejection + recurrent hepC
with grade 2 inflammation, stage ___ fibrosis.
-Got 3 days of methylpred, sirolimus decreased from 1.5mg -> 1mg
due to pancytopenia and levels over 18.
___:
-LFTs stably elevated
-biopsy shows mild acute cellular rejection + recurrent hepC
with Grade 2 inflammation + bile duct proliferation with
associated neutrophils which raises the possibility of bile duct
obstruction, ischemia or ascending cholangitis.
-ERCP ___ non-obstructive, old stents removed.
-Got 1 dose of methylpred, sirolimus changed to tacrolimus.
___:
-LFTs rising more
-biopsy shows no rejection + recurrent hepatitis C + bile duct
proliferation with associated neutrophils which raises the
possibility of bile duct obstruction, ischemia or ascending
cholangitis
-ERCP ___ non-obstructive
Other Past Medical History
-Hepatitis C Cirrhosis diagnosed ___ (recurrent/refractory
ascites requiring frequent paracenteses, history of hepatic
encephalopathy, portal gastropathy without esophageal varices)
-hepatocellular carcinoma detected incidentally on liver
ex-plant, was outside ___ criteria, surveillance CT
negative ___
-Low back pain s/p disc surgery ___
-Radial right wrist fx at the end of ___ after fall
-Hemachromatosis, HETEROZYGOUS FOR THE ___ MUTATION
-Spur cell hemolytic anemia
-hypertension
-diabetes
Social History:
___
Family History:
His father had ETOH cirrhosis. No history of kidney problems.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.1, 120/78, 90, 18, 96% RA
GENERAL: Well appearing M who appears stated age. Comfortable,
appropriate
HEENT: Sclera ANicteric. PERRL, EOMI.
NECK: Supple with normal JVP
CARDIAC: RRR, S1 S2 clear, no murmurs, rubs or gallops. No S3 or
S4 appreciated.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: well healed incisions. Distended but Soft, non-tender
to palpation.
EXTREMITIES: 1+ edema bilaterally to knees
NEURO: A&O x 3, ___ strength and normal sensation throughout. No
asterixis.
DISCHARGE PHYSICAL EXAMINATION:
GENERAL: Well appearing M who appears stated age. Comfortable,
appropriate
HEENT: Sclera Anicteric. PERRL, EOMI.
NECK: Supple with normal JVP
CARDIAC: RRR, S1 S2 clear, no murmurs, rubs or gallops. No S3 or
S4 appreciated.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: well healed incisions. Soft, non-tender to palpation.
+BS.
EXTREMITIES: 1+ edema bilaterally to knees
NEURO: A&O x 3, ___ strength and normal sensation throughout. No
asterixis.
Pertinent Results:
ADMISSION LABS
___ 12:20PM BLOOD WBC-7.0# RBC-4.08* Hgb-11.9* Hct-38.5*
MCV-94 MCH-29.3 MCHC-31.0 RDW-15.4 Plt Ct-92*
___ 06:00PM BLOOD Neuts-74.3* ___ Monos-2.9 Eos-0.9
Baso-0.5
___ 05:55AM BLOOD ___ PTT-39.1* ___
___ 12:20PM BLOOD UreaN-21* Creat-1.8* Na-137 K-6.1* Cl-102
HCO3-25 AnGap-16
___ 12:20PM BLOOD ALT-85* AST-183* AlkPhos-183*
TotBili-5.6*
___ 06:00PM BLOOD Calcium-9.6 Mg-1.3*
___ 05:55AM BLOOD tacroFK-14.3
URINE
___ 07:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.0 Leuks-NEG
___ 03:32AM URINE RBC-0 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
___ 03:32AM URINE Eos-NEGATIVE
___ 03:32AM URINE Hours-RANDOM UreaN-395 Creat-131 Na-49
K-73 Cl-41 TotProt-17 Prot/Cr-0.1
___ 03:32AM URINE Osmolal-442
MICROBIOLOGY
___: HCV VL: 21,737,817 IU/mL
MEDICATION MONITORING
___ 05:55AM BLOOD tacroFK-14.3
___ 05:20AM BLOOD tacroFK-14.6
___ 05:35AM BLOOD tacroFK-12.7
___ 06:30AM BLOOD tacroFK-PND
DISCHARGE LABS
___ 06:30AM BLOOD WBC-2.6* RBC-3.30* Hgb-9.6* Hct-30.2*
MCV-92 MCH-29.0 MCHC-31.7 RDW-15.9* Plt Ct-95*
___ 06:30AM BLOOD Glucose-123* UreaN-17 Creat-1.5* Na-138
K-4.8 Cl-104 HCO3-26 AnGap-13
___ 06:30AM BLOOD ALT-67* AST-196* AlkPhos-164*
TotBili-4.1*
___ 05:35AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.8
IMAGING/PROCEDURES
___ ECG: Sinus rhythm. There is inferior ST segment elevation
which is less than one millimeter and non-specific.
___ ABDOMINAL U/S: IMPRESSION:
1. Little change in comparison to the prior study with patent
hepatic
vasculature, stable resistive indices and no ductal dilatation,
2. Splenomegaly, no ascites.
___ RUSH CORE LIVER BIOPSY:
There are no diagnostic features of rejection. There is
prominent lymphocytic and neutrophilic cholangitis. The
lymphocytic cholangitis could be attributed to either recurrent
viral hepatitis C or treated cellular rejection. However, the
presence of neutrophils would suggest an obstruction or ischemic
injury or could be part of recurrent viral hepatitis C with
biliary features. Compared to previous biopsies, there is no
venulitis in the current biopsy, and there is progression in the
biliary proliferation with associated neutrophils. Case
findings were discussed with Dr. ___ by Dr. ___ on
___.
___ ERCP
- Evidence of a previous sphincterotomy was noted in the major
papilla.
- Cannulation of the biliary duct was successful and deep with a
balloon using a free-hand technique.
- The common bile duct was well opacified with identification of
the anastomosis.
- The duct above the anastomosis measured 10-11mm with minimal
caliber change at the anastomosis.
- There was a somewhat mildly tortuos duct at the anastomosis.
- The intrahepatic biliary tree was well filled with contrast,
with no abnormality found.
- A 12mm balloon was swept through the anastomosis with no
resistance.
- Otherwise normal ercp to third part of the duodenum.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Famotidine 20 mg PO Q12H
3. fenofibrate *NF* 54 mg Oral daily
4. Metoprolol Tartrate 12.5 mg PO BID
hold for SBP<100, HR<60
5. Mycophenolate Mofetil 1000 mg PO BID
6. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
hold for oversedation, RR<12
7. Oxycodone SR (OxyconTIN) 80 mg PO Q6H
hold for oversedation, RR<12
8. Senna 1 TAB PO BID:PRN constipation
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Ursodiol 300 mg PO BID
11. ValGANCIclovir 900 mg PO Q24H
12. Furosemide 20 mg PO DAILY
hold for SBP<100
13. Glargine 30 Units Bedtime
14. Tacrolimus 3 mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Famotidine 20 mg PO Q12H
3. Furosemide 20 mg PO DAILY
hold for SBP<100
4. Glargine 30 Units Bedtime
5. Metoprolol Tartrate 12.5 mg PO BID
hold for SBP<100, HR<60
6. Mycophenolate Mofetil 1000 mg PO BID
7. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
hold for oversedation, RR<12
8. Oxycodone SR (OxyconTIN) 80 mg PO Q6H
hold for oversedation, RR<12
9. Senna 2 TAB PO BID
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Ursodiol 300 mg PO BID
12. Tacrolimus 1 mg PO BID
13. ValGANCIclovir 450 mg PO DAILY
14. fenofibrate *NF* 54 mg Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Transaminitis
- Acute on chronic renal failure
Secondary Diagnosis:
- Orthotopic Liver transplant recipient
- Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ year old man with HCV s/p liver tx ___ yrs prior, now w/ elevated
transaminases, recurrent HCV
PHYSICIANS: ___
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained. A preprocedure timeout was
performed discussing the planned procedure, confirming the patient's identity
with three identifiers, and reviewing a checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
An 18 gauge biopsy needle was advanced into the right hepatic lobe under
ultrasound guidance via a right lateral intercostal approach and a single core
biopsy was obtained.
Moderate sedation was provided by administering divided doses of 2.5 mg Versed
and 150 mcg fentanyl throughout the total intra-service time of 10 minutes
during which the patient's hemodynamic parameters were continuously monitored
by radiology nursing personnel.
The patient tolerated the procedure well with no immediate complication.
Estimated blood loss was minimal.
Dr. ___ attending radiologist, was present throughout the entire
procedure. Post-procedure instructions were written in the ___ medical
record.
IMPRESSION:
Ultrasound-guided 18 G non-targeted core liver biopsy. One core was taken.
Pathology pending.
Radiology Report
HISTORY: Status post liver transplant with worsening liver enzymes.
COMPARISON: Abdominal ultrasound from ___.
FINDINGS: The liver is normal in echogenicity with no focal lesion. The
gallbladder is surgically absent and the common bile duct is not dilated at
1.0 cm. The spleen remains enlarged at 15.6 cm. The pancreas is not well
visualized due to overlying bowel gas. There is no significant free fluid.
Color and Doppler Evaluation: The inferior vena cava is patent with normal
flow. The right, left, and middle hepatic veins are patent. The main, right,
and left hepatic arteries are patent with resistive indices that range from
0.40 to 0.7 and stable velocities in comparison to the prior study. The main,
right, and left portal veins are patent.
IMPRESSION:
1. Little change in comparison to the prior study with patent hepatic
vasculature, stable resistive indices and no ductal dilatation,
2. Splenomegaly, no ascites.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RECHECK POTASSIUM
Diagnosed with HYPERKALEMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 97.8
heartrate: 79.0
resprate: 18.0
o2sat: 100.0
sbp: 113.0
dbp: 74.0
level of pain: 3
level of acuity: 3.0 | REASON FOR ADMISSION
Mr. ___ is a ___ gentleman with a history of
hepatitis C cirrhosis who received an orthotopic liver
transplant on ___. His post-transplant course has been
complicated by recurrent hepatitis C (HCV), acute cellular
rejection, and stage I fibrosis. He was admitted from clinic
with hyperkalemia, acute-on-chronic renal insufficiency, and
transaminitis.
ACTIVE ISSUES
1. Transaminitis: As noted in the HPI, Mr. ___ was recently
admitted for acute cellular rejection, which was treated with a
dose of IV methylprednisolone and an increase in his
immunosuppression from sirolimus to tacrolimus. Biopsy during
his prior admission also showed evidence of recurrent HCV. Mr.
___ now presents with elevation of his AST/ALT/Tbili to
183/85/5.6 from his prior discharge values of 98/76/2.3 on
___. Liver biopsy this admission was negative for acute
cellular rejection but did show recurrent HCV vs. biliary
obstruction. A repeat ERCP showed a tortuous duct but no
evidence of obstruction. He has had recent negative CMV viral
load in ___ and ___. HCV viral load has increased
steadily and is now 21,737,817. Patient's LFT's improved
slightly during hospital stay. His tacrolimus was
supratherapeutic at 14. Given recent evidence of rejection,
tacrolimus goal is 10. His dose was reduced to 1 mg BID. He was
continued on home dose of mycofenalate mofetil 1000 mg BID. He
will be discharged with close outpatient follow-up and
consideration of outpatient treatement for his recurrent HCV.
2. Acute-on-Chronic Renal Failure: During his previous
admission, Mr. ___ immunosuppression was changed from
sirolimus to tacrolimus to better treat acute cellular rejection
of his liver graft. He was noted to have elevation of his
creatinine from a baseline of 1.0 to 1.5 at the time of
discharge, which was attributed to tacrolimus toxicity given his
history of tacrolimus-induced kidney failure and the fact that
it did not respond to fluids or to reductions in diuretic dose.
His providers agreed to tolerate the elevation in creatinine
given the importance of treating his rejection. Upon admission,
creatinine had increased to 1.9 in the setting of a
supratherapeutic tacrolimus level. Fractional excretion of Urea
was 24% and fractional excretion of sodium, 0.5%, both of which
supported a pre-renal etiology such as tacrolimus toxicity.
Patient's tacrolimus dose was decreased from 3 mg BID to 1 mg
BID with a goal trough of ___. His valganciclovir was
decreased to 450 mg daily given CrCl < 50. Patient's creatinine
improved to 1.5 on day of discharge. He will need close
monitoring of renal function as an outpatient.
3. Hematocrit Drop: Mr. ___ had a drop in his hematocrit
from 38 to the low 30's during admission. There was no obvious
source of bleeding, and he remained hemodynamically stable. It
is possible this drop was due to dilution and frequent
phlebotomy. Hematocrit remained stable after liver biopsy.
Please continue to monitor hematocrit as an outpatient.
4. Hepatitis C Cirrhosis, s/p Liver Transplant: As discussed
above, patient's tacrolimus dosing was decreased to 1 mg BID
with a goal trough of ___. He was continued on MMF 1000 mg
BID. For prophylaxis, he was continued on Bactrim SS 1 tab
daily. His Valgancyclovir was decreased from 900 mg to 450 mg
daily due to renal failure. He continued Ursodiol 300mg BID and
Femotidine 20mg q12h.
CHRONIC ISSUES
1. Hypertension: Patient's furosemide was initially held in the
setting of acute renal failure. It was then restarted. He was
continued on home metoprolol.
2. Diabetes Mellitus: Patient continued his home regimen of
glargine 30 units QHS. In addition, he received a Humalog
sliding scale.
3. Back pain: Patient continued home oxycodone and oxycontin.
4. HLD: Patient's home fenofibrate was held given LFT
abnormalities.
TRANSITIONAL ISSUES
1. Follow-up pending tacrolimus level from ___
2. Patient will walk in for a repeat chemistry, liver panel, and
tacrolimus level on ___
3. Adjust Valgancyclovir dose as creatinine improves
4. Consider treatment of HCV as outpatient once appropriate
5. On discharge medication reconciliation, I inadvertently
checked that patietn should restart fenofibrate. This is
incorrect; he should continue to hold his fenofibrate given his
transaminitis. I will call him to clarify the instructions.
6. Goal tacrolimus level ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / Atenolol / Pravastatin
Attending: ___.
Chief Complaint:
Facial pain and spasm
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of migraines, prior admission for L sided
facial pain with negative work up for temporal arteritis,
presenting with bilateral episodes of facial pain and spasms,
associated with tearing that started last night. Patient first
noticed pain around her eyes. Per son, patient's speech is
slightly more slurred than normal. No muscle weakness of facial
droop. Pain is sharp and stabbing, intermittent.
No CP, SOB, fevers/chills, or sudden changes in vision. Patient
does note occasional mild blurriness during this episode.
Patient has been seen in ED in the past for facial pain and
spasms.
In the ED, initial VS were notable for BP of 192/82, 97.7, 65,
98% on RA Exam notable for patient being in NAD, words
moderately slurred, limited quiet speech, normal cardiopulmonary
exam, neuro exam with no ___ deficits, strength was noted to be
equal and intact, gait at baseline per her son. Labs showed
normal CBC, normal BMP, LFTs all WNL, neg trop x 1 (second
pending), CK of 144, UA negative, and Utox negative. Serum tox
negative. CRP was 4.8.
Imaging showed:
CTA head & neck showed no acute pulmonary process, however there
was a peripheral filling defect in right upper lobar artery and
so PE cannot be excluded. 1.9 cm hypodense nodule within the
left lower thyroid lobe, should be further evaluated with
dedicated nonemergent outpatient thyroid ultrasound.
CTA chest:
1. Bilateral pulmonary emboli involving up to lobar pulmonary
arteries.
2. There is evidence of pulmonary hypertension with dilation of
the left and right pulmonary arteries.
Received Tylenol and a heparin bolus and gtt. Transfer VS were
BP 137/73 (steadily decreased during ED course), 98.7, 66, 18,
95% RA.
Cardiology was consulted and recommended heparin bolus and gtt,
as well as TTE and ___ dopplers. Neurology was consulted and
noted that the episodes of facial pain and spasm with hearing
loss and possible R sided ptosis could be autonomic neuralgia,
and noted low concern for temp arteritis given intact vision and
artery pulses. Recommended increased gabapentin 100mg in AM and
midday and continuing 300mg at night. MASCOT was consulted and
recommended no additional intervention (per ED report).
Neurology consulted, thought symptoms of R sided ptosis and
spasm could be an autonomic neuralgia, recommended CTA per above
and increasing gabapentin.
On arrival to the floor, patient reports that her facial pain is
generally better. She is not feeling short of breath, but notes
that in general, she has felt more short of breath over the last
few months with exertion. She notes one episode of traveling to
and from ___ between ___ and returning ___, driving one
way and flying the other. No fevers/chills. No changes in
vision.
Past Medical History:
Past Medical History: chronic constipation,
hypercholesterolemia, hypertension, insomnia, low
back pain, obstructive sleep apnea, osteopenia, GERD, depression
and anxiety, migraine headaches, memory loss, prediabetes,
bursitis, neuropathy.
.
Past Surgical History: Right knee surgery, hemorrhoidectomy,
right CMC arthroplasty, right foot repair.
Social History:
___
Family History:
Hypertension. Daughter with breast cancer. Mom with colon
cancer. Son had pulmonary embolism and DVT.
Physical Exam:
==========================
Admission Physical Exam:
==========================
VS: 98.3 135/77 66 94% RA
GENERAL: NAD, patient with ongoing facial twitching
HEENT: AT/NC, EOMI, 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, some mild nonpitting edema
bilaterally.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CNII-XII intact, though facial muscles are
twitching throughout examination. No significant pain on
palpation. UE and ___ strength is full bilaterally.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
========================
Discharge physical exam ___
========================
Vitals
Temp 97.8
BP 107 / 68
HR 79
RR 18
Sa02 98 Ra
GENERAL: Patient was resting comfortably with CPAP with nasal
prongs in place, in no apparent pain or distress.
HEENT: AT/NC, EOM grossly intact, anicteric sclera, pink
conjunctiva
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi. Breathing comfortably
ABDOMEN: no distended, non-tender in all quadrants, no
rebound/guarding
NEURO: A&Ox3, CNII-XII intact.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
============================
Admission labs
============================
Labs:
___ 01:17PM BLOOD WBC-5.4 RBC-4.36 Hgb-11.5 Hct-37.0 MCV-85
MCH-26.4 MCHC-31.1* RDW-16.5* RDWSD-50.6* Plt ___
___ 01:17PM BLOOD Neuts-65.4 ___ Monos-5.0 Eos-1.1
Baso-0.6 Im ___ AbsNeut-3.54 AbsLymp-1.49 AbsMono-0.27
AbsEos-0.06 AbsBaso-0.03
___ 01:17PM BLOOD ___ PTT-31.0 ___
___ 12:40PM BLOOD Glucose-102* UreaN-13 Creat-0.9 Na-141
K-4.3 Cl-104 HCO3-25 AnGap-16
___ 12:40PM BLOOD ALT-11 AST-20 CK(CPK)-144 AlkPhos-93
TotBili-0.3
___ 12:40PM BLOOD cTropnT-<0.01
___ 12:40PM BLOOD Albumin-4.2 Calcium-9.5 Phos-3.6 Mg-2.2
___ 12:40PM BLOOD CRP-4.8
___ 12:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging:
(___) CTA head and neck w/ and w/o contrast:
COMPARISON: Prior brain MRI brain ___, MRI, MRA
brain, MRA neck
___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
IMPRESSION:
No acute intracranial process.
Fibromuscular dysplasia of the extracranial cervical internal
carotid arteries bilateral, and probably mild involvement of the
extracranial right vertebral artery. No evidence of dissection,
aneurysm formation, thrombosis or significant atherosclerotic
stenosis.
Incidental finding of a peripheral filling defect in the right
superior lobar pulmonary artery suggesting a pulmonary embolus.
This has the appearance of being late subacute to chronic.
Dedicated chest imaging advised.
19 mm hypodense nodule in the left lobe of thyroid for which
correlation with thyroid ultrasound is advised.
RECOMMENDATION(S): Thyroid ultrasound.
(___) CTA chest:
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level. There are several filling defects in the
pulmonary
arterial tree, for example in the subsegmental pulmonary
arteries in the left lower lobe, right upper lobe are pulmonary
artery, and right lower lobe segmental pulmonary artery (for
example, 3:74, 3:122, and 3:142). The right and left pulmonary
arteries are dilated, suggestive of pulmonary hypertension. The
thoracic aorta is normal in caliber without evidence of
dissection or intramural hematoma. . No pericardial effusion is
seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is bibasilar subsegmental atelectasis.
Lungs are clear without masses or areas of parenchymal
opacification. 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: There are multiple hypodensities throughout the liver,
which are most compatible with cysts. There is sludge in the
gallbladder without evidence of acute cholecystitis. There is a
small hiatal hernia. Otherwise the upper abdominal structures
are unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
IMPRESSION:
1. Bilateral pulmonary emboli involving up to lobar pulmonary
arteries of
indeterminate age, but may be chronic given areas of strand-like
appearance.
2. There is evidence of pulmonary hypertension with dilation of
the left and right pulmonary arteries.
3. Cholelithiasis without evidence of cholecystitis.
(___) bilateral lower extremity ultrasound
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
=======================
Discharge Labs/Studies
=======================
___ 06:50AM BLOOD WBC-5.6 RBC-4.49 Hgb-12.1 Hct-38.8 MCV-86
MCH-26.9 MCHC-31.2* RDW-16.7* RDWSD-51.7* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-139
K-4.2 Cl-101 HCO3-26 AnGap-16
___ 06:50AM BLOOD Calcium-9.0 Phos-5.1* Mg-2.3
Trans Thoracic ECHO Results: ___
IMPRESSION: Dynamic left ventricular systolic function. Normal
right ventricular size and systolic function. Moderate pulmonary
hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. QUEtiapine Fumarate 50 mg PO QHS
3. Hydrochlorothiazide 25 mg PO DAILY
4. Gabapentin 300 mg PO QHS
5. DULoxetine 60 mg oral DAILY
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
___ puffs every ___ hours as needed for cough/wheeze
7. Docusate Sodium 100 mg PO BID
8. Avapro (irbesartan) 75 mg oral daily
9. aspirin 81 mg oral daily - asperdrink formulation
10. Advair HFA (fluticasone-salmeterol) 115-21 mcg/actuation
inhalation 1 puff daily
11. Lactulose 30 mL PO BID:PRN constipation
12. Ambien CR (zolpidem) 12.5 mg oral QHS
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*41 Tablet Refills:*0
2. Gabapentin 100 mg PO QAM
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. Gabapentin 100 mg PO Q12PM DAILY
4. Advair HFA (fluticasone-salmeterol) 115-21 mcg/actuation
inhalation 1 puff daily
RX *fluticasone-salmeterol [Advair HFA] 115 mcg-21 mcg/actuation
1 puff inhaled once a day Disp #*1 Inhaler Refills:*0
5. Ambien CR (zolpidem) 12.5 mg oral QHS
6. Aspirin 81 mg oral DAILY - ASPERDRINK FORMULATION
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Avapro (irbesartan) 75 mg oral daily
RX *irbesartan 75 mg 1 tablet(s) by mouth once a day 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. DULoxetine 60 mg oral DAILY
RX *duloxetine 60 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *fluticasone 50 mcg/actuation 1 spray intranasal once a day
Disp #*30 Spray Refills:*0
11. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
12. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
13. Lactulose 30 mL PO BID:PRN constipation
RX *lactulose 10 gram/15 mL 30 ml by mouth twice a day
Refills:*0
14. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
___ puffs every ___ hours as needed for cough/wheeze
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled
every 4 to 6 hours Disp #*2 Inhaler Refills:*0
16. QUEtiapine Fumarate 50 mg PO QHS
RX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
17.Rolling Walker
Please provide rolling walker
Diagnosis: Gait instability ICD 10: ___
Prognosis: Good
Length of Need: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Pulmonary embolism
Secondary diagnosis:
Trigeminal neuralgia
Facial spasms
Hypertension
Pulmonary Hypertension
Thyroid nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with hx neuropathic pain migranies presenting with
b/l facial spasms and pain x14 hours// etiology of facial spasms pain x14
hours
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque350 intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
3) Spiral Acquisition 5.2 s, 40.7 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,262.6 mGy-cm.
Total DLP (Head) = 2,196 mGy-cm.
COMPARISON: Prior brain MRI brain ___, MRI, MRA brain, MRA neck
___
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.
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. Dominant
right-sided vertebral artery. Fetal origin of the right PCA. The dural
venous sinuses are patent.
CTA NECK:
Tortuous and beaded appearance of the bilateral extracranial internal carotid
arteries in keeping with fibromuscular dysplasia, similar to prior MRA. No
dissection, thrombosis, significant atherosclerotic stenosis or aneurysm
formation. No ICA stenosis by NASCET criteria. Mild tortuosity with a
slightly beaded appearance of the extracranial dominant right vertebral artery
suggesting FMD, better seen compared to prior, probably present on prior as
well.. No obvious involvement of a non dominant left vertebral artery.
OTHER:
Peripheral, contracted filling defect in the right superior lobar pulmonary
artery extending into the segmental upper lobe arteries.
The visualized portion of the lungs are clear. No suspicious pulmonary
nodules or masses. 19 mm hypodense nodule in the inferior aspect of the left
lobe of thyroid. There is no lymphadenopathy by CT size criteria. There are
degenerative changes in the cervical spine with multilevel probably moderate
central canal narrowing.
IMPRESSION:
No acute intracranial process.
Fibromuscular dysplasia of the extracranial cervical internal carotid arteries
bilateral, and probably mild involvement of the extracranial right vertebral
artery. No evidence of dissection, aneurysm formation, thrombosis or
significant atherosclerotic stenosis.
Incidental finding of a peripheral filling defect in the right superior lobar
pulmonary artery suggesting a pulmonary embolus. This has the appearance of
being late subacute to chronic. Dedicated chest imaging advised.
19 mm hypodense nodule in the left lobe of thyroid for which correlation with
thyroid ultrasound is advised.
RECOMMENDATION(S): Thyroid ultrasound.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 4:03 pm, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with peripheral filling defect within the right
upper lobar artery on CTA neck today. Pt is otherwise asymptomatic from
pulmonary standpoint.// ?PE- peripheral filling defect is noted within the
right upper lobar artery on CTA neck today
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 521 mGy-cm.
COMPARISON: CTA head and neck from ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level. There are several filling defects in the pulmonary
arterial tree, for example in the subsegmental pulmonary arteries in the left
lower lobe, right upper lobe are pulmonary artery, and right lower lobe
segmental pulmonary artery (for example, 3:74, 3:122, and 3:142). The right
and left pulmonary arteries are dilated, suggestive of pulmonary hypertension.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. . No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is bibasilar subsegmental atelectasis. Lungs are clear
without masses or areas of parenchymal opacification. 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: There are multiple hypodensities throughout the liver, which are most
compatible with cysts. There is sludge in the gallbladder without evidence of
acute cholecystitis. There is a small hiatal hernia. Otherwise the upper
abdominal structures are unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Bilateral pulmonary emboli involving up to lobar pulmonary arteries of
indeterminate age, but may be chronic given areas of strand-like appearance.
2. There is evidence of pulmonary hypertension with dilation of the left and
right pulmonary arteries.
3. Cholelithiasis without evidence of cholecystitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:15pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with new PE, RLE pain.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Facial pain
Diagnosed with Jaw pain
temperature: 97.7
heartrate: 65.0
resprate: 18.0
o2sat: 98.0
sbp: 192.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | ===========================
Patient summary statement for admission
===========================
Ms. ___ is a ___ with history of migraines, prior admission
for L sided facial pain with negative work up for temporal
arteritis, presenting with bilateral episodes of facial pain and
spasms, associated with tearing that started night prior to
admission. Patient had CTA head and neck for stroke workup, and
bilateral filling defects in upper lobes of lungs were found
incidentally.
============================
Acute medical/surgical issues addressed
============================
#Bilateral lobar pulmonary embolism
Patient with incidental finding of bilateral pulmonary embolisms
found on CTA head and neck, confirmed later by CTA chest. Due to
stranding appearance, PEs thought to be chronic. Not a candidate
for thrombolytics. Upon further questioning, patient stated she
did have shortness of breath with exertion, new in the last 2
weeks. Did have a long trip several months ago but unclear if
related. Lower extremity ultrasound were negative for DVTs.
While admitted, patient was hemodynamically stable with good O2
sat on RA. Started on heparin drip initially but transitioned to
Apixiban 5mg BID ___. Moderate Pulmonary hypertension as a
result of PE was demonstrated on TTE, this will need pulmonary
follow up.
#Bilateral facial pain and spasms
#History of trigeminal neuralgia
Patient presented after worsening facial pain/headache and
facial spasms that started the evening prior to admission.
Neurology was consulted in the ED. Patient was found to have
intact temporal pulses and normal visual acuity. CK/CRP were
WNL. CTA head and neck showed no arterial dissection or
structural abnormalities. Since patient with no focal deficits,
Neurology recommended deferring further stroke workup. Per
neurology facial pain and twitching could be due to autonomic
neuralgia in setting of her underlying trigeminal neuralgia vs
autonomic dysfunction due to SUNCT. Headache improved with
Tylenol and increased Gabapentin dose. Facial twitching subsided
the following day. Patient to follow-up with outpatient
Neurologist, Dr. ___.
=========================
Chronic issues pertinent to admission
=========================
#Hypertension
Started losartan 25mg and continued hydrochlorothiazide with SBP
in 130s to 150s. Will transition to home irbesartan at discharge
#Thyroid nodule
1.9 cm hypodense nodule within the left lower thyroid lobe,
should be further evaluated with dedicated nonemergent
outpatient thyroid ultrasound.
# h/o depression
continued duloxetine
#insomnia
continued zolpidem in lower dose (ER nonformulary). Continued
Seroquel
================
Transitional issues
================
- Gabapentin dose increased from 300 mg PO QHS to TID
(___)
- Patient started on Apixaban 5mg BID for PE
- 1.9 cm hypodense nodule within the left lower thyroid lobe,
should be further evaluated with dedicated nonemergent
outpatient thyroid ultrasound.
- Patient with evidence of pulmonary hypertension on CTA chest
not noted in previous ECHO (___) and on Echo trom ___-
Moderate Pulmonary HTN.
- Given PEs diagnosed on this admission, please ensure patient
has age-appropriate cancer screening
- Please consider hypercoagulability work-up in 6 months, when
patient has completed appropriate course of apixiban |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
hydrochlorothiazide
Attending: ___
Major Surgical or Invasive Procedure:
___ Colonoscopy
___ ultrasound-guided biopsy of the spleen
attach
Pertinent Results:
ADMISSION LABS
==============
___ 03:50PM BLOOD WBC-8.5 RBC-3.13* Hgb-7.6* Hct-25.2*
MCV-81* MCH-24.3* MCHC-30.2* RDW-17.4* RDWSD-50.6* Plt ___
___ 03:50PM BLOOD Neuts-80.6* Lymphs-11.1* Monos-7.5
Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.85* AbsLymp-0.94*
AbsMono-0.64 AbsEos-0.01* AbsBaso-0.02
___ 07:02PM BLOOD ___ PTT-27.1 ___
___ 03:50PM BLOOD Glucose-655* UreaN-23* Creat-1.5* Na-125*
K-5.1 Cl-94* HCO3-23 AnGap-8*
___ 03:50PM BLOOD ALT-<5 AST-6 LD(LDH)-180 AlkPhos-67
TotBili-0.2
___ 03:50PM BLOOD Albumin-3.2* Calcium-8.6 Phos-1.9* Mg-1.6
Iron-14*
___ 03:50PM BLOOD calTIBC-186* VitB12-735 Folate-9
Hapto-353* Ferritn-193 TRF-143*
___ 09:30PM BLOOD Ret Aut-0.8 Abs Ret-0.03
OTHER PERTINENT LABS
=====================
___ 07:05AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 07:05AM BLOOD CRP-75.2*
___ 06:41AM BLOOD b2micro-4.5*
MICRO
=====
___ 01:07AM URINE Color-Straw Appear-Hazy* Sp ___
___ 01:07AM URINE Blood-NEG Nitrite-POS* Protein-TR*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5
Leuks-LG*
___ 01:07AM URINE RBC-3* WBC-64* Bacteri-FEW* Yeast-NONE
Epi-<1
___ 01:07AM URINE CastHy-1*
___ 1:07 am URINE Source: ___.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/OTHER STUDIES
=====================
___ LENIs
Nonocclusive deep venous thrombosis within proximal left
popliteal vein.
___ Knee XR
The osseous structures are diffusely demineralized. No acute
fracture or
dislocation. Small joint effusion. Minimal degenerative
spurring is seen in the medial compartment of the knee. Small
superior patellar enthesophyte. Mild prepatellar soft tissue
swelling. No suspicious lytic or sclerotic osseous
abnormalities. No radiopaque foreign body or concerning soft
tissue calcification.
___ CT head
1. Findings concerning for a likely chronic subdural hematoma
with hypo and
hyperdense components, over the left frontal convexity. The
hyperdense
components are age-indeterminate but cannot exclude an acute or
subacute
process.
2. There is a focal hypodensity at the inferior left frontal
lobe near the
gyrus rectus which is concerning for a prior contusion injury.
___ Neck U/s
Transverse and sagittal images were obtained of the superficial
tissues of the right neck. In the region of the patient's
palpable abnormality, there is a normal-appearing lymph node
measuring up to 0.2 cm in short axis. No other abnormalities
are detected in the right neck.
___ CT Head
Stable small subdural hematoma along the left frontal cerebral
convexity. No new sites of intracranial hemorrhage.
___ Colonoscopy
Diffuse friability, granularity, erythema, and ulceration in
rectum compatible with diversion colitis. Segmental continuous
edema, erythema, erosion, friability, exudate, and granularity
with contact bleeding noted in colon from ostomy to 40cm. There
was sparing from 40cm to the cecum. Terminal ileium normal.
___ CT A/p
1. Interval enlargement of the spleen with development of
multiple
hypoenhancing lesions measuring up to 2.5 cm concerning for
infiltrative
process such as lymphoma or in the spectrum of extramedullary
hematopoiesis.
Differential diagnosis includes abscesses
___ CT Chest
1. No evidence of intrathoracic malignancy.
2. Small bilateral pleural effusions with associated compressive
atelectasis.
3. Please refer to separate report of CT abdomen and pelvis
performed on the
same day for description of the subdiaphragmatic findings.
___ SPLEEN ULTRASOUND
Multiple hypoechoic variable-sized rounded splenic lesions.
These lesions are amenable to ultrasound-guided biopsy.
___ Cytogenetics Tissue: SPLEEN
Chromosome analysis was not possible because the culture set up
from this splenic lesion core biopsy did not produce mitotic
cells.
DISCHARGE LABS
==============
CBC/COAGS
___ 06:54AM BLOOD WBC-4.7 RBC-3.22* Hgb-8.2* Hct-27.4*
MCV-85 MCH-25.5* MCHC-29.9* RDW-22.3* RDWSD-68.5* Plt ___
___ 06:54AM BLOOD ___ PTT-66.7* ___
CMP
___ 06:54AM BLOOD Glucose-153* UreaN-34* Creat-1.1 Na-135
K-5.2 Cl-99 HCO3-26 AnGap-10
___ 06:54AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2
OTHER NUTRITION
___ 03:50PM BLOOD calTIBC-186* VitB12-735 Folate-9
Hapto-353* Ferritn-193 TRF-143*
DIABETES
___ 07:02AM BLOOD %HbA1c-8.5* eAG-197*
HEPATITIS
___ 07:05AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
OTHER
___ 06:41AM BLOOD b2micro-4.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 12.5 mcg PO DAILY
2. CARVedilol 3.125 mg PO BID
3. Tamsulosin 0.4 mg PO QHS
4. Finasteride 5 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
7. Lisinopril 10 mg PO DAILY
8. Ferrous GLUCONATE 240 mg PO DAILY
9. Simethicone 120 mg PO QID:PRN constipation
10. Docusate Sodium 100 mg PO BID
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Lidocaine Viscous 2% 15 mL PO TID:PRN tooth pain
RX *lidocaine HCl [Lidocaine Viscous] 2 % take 15mL three times
a day as needed Disp ___ Milliliter Milliliter Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H Duration: 8 Days
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. Repaglinide 0.5 mg PO BIDWM
take at breakfast and at dinner with food
RX *repaglinide 0.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Warfarin 7.5 mg PO DAILY16 leg clot
RX *warfarin 2.5 mg 3 tablet(s) by mouth once a day Disp #*21
Tablet Refills:*0
7. Glargine 22 Units Breakfast
RX *blood sugar diagnostic ___ Aviva Plus test strp] use
with glucose meter Disp #*100 Strip Refills:*0
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 22 Units before BKFT; Disp #*2 Package Refills:*0
RX *blood-glucose meter ___ Aviva Plus Meter] use as
directed Disp #*1 Each Refills:*0
RX *lancets ___ Softclix Lancets] as directed once a day
Disp #*100 Each Refills:*0
8. Docusate Sodium 100 mg PO BID
9. Ferrous GLUCONATE 240 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Levothyroxine Sodium 12.5 mcg PO DAILY
12. Lisinopril 10 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
14. Simethicone 120 mg PO QID:PRN constipation
15. Tamsulosin 0.4 mg PO QHS
16. HELD- CARVedilol 3.125 mg PO BID This medication was held.
Do not restart CARVedilol until you speak with your primary care
provider about why you were taking this medication.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES
=================
Gastrointestinal bleed
Deep venous thrombosis
Splenic Lesions
SECONDARY DIAGNOSES
====================
Type II Diabetes
Hypertension
History of subarachnoid hemorrhage
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 LEFT
INDICATION: History: ___ presenting with fall, LLE swelling from PCP // ?
DVT, ? fracture
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Left unilateral lower extremity ultrasound dated ___.
FINDINGS:
The proximal popliteal vein is noncompressible and demonstrates some
color-flow indicative of nonocclusive thrombus.
There is normal compressibility, color flow, and spectral doppler of the left
common femoral and femoral 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:
Nonocclusive deep venous thrombosis within proximal left popliteal vein.
Radiology Report
INDICATION: History: ___ presenting with fall, LLE swelling from PCP // ?
DVT, ? fracture
TECHNIQUE: Left knee, three views
COMPARISON: None.
FINDINGS:
The osseous structures are diffusely demineralized. No acute fracture or
dislocation. Small joint effusion. Minimal degenerative spurring is seen in
the medial compartment of the knee. Small superior patellar enthesophyte.
Mild prepatellar soft tissue swelling. No suspicious lytic or sclerotic
osseous abnormalities. No radiopaque foreign body or concerning soft tissue
calcification.
IMPRESSION:
No acute fracture or dislocation. Mild prepatellar soft tissue swelling.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with hx of traumatic subarachnoid hemorrhage in
___ // eval for interval change in sub arachnoid hemorrhage. Need to know
this in order to anticoagulated for a DVT
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 11.0 s, 18.7 cm; CTDIvol = 48.5 mGy (Head) DLP =
906.8 mGy-cm.
Total DLP (Head) = 917 mGy-cm.
COMPARISON: MRI ___
FINDINGS:
Along the left frontal convexity, there is an area of crescentic density
(series 606, image 35, series 605, image 15) with mild and asymmetric
expansion of the extra-axial space over the left frontal lobe (series 3, image
11, 21). This is consistent with a subdural hematoma with heterogeneous blood
products. There is a focal hypodensity at the inferior left frontal lobe near
the gyrus rectus which is concerning for a prior contusion injury. No large
territorial infarction or substantial midline shift. The ventricles and sulci
are in normal configuration for age.
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. Findings concerning for a likely chronic subdural hematoma with hypo and
hyperdense components, over the left frontal convexity. The hyperdense
components are age-indeterminate but cannot exclude an acute or subacute
process.
2. There is a focal hypodensity at the inferior left frontal lobe near the
gyrus rectus which is concerning for a prior contusion injury.
NOTIFICATION: The findings were discussed with ___, M.D. by ___.
___, M.D. on the telephone on ___ at 8:18 pm, 18 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: US NECK, SOFT TISSUE
INDICATION: ___ history of DM2, HTN, hx of large bowel obstruction
s/pcolostomy, poor social support at home, deficiencies in cognitive
functioning, recent trauamtic SAH and UTI with prolonged rehab course,
presenting from PCP for elevated blood glucose to 500-600s, anemia with c/f
GIB, and LLE DVT with general picture concerning for malignancy given R
cervical LN and cachexia. possibly also represents reactive LAD from dental
infection. Right sided firm cervical lymph node felt on exam
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right neck, in the region of patient's concern.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right neck. In the region of the patient's palpable abnormality, there is a
normal-appearing lymph node measuring up to 0.2 cm in short axis. No other
abnormalities are detected in the right neck.
IMPRESSION:
No abnormality detected in the imaged portion of the soft tissues of the right
neck.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with DVT and SDH started on heparin after
discussion with NSGY. now confirming no enlargement in SDH // eval for
interval change of SDH after therapeutic heparin levels.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.5 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
A small mixed density subdural hematoma along the left frontal cerebral
convexity is unchanged. No new sites of intracranial hemorrhage are
identified.
A small hypodense area in the left frontal lobe gyrus rectus is unchanged, and
likely reflects sequela of prior injury.
There is no evidence of fracture, acute infarction, edema,or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
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:
Stable small subdural hematoma along the left frontal cerebral convexity. No
new sites of intracranial hemorrhage.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ history of DM2, HTN, hx of large bowel obstruction
s/pcolostomy, cognitive decline, recent traumatic SAH and UTI with prolonged
rehab course, presenting hyperglycemia, anemia with c/f GIB, and LLE DVT. //
malignancy workup
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 69.7 cm; CTDIvol = 9.8 mGy (Body) DLP = 681.4
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 7.8 s, 0.5 cm; CTDIvol = 43.6 mGy (Body) DLP =
21.8 mGy-cm.
Total DLP (Body) = 705 mGy-cm.
COMPARISON: CT abdomen pelvis ___ and ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas is atrophic, without evidence of focal lesions or
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen is enlarged measuring up to 13.3 cm with multiple new
hypodense lesions throughout the spleen the largest measuring up to 2.5 cm
concerning for infiltrative process (2; 59).
ADRENALS: The right adrenal gland is normal in size and shape. There is mild
thickening of the left adrenal gland without discrete nodule.
URINARY: The right kidney is atrophic compared to the left. There is also
delayed nephrogram in the right kidney. Multiple subcentimeter hypodense
lesions in the left kidney are too small to characterize but similar to prior
(2; 62). There is no evidence of solid renal lesions or hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Patient is status
post sigmoid colectomy with a left lower quadrant colostomy. Rectal stump
appears unremarkable. The appendix is normal.
A low density structure adjacent to the right external iliac vessels measuring
3.2 x 1.8 x 2.4 cm (2; 95) may represent a lymphocele, stable since ___.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged.
LYMPH NODES: Multiple nonenlarged retroperitoneal lymph nodes are seen
measuring up to 1.1 cm (2; 67, 72), similar to prior. Multiple gastrohepatic
lymph nodes are seen measuring up to 0.9 cm (2; 57). There is 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.
There is scoliosis of the thoracolumbar spine with moderate multilevel
degenerative changes most notable at L4-L5 and L5-S1.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Interval enlargement of the spleen with development of multiple
hypoenhancing lesions measuring up to 2.5 cm concerning for infiltrative
process such as lymphoma or in the spectrum of extramedullary hematopoiesis.
Differential diagnosis includes abscesses
RECOMMENDATION(S): MRI could be considered for further evaluation of splenic
lesions
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ history of DM2, HTN, hx of large bowel obstruction
s/pcolostomy, cognitive decline, recent traumatic SAH and UTI with prolonged
rehab course, presenting hyperglycemia, anemia with c/f GIB, and LLE DVT. //
malignancy workup
TECHNIQUE: MD CT axial images of the chest were obtained following the
administration of intravenous contrast. Coronal, sagittal, and axial MIP
reformations were obtained and reviewed in PACS
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 69.7 cm; CTDIvol = 9.8 mGy (Body) DLP = 681.4
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 7.8 s, 0.5 cm; CTDIvol = 43.6 mGy (Body) DLP =
21.8 mGy-cm.
Total DLP (Body) = 705 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: None.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There are no suspicious thyroid
lesions warranting further imaging. There are multiple subcentimeter left
supraclavicular lymph nodes, not pathologically enlarged based on CT size
criteria. There is no axillary lymphadenopathy. There are no suspicious
chest wall lesions.
UPPER ABDOMEN: Please refer to separate report of CT abdomen and pelvis
performed on the same day for description of the subdiaphragmatic findings.
MEDIASTINUM: There is no mediastinal lymphadenopathy. There is no mediastinal
mass. The esophagus is unremarkable.
HILA: There is no hilar lymphadenopathy.
HEART and PERICARDIUM: The thoracic aorta is normal in caliber with mild
atherosclerotic calcifications of the aortic arch. There are mild coronary
artery atherosclerotic calcifications. There are moderate aortic and mitral
valve annular calcifications. The heart is normal in size. There is no
pericardial effusion.
PLEURA: There are small nonhemorrhagic bilateral pleural effusions. There is
no pneumothorax.
LUNG:
1. PARENCHYMA: There are no suspicious pulmonary lesions or nodules. There
is no parenchymal consolidation.
2. AIRWAYS: There is moderate bibasilar compressive atelectasis. Otherwise,
the airways are patent to the segmental bronchi bilaterally.
3. VESSELS: The pulmonary vasculature is unremarkable.
CHEST CAGE: There are multiple chronic healed left rib fractures. Although
there are no bone lesions in the imaged chest cage suspicious for malignancy
or infection, it should be noted that radionuclide bone and FDG PET scanning
are more sensitive in detecting early osseous pathology than chest CT
scanning.
IMPRESSION:
1. No evidence of intrathoracic malignancy.
2. Small bilateral pleural effusions with associated compressive atelectasis.
3. Please refer to separate report of CT abdomen and pelvis performed on the
same day for description of the subdiaphragmatic findings.
Radiology Report
EXAMINATION: SPLEEN ULTRASOUND
INDICATION: ___ year old man with spleen lesions, ?lymphoma vs mets //
limited abd U/S, feasability U/S to assess for splenic lesion for biopsy
TECHNIQUE: Feasibility ultrasound of the spleen
COMPARISON: CT abdomen from ___ and priors
FINDINGS:
Targeted exam demonstrates a top-normal spleen measuring 13.1 cm in the
craniocaudal axis. There are multiple hypo to anechoic variable-sized rounded
lesions throughout the spleen. No vascularity was noted within these lesions.
There was minimal internal complexity in the form of echogenic septate and
debris. There is a safe access route to biopsy these lesions.
IMPRESSION:
Multiple hypoechoic variable-sized rounded splenic lesions. These lesions are
amenable to ultrasound-guided biopsy.
Radiology Report
EXAMINATION: Ultrasound-guided targeted splenic biopsy
INDICATION: ___ with history of DM2, HTN, hx of large bowel obstruction s/p
colostomy, recent traumatic SAH who presented with acute on chronic anemia
with concern for GIB as well as LLE DVT. Colonoscopy on showed pouchitis and
colitis s/p biopsy. CT A/P showing "hypoenhancing splenic lesions measuring up
to 2.5 cm concerning for infiltrative process such as lymphoma." consult for
splenic lesion biopsy // splenic lesion biopsy. Please send a core needle
tissue for lymphoma protocol hematopathology and flow cytometry and also for
bacterial stain, culture and
COMPARISON: Ultrasound of ___, CT of the abdomen and pelvis of ___
PROCEDURE: Ultrasound-guided splenic lesion biopsy.
OPERATORS: Dr. ___, radiology trainee and Dr. ___, attending
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a right posterior oblique position on the ultrasound
scan table. Limited preprocedure ultrasound of the spleen was performed.
Based on the ultrasound findings an appropriate position for the biopsy was
chosen. The site was marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under continuous ultrasound guidance, a 17 gauge coaxial needle was
advanced to the target lesion. Through the coaxial needle, an 18 gauge core
biopsy device with a 22 mm throw was used to obtain 6 core biopsy specimens,
which were sent for pathology, cytogenetics, flow cytometry, and microbiology
evaluation.
As the coaxial needle was removed, Gelfoam was injected into the tract to
prevent further bleeding.
The procedure was tolerated well. Small amount of ___ hemorrhage
within the targeted lesion and splenic parenchyma was noted. There were no
immediate post-procedural complications.
SEDATION: Moderate sedation was provided by administering divided doses of 75
mcg fentanyl throughout the total intra-service time of 27 minutes during
which patient's hemodynamic parameters were continuously monitored by an
independent trained radiology nurse.
FINDINGS:
Multiple hypoechoic lesions were identified scattered throughout the spleen,
few of which show through transmission. Internal echoes were again noted. No
evidence of internal vascularity. One of the larger lesions was targeted for
ultrasound-guided biopsy, measuring 2.3 cm.
Immediate bleeding was noted within the targeted lesion as the coaxial needle
was brought into close approximation, suggestive of cystic rather than solid
content. 6 core biopsies were performed that yielded disintegrated
tissue/debris.
Postprocedural imaging shows echogenicity within the targeted lesion
consistent with hematoma. Echogenicity along the tract of the biopsy needle
relates to Gelfoam. No evidence of a postprocedural hematoma.
IMPRESSION:
1. Technically successful ultrasound-guided core biopsy of splenic lesion.
Immediate bleeding within the lesion at time of close approximation of the
biopsy needle is suggestive of cystic rather than solid content.
2. Mild periprocedural intraparenchymal hemorrhage. Otherwise no immediate
postprocedural complications.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hyperglycemia, Knee pain, s/p Fall
Diagnosed with Anemia, unspecified
temperature: 96.9
heartrate: 80.0
resprate: 18.0
o2sat: 96.0
sbp: 120.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | TRANSITIONAL ISSUES
===================
[ ] Discharge Hgb 8.2
[ ] Discharge Cr 1.1
[ ] Discharged on warfarin, though displayed poor understanding
of dosing of medication. Please closely follow his INR. Next INR
should be drawn on ___. He will require 3 months of
anticoagulation as provoked DVT (___). INR on discharge
2.0.
[ ] He has a history of medication noncompliance with his
diabetes regimen. ___ was consulted to try to simplify his
diabetes regimen, as detailed below. IF ___ follow up is
preferred, please contact ___ Central Appointment at (___) or email ___.
[ ] Please obtain repeat INR and FSBG on ___. We
discharged him on 7.5mg warfarin daily (for one week, please
adjust as indicated by INR), and added Repaglinide at dinnertime
to compensate for removal of dinnertime insulin.
[ ] Hep B nonimmune, so will need Hep B vaccine series
[ ] His spleen biopsy was nondiagnostic, and hematology oncology
recommended outpatient PET/CT scan. They have set up an
appointment and imaging time.
[ ] Can consider discontinuing PPI after 1 month (___)
if symptoms have resolved.
[ ] Need for tooth extraction, but is on warfarin now. Patient
has private dentist that he wants to see upon discharge.
Recommend at least 1 month of uninterrupted anticoagulation
(AC), though preferably should complete 3 month of AC and then
get dental procedure done. Patient should see outpatient dentist
post discharge and see how urgent this procedure is and what his
dentist recommends regarding timing off AC.
BRIEF HOSPITAL COURSE
======================
Mr. ___ is a ___ man with a history of type 2
diabetes, hypertension, large bowel obstruction s/p colostomy,
poor social support at home, deficiencies in cognitive
functioning, and recent traumatic subarachnoid hemorrhage who
presented with hyperglycemia, anemia with concern for
gastrointestinal bleed, and left lower extremity deep venous
thrombosis (DVT). For his DVT, he was started on a heparin drip
which was bridged to warfarin. He underwent colonoscopy with
biopsy, which showed pouchitis and colitis. He had a CT
abdomen/pelvis which showed multiple splenic lesions, which were
biopsied and nondiagnostic, prompting recommendation for further
outpatient work-up with hematology oncology. His diabetes
medication regimen was also optimized to maximize non-injectable
medications.
=============
ACUTE ISSUES
=============
#Provoked DVT
#Non-occlusive popliteal vein clot
Patient was found to have a non-occlusive popliteal vein clot,
considered provoked given recent hospitalization and prolonged
immobility. No evidence of pulmonary embolus. Given concern for
acute anemia, GIB with oozing colitis, risk of falls, and head
bleed, discussed anticoagulation with neurosurgery and GI teams
with plan to start heparin drip with subsequent coumadin bridge,
given easy reversibility of the latter. He was successfully
bridged to warfarin with 48 hour overlap period. Given history
of medication noncompliance with diabetes regimen, had
considered DOAC or Lovenox; however, neurosurgery, in the
context of head bleed, recommended against those agents, with
preference for warfarin, given easy reversibility. Will plan for
3 months of anticoagulation as provoked DVT.
#Iron Deficiency Anemia
#Gastrointestinal bleed
Patient admitted with Hgb 7.6, from 12.6 on ___, and
hematochezia. Patient was transfused as needed and remained
hemodynamically stable. Colonoscopy ___ showed pouchitis and
colitis up to cecum with terminal ileum sparing, with very
friable and oozing mucosa, concerning for IBD, and biopsy was
taken. Given cachexia/weight loss/lymphadenopathy and bright red
blood per rectum, there was also concern for malignancy;
however, no findings of mass seen on colonoscopy. CRP was
elevated at 75.2. Biopsy showed severely active chronic colitis,
without evidence of inflammatory bowel disease or malignancy. He
was placed on a proton pump inhibitor for a 1 month course, plan
to end ___.
#Severe Malnutrition
#Cervical Lymphadenopathy
#Splenic lesions
Patient was noted to have right-sided cervical lymphadenopathy
on exam. He has also had weight loss, which raises concern for
malignancy. He does also have poor dentition and supposed to get
teeth extracted so palpated LN could be reactive LAD. Neck U/s
on ___ showing normal-appearing LNs with no abnormality.
Colonoscopy did not show mass; it did show mucosal friability
and inflammation. CT A/P showed multiple hypoenhancing splenic
lesions measuring up to 2.5 cm concerning for infiltrative
process such as lymphoma or in spectrum of extramedullary
hematopoiesis. CT chest negative. LDH negative. Beta 2
macroglobulin mildly elevated. Splenic biopsy was inconclusive,
and hematology/oncology recommended outpatient PET/CT scan.
#Hyperglycemia
#Type 2 diabetes mellitus
Patient was admitted with significant hyperglycemia but no
evidence of DKA/HHS. He showed initial improvement with addition
of long acting insulin. Discharged home on Glargine 22u in the
morning and Repaglinide at breakfast and dinner.
#Tooth Pain
Patient reported significant left-sided dental pain. Poor
dentition on exam with gum tenderness, erythema, no clear
collection. Soft tissue swelling overlying. Patient needs teeth
extraction, but will defer to the outpatient. He completed a 5
day course of amoxicillin.
#H/o traumatic SAH
Patient has a small frontal SAH. Repeat imaging on admission and
upon reaching therapeutic heparin PTT was stable. No neurologic
deficits. Neurosurgery following, with discussion re:
anticoagulation as above. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: laparoscopic appendectomy
History of Present Illness:
Ms. ___ is a ___ year old woman with a PMH of IBS who presents
with 1 day of RLQ abdominal pain, N/V, and diarrhea. She states
that the pain started at 7AM yesterday in the RLQ. She initial
believed the pain was related to 'food poisoning', since a
friend
initially had similar symptoms following a shared meal. When her
symptoms did not improve, she presented to the ___ ED. A CT
A/P
showed appendicitis without evidence of abscess, phlegmon or
perforation. ACS was consulted for further management.
Upon initial assessment by ___, Ms. ___ reports mild RLQ
tenderness without continued nausea. She denies fever, chills,
shortness of breath, chest pain, or dysuria.
Past Medical History:
Past Medical History:
-IBS
Past Surgical History:
-Knee surgery
Social History:
Marital status: Single
Children: No
Work: ___
Multiple partners: ___
___ activity: Present
Sexual orientation: Male
Domestic violence: Denies
Contraception: OCPs
Tobacco use: Former smoker
Tobacco Use 1 pack per week for ___ year in ___
Comments:
Alcohol use: Present
drinks per week: ___
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Exercise: None
Seat belt/vehicle Always
restraint use:
Family History:
non-contributory
Physical Exam:
At admission:
97.7F, 70, 120/75, 16, 99% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Soft, non-distended, non-tympanic, mildly tender RLQ
Ext: No ___ edema, ___ warm and well perfused
At discharge:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Soft, non-distended, non-tympanic, appropriately TTP near
incisions, incisions c/d/I
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
CT A/P (___):
1. Enlarged fluid filled appendix, measuring up to 10 mm, with
associated fat stranding and hyper enhancement, compatible with
acute appendicitis. No evidence of perforation or abscess
formation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Do not exceed 4000 mg daily.
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
Do not drink alcohol or drive while taking this medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: NO_PO contrast; History: ___ with RLQ pain and leukocytosisNO_PO
contrast// evaluate for appendicitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 4.3 s, 47.4 cm; CTDIvol = 9.0 mGy (Body) DLP = 427.4
mGy-cm.
Total DLP (Body) = 436 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. Small hiatus hernia is present.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of 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 enlarged fluid filled
measuring up to 10 mm with associated hyper enhancement and mild fat
stranding, concerning for early acute appendicitis (series 601b: Image 18).
The appendix is retrocecal in origin and curves lateral to the colon. In
addition appendix appears adhesed to the colonic wall. There is no evidence
of perforation or abnormal fluid collection concerning for abscess formation.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: An IUD is noted in the uterus. The bilateral adnexa
appear 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.
No acute osseous findings are noted. There is a mild retrolisthesis of L3 on
L4 subtle retrolisthesis of L4 on L5.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Enlarged fluid filled appendix, measuring up to 10 mm, with associated fat
stranding and hyper enhancement, compatible with acute appendicitis. No
evidence of perforation or abscess formation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Unspecified acute appendicitis
temperature: 97.2
heartrate: 77.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 82.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ presented to ___ ED on ___ with abdominal pain.
CT scan showed acute appendicitis. She was given IV antibiotics
and taken to the Operating Room where she underwent a
laparoscopic appendectomy. For full details of the procedure,
please refer to the separately dictated Operative Report. She
was extubated and returned to the PACU in stable condition.
Following satisfactory recovery from anesthesia, she was
transferred to the surgical floor for further monitoring.
Diet was advanced to regular post-operatively which she
tolerated well. IV fluids were discontinued when oral intake was
adequate. Pain was well controlled with oral medication. She had
no issues voiding spontaneously and ambulating independently.
She was discharged home on ___ with instructions to follow up
in ___ clinic in 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Prozac / Penicillins
Attending: ___.
Chief Complaint:
Right hip valgus impacted femoral neck fracture
Major Surgical or Invasive Procedure:
Surgical fixation of right femoral neck fracture
History of Present Illness:
___ female hx of hypothyroidism, active smoker who
sustained a right hip injury after a mechanical fall earlier
today while walking. She states she experienced immediate pain
however was able to stand up and partially weight-bear albeit
with severe pain. She was initially brought to an outside
hospital by a friend where x-rays reportedly revealed a right
femoral neck fracture. Given patient's desire to be treated
elsewhere she was transferred to ___ for
further evaluation and management. Currently she states that
her
pain is well controlled at rest however she has severe pain with
movement of the hip. She denies any numbness tingling or
weakness in the foot. She is a community ambulator without
assistance. She lives alone.
Past Medical History:
ACNE
ANXIETY
CONSTIPATION
DEPRESSION
ERYTHEMA NODOSUM
FIBROCYSTIC CHANGES IN BREAST
HEALTH MAINTENANCE
HYPOTHYROIDISM
LOW BACK PAIN
MENOPAUSE
OSTEOARTHRITIS
OSTEOPOROSIS
TAH/BSO
TOBACCO USE
Social History:
___
Family History:
Noncontributory
Physical Exam:
Right lower exam
-dressing c/d/I
-fires ___
-silt s/s/sp/dp/t nerve distributions
-foot WWP
Medications on Admission:
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000
unit capsule. 1 capsule(s) by mouth once a day - (OTC)
IBUPROFEN - ibuprofen 600 mg tablet. tablet(s) by mouth three
times a day with food - (OTC)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ 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
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right valgus impacted femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP)
INDICATION: History: ___ with R fem neck fx// assess PNA/preOP, assess R fem
fx
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: Chest radiograph ___, CT chest ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are hyperinflated but clear. No
pleural effusion or pneumothorax is seen. There are no acute osseous
abnormalities. Clips are noted projecting over the breasts bilaterally.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: History: ___ with R fem neck fx// assess PNA/preOP, assess R fem
fx
TECHNIQUE: Right femur, two views
COMPARISON: Outside institution right hip radiographs from ___ at
10:24
FINDINGS:
An impacted oblique fracture through the subcapital femoral neck is
re-demonstrated with minimal medial displacement. No dislocation. Right hip
joint appears preserved. No diastases of the pubic symphysis or sacroiliac
joints. No concerning lytic or sclerotic osseous abnormality. Imaged right
knee is grossly unremarkable. Minimal vascular calcifications.
IMPRESSION:
Minimally displaced and impacted right subcapital femoral neck fracture.
Radiology Report
EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO RIGHT
INDICATION: RT HIP FX. ORIF
TECHNIQUE: Single intraoperative images obtained
COMPARISON: ___
IMPRESSION:
Fluoroscopic assistance was provided to the surgeon without the radiologist
present. These demonstrate 2 partially threaded screws transfixing the right
femoral neck.. The total intra-service fluoroscopic time was 70 seconds .
Please refer to the procedure note for additional details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Hip fracture, s/p Fall, Transfer
Diagnosed with Unsp intracapsular fracture of right femur, init for clos fx, Other fall on same level, initial encounter
temperature: 98.9
heartrate: 66.0
resprate: 18.0
o2sat: 97.0
sbp: 118.0
dbp: 51.0
level of pain: 0
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right valgus impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for surgical fixation
of right femoral neck fracture, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to 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 right lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right valgus impacted femoral neck fracture
Major Surgical or Invasive Procedure:
CRPP of right valgus impacted femoral neck fracture
History of Present Illness:
She was at a ___ when she stepped over the
pelvic rope, and tripped. She felt immediate pain and presented
to ___ where ___ was placed and she was
attempted to transfer out last night but was unable to due to
the weather for her femoral neck fracture diagnosed on plain
films. She has been stable since then. She otherwise feels
well without fever chills sweats nausea vomiting or diarrhea.
Past Medical History:
Chronic low back pain
Social History:
___
Family History:
non contributory
Physical Exam:
Vitals: ___ 0718 Temp: 98.3 PO BP: 90/51 R Lying HR: 68 RR:
18 O2 sat: 97% O2 delivery: ra
General: Well-appearing, breathing comfortably
MSK:
Right lower extremity:
- Dressing C/D/I
- No erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 12:45PM URINE HOURS-RANDOM
___ 12:45PM URINE UHOLD-HOLD
___ 12:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:45PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 12:45PM URINE RBC-19* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 12:45PM URINE MUCOUS-RARE*
___ 12:40PM GLUCOSE-119* UREA N-15 CREAT-0.6 SODIUM-140
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-10
Medications on Admission:
Trazodone, Celebrex
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 1 (One) syringe subcutaneous once a
day Disp #*30 Syringe Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*15 Capsule Refills:*0
5. Senna 8.6 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right valgus impacted femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right hip fracture. ORIF.
COMPARISON: Radiographs from ___
IMPRESSION:
Intraoperative images demonstrate placement of three cannulated screws
fixating a femoral neck fracture. No hardware related complications are seen.
Total intra service fluoroscopic time is 89.9 seconds. Please refer to the
operative note for additional details.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: R Femur fracture, s/p Fall
Diagnosed with Unsp fracture of right femur, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 98.1
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 119.0
dbp: 56.0
level of pain: 5
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right valgus impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for CRPP, 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
weight bearing as tolerated in the right lower extremity, and
will be discharged on Lovenox 40mg daily 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:
Penicillins / Fenofibrate / STEROIDS / Wellbutrin / lobsters /
crabs
Attending: ___
Chief Complaint:
Mild confusion and unsteady gait.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo M with a PMHx of stage IV adenocarcinoma of the
lung s/p ___ with progression now with brain
met's who s/p multiple cycles of brain XRT who p/w unsteady gait
and mild confusion.
.
The patient had a prior admission ___ to ___ with
similar complaints of AMS and confusion. At that time the
patient was found to have a Na of 119 and without intervention,
AMS resolved without intervention. Na was 130 on d/c.
.
Several days prior to admission, the patient wife reports mild
confusion and the patient to have a "temper" which isn't typical
for the patient. She also reports an unsteady gait, without
falls or head trauma. This gait is improved from prior
admissions but has never returned to normal. Over the last few
days the patient has devloped coughing (without blood) and
wheezing. The patient last dose of XRT was ___ and last dose
of chemo was ___. The patient currently endorses a frontal
h/a, ___ in nature without changes in vision. The patient also
reported bilateral rib pain last ___ which resolved with po pain
medications. The patients last BM was yesterday and was
non-bloody.
.
The patient reported to his Oncologists office today and was
found to have a Na of 118 and came to the ED. In the Ed they
gave the patient IVF's and sent him to the floor.
.
12 point ros is otherwise negative.
Past Medical History:
Stage IV Adenocarcinoma lung (KRAS wild-type;EGFR negative; ALK
rearrangement unknown)
Oncologic history:
- ___ - Imaging of the back for severe back pain revealed
metastatic vertebral lesions
- ___ - Biopsy of L2 lesion consistent with metastatic
carcinoma positive for CK7 and TTF-1.
- Staging scans revealed primary lesion in the right lower lobe
and right hilum with mediastinal lymphadenopathy, lung lesion in
the left lower lobe, liver lesion, left adrenal lesion, and
multiple bone lesions. No brain lesions.
- ___ - Carboplatin (6 AUC)/Paclitaxel (200
mg/m2)/Bevacizumab (15 mg/kg) initiated (C1D1)
- ___ - C2D1 ___
- ___ - Palliative radiotherapy to lumbosacral vertebrae.
- ___ - C3D1 ___ (Bevacizumab held as patient
receiving radiation treatment)
- ___ - C4D1 ___
- ___ - C5D1 ___
- ___ - ___ C1-6 Maintenance Bevacizumab (15 mg/kg)
- ___ - MRI brain revealed metastatic lesions to the brain.
Presented with gait changes and headaches.
- ___ - whole brain radiation, completed 10 cycles. Also with
dexamethasone PO
- ___ - C1D1 of pemetrexed
- ___ - admission for hyponatremia not responsive to fluid
restriction/salt tabs, discharged on lasix
.
Other medical history:
1) Hypertension
2) Hyperlipidemia
3) Vitamin D deficiency
4) Bronchial asthma
5) Allergic rhinitis/sinusitis
6) Monoclonal gammopathy
Social History:
___
Family History:
His mother died at the age of ___ nine of unknown causes. His
father died at the age of ___ of emphysema. He has a sister who
is ___ years old and is well.
Physical Exam:
Admission PE:
97.0 140/82 80 18 98% on RA w-153.8
General:AAOX3 in NAD
HEENT: OP clear, MMM
Neck: no obvious LAD, no thryoid masses
CV: RRR, no RMG
Lungs: CTAB, no wrr
Abdomen: NT, obese, active BS X4 no HSM
Extremities: no edema, pulses 2+ and equal, WWP
Derm: no obvious rashes
Psyc: thought processing is slightly delayed but linear, mood
and affect is wnl
Neuro: CN and MS wnl, strength and sensation wnl, FTN also wnl
.
Discharge Exam:
Vitals: 98.2 122/70 68 18 95% RA
GEN: AOx3, normal gait, NAD
otherwise unchanged
Pertinent Results:
ADMISSION LABS:
___ 03:00PM PLT SMR-LOW PLT COUNT-99*
___ 03:00PM NEUTS-85.6* LYMPHS-7.5* MONOS-5.7 EOS-0.9
BASOS-0.2
___ 03:00PM WBC-7.1# RBC-3.78* HGB-11.9* HCT-37.2*
MCV-99* MCH-31.6 MCHC-32.1 RDW-14.1
___ 03:00PM SODIUM-118* POTASSIUM-4.2 CHLORIDE-84*
___ 06:59PM PLT COUNT-98*
___ 06:59PM NEUTS-88.5* LYMPHS-8.4* MONOS-1.9* EOS-0.9
BASOS-0.3
___ 06:59PM CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-1.9
___ 06:59PM CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-1.9
___ 06:59PM estGFR-Using this
___ 06:59PM GLUCOSE-93 UREA N-10 CREAT-0.6 SODIUM-120*
POTASSIUM-4.0 CHLORIDE-84* TOTAL CO2-30 ANION GAP-10
___ 07:21PM NA+-122*
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-6.8 RBC-3.90* Hgb-12.0* Hct-37.8*
MCV-97 MCH-30.9 MCHC-31.8 RDW-15.0 Plt ___
___ 07:05AM BLOOD Glucose-81 UreaN-17 Creat-0.6 Na-131*
K-4.0 Cl-93* HCO3-30 AnGap-12
___ 07:05AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.3
ENDOCRINE:
___ 07:32AM BLOOD T4-5.7 T3-77* Free T4-1.1
___ 07:32AM BLOOD TSH-2.1
___ 07:54AM BLOOD Cortsol-4.8
IMAGING:
___ CXR: New patchy left infrahilar opacity concerning for
possible
pneumonia. Followup radiographs may be helpful in this regard.
MICROBIOLOGY:
NONE
Medications on Admission:
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily
CLONAZEPAM - 1 mg Tablet - ___ Tablet(s) by mouth qhs prn
DEXAMETHASONE - 2 mg po QD
FLUTICASONE - (Prescribed by Other Provider) - 50 mcg Spray,
Suspension - 1 spray(s) in each nostril daily as needed
FOLIC ACID - 1 mg Tablet - One Tablet(s) by mouth Daily
HYDROMORPHONE - 2 mg Tablet - 1 Tablet(s) by mouth every four
(4)
hours as needed for moderate to severe pain
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puff inhalation q ___ hrs prn
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one
Capsule(s) by mouth once a day
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every 6 hours as needed for nausea
ROSUVASTATIN [CRESTOR] - 40 mg Tablet - 1 Tablet(s) by mouth at
bedtime
SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth once
a
day as needed
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet
-
1 to 2 Tablet(s) by mouth every ___ hours DO NOT EXCEED 3 GMS
ACETAMINOPHEN IN 24 HOURS
ASPIRIN - (Prescribed by Other Provider: Dr. ___ - 81
mg
Tablet, Chewable - 1 Tablet(s) by mouth daily
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
2,000 unit Tablet - 4 Tablet(s) by mouth daily (8000 IU daily)
LORATADINE [CLARITIN] - (Prescribed by Other Provider) - Dosage
uncertain
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other
Provider) - Dosage uncertain
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Prescribed by Other
Provider) - Dosage uncertain
SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg
Tablet - ___ Tablet(s) by mouth at bedtime as needed
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for insomnia.
3. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day) as needed for congestion.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for moderate to severe pain.
6. Combivent ___ mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation every ___ hours as needed for shortness of breath or
wheezing.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
9. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. sildenafil 100 mg Tablet Sig: One (1) Tablet PO once a day
as needed.
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Vitamin D3 2,000 unit Tablet Sig: Four (4) Tablet PO once a
day.
13. loratadine 5 mg Tablet, Chewable Sig: ___ Tablet, Chewables
PO every eight (8) hours as needed for allergy symptoms.
14. Fish Oil Oral
15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
16. senna 8.6 mg Tablet Sig: ___ Tablets PO at bedtime as needed
for constipation.
17. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six
(6) hours as needed for pain.
18. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO once a
day.
19. Hospital Bed
Patient with metastatic non small cell lung carcinoma to brain
and spine, and also with history of falls, would require
hospital bed for safety.
20. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
21. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day: for total
of 10 mg per day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: toxic metabolic encephalopathy due to
hyponatremia, syndrome of inappropriate anti-diuretic hormone
Secondary Diagnosis: metastatic lung cancer with brain
metastases, hypertension, hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PA AND LATERAL CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Heart size is normal, and mediastinal and hilar contours are
unchanged. Lungs remain hyperinflated with attenuation of upper lobe vessels
suggesting the presence of emphysema and chronic obstructive pulmonary
disease. New patchy opacity has developed in the left infrahilar region, and
lungs otherwise appear clear. No pleural effusion. Compression deformity
with sclerosis in the mid thoracic spine as well as additional mild
compression deformity at the thoracolumbar junction appear unchanged.
IMPRESSION: New patchy left infrahilar opacity concerning for possible
pneumonia. Followup radiographs may be helpful in this regard.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: HYPONATREMIA
Diagnosed with HYPOSMOLALITY/HYPONATREMIA, SEC MAL NEO BRAIN/SPINE, HX-BRONCHOGENIC MALIGNAN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 99.0
heartrate: 103.0
resprate: 16.0
o2sat: 94.0
sbp: 135.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES:
[ ] Chem 7 check on ___ with Dr. ___. Patient
instructed to call Dr. ___ office on ___ morning to
make an appt.
==================================
Mr. ___ is a ___ M w h/o metastatic lung ca s/p ___
sessions total brain irradiation presenting with acute
confusion/MS changes, found to have hyponatremia. His
hyponatremia was thought to be due to SIADH and treated with
volume restriction and salt tabs without much improvement.
Demeclocycline was tried without effect. Patient responded well
to tolvaptan, however, given the cost, there was no feasible way
that the patient could be on it as an outpatient. He was started
on lasix and fluid restriction and his sodium remained stable.
# Hyponatremia: Most likely due to SIADH ___ lung cancer and
brain metastasis (similar presentation as last admission, and
improved with fluid restriction and salt tabs at that time).
Given FeNA of <1% during this admission, he was fluid challenged
without improvement. Other causes of hyponatremia was checked
and his TFT panel was wnl except for slightly low T3, and AM
cortisol was slightly low, but thought to be due to
dexamethasone he is on. As his Na did not improve on 1L fluid
restriction daily and salt tabs, he was started on
democlocycline without effect. Renal was consulted and
recommended trial of tolvaptan, which increased his Na to 136
(from 122). However, patient could not afford the medication as
outpatient, so he was changed to lasix with ___ L fluid
restriction and his Na remained stable in low 130s. His mental
status remained clear throughout.
# Toxic metabolic encephalopathy from hyponatremia: Confused on
initial presentation, most likely related to hyponatremia. As
his sodium improved and remained in 120s, he felt well with
resolution of confusion, and remained AOX3.
# Brain metastases: Had recently completed his outpt course of
whole brain radiation for brain mets. He was continued on
dexamethasone 2 mg daily per outpt taper, with pulse dosing for
his pemetrexate. He was tapered down to dexamethasone 1 mg daily
prior to discharge and will follow further instruction from Dr.
___ his taper.
# Metastatic lung adenocarcinoma: Diagnosed in ___ with
metastatic disease to vertebrae. Brain mets found in ___ and
treated with a course of whole brain radiation, and started on
Pemetrexed (last dose ___. Further treatment per outpatient
oncologist (Dr. ___
# Reported unsteady gait without falls: patient was evaluated by
physical therapy and was cleared to go home with home physical
therapy. |
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 and deformity post fall
Major Surgical or Invasive Procedure:
ORIF left ankle fx
History of Present Illness:
This is a ___ who sustained a fall while climbing down a
ladder earlier today. Patient states his ladder slipped, and
while he was sliding down, his L foot was caught inbetween the
ladder rungs. He denies any headstrike, LOC or other injuries.
He
had immediate pain and obvious deformity in his L ankle and was
unable to ambulate. He was taken urgently to the ___ ED where
clinical exam and imaging demonstrated a closed fracture
dislocation of the L ankle. He was NV intact on arrival.
Orthopedics was consulted for further management.
Past Medical History:
PMH: CAD sp 5 stents in ___, HL, HTN
Social History:
___
Family History:
Non contributory
Physical Exam:
AFVSS
Gen: A&Ox3, NAD
Neuromuscular: LLE bivalve cast in place, SILT sp/dp, ___,
WWP, incisions c/d/i, dressings c/d/i
Pertinent Results:
Ankle (AP, Mortise, Lat) ___: IMPRESSION: Status post ORIF
medial malleolar and distal fibular fractures,
in overall anatomic alignment.
Ankle AP/Lat ___: FRONTAL, LATERAL AND OBLIQUE VIEWS OF THE
LEFT LEFT LOWER EXTREMITY: There is
a transverse fracture through the distal fibular diaphysis with
apex medial
angulation and superior displacement. There is also an impacted
fracture of
the medial tibial epiphysis. In addition, a displaced fracture
through the
medial malleolus is present. The posterior malleolus is intact.
The ankle is
dislocated and the syndesmosis is widened. There is soft tissue
swelling. No
other fracture is identified, particularly, the talus appears
intact.
___ 10:40AM ___ PTT-25.0 ___
___ 10:40AM PLT COUNT-217
___ 10:40AM NEUTS-50.8 ___ MONOS-12.2* EOS-0.2
BASOS-0.6
___ 10:40AM WBC-7.4 RBC-4.84 HGB-15.2 HCT-42.9 MCV-89
MCH-31.5 MCHC-35.5* RDW-13.6
___ 10:40AM estGFR-Using this
___ 10:40AM GLUCOSE-145* UREA N-18 CREAT-1.1 SODIUM-138
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
___ 10:49AM LACTATE-2.1*
___ 10:49AM COMMENTS-GREEN TOP
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO EVERY OTHER DAY
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amlodipine 10 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours as
needed for pain control Disp #*60 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice daily as
needed for pain control Disp #*14 Capsule Refills:*0
5. Cephalexin 500 mg PO Q12H
RX *cephalexin 500 mg 1 capsule(s) by mouth Twice daily for 10
days Disp #*20 Capsule Refills:*0
6. Atorvastatin 40 mg PO DAILY
7. Clopidogrel 75 mg PO EVERY OTHER DAY
8. Enoxaparin Sodium 40 mg SC DAILY Duration: 10 Days Start:
___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sub-q Daily for 10 days Disp
#*10 Syringe Refills:*0
9. Lisinopril 20 mg PO DAILY
10. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
L bimalleolar ankle fracture-dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Left ankle deformity, evaluate for fracture.
COMPARISON: None.
FRONTAL, LATERAL AND OBLIQUE VIEWS OF THE LEFT LEFT LOWER EXTREMITY: There is
a transverse fracture through the distal fibular diaphysis with apex medial
angulation and superior displacement. There is also an impacted fracture of
the medial tibial epiphysis. In addition, a displaced fracture through the
medial malleolus is present. The posterior malleolus is intact. The ankle is
dislocated and the syndesmosis is widened. There is soft tissue swelling. No
other fracture is identified, particularly, the talus appears intact.
Radiology Report
INDICATION: Post-reduction radiographs.
COMPARISON: Pre-reduction radiograph 10:35 a.m. today.
FRONTAL, LATERAL, AND OBLIQUE VIEWS OF THE LEFT LOWER EXTREMITY (FIVE IMAGES):
The ankle is in near anatomic alignment after reduction. Again, a transverse
fracture through the distal fibular diaphysis with minimal anteromedial
displacement is noted. A fracture of the medial malleolus is unchanged.
Osseous detail is obscured by the overlying cast.
The knee is intact. There is no suprapatellar joint effusion.
Radiology Report
INDICATION: Left ankle fracture.
COMPARISON: ___.
THREE TOTAL VIEWS OF THE LEFT ANKLE
There is a plate and screws transfixing the distal fibular fracture in good
alignment. There are two syndesmotic screws as well as two cannulated screws
transfixing the medial malleolar fracture. The alignment is overall
unchanged. The total fluoroscopic time is 60.2 seconds. For further details,
please see the intraoperative report.
Radiology Report
HISTORY: Left ankle fracture status post ORIF.
LEFT ANKLE, THREE VIEWS.
Cast or splint is in place, considerably limiting assessment of fine bony
detail. The patient is status post ORIF of distal fibular and medial
malleolar fractures. The fracture lines remain visible. No hardware
loosening or failure is detected. Overall alignment is anatomic, markedly
improved compared with pre-operative films from ___. Mortise is grossly
congruent. Some degenerative spurring and possible subchondral sclerosis
about the tibiotalar joint is noted. Surrounding soft tissue swelling noted.
IMPRESSION: Status post ORIF medial malleolar and distal fibular fractures,
in overall anatomic alignment.
Radiology Report
INDICATION: Fall from ladder. Evaluate for a traumatic injury.
COMPARISONS: None.
PORTABLE FRONTAL VIEW OF THE CHEST: No pleural effusions, pneumothorax or
focal airspace consolidations. Heart size is normal. There is no definite
widening of the mediastinum which shows sharp margins. There is no displaced
fracture evident. If concern for an aortic injury persists, cross-sectional
imaging would be recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with FX BIMALLEOLAR-CLOSED, FALL-1 LEVEL TO OTH NEC
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 left bimalleolar ankle
fracture-dislocation and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for ORIF left ankle fx, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with ___ as decided after ortho follow up was appropriate. The
patient was kept until ___ to evaluate his soft tissues.
Silvadine cream was applied to the blisters and soft tissues on
___ before redressing and applying the bivalve cast. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non weight bearing in the left
lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: 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:
___ yo female with history of ileocolonic Crohn's disease s/p
laparoscopic left hemicolectomy, proctectomy, end colostomy and
subsequent completion colectomy with end ileostomy on ___
currently on tofacitinib 5mg bid since ___ with last
steroid use in ___ presenting with recurrent abdominal pain.
She has also had multiple ileostomy revisions, two in the past
year, and the last of which was in ___, with a revision of
the ileostomy and debridement/drainage of abscess/fistula. She
had a hospital admision in ___ for partial small bowel
obstruction, and following a normal ileoscopy on ___, was
discharged on home tofacitinib after bowel rest, antiemetics and
pain control. She was readmitted in early ___ for similar
symptoms. Ileoscopy at that time noted that the stoma appeared
narrow but was easily palpated on exam. She has been scoped
through these episodes without evidence of recurrent disease or
fixed obstruction of her ileostomy (and does feel better
thereafter), however there may be some mechanical kinking in
conjunction with her delayed small bowel emptying due to
narcotics. She was seen by Dr. ___ her second admission
and discharge on ___.
Currently, she reports this episode started on ___. She
notes abdominal pain at the site of her stoma when food passes
through the stoma. She notes associated nausea and vomiting
with chills but no fevers. She reports emptying her bag ___
per day which decreases to ___ empties per day when the episodes
occur. She also notes increased bloating with abdominal
pressure recently, even in between the acute pain episodes and
unrelated to eating. She started on liquids and applesauce only
but her pain increased yesterday morning and so came to the ED
on ___. She notes low energy and a ___ weight loss in the
past ___ weeks. She denies any EIM's including rash, joint
pain, or eye problems. She notes chronic low level LLQ
discomfort at the site of her prior stoma. She denies any
antibiotics, sick contacts, or recent travel. She denies any
dysuria or back pain.
Of note there have been two recent deaths in her family. Stress
and frustration have been contributing to the overall picture.
ROS: A 10 point review of systems was performed in detail and
negative except as noted in the HPI.
Past Medical History:
-Ileocolonic Crohn's Disease dx age ___, failed treatment with
Remicade, ___, Humira and Tysabri, rectovaginal fistula s/p
laparoscopic diverting ileostomy ___, laparoscopic left
hemicolectomy, proctectomy and excision of anus, with
end-colostomy and takedown ileostomy ___, s/p laparoscopic
completion colectomy with end-ileostomy ___, s/p revision
ilestomy ___ and s/p Revision of ileostomy and debridement
and drainage of abscess cavity ___. Currently on tofacitinib
5mg bid since ___.
-Pyoderma gangrenosum at stoma, resolved
-Migraines
-Osteomyelitis of left leg at age ___ due to complication of a
broken bone
-Remote history of H. Pylori
-Prior DVT
-Allergic rhinitis
-TMJ
-Transvaginal revision of levatorplasty (release of mid vaginal
band) ___.
Social History:
___
Family History:
Mother and cousin with Crohn's disease. No family history of
colorectal cancer.
Physical Exam:
Admission Exam:
VS: 99.6 97.5 116/80 80 18 98% on RA ___ 75.4kg
GENERAL: NAD. Comfortable laying in bed
Eyes: Anicteric without conjunctival injection
ENT: MMM. No oral lesions
NECK: Supple.
___: RRR, no m/r/g
LUNGS: CTAB, no w/r/c
ABDOMEN: normoactive bowel sounds, soft, mildly distended
throughout, tender over llq old ostomy site with scar tissue
appreciated, current stoma pink and easily palpated without
stricture, erythema surrouding stoma is clean and without
induration, voluntary guarding, no rebound tenderness
SKIN: Warm. Dry.
NEURO: [x] Oriented x3 [x] Fluent speech
Psych: [x] Alert [x] Calm
Discharge exam:
Exam:
VS: 98.0 BP:95/59 HR:72 RR:16 O2:97%RA. Pain: ___
Gen: Sleeping but easily arousable. A&Ox3
HEENT: MMM, EOMI. NCAT
CV: RRR. No M/R/G.
Resp: CTAB. Good air entry.
GI: BS+4. Non-tender. No rebound or guarding.
Ext: No c/c/e
Psych: appropriate and pleasant
Pertinent Results:
Admission Labs:
CBC: 8.5 > 13.6/41.5 < 611 MCV 78
N:75.8 L:15.5 M:7.4 E:1.0 Bas:0.4
138 102 11
------------<
4.1 20 1.0
ALT: 81 AST: 37 AP: 143 Tbili: 0.2 Alb: 4.8
Lip: 43
Lactate 1.4
UA 16 WBC +leuks no bacteria -nitrates
CRP: 32.5 -->2.9
___ KUB: Largely gasless bowel, which is not specific,
without convincing evidence for obstruction, although it cannot
be excluded. No free air identified.
MRE:
MR ENTEROGRAPHY:
The patient is status post total colectomy. Ileostomy is present
in the right lower quadrant. The last 9 cm of the distal ileum
proximal to the ileostomy demonstrates mild circumferential wall
thickening with mild transmural hyper enhancement, but no
significant mural edema, mural stratification or adjacent fat
stranding. There is no evidence of fistulas or intraabdominal
abscess. No bowel obstruction or stricture is demonstrated.
Overall, this finding appears relatively unchanged compared to
the previous CT from ___.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Visualized portions of the liver have homogeneous signal and
enhancement. 1.3 cm T2 hyperintense nonenhancing cystic lesion
in segment IV is consistent with ciliated foregut cyst. There is
no intra or extra-hepatic biliary dilatation. The gallbladder
is normal.
The pancreas is normal in size and signal, without focal mass or
ductal
dilatation. The kidneys and adrenals are unremarkable.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The bladder is normal. IUD is present in the endometrial
cavity. The uterus and adnexa appear normal.
There is no free fluid in the abdomen and pelvis.
Multiple mesenteric subcentimeter lymph nodes are demonstrated
(11:83), in keeping with chronic bowel disease.
The bone marrow signal is normal.
IMPRESSION:
Predominantly chronic inflammatory bowel disease involving the
distal 9 cm of ileum from the level of the ileostomy. These
findings appear unchanged from the prior CT from ___.
No evidence of abscess, fistula formation, or obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Sumatriptan Succinate 100 mg PO DAILY:PRN headache
3. Xeljanz (tofacitinib) 5 mg oral BID
4. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
5. cranberry 0 2 ORAL DAILY
6. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
7. Multivitamins 1 TAB PO DAILY
8. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 0 1 ORAL DAILY
9. Lorazepam 1 mg PO BID:PRN anxiety
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. Lorazepam 1 mg PO BID:PRN anxiety
3. Multivitamins 1 TAB PO DAILY
4. Sumatriptan Succinate 100 mg PO DAILY:PRN headache
5. Xeljanz (tofacitinib) 5 mg oral BID
6. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
7. cranberry 0 2 ORAL DAILY
8. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 0 1 ORAL DAILY
9. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
Do not take this medication and drive
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, possibly due to partial small bowel obstruction
Crohn's disease
Anemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___
INDICATION: ___ year old woman with ileocolonic Crohn disease status post
completion colectomy and ileostomy with 2 revisions this past year on
tofacitinib since ___ now with 3 episodes of recurrent abdominal pain.
TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis
were acquired within a 1.5 T magnet, including 3D dynamic sequences performed
prior to, during, and following the administration of 0.1 mmol/kg of Gadavist
intravenous contrast (7 cc). Oral contrast consisted of 900 mL of VoLumen. 1.0
mg of Glucagon was administered IM to reduce bowel peristalsis.
COMPARISON: CT from ___. MRI from ___.
FINDINGS:
MR ENTEROGRAPHY:
The patient is status post total colectomy. Ileostomy is present in the right
lower quadrant. The last 9 cm of the distal ileum proximal to the ileostomy
demonstrates mild circumferential wall thickening with mild transmural hyper
enhancement, but no significant mural edema, mural stratification or adjacent
fat stranding. There is no evidence of fistulas or intraabdominal abscess. No
bowel obstruction or stricture is demonstrated. Overall, this finding appears
relatively unchanged compared to the previous CT from ___.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Visualized portions of the liver have homogeneous signal and enhancement. 1.3
cm T2 hyperintense nonenhancing cystic lesion in segment IV is consistent with
ciliated foregut cyst. There is no intra or extra-hepatic biliary dilatation.
The gallbladder is normal.
The pancreas is normal in size and signal, without focal mass or ductal
dilatation.
The kidneys and adrenals are unremarkable.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The bladder is normal. IUD is present in the endometrial cavity. The uterus
and adnexa appear normal.
There is no free fluid in the abdomen and pelvis.
Multiple mesenteric subcentimeter lymph nodes are demonstrated (11:83), in
keeping with chronic bowel disease.
The bone marrow signal is normal.
IMPRESSION:
Predominantly chronic inflammatory bowel disease involving the distal 9 cm of
ileum from the level of the ileostomy. These findings appear unchanged from
the prior CT from ___. No evidence of abscess, fistula formation,
or obstruction.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, SBO
Diagnosed with ABDOMINAL PAIN UNSPEC SITE, REGIONAL ENTERITIS NOS
temperature: 99.3
heartrate: 117.0
resprate: 18.0
o2sat: 96.0
sbp: 97.0
dbp: 73.0
level of pain: 7
level of acuity: 3.0 | ___ yo female with history of ileocolonic Crohn's disease s/p
laparoscopic left hemicolectomy, proctectomy, end colostomy and
subsequent completion colectomy with end ileostomy on ___ and
revisions in ___ and ___ currently on tofacitinib 5mg bid
since ___ presenting with recurrent abdominal pain.
#Abdominal pain, possible small bowel obstruction:
She has had three episodes of abdominal pain over the past 6
weeks. She has been scoped through these episodes without
evidence of recurrent disease or fixed obstruction of her
ileostomy, however there may be some mechanical kinking in
conjunction with her delayed small bowel emptying due to
narcotics. Recurrent Crohn's proximal to the points evaluated
by ileoscopy is also possible especially in the setting of
microcytosis, thrombocytosis, and elevated CRP. She was followed
by gastroenterology while hospitalized. The patient underwent
MRE without evidence of active inflammation. She was treated
with bowel rest, IVF and pain medications with improvement in
her symptoms. Her CRP trended down to 2.9 without intervention.
LFTs were rechecked and trended down. It is possible that her
symptoms were due to intermittent partial SBO which resolved
during the course the patient's hospitalization. Pain control
was challenging but was ultimatley achieved with liquid
oxycodone. She was tolerating a regular diet prior to discharge.
# Chronic LLQ pain at site of prior stoma. Differential
includes fibrous tissue with nerve involvement versus fistulous
disease, the latter of which would necessitate switch to another
medication for Crohn's disease.
-ultrasound of the abdominal wall to evaluate for fistulous
disease (may be done as outpatient)
# Ileocolonic Crohn's disease on tofacitinib
Continued tofacitinib
# Transaminitis.
Resolved without intervention
#Microcytosis without anemia.
___ be due to chronic inflammmation. Consider further w/o if
persists.
# Depression
Patient was intermittently tearful, and labile. She was seen by
social work for coping support and encouraged to follow up with
her outpatient therapist. Citalopram and lorazepam were
continued |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx A Fib, diastolic CHF, radiation-cystitis, and
recent admission for trochanteric bursitis who presents with
fever to 101.8 from Rehab. Patient was recently discharged for
trochanteric bursitis here at ___. He was evaluated by an MD
at rehab and found to be febrile with increased confusion. He
continues to have hip pain, but denies any subjective fevers,
chills, cough, chest pain, abdominal pain, dysuria, nausea,
vomiting or diarrhea.
___ the ED, initial vitals 99 88 97/44 16 95%. Patient febrile to
101.8, ___ A Fib with HR's ___ ___, his R hip was notable
for slight decrease range of motion but no masses and no
external cellulitis. Per the ED resident pressure dropped to the
low 80's and may have been related to getting narcotics. He
refused a central line. He received 2L of NS and his pressures
improved. He was given vanc/cefepime. His labs were notable for
WBC of 15.9, lactate of 2.6, BUN/Creat of 39/1.2, K of 5.5, UA
of >70 WBCs, with positive leuk esterase and negative nitrites.
On arrival to the MICU, patient was complaining of minimal R hip
pain. He denied coughs/fevers. He was complaining of acute onset
dysphagia to both solids/liquids, the exact time course was
uncertain.
Past Medical History:
HYPERTENSION - ESSENTIAL
OSTEOARTHRITIS, UNSPEC
COLONIC POLYP
Anemia, vitamin B12 deficiency
CANCER - PROSTATE, s/p XRT
OCULAR HYPERTENSION
THYROID NODULE
RHINITIS - ALLERGIC, UNSPEC CAUSE
ATRIAL FIBRILLATION
dCHF, chronic
Gait abnormality
Cerebrovasc disease
Ventral hernia
Social History:
___
Family History:
His sons all died of complications of contaminated blood
transfusions as they were hemophiliacs.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.6 BP: P: 111/51 84 R: 28 O2: 98%
General- Confused, oriented x3
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Crackles at left lung from mid lung to lower base, no
wheezes, rales, ronchi
CV- Irregular irregular, normal S1 + S2, ___ SEM
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- RLE: ___ hip flexor and extensor strength, limited by right
lateral hip pain. ___ leg flexion and extension. ___ LLE. No
tenderness to palpation over IT band right greater trochanter.
No
tenderness to palpation along the spinal column.
Neuro- CNs2-12 intact
Pertinent Results:
ADMISSION LABS:
___ 03:00PM BLOOD WBC-15.9*# RBC-3.83* Hgb-12.4* Hct-39.1*
MCV-102* MCH-32.4* MCHC-31.7 RDW-13.8 Plt ___
___ 03:00PM BLOOD Neuts-89.3* Lymphs-4.8* Monos-5.6 Eos-0.1
Baso-0.1
___ 03:00PM BLOOD Plt ___
___ 03:00PM BLOOD Glucose-126* UreaN-39* Creat-1.2 Na-131*
K-5.5* Cl-94* HCO3-25 AnGap-18
___ 03:00PM BLOOD ALT-17 AST-28 AlkPhos-55 TotBili-0.5
___ 03:00PM BLOOD Calcium-9.2 Phos-3.9 Mg-2.5
___ 03:07PM BLOOD Lactate-2.6*
DISCHARGE LABS:
IMAGES:
Chest Xray ___
Patchy opacities within the left mid and lower lung fields may
reflect atelectasis or infection. Chronic opacities within the
right upper and mid fields peripherally.
MICRO:
Urine cx ___: pending
Blood cx ___: pending
Sputum cx ___:
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Digoxin 0.0625 mg PO DAILY
4. Furosemide 80 mg PO QAM
5. Furosemide 40 mg PO QHS
6. Lisinopril 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Potassium Chloride 20 mEq PO DAILY
9. Pravastatin 80 mg PO DAILY
10. Tamsulosin 0.4 mg PO DAILY
11. Terazosin 2 mg PO HS
12. Acetaminophen 1000 mg PO Q8H
13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN leg pain
14. Docusate Sodium 200 mg PO BID
15. Senna 2 TAB PO BID constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Cyanocobalamin 1000 mcg PO DAILY
3. Digoxin 0.0625 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN leg pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every 3 hours Disp #*60
Tablet Refills:*0
6. Pravastatin 80 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Senna 2 TAB PO BID constipation
9. Tamsulosin 0.4 mg PO DAILY
10. Docusate Sodium 200 mg PO BID
11. CefePIME 2 g IV Q12H
12. Vancomycin 750 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Primary
healthcare associated pneumonia
hematuria
acute kidney injury
Secondary
right hip pain
diastolic CHF
hypertension
atrial fibrillation
Discharge Condition:
The patient is clinically stable with a normal mental status. He
needs assistance with all ambulation due to chronic hip pain.
Followup Instructions:
___
Radiology Report
HISTORY: New fever to 101.8 with abnormal lung exam.
TECHNIQUE: Upright AP view of the chest.
COMPARISON: Chest radiograph from Atrius, ___.
FINDINGS:
The lung volumes are reduced. The heart size is mildly enlarged with dense
mitral annular calcifications noted. Aortic knob is calcified. There is
crowding of the bronchovascular structures, but no pulmonary edema is
demonstrated. The hilar contours are unremarkable. Peripheral patchy
opacities are noted projecting over the right upper and mid lung fields which
are unchanged and may be attributable to a chronic interstitial abnormality.
Patchy opacities within the left mid and lower lung fields may reflect areas
of atelectasis or infection. Minimal blunting of the right costophrenic angle
is chronic and compatible with pleural thickening. No pleural effusion is
otherwise seen. No pneumothorax is identified. Remote left-sided rib
fractures are seen.
IMPRESSION:
Patchy opacities within the left mid and lower lung fields may reflect
atelectasis or infection. Chronic opacities within the right upper and mid
lung fields peripherally.
Radiology Report
INDICATION: ___ man with dysphagia. Rule out silent aspiration.
COMPARISON: None available.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
FINDINGS: Barium passes freely through the oropharynx and esophagus without
evidence of obstruction. There was no gross aspiration. There was
penetration with thin consistency barium. For details, please refer to the
speech and swallow division note in OMR.
IMPRESSION: Penetration with thin consistency barium.
Radiology Report
HISTORY: PICC line placement.
TECHNIQUE: Single, AP, portable view of the chest.
COMPARISON: Comparison is made to radiographs dated ___.
FINDINGS:
Interval placement of a right PICC line which terminates in the upper to mid
SVC. There is no associated pneumothorax. Largely unchanged, patchy
opacities are again seen diffusely and may represent chronic interstitial
disease, although a superimposed infection cannot be excluded in the proper
clinical setting. There is no significant pleural effusion or pulmonary edema
identified. The heart size is top normal. Dense aortic and mitral annular
calcifications are noted. Mediastinal and hilar contours are unchanged.
Findings were conveyed by Dr. ___ to ___ via telephone at 14:59 on ___, 5 min after discovery.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with URIN TRACT INFECTION NOS, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 99.0
heartrate: 88.0
resprate: 16.0
o2sat: 95.0
sbp: 97.0
dbp: 44.0
level of pain: 0
level of acuity: 3.0 | ___ year old male with atrial fibrillation, HTN, diastolic heart
failure and prostate CA s/p distant XRT presents with fevers and
malaise.
# Pneumonia: patient presented with fever, elevated white count,
and new infiltrates on CXR, concerning for pneumonia. The
patient was started on vancomycin and cefepime on the evening of
___. The patient is to complete an eight day course so he
should receive his final dose on the morning of ___. The
patient clinically improved and was asymptomatic and off oxygen
at the time of discharge.
# Hypotension: The patient had an episode of hypotension ___ the
ED with SBPs ___ ___, which resolved after 2L of IVF. Likely
related to hypovolemia due to poor PO intake and dysphagia for
past two days. BUN/Cr c/w pre-renal azotemia and hypovolemia.
The patient's blood pressures remained stable for the remainder
of his admission.
# Dysphagia: The patient complained of new onset dysphagia for
the 2 days prior to admission. Says to both solids and liquids.
He tolerated a normal diet well. Speech and swallow consuled and
recommended normal diet. Video swallow was done and was normal.
# ___: Patient with elevated BUN and creatinine from baseline on
admission. Creatinine 1.2 from baseline of 0.9. Likely from
hypovolemia. The patient's creatinine on discharge was 0.9.
# AMS: On admission had a report of AMS per report of rehab
attending and daughter ___ law. On admission to MICU no evidence
of AMS, no focal neuro deficits. Most likely was related
toinfection.
# Hyperkalemia: Increased K on admission to 5.5, likely ___ home
potassium supplements ___ setting of ___. Resolved.
# Hyponatremia: patient with sodium of 131 on admission,
appeared dry on exam, likely hypovolemic hyponatremia.
# Right lateral hip pain: Likely trochanteric bursitis. Previous
admission no fracture on CT with MRI showed evidence of greater
trochanteric bursitis versus gluteus medius tendinosis with a
small labral tear. Pt treated with oxydocone.
.
# Radiation cystitis: The patient did have evidence of hematuria
on exam. Urology was consulted and recommended conservative
management: they recommended not starting bladder irrigation and
monitoring the patient. His hematocrit was stable throughout the
hospitalization. His last hematocrit was 34 on ___. Explicit
instructions from urology for managing hematuria are attached to
this discharge summary.
.
# Chronic diastolic CHF: No increased evidence of worsening
heart failure. Lasix was initially held due to hypotension ___
ED.
.
# Atrial fibrillation: currently with good rate control.
Continued ASA, digoxin.
.
# HTN: Pt normotensive on admission. His lisinopril was held ___
setting ___ but then restarted. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Nitrate Analogues / Flagyl / Hydromorphone
Attending: ___.
Chief Complaint:
jaw pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with PMH CAD, lung CA s/p VATS and wedge resection of
spicukated LUL nodule on ___ presenting with dyspnea and jaw
pain. Pt states he awoke from sleep around ___ in the morning
with severe pain in tghe ___ his jaw of a sudden onset.
Also felt SOB at the time. No CP or arm pain but does have
recurrent epigastric pain. Took maalox overnight with some
relief. Has had a small cough since VATS procedure but only
minimally productive of sputum and hemoptysis once. Has had
increased DOE after the surgery as well. Denies fevers or
diaphoresis but "feels cold constantly." Denies orthopnea or
PND. No N/V/D/C, abd pain. Feels he has gained about 4lbs over
the course of the past few days.
In the ED, initial VS 98 68 130/70 18 94% ra. CT scan done to
r/o PE vs post surg changes and was neg. Pt sent to CDU for
overnight observation and ___. trop neg x 2 but EKG developed
new deep TWI in V1-V3 so cards consulted and decided to admit to
___ w/ planned perfusion test in AM.
On the floor, VS 98.0, 145/87, 64, 20, 94% RA. He notes ongoing
indigestion pains but otherwise asx.
Past Medical History:
1. BPH, s/p TURP in ___. thyroidectomy in ___. CAD, s/p stent placement in ___ and ___
4. pacemaker placement several years ago
5. left colon resection secondary to diverticulitis, ___ years
ago
6. Hyperlipidemia
7. Gout
8. GERD
9. anxiety
10. 3 cm abdominal aortic aneurysm
11. DJD of spine and hips
12. spinal fusion at age ___ secondary to spondylolisthesis
Social History:
___
Family History:
Father had gout and ___ syndrome. Sister with bladder
cancer.
Physical Exam:
ADMISSION
VS: 98.0, 145/87, 64, 20, 94% RA
General: elderly male in NAD
HEENT: NC/AT, MM dry
CV: RRR ___ systolic murmur at ___
Lungs: fine crackles at bases bilaterally, no wheezes or rhonchi
Abdomen: soft, NT, ND, NABS
Ext: 2+ pulses, trace ___ edema to shins
.
DISCHARGE
General: elderly male in NAD
HEENT: NC/AT, MM dry
CV: RRR ___ systolic murmur at ___
Lungs: CTAB, no w/r/r
Abdomen: soft, NT, ND, NABS
Ext: 2+ pulses, no ___ edema
Pertinent Results:
___ 06:40AM BLOOD WBC-4.1 RBC-3.21* Hgb-10.8* Hct-30.6*
MCV-95 MCH-33.7* MCHC-35.3* RDW-13.7 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-93 UreaN-14 Creat-0.9 Na-138
K-3.9 Cl-101 HCO3-28 AnGap-13
___ 11:15AM BLOOD ALT-22 AST-38 AlkPhos-55 TotBili-0.5
___ 06:47AM BLOOD CK-MB-3 cTropnT-<0.01
___ 12:18AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:25PM BLOOD cTropnT-<0.01
___ 11:15AM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9 Cholest-112
___ 06:40AM BLOOD Triglyc-65 HDL-40 CHOL/HD-2.8 LDLcalc-59
LDLmeas-59
IMAGING
-CTA Chest
1. No evidence of pulmonary embolism.
2. Patient is status post left upper lobe wedge resection with
post-surgical changes in the medial aspect of the left upper
lobe, small left pneumothorax, and small bilateral pleural
effusions.
3. Minimally increased size of infrarenal abdominal aortic
aneurysm since ___, measuring 3.5 cm in maximum diameter.
4. Small locules of gas within the bladder could relate to
recent
instrumentaion; however, cystitis is also possible and
correlation with UA is suggested.
-ECG ___ Atrially paced rhythm. Poor R wave progression in
leads V1-V3. Cannot exclude old anteroseptal myocardial
infarction. T wave inversions in leads V2-V3. Q-T interval is
borderline prolonged for rate. Compared to the previous tracing
of ___ T wave inversions have improved slightly
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. DiCYCLOmine 10 mg PO BID:PRN IBS
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Levothyroxine Sodium 137 mcg PO DAILY
8. Lorazepam 1 mg PO BID:PRN anxiety
9. Omeprazole 20 mg PO BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. Docusate Sodium 100 mg PO BID
12. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
13. Atenolol 25 mg PO DAILY
14. Ibuprofen 200 mg PO BID:PRN pain
15. Indomethacin 25 mg PO QID:PRN gout
16. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY:PRN
itching
17. Acetaminophen 650 mg PO Q6H
18. Lidocaine 5% Patch 1 PTCH TD DAILY pain
Discharge Medications:
1. oxygen
Home Oxygen at 2 LPM via nasal cannula while ambulating
conserving device for portability
2. Acetaminophen 650 mg PO Q6H
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. Atorvastatin 20 mg PO DAILY
7. DiCYCLOmine 10 mg PO BID:PRN IBS
8. Docusate Sodium 100 mg PO BID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
10. Levothyroxine Sodium 137 mcg PO DAILY
11. Lorazepam 1 mg PO BID:PRN anxiety
12. Omeprazole 20 mg PO BID
13. Tiotropium Bromide 1 CAP IH DAILY
14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY:PRN
itching
15. Simethicone 40-80 mg PO QID:PRN gas
16. Rehab
Outpatient pulmonary rehab
496.0 COPD
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Hypoxia
Atypical chest pain
Secondary
Lung adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male status post lung resection with shortness of
breath.
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest. Left chest wall dual lead pacing device is
again seen. There are small bilateral effusions similar to prior. Streaky
left basilar opacity is seen, potentially atelectasis noting that the
infection is not completely excluded. Cardiomediastinal silhouette is
unchanged. Surgical clips again project over the left lung likely from prior
resection. No acute osseous abnormality detected.
IMPRESSION:
Small bilateral effusions are unchanged from prior. Left basilar streaky
opacity potentially atelectasis noting that infection is not completely
excluded.
Radiology Report
INDICATION: Status post wedge resection, now with dyspnea on exertion and
abdominal pain and tenderness, rule out pulmonary embolism and intraperitoneal
pathology.
COMPARISON: CT interventional from ___ and a CTA chest from ___, CT abdomen and pelvis from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the chest,
abdomen, and pelvis after infusion of 130 cc Omnipaque intravenous contrast.
Coronal and sagittal reformatted images were obtained.
FINDINGS:
CTA CHEST: Pulmonary arteries are well opacified to the segmental level
without filling defect to suggest pulmonary embolism. Thoracic aorta is of
normal caliber without evidence of aneurysm or dissection.
CT CHEST: There is no axillary, mediastinal or hilar lymphadenopathy. The
heart is normal in size and there is no pericardial effusion. Pacemaker leads
are noted. Trachea and airways are patent to subsegmental level. Irregular
linear opacities in the medial aspect of the left upper lobe likely reflect
scarring from recent surgery. Small pneumothorax is seen along the
superiomedial and lateral aspect of the left upper lobe, likely postsurgical.
Small bilateral pleural effusions, left greater than right, are also noted.
Previously seen lung nodules including a 3 mm subpleural nodule in the right
upper lobe (2a:29) and 2 mm nodule in the left upper lobe (2a:37) are stable
since ___.
CT ABDOMEN: Liver enhances homogeneously without focal lesions. The
gallbladder, spleen, pancreas, and adrenal glands are within normal limits.
Multiple bilateral hypodensities in the kidneys remain too small to fully
characterize, but statistically likely represent cysts. Stomach and
decompressed loops of the small bowel do not show wall thickening or signs of
obstruction. Colon is notable for evidence of sigmoidectomy. There is no
mesenteric or retroperitoneal lymphadenopathy. There is no free air or fluid
within the abdomen. Note is made of a fusiform infrarenal abdominal aortic
aneurysm measuring 3.4 x 3.5 cm, previously 3.2 x 3.3 in ___. Extensive
atherosclerotic calcifications are seen along the abdominal aorta and its
major branches.
Well-distended bladder demonstrates several locules of intraluminal gas.
Terminal ureters are within normal limits. Prostate and seminal vesicles are
unremarkable. There is no free fluid within the pelvis. There is no pelvic
or inguinal lymphadenopathy. Bones demonstrate multilevel degenerative
changes especially within the lower lumbar spine, but no acute fracture or
suspicious lytic or sclerotic lesions.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Patient is status post left upper lobe wedge resection with post-surgical
changes in the medial aspect of the left upper lobe, small left pneumothorax,
and small bilateral pleural effusions.
3. Minimally increased size of infrarenal abdominal aortic aneurysm since
___, measuring 3.5 cm in maximum diameter.
4. Small locules of gas within the bladder could relate to recent
instrumentaion; however, cystitis is also possible and correlation with UA is
suggested.
COMMENT:
Above findings were discussed with Dr. ___ by Dr. ___ at 5:10 pm
on ___ via telephone.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 98.0
heartrate: 68.0
resprate: 18.0
o2sat: 94.0
sbp: 130.0
dbp: 70.0
level of pain: 2
level of acuity: 2.0 | ___ yo M with PMH of CAD, lung CA s/p VATS and wedge resection of
spicukated LUL nodule on ___ presenting with dyspnea and jaw
pain found to have new TWI on EKG in ED during ___.
.
ACUTE ISSUES
# Jaw pain, EKG changes: New TWI on V2-V3 along with jaw
pain/dyspnea initially concerning for cardiac ischemia. However,
finding in V3 is non-specific, patient had no recurrence of
symptoms and his trops were negative x 4. Also, pt had normal
Stress MIBI last month so likelihood of new obstructive CAD is
unlikely. Patient was discharged on his home regimen of aspirin,
beta-blocker, and statin.
.
# Dyspnea on exertion: CTA Chest negative for acute
intrathoracic process. Patient was found to be mildly hypoxic
with ambulation so he was started on supplemental oxygen with
exertion for symptom relief.
.
# Adenocarcinoma pT2a w/o lymph node involvement s/p recent
VATS. CTA Chest on admission showed no acute post-surgical
changes that could account for symptoms.
.
# Anxiety: Likely a large contributor to patient's symptoms.
Continued ativan
.
CHRONIC ISSUES
# Hpothyroidism: continued levothyroxine
# Gout: continued allopurinol
# GERD: continued omeprazole
# COPD: continued tiotropium; fluticasone causes nose burning so
was held
.
TRANSITIONAL ISSUES
#CODE: Full
#Patient would benefit from further treatment of his anxiety |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
testicular pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ sudden onset of left testicular pain approximately one hour
prior to presentation to ED, that radiated into his left flank
associated with one episode of vomiting and some hematuria. He
denies prior episodes. Pain resolved in ED without meds. Pt
refused further medications, was able to ambulate in ED. He
denies family history of cancer. He also denies fever, night
sweats, weight loss, adenopathy, dysuria. He denies pain
currently and feels well.
CT-U revealed a 6x6x9 cm mass concerning for testicular cancer
versus lymphoma. Urology was consulted and requested admission
to medicine for expedited work up.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
Rhinitis due to pollen
GERD (gastroesophageal reflux disease)
Asthma
Social History:
___
Family History:
No family history of cancers that he is aware of. Parents and
siblings are healthy.
Physical Exam:
Vitals: T: 97.9 BP: 144/98 P: 78 R: 14 O2: 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: No testicular mass palpable on my exam, no CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: A+Ox3, pleasant, fluent speech
Pertinent Results:
___ 06:05AM BLOOD WBC-8.5 RBC-5.49 Hgb-16.1 Hct-48.9 MCV-89
MCH-29.3 MCHC-32.9 RDW-12.4 Plt ___
___ 10:00PM BLOOD WBC-11.3* RBC-5.50 Hgb-16.4 Hct-47.7
MCV-87 MCH-29.9 MCHC-34.5 RDW-12.3 Plt ___
___ 10:00PM BLOOD Neuts-85.0* Lymphs-9.4* Monos-3.4 Eos-1.5
Baso-0.6
___ 06:05AM BLOOD ___ PTT-31.6 ___
___ 06:05AM BLOOD Glucose-113* UreaN-15 Creat-1.0 Na-142
K-4.3 Cl-107 HCO3-26 AnGap-13
___ 10:00PM BLOOD Glucose-118* UreaN-17 Creat-1.1 Na-138
K-4.4 Cl-102 HCO3-26 AnGap-14
___ 10:00PM BLOOD LD(LDH)-181
___ 10:00PM BLOOD Albumin-4.8 Calcium-9.6 Phos-3.1 Mg-2.2
.
CT abdomen:
IMPRESSION:
1. A large homogeneously hypoenhancing mass centered in the
left renal
collecting system, which may represent lymphoma or transitional
cell
carcinoma. Additional less likely considerations include
metastatic disease or inflammatory lesion. Renal veins appear
patent. There are prominent retroperitoneal lymph nodes, which
do not appear pathologically enlarged.
2. A 4 mm right lung pulmonary nodule. Consider dedicated
chest CT for full evaluation.
.
Wet read MRI-per radiologist-favor angiomyolipoma with some old
bleeding vs. less likely papillary carcinoma. Hydronephrosis.
CT chest-pulm nodule as per above. Will need further f/u if
renal mass found to be malignancy.
.
Urine cytology-ordered but not yet pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*15 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
6. Senna 1 TAB PO BID:PRN c
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
hematuria
renal mass
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 renal mass, found to have pulmonary nodule
COMPARISON: Abdominopelvic CT dated ___.
TECHNIQUE: Multidetector CT imaging of the chest was performed without
contrast. Thin section reformatted images, lung reconstructions and coronal
and sagittal reformations are provided.
FINDINGS: The heart is normal in size. The major airways are patent to
subsegmental levels bilaterally. The previously described nodular opacity in
the right middle lobe measures 4 x 2 mm and is triangular, most compatible
with an intrapulmonary lymph node. No other pulmonary nodules are identified.
The mediastinal great vessels are normal. No pathologic mediastinal, hilar or
axillary lymphadenopathy is seen. There is no pleural or pericardial
effusion. No bone lesions worrisome for infection or malignancy are detected.
Please refer to separately dictated preceding CT of abdomen and pelvis and MR
abdomen for discussion of intra-abdominal findings including left renal mass.
IMPRESSION:
1. No definite evidence for intrathoracic malignancy.
2. A 4 mm nodule in right middle lobe shows features most consistent with an
intrapulmonary lymph node, a benign finding. If the patient is proven to have
a malignancy, then follow up imaging in 3 months would be recommended.
Radiology Report
INDICATION: Left renal collecting system mass, please further characterize
and assess for metastatic disease.
COMPARISON: Abdominal and pelvic CT of ___.
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired through the
abdomen on a 1.5 Tesla magnet, including dynamic images obtained prior to,
during, and following the uneventful intravenous administration of 8 mL of
Gadovist. Subtraction images were generated and reviewed.
MR OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Within the left kidney, a mass
is seen largely replacing the lower pole and interpolar region, with extension
to the renal sinus and surrounding the hilar branch vessels. This measures
9.4 SI x 6.5 TR x 5.5 AP cm. The mass is of predominantly low signal
intensity with respect to renal cortex on T2-weighted images, and is mildly
hyperintense to cortex on pre-contrast T1-weighted images. There is no
evidence for intravoxel fat or hemosiderin deposition. The mass enhances
homogeneously and avidly, to a similar extent as the renal cortex in the
corticomedullary phase. Multiple prominent vessels course about the periphery
of the lesion (1101:55). The lesion shows homogeneous restriction of diffusion
confirmed at ADC map. There is moderate hydronephrosis of the upper pole
collecting system and displacement of the renal pelvis anteriorly. Within the
dilated upper pole calices is thrombus which is markedly hyperintense on
pre-contrast T1-weighted imaging and shows significant restriction of
diffusion, but no evidence of enhancement which is confirmed with subtraction
images (102:28).
There are two left renal arteries. A dominant main renal artery (1101:61),
supplies the upper pole and interpolar region of the kidney, while an
accessory artery (1101:66), supplies the anterior aspect of the interpolar
region. There is no encasement of the accessory renal artery or its branches
by the mass. The most superior branch of the main renal artery appears
unaffected, while branches of its more inferior bifurcation are encased.
There is no evidence of tumor thrombus within the renal vein. A portion of
the renal vein coursing to the upper pole, is not encased by tumor, while
branches extending into the interpolar region, are encased. There are two
right-sided renal arteries. The right kidney is normal in signal intensity
and enhancement with no focal lesions. There are no pathologically enlarged
retroperitoneal lymph nodes. Some paraaortic nodes on the left measure up to
7 mm in short axis diameter, but do not meet criteria for pathologic
enlargement.
The mass shows relatively well demarcated margins, although there is some
smooth protrusions of portions of the mass beyond or pushing the renal capsule
laterally and medially (1101:35 as representative image).
The adrenal glands, liver, and spleen appear within normal limits.
The pancreatic parenchyma is normal in signal intensity. Within the uncinate
process, there is focal dilation of either a side branch duct or of the duct
of Santorini, with slight peripheral hyperenhancement (4:18; 14:63). Of note,
a replaced common hepatic artery arises from the superior mesenteric artery
directly adjacent to this. A tiny polyp may be present in the gallbladder
(14:51). This measures 3 mm. The abdominal aorta and inferior vena cava are
normal in caliber. Abdominal loops of bowel appear unremarkable. Imaged
marrow signal appears within normal limits.
IMPRESSION:
1. 9.4 x 6.5 x 5.5 cm mass involving the interpolar region and lower pole of
the left kidney with extension to the renal sinus and collecting system. The
imaging features of this lesion, including T2 hypointensity and avid
enhancement, homogenous restriction of diffusion at DWI, as well as
hyperdensity on non-contrast portion of prior CT, are most suggestive of
angiomyolipoma with minimal fat. Papillary renal cell carcinoma is less
likely given the enhancement and signal intensity characteristic pattern.
2. Two left renal arteries, each of which supplies portions of the left
kidney that are uninvolved by tumor, with the tumor and involved portions of
the left kidney also supplied by branches from the main left renal artery. No
evidence of renal vein tumor thrombus.
3. No findings worrisome for metastatic disease in the abdomen or pelvis.
Two right renal arteries. Replaced common hepatic artery arising from the
superior mesenteric artery, possibly resulting in mild dilatation of the
adjacent duct of Santorini of doubtful significance.
4. Further evaluation of the left renal lesion could be obtained through
percutaneous biopsy if a nonoperative course of therapy is contemplated.
The results were discussed via telephone with ___ by Dr. ___
___ 15 minutes following discovery on ___ at 4:30 p.m.
Gender: M
Race: HISPANIC/LATINO - MEXICAN
Arrive by AMBULANCE
Chief complaint: L TESTICULAR PAIN
Diagnosed with RENAL & URETERAL DIS NOS, ABDOMINAL PAIN OTHER SPECIED
temperature: 97.4
heartrate: 92.0
resprate: 16.0
o2sat: 98.0
sbp: 162.0
dbp: 98.0
level of pain: 10
level of acuity: 2.0 | ___ y.o male with h.o asthma who presented with hematuria and
flank pain.
#RENAL MASS/HEMATURIA: Pt presented with one day of gross
hematuria and transient episode of flank/testicular pain and was
found to have 5.7 x 6.9 x 8.9 cm homogeneously hypoenhancing
mass arising from the left renal collecting system. Initial
different considered included TCC, RCC vs. lymphoma. MRI
abdomen was obtained for further characterization which
preliminary revealed concern for angiomyolipoma with former
bleeding vs. less likely papillary carcinoma. Differential is
still unclear at this time. Urine cytology was ordered twice and
does not appear to have been logged at the time of discharge.
The urology service was consulted (Dr. ___ who recommended
that pt could be discharged and the urology service will follow
up with the patient to schedule a follow up appointment to
discuss his options diagnosis and treatment of the underlying
mass. Pt is aware of this plan and was also provided with the
contact information to Dr. ___. Pt was given a small
supply of oxycodone and a bowel regimen to help with any flank
pain. Hematuria had resolved by the time of discharge and pain
was much improved.
.
#pulmonary nodule-Surveillence type of this lesion will depend
on if renal mass is malignant.
.
Transitional care
___ MRI abdomen and CT chest results
2.urine cytology
3.pulmonary nodule
4.pt will need urology f/u |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizure, benzo withdrawal
Major Surgical or Invasive Procedure:
bone marrow biopsy
History of Present Illness:
___ with PMH depression, anxiety, chronic back pain, renal mass
suspicious for possible cell carcinoma, seen in ED on ___ for
low back pain and given 1 unit RBC for HCT of 22, now p/w
unwitnessed fall and possible seizure this morning. Patient
states she had an episode of diarrhea in the bed then again in
the bathroom this morning. She states she was walking back from
the bathroom when she had a "seizure." She woke up in her bed
and was told she had a seizure. Per family, patient reported
having a fall in kitchen this morning. Was found in her bed
incontinence of loose stools. Had not had diarrhea until today.
Stopped her ativan "cold ___ as ran out of her ativan and
endocet ___ days ago. Per her family she went through her 90mg
of Ativan and her entire bottle of endocet in roughly 2 weeks.
In the ED initial vitals were 98 77 120/61 18 99% ra. A CT head
showed no acute pathology. A CT spine showed no acute fracture
or vertebral malalignment. While in the ED she had a witnessed
seizure that presented as unresponsive, twitching lasting ___
seconds, she was given 2mg ativan at that time and placed ___
___. Patient was given a total of 4mg.
MICU COURSE:
Restarted on her home medication regimen of ativan and percocet.
On ___ with no evidence of additional withdrawal symptoms.
Vitals remained stable overnight with no additional seizure
activity.
Upon arrival to the floor, Pt's daughter reports that since ___, Pt started having lower back pain and started using lots
of percocets. Since then, she has been taking 8 percocets daily
and finishing prior to the expected date. Daughter states since
___, Pt has really started taking more pills. Pt's
daughters noticed that Pt was more agitated and tried to get
covering doctor to increase the pain medications and refused
tramadol (one daughter was with Pt during this appointment and
noted the aggressive seeking behavior). Pt's daughters then took
over Pt's Percocets. She filled her prescription on ___,
but her daughters gave the rest of her pills on ___ when Pt
became highly belligerent about her meds. Per caughters, Pt ran
completely out ___ (~10 day prior to next rx). Daughters
noticed that Pt started running out of lorazepam early when her
Percocets were controlled. Lorazepam was filled on ___, ran
out on ___. Pt daughters suggested, but Pt refused to go to
detox.
ROS:
+ diarrhea, stool incontinence, cough productive of sputum,
chronic pain in sacrum and lateral bilateral legs
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No shortness of
breath, no dyspnea on exertion. No chest pain or palpitations.
No nausea or vomiting. No dysuria or hematuria. No hematochezia,
no melena. No numbness or weakness, no focal deficits.
Past Medical History:
MGUS
(JAK-2) positive thrombocytosis, now resolved
AAA s/p repair in ___
anxiety
back pain
depression
Renal Mass, presumed renal ca but refused workup
macular degeneration
___: multiple ERCPs, PD stent (removed), balloon dilation of
CBD
___: unknown kidney operation
Social History:
___
Family History:
Mother died age ___ - AAA
Father died age ___ - ___
Denies family hx of autoimmune diseases and cancer.
Physical Exam:
ADMISSION:
Gen: NAD, resting in bed,
HEENT: No tongue lac noticed, clear oropharynx
CV: RRR, no m/r/g
RESP: CTA b/l
ABD: soft, nontender
GU: foley in place
Neuro: AAOx3 (person, place, president), able to say days of
week forward and backwards, able to move all 4 extremities, ___
strength inupper and
Ext: no edema
PHYSICAL EXAM: on discharge
Vitals- 98.4F, 117-126/44-61, 77-81, 16, 93% RA
Wt not recorded, 51.2kg standing yesterday
General- Elderly woman lying in bed sleeping comfortably, easily
awoken, oriented x3
HEENT- Sclera anicteric, slightly dry, oropharynx clear
Neck- supple, JVP not elevated
Lungs- Bibasilar faint inspiratory crackles
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- A&O x3, able to relay history of her illness, CNs2-12
intact, motor exam non-focal
Pertinent Results:
ADMISSION LABS:
___ 12:40PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-NEG
___ 12:40PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-2+ TEARDROP-OCCASIONAL
___ 12:40PM NEUTS-67 BANDS-10* LYMPHS-10* MONOS-3 EOS-0
BASOS-0 ___ METAS-5* MYELOS-3* NUC RBCS-3* OTHER-2*
___ 12:40PM WBC-9.3 RBC-2.70* HGB-8.5* HCT-23.9* MCV-89
MCH-31.7# MCHC-35.8*# RDW-24.9*
___ 12:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:40PM GLUCOSE-86 UREA N-31* CREAT-0.9 SODIUM-137
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-24 ANION GAP-18
___ 12:47PM LACTATE-1.3
___ 12:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING
CT head ___
IMPRESSION: No acute intracranial process.
CT Spine ___
IMPRESSION: No acute fracture or vertebral malalignment.
SKeletal survey ___
SKULL: No concerning lytic or sclerotic lesion seen. No fracture
is seen. CERVICAL SPINE: This is severely limited in assessment,
degenerative changes in the mid portion of the cervical spine
are similar to prior CT from ___. The CT study is
more appropriate for assessment of the cervical spine as the
images are obscured by the patient's arms. BILATERAL HUMERI:
There are two lucencies in the right humeral head with sclerotic
margins consistent with a non-aggressive lesion such as a
subchondral. This area is partially visualized on the CT chest
from ___ and there is at least one well defined
non-aggressive lytic lesion in the right humeral head on that
study. There is a small sclerotic lesion in the left humeral
head measuring 7 mm consistent with a bone island. No concerning
lytic or sclerotic lesion seen. No fracture seen. THORACIC
SPINE: There is a mild thoracic scoliosis convex to the right.
No concerning lytic or sclerotic lesions seen. There is diffuse
osteopenia; however, and mild endplate depression at multiple
levels. Vascular calcification noted. The visualized portions of
the lungs are clear. LUMBAR SPINE: There are five
non-rib-bearing lumbar-type vertebrae. There is mild scoliosis
convex to the left. Severe degenerative disc disease noted at
L4-L5 and L5-S1, also at L3-L4. Surgical clips project over the
left side of the abdomen, again diffuse osteopenia noted.
PELVIS: There are mild degenerative changes in bilateral hip
joints. No concerning lytic or sclerotic lesions. No fracture or
dislocation is seen. No radiopaque foreign body or soft tissue
calcification. BILATERAL FEMORA: No concerning lytic or
sclerotic bone lesions. No fracture is seen. Mild vascular
calcifications.
IMPRESSION: 1. No convincing radiographic evidence of myeloma.
2. Degenerative changes in the lower lumbar spine. 3.
Degenerative changes in the mid cervical spine, better assessed
on the recent CT. 4. Diffuse osteopenia in the spine
Micro
___ CULTUREBlood Culture, Routine-PENDING
x 2
___ 01:00PM BLOOD HIV Ab-NEGATIVE
___ 01:00PM BLOOD HCV Ab-NEGATIVE
___ 11:10AM BLOOD FreeKap-36.8* ___ Fr K/L-3.26*
b2micro-4.3* IgG-724 IgA-77 IgM-936*
___ 07:00AM BLOOD calTIBC-172* Ferritn-431* TRF-132*
___ 07:00AM BLOOD Iron-46
___ 11:10AM BLOOD Hapto-247*
___ 05:36AM BLOOD TotProt-6.3* Albumin-3.6 Globuln-2.7
Calcium-8.1* Phos-3.8 Mg-2.4
___ 06:10AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1
___ 05:36AM BLOOD ALT-9 AST-19 LD(LDH)-379* AlkPhos-104
TotBili-0.5
___ 05:36AM BLOOD ALT-9 AST-19 LD(LDH)-379* AlkPhos-104
TotBili-0.5
___ 06:10AM BLOOD WBC-7.6 RBC-2.71* Hgb-8.3* Hct-24.5*
MCV-90 MCH-30.5 MCHC-33.8 RDW-23.9* Plt ___
Medications on Admission:
MEDICATIONS: this is what she reports taking
The Preadmission Medication list is accurate and complete
1. Cyanocobalamin 1000 mcg IM/SC EVERY 2 WEEKS
2. Lorazepam 1 mg PO TID
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Acetaminophen 500 mg PO Q4H:PRN pain, fever
do not take more than 6 pils in one day
RX *acetaminophen 500 mg 1 tablet(s) by mouth q4 hrs Disp #*120
Tablet Refills:*0
3. Mirtazapine 15 mg PO HS
RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
4. TraMADOL (Ultram) 25 mg PO Q6H:PRN severe pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*60 Tablet Refills:*0
5. Cyanocobalamin 1000 mcg IM/SC EVERY 2 WEEKS
6. Ondansetron 4 mg PO Q8H:PRN nausea when taking mirtazapine
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
prescription opiate and benzodiazepine addiction and abuse
benzodiazepine withdrawal seizure
normocytic anemia
thrombocytopenia
Secondary:
chronic degenerative changes of lower lumbar spine
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: ___ female status post fall, seizure. Assess for
acute intrathoracic injury.
FINDINGS: Portable AP upright view of the chest was provided. The lungs are
clear bilaterally. No focal consolidation, effusion or pneumothorax is seen.
The heart size appears grossly within normal limits though not optimally
assessed. The mediastinal contour is normal. No acute displaced rib
fractures are identified.
IMPRESSION: No acute findings. If there is strong clinical concern for rib
fracture, recommend dedicated rib series to further assess.
Radiology Report
HISTORY: Fall, seizure.
COMPARISON: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm reconstructed images were acquired in.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large
infarction. Midly prominent ventricles and sulci suggest age related
involutional changes or atrophy. Mild periventricular white matter
hypodensities are consistent with chronic small vessel ischemic disease. The
basal cisterns appear patent and there is preservation of gray-white matter
differentiation.
No fracture is identified. Mucous retention cyst and mucosal thickening is
seen in the sphenoid sinuses. Mucosal thickening is seen in the right
maxillary sinus. Otherwise, the visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. Atherosclerotic mural calcification
of the internal carotid arteries is noted. The globes are intact.
IMPRESSION: No acute intracranial process.
Radiology Report
HISTORY: Fall, seizure.
COMPARISON: None.
TECHNIQUE: Helical axial MDCT sections were obtained from the skull base
through the T1 level. Reformatted images in sagittal and coronal axes were
obtained.
FINDINGS: No acute fracture or vertebral malalignment is seen. There is no
prevertebral soft tissue swelling. There is preservation of normal cervical
lordosis. Multilevel degenerative changes are seen throughout the C-spine,
with minimal disc bulges and ligamentum flavum hypertrophy seen at multiple
levels. The vertebral body heights are maintained. CT is not able to provide
intrathecal detail comparable to MRI, but the visualized outline of the thecal
sac appears unremarkable. Sinus disease is noted in the sphenoid and right
maxillary sinuses. No lymphadenopathy is present by CT size criteria.
Blebs are noted in the lung apices bilaterally. The thyroid gland is noted to
be slightly small.
IMPRESSION: No acute fracture or vertebral malalignment.
Radiology Report
INDICATION: MGUS, worsening anemia, thrombocytopenia, concerning for
progression to myeloma, question lytic lesions.
TECHNIQUE: Skeletal survey of the axial and appendicular skeleton, total of
13 images obtained.
COMPARISON: Chest radiograph ___ and CT abdomen and pelvis ___.
SKULL:
No concerning lytic or sclerotic lesion seen. No fracture is seen.
CERVICAL SPINE:
This is severely limited in assessment, degenerative changes in the mid
portion of the cervical spine are similar to prior CT from ___.
The CT study is more appropriate for assessment of the cervical spine as the
images are obscured by the patient's arms.
BILATERAL HUMERI:
There are two lucencies in the right humeral head with sclerotic margins
consistent with a non-aggressive lesion such as a subchondral. This area is
partially visualized on the CT chest from ___ and there is at least
one well defined non-aggressive lytic lesion in the right humeral head on that
study. There is a small sclerotic lesion in the left humeral head measuring 7
mm consistent with a bone island. No concerning lytic or sclerotic lesion
seen. No fracture seen.
THORACIC SPINE:
There is a mild thoracic scoliosis convex to the right. No concerning lytic
or sclerotic lesions seen. There is diffuse osteopenia; however, and mild
endplate depression at multiple levels. Vascular calcification noted. The
visualized portions of the lungs are clear.
LUMBAR SPINE:
There are five non-rib-bearing lumbar-type vertebrae. There is mild scoliosis
convex to the left. Severe degenerative disc disease noted at L4-L5 and
L5-S1, also at L3-L4. Surgical clips project over the left side of the
abdomen, again diffuse osteopenia noted.
PELVIS:
There are mild degenerative changes in bilateral hip joints. No concerning
lytic or sclerotic lesions. No fracture or dislocation is seen. No
radiopaque foreign body or soft tissue calcification.
BILATERAL FEMORA:
No concerning lytic or sclerotic bone lesions. No fracture is seen. Mild
vascular calcifications.
IMPRESSION:
1. No convincing radiographic evidence of myeloma.
2. Degenerative changes in the lower lumbar spine.
3. Degenerative changes in the mid cervical spine, better assessed on the
recent CT.
4. Diffuse osteopenia in the spine.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall, Diarrhea
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY
temperature: 98.0
heartrate: 77.0
resprate: 18.0
o2sat: 99.0
sbp: 120.0
dbp: 61.0
level of pain: 13
level of acuity: 2.0 | ___ with PMH depression, anxiety, chronic back pain, ?renal cell
carcinoma, seen in ED on ___ for low back pain and anemia now
presenting s/p fall and seizures likely due to benzo and opiate
withdrawal and worsening anemia and thrombocytopenia.
# withdrawal seizure: reports only 1 seizure in a past about ___
years ago, back when she was "partying too much" which she had
attributed to drugs and alcohol (which she denies currently).
Pt's recent seizure was most likely due withdrawal from
lorazepam and percocets. Pt was restarted on her home regimen of
lorazepam 1mg TID in the MICU with no further signs of seizures.
Per Pt's daughter, Pt started overusing lorazepam when her
percocets were controlled by her daughters. Other possible
etiologies include hyperviscosity syndrome given her previously
known IgM MGUS (see below), but serum viscosity was checked and
normal. Social work was consulted and met with patient for
prescription medication abuse, but she perseverated on obtaining
more benzos and opiates. Pt did not scoring significantly on the
___ and never needed another dose of diazepam. ___ was
discontinued on ___. Pt's condition was discussed in detail
with PCP and new anxiety and pain control plan instituted (see
below). Pt was tapered completely off her lorazepam and
percocets by ___.
# prescription opiate and benzodiazepine abuse: Pt's behavior is
highly concerning for prescription opiate and benzodiazepine
addiction and abuse. Pt's daughters feel that she is addicted
and report that she became extremely belligerent when they
attempted to control her medications. Situation was discussed in
detail with Pt's PCP ___, who agrees that she cannot be
prescribed strong opiates or benzos. Pt was transitioned
completely off lorazepam and percocets during her admission. For
her reported pain, she was started on acetaminophen 650mg po q6h
prn and tramadol 25mg po q6h prn. A pain clinic appointment at
the ___ was arranged for 3 days after discharge. She
was encouraged to try acetaminophen first and only use tramadol
if needed. She was also started on mirtazapine for anxiety and
insomnia per her daughter ___ suggestion (see below). Her
pharmacy was called to cancel the remaining refills on her
lorazepam. Her daughters and family members were also informed
to secure their own supplies of these medications (her son, who
lives with her also uses lorazepam). Pt remained highly
insistent that she be prescribed her old regimen of percocets
and lorazepam on discharge, which was not provided.
# normocytic anemia, thrombocytopenia: possibly due to
underlying MGUS, however Pt's daughter reports that she has now
with small dark guaiac positive stool raising possibility of
some acute GI bleeding. Plts were previously elevated and Pt is
positive for JAK2 V617F mutation, but Plts have been dropping
for the past few months, suggesting possible progression of MGUS
to MDS. ___ is also possible that Pt has a GI malignancy given
her heavy smoking history, two guaiac positive stools in MICU,
lack of any screening colonoscopy, and reported weightloss.
Hematology was consulted and concerned for possible progression
with hyperviscosity syndrome as a potential etiology of her
seizures, and recommended workup with repeat SPEP showing
monoclonal IgM Kappa now representing 6% of total serum, serum
viscosity normal, UPEP not collected, B2 microglobulin 4.3,
quantitative Ig's with elevated IgM, peripheral smear with
evidence of possible infiltrating or fibrotic marrow, iron
studies normal, retic index low, and skeletal survey that showed
no evidence of lytic lesions. Bone marrow biopsy was performed
on ___ with results pending. Pt was transfused 1 x pRBCs with
appropriate increase in serum hemoglobin. Pt has follow-up with
heme-onc in three weeks. Pt has never had a colonoscopy and
given anemia and guaiac positive stools, should have a
colonoscopy as an outpatient.
# weightloss: daughter reports that Pt has lost a significant
amount of weight over the last six months unintentionally.
States that she was generally 170 lbs, though per OMR PCP
records, she ___ been this that weight since ___. She was
in the 130lb range in ___, and ~120 lbs [54.4 kg] for the
later half of ___. Given Pt's long smoking history and absence
of screening colonoscopy, together with now guaiac positive
stools, concern for possible colonic malignancy. Pt also reports
reduced appetite, which could also be due to rx medication
abuse. Pt's weight is 51.2kg, which indicates ~ 7 lb weight loss
over 6 months. Albumin is normal. Pt's weight should be closely
monitored. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Right Knee Pain
Major Surgical or Invasive Procedure:
Right Knee Arthrocentesis ___
Right Knee Arthrocentesis and Steroid Injection ___
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of atrial
fibrillation, anxiety/depression, and breast cancer (T1N0M0
invasive lobular adenocarcinoma s/p RTX/implant/tamoxifen for ___
years) s/p bilateral mastectomy,
bilateral tissue expander placement and implant removal from the
left breast in ___ secondary to infection who presents
with right knee pain. Of note she was recently discharged from
the plastic surgery service for SSI c/b MSSA bacteremia for
which she was on a nafcillin pump.
She noticed today that her RLE became acutely swollen and
painful. She presented to an urgent care ___ which suggested
she may have "bone on bone pain." She presented to the ED as she
was unable to walk. She denied fever, chills, nausea, vomiting,
diarrhea, rash.
In the ED initial vitals were: Pain ___ Temp 98.1 HR 83 BP
167/80 RR 16 98%. Exam was notable for warm swollen asymmetric
right knee, unable to range with a large effusion. Xray revealed
native knee with effusion. She was seen by ortho who tapped >50
cc of cloudy yellow fluid removal, sent for culture/gram stain.
She was evaluated by plastic surgery in the ED who noted she did
not have any acute plastic surgery issues and admitted to the
medicine service.
- Labs were significant for
WBC 9.4 HCt 28.3 K 3.3 CRP 78.6 Lactate 1.1
UA: Negative
- Patient was given morphine 5 mg x2, dilaudid 0.5 mg x2, zofran
4 mg x1.
Vitals prior to transfer were: 98.9 80 152/79 16 95% RA
On the floor, she is crying out in pain and uncomfortable.
Review of Systems:
(+) per HPI
Past Medical History:
1. adjustment disorder
2. atrial fibrillation (cardiologist - Dr. ___,
___
3. anxiety and depression
4. vitamin B12 deficiency
5. breast cancer (T1N0M0 invasive lobular adenocarcinoma
s/p RTX/implant/tamoxifen for ___ years)
6. colonic polyps (___)
7. constipation
8. hypertension
9. osteopenia
10. seasonal affective disorder
11. gastric bypass 01
12. SBO s/p exploratory laparotomy and small bowel resection
(___)
Social History:
___
Family History:
Mother deceased from recurrent non-Hodgkin's lymphoma. Multiple
family members with ovarian and breast ca at early ages (mother
with ovarian ca in her ___, 2 aunts with breast ca)
Physical Exam:
Admission Physical Exam:
Vitals - 98.3 159/73 87 20 97% RA
GENERAL: Tearful, uncomfortable appearing
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Swollen R knee, TTP, unable to move ___ severe pain
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam:
Vitals: T: 98.3 P:70s BP: 140-150s/70-80s RR: 20 O2: 98%RA
GENERAL: Resting comfortably in NAD, AAO x3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Decreased edema in R knee, not TTP can lift off of
bed and flex
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs:
___ 08:05PM URINE HOURS-RANDOM
___ 08:05PM URINE HOURS-RANDOM
___ 08:05PM URINE UHOLD-HOLD
___ 08:05PM URINE GR HOLD-HOLD
___ 08:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:05PM URINE RBC-<1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-3
___ 08:05PM URINE HYALINE-1*
___ 08:05PM URINE MUCOUS-RARE
___ 06:30PM JOINT FLUID ___ RBC-21* POLYS-94*
___ MACROPHAG-4
___ 06:30PM JOINT FLUID NUMBER-FEW SHAPE-RHOMBOID
LOCATION-I/E BIREFRI-POS COMMENT-c/w calciu
___ 05:07PM LACTATE-1.1
___ 04:55PM GLUCOSE-88 UREA N-12 CREAT-0.9 SODIUM-141
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
___ 04:55PM estGFR-Using this
___ 04:55PM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-2.1
___ 04:55PM CRP-78.6*
___ 04:55PM WBC-9.4 RBC-3.18* HGB-9.4* HCT-28.3* MCV-89
MCH-29.4 MCHC-33.0 RDW-15.9*
___ 04:55PM NEUTS-75.3* LYMPHS-15.8* MONOS-6.9 EOS-1.5
BASOS-0.5
___ 04:55PM PLT COUNT-322
___ 04:55PM ___ TO PTT-UHNABLE TO ___
TO
Microbiology:
Joint fluid: WBC ___ RBC 21 Poly 94
Crystal: Few
Shape: Rhomboid
Birefrigence: Positive
Comment: Consistent with calcium pyrophosphate
___: Blood culture x2 pending
___: Joint fluid culture pending
Imaging:
___ CXR: PICC line terminating in the right upper superior vena
cava. No evidence of acute cardiopulmonary disease.
___ Right knee: Moderate to large joint effusion. Mild
degenerative changes.
Discharge Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 04:58 10.4 2.55* 7.7* 23.4* 92 30.3 33.0 16.7* 271
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 04:58 106*1 22* 1.0 142 3.5 ___
HEMATOLOGIC calTIBC Hapto Ferritn TRF
___ 04:51 219*
Source: Line-___
___ 12:05 242* 95 186*
___ Iron 14
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain, fever, headache
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. Aspirin 81 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Mirtazapine 15 mg PO HS
6. Senna 8.6 mg PO BID:PRN constipation
7. Lisinopril 2.5 mg PO DAILY
8. Docusate Sodium 200 mg PO DAILY:PRN constipation
9. Citalopram 20 mg PO DAILY
10. Nafcillin 2 g IV Q4H
11. anastrozole 1 mg oral daily
12. Calcium Carbonate 1250 mg PO DAILY
13. Cyanocobalamin 1000 mcg IM/SC MONTHLY
14. Ferrous Sulfate 325 mg PO DAILY
15. nystatin 100,000 unit/gram topical daily
16. Vitamin D 400 UNIT PO BID
17. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
18. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain offer
second
Discharge Medications:
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. Aspirin 81 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Docusate Sodium 200 mg PO DAILY:PRN constipation
5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Mirtazapine 15 mg PO HS
9. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 grams IV every
four (4) hours Disp #*72 Intravenous Bag Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. anastrozole 1 mg oral daily
12. Acetaminophen 325-650 mg PO Q6H:PRN Pain, fever, headache
13. Calcium Carbonate 1250 mg PO DAILY
14. Cyanocobalamin 1000 mcg IM/SC MONTHLY
15. Ferrous Sulfate 325 mg PO DAILY
16. nystatin 100,000 unit/gram topical daily
17. Vitamin D 400 UNIT PO BID
18. Indomethacin 50 mg PO TID
RX *indomethacin 50 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
19. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
breakthrough pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
1. Pseugout
2. MSSA Bacteremia
3. Hypokalemia
4. Intraductal Carcinoma
5. Atrial Fibrillation
6. Hypertension
7. Anxiety/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: RIGHT KNEE RADIOGRAPHS
INDICATION: Right knee pain and edema.
COMPARISON: ___.
TECHNIQUE: Right knee, three views.
FINDINGS:
The medial compartment appears preserved. The lateral compartment is mildly
narrowed. Small tricompartmental osteophytes are present. Mild periarticular
calcification is detected posteriorly. There is no evidence for fracture,
dislocation or bone destruction. A moderate to large joint effusion is
present. The bones are probably demineralized to some extent.
IMPRESSION:
Moderate to large joint effusion. Mild degenerative changes.
Radiology Report
EXAMINATION: CHEST RADIOGRAPH
INDICATION: Difficulty drawing from PICC line.
COMPARISON: ___ in 20, ___.
TECHNIQUE: Chest, AP upright view.
FINDINGS:
A left-sided PICC line terminates in the upper superior vena cava. The
cardiac, mediastinal and hilar contours appear stable. There is no pleural
effusion or pneumothorax. Streaky opacity at the left base suggests minor
scarring. Otherwise, within the limitations of technique, including low lung
volumes, the lungs appear clear. Surgical clips project over the right axilla,
as before.
IMPRESSION:
PICC line terminating in the right upper superior vena cava. No evidence of
acute cardiopulmonary disease.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Knee pain
Diagnosed with ACUTE GOUTY ARTHROPATHY
temperature: 98.1
heartrate: 83.0
resprate: 16.0
o2sat: 98.0
sbp: 167.0
dbp: 80.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with a history of atrial
fibrillation, anxiety/depression, and breast cancer s/p
bilateral mastectomy, bilateral tissue expander placement and
implant removal from the left breast in ___ secondary to
infection who presents with right knee pain, with joint aspirate
consistent with calcium pyrophosphate crystal deposition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever and chills
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ h/o paranoid schizophrenia
referred from ___ with fever and hypoxemia. Initially
patient was noted to be shaking with O2 88% on room air and T
101.1. Patient given 650mg tylenol.
.
Patient denies any cough/ dyspnea/ neck stiffness/ dysuria,
although is a limited historian. She does endorse fevers and
denies diarrhea. Denies melena and hematochezia. Patient had a
mechanical fall ___ and was seen in the ED. Flu vaccine given
___.
.
In the ED, initial VS: 101.6 80 118/72 24 99%. Recieved
Azithromycin 250 and ceftriaxone 1g, 1000mg tylenol.1 liter of
NS given.
.
Currently, the patient denies pain but feels cold and tired. She
denies confusion, abdominal pain,headache,orthopnea, neck
stiffness, diarrhea,nausea,back pain, vomiting, dysuria.
.
REVIEW OF SYSTEMS:
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Paranoid schizophrenia - Denies AH, VH, paranoid thoughts.
Denies SI. HI. Patient unable to provide presenting symptoms at
the time of diagnosis.
Breast LCIS s/p L lumpectomy ___ - f/u with NP until ___
bilateral then was negative for any suspicious changes. Was
recommended Tamoxifen per OMR, but Pt denies taking any meds for
breast CA
Insomnia
Osteoperosis
Anxiety
L hip OA s/p L THR
Social History:
___
Family History:
Denies family hx of autoimmune disease. Mother w/ breast CA.
Physical Exam:
ADMISSION
VS - ___ 3L
GENERAL - Awake but drowsy, tired looking female in NAD
HEENT - Dressing over L eye brow prior laceration repair without
stitches with surruonding hematoma, PERRLA (1.5mm -> 1mm),
conjunctivae injected, L eye with clear discharge, EOMI, sclerae
anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits; no
cervical or supraclavicular lymphadenopathy
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, good air movement, expiratory crackles at the LLL,
resp unlabored, no accessory muscle use.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses;
hyperpigmentation of chronic venous insufficiency involving the
anterior aspect of lower L sheen. Nontender, non-erythematous
palpable cord in the L popliteal foassa extending down to the
mid calf
SKIN - No rashes. 4cm tender erythematous patch with dry scab in
the center without discharge.
NEURO - awake, A&Ox3, CNs II-XII tested and intact, muscle
strength ___ upper extremiteis bilterally and wtih hip
extension/flexion, plantar and dorsiflexion, ___ knee flex/ext
b/l, sensation grossly intact throughout, DTRs 2+ lower ext, 3+
upper; symmetric; downgoing toes b/l; gait deferred due to
patient discomfort
DISCHARGE
################
Pertinent Results:
ADMISSION
___ 09:10PM WBC-11.6*# RBC-4.34 HGB-12.9 HCT-40.8 MCV-94
MCH-29.8 MCHC-31.7 RDW-13.0
___ 09:10PM NEUTS-90.8* LYMPHS-4.5* MONOS-3.4 EOS-1.0
BASOS-0.4
___ 09:10PM PLT COUNT-229
___ 09:10PM GLUCOSE-143* UREA N-23* CREAT-0.8 SODIUM-139
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
___ 10:12PM LACTATE-2.1*
___ 09:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-8.5*
LEUK-NEG
___ 09:52PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:52PM URINE RBC-7* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:52PM URINE MUCOUS-OCC
DISCHARGE
___ 05:17AM BLOOD WBC-5.9 RBC-3.82* Hgb-11.6* Hct-36.8
MCV-96 MCH-30.3 MCHC-31.5 RDW-13.0 Plt ___
___ 05:17AM BLOOD Glucose-84 UreaN-18 Creat-0.5 Na-142
K-4.5 Cl-104 HCO3-29 AnGap-14
___ 06:15AM BLOOD calTIBC-209* Ferritn-166* TRF-161*
##############
___ 07:10PM URINE Color-Straw Appear-Clear Sp ___
___ 07:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 10:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending)
CHEST (PA & LAT)Study Date of ___ 10:12 ___
Increased markings behind the heart may reflect some atelectasis
or perhaps
pneumonia. There is increasing effusion and probably background
minor
interstitial edema. Unchanged thoracic compression wedge
fracture with acute(approximately 70 degrees) angulation.
CHEST PORT. LINE PLACEMENTStudy Date of ___ 2:40 ___
Right PICC line tip terminates at the cavoatrial junction. Heart
size and
mediastinum are stable. Lungs are essentially clear.
ECG ___
Sinus bradycardia. Isolated atrial premature beat. Otherwise,
normal tracing. No significant change from tracing of ___.
Radiology Report
STUDY: Chest radiograph.
INDICATION: Cough, fever, shaking chills, infection, pneumonia.
TECHNIQUE: Two views of the chest were obtained.
COMPARISON: ___.
REPORT: The examination is technically limited. There is blunting of the
left costophrenic sulcus, suggesting a small effusion, new from prior study.
There is also evidence of increased lung markings projected behind the heart,
with focal silhouetting of the left hemidiaphragm. These could reflect
atelectasis or pneumonia, but given the symptoms, should be treated as
infection. Lateral view is somewhat degraded due to motion artifact. There
are increased lung markings as previously noted in the lung bases. There is
also evidence of an unchanged dorsal kyphotic fracture with an acute wedge.
CONCLUSION:
Increased markings behind the heart may reflect some atelectasis or perhaps
pneumonia. There is increasing effusion and probably background minor
interstitial edema. Unchanged thoracic compression wedge fracture with acute
(approximately 70 degrees) angulation.
Radiology Report
REASON FOR EXAMINATION: New PICC line placement.
AP radiograph of the chest was reviewed in comparison to ___.
Right PICC line tip terminates at the cavoatrial junction. Heart size and
mediastinum are stable. Lungs are essentially clear.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, HX OF BREAST MALIGNANCY
temperature: 101.6
heartrate: 80.0
resprate: 24.0
o2sat: 99.0
sbp: 118.0
dbp: 72.0
level of pain: 0
level of acuity: 3.0 | ___ h/o L-LCIS s/p lumpectomy ___ and paranoid schizophrenia
referred from ___ with fever, hypoxemia, and
leukocytosis.
# PNA
Pt presented with fever of 101, chills, O2 sat 88%,
leukocytosis. CXR showed LLL opacity most concerning for
pneumonia. UA was negative for infection. Legionella Ag was
negative. She had no neck pain or HA. Patient was treated for
healthcare-associated pneumonia given residence at a care
facility and recent ED stay. She was started on vancomycin
(start: ___, azithro (___), and ceftriaxone (___). Patient's
respiratory improved rapidly. She came off O2 and was satting
mid-90s on RA by the time of discharge. She had transient chills
but remained aftebrile and HD stable. She had a PICC line placed
for the total 8d course of abx. Azithromycin will continue for
1 more day (5 days total- last day ___, vancomycin for 5 more
days (8 days total- last day ___, and ceftriaxone for 4
more days (8 days total- last day ___. BCx is pending at
the time of discharge.
.
# ASPIRATION
Patient's history of cough after meals (esp. solids), no
dentures, and CXR notable for chronic bibasilar findings raised
a concern for aspiration. Speech and swallow found no acute
process with good muscle strength but silent aspiration could
not be ruled out. Patient was maintained on ground foods and
thick nectar as well as on general aspiration precautions. This
should be followed up outpatient along with proper denture
fitting.
.
# PLEAURAL EFFUSION
There was L-small pleural effusion increased from prior imaging
on ___. There was no clinical signs or symptoms of heart
failure. Differentials included parapneumonic effusion vs.
recurrent malignancy given her recent history of breast cancer
on the same side. Repeat CXR on ___ showed stable or decreased
effusion although comparison was limited due to portal CXR. We
recommended outpatient follow up.
.
# HISTORY OF BREAST CANCER
Patient has history of L-DCIS and LCIS. Her last mammogram and
follow up was in ___ per OMR. Her providers were contacted
regarding any recent followup. We recommend that patient gets
reconnected with outpatient followup especially given the new
pleural effusion on the same side.
.
# CHRONIC ANEMIA
Patient's Hct was 40 upon admission, which dropped to 35, which
was her baseline from ___, after IV fluid. This stayed stable
throughout. There was no overt active bleeding. MCV was wnl.
Iron studies 32, TIBC 209, Ferritin 166, TRF 161.
.
#Paranoid Schizophrenia
Remained stable with no auditory or visual hallucination or
suicidal or homocidal intentions. She remained alert and
oriented to time, place, and person. Her attention remained
intact with fluent days of week forward and backward. She was
continued on home resperidone, clonazepam, and trazodone.
.
#Chronic constipation
This remained stable on home regimen.
.
#Bradycardia
Patient has baseline bradycardia in 40-50s. This remained stable
on sinus bradycardia throughout.
.
# TRANSITIONAL ISSUES:
- Follow-up final read blood culture
- Proper denture fitting
- Follow up of possible silent aspiration given bibasilar
findings on CXR and h/o cough with meals
- Follow-up of breast cancer and if she desires consideration of
future treatment
- Follow-up of resolution of the non-tender L palpable cord
extending from the L popliteal fossa to the mid calf (chronic
thrombophlebitis)
- CODE: DNR/DNI (confirmed with patient)
- CONTACT: Sister, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
clarithromycin / Haldol
Attending: ___
Chief Complaint:
Suicide attempt
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ polysubstance abuse (including alcohol, opioids, on
suboxone), anxiety, depression, PTTSD, chronic SI with multiple
suicide attempts presenting after suicide attempt with injection
of bleach and cocaine.
Pt presenting after suicide attempt via injecting bleach and
cocaine into his arm veins. He reported injection occurred about
2 hours prior to arrival in the ED in order to stop his heart as
a suicide attempt. He denies prior suicide attempts. Denies
other ingestions, alcohol, drug use. He denies HI. He endorses
chest pain, worse with palpation and general weakness, but
otherwise denies N/V/D or other symptoms.
In the ED, initial vitals were:
- Exam notable for: Sleepy on exam, but AAOx3, arousable and
able to answer questions.RRR, slight systolic murmur. CTAB. NTND
abd. No c/c/e.
- Labs notable for: H/H 11.2/33.4, CHEM7 nl, serum tox +benzos,
utox +benzos +cocaine +amphet. UA negative.
- EKG: NSR, rate 96, nl axis, nl R wave progression, no ST-T
wave changes
- Imaging was notable for: none
- Patient was given: nothing
Upon arrival to the floor, VS: 98 139/88 58 20 95RA
Pt reports fatigue and discomfort at the injection site. Denies
any chest pain or discomfort. No fevers or chills. No
abdominal pain, nausea or vomiting. No shortness of breath.
Past Medical History:
Hepatitis C
Reportedly HIV negative
PSYCHIATRIC HISTORY:
Dx: per pt he has bipolar d/o, PTSD and ___
___: ~30 lifetime
SI/SIB: attempted to slit his wrists in ___
Social History:
has alcohol use disorder, opioid use disorder, and has endorsed
using prescription pills, marijuana, and cocaine. Reports last
alcoholic beverage was "a long time ago." Reports current
cocaine use, no other illicit drug use currently.
per Chart Review:
Arrests: Was arrested in ___
Convictions and jail terms: Spent ___ in year
Lives: with girlfriend of ___ years.
Works: unemployed. Used to work at ___ store.
Childhood: Traumatic. Describes how his father beat him, was an
alcoholic. He had to do through foster care where he was
"malnourished and not allowed to eat for days. They would hang
me
by my ears. I had teeth rotting".
Trauma: Endorses physical and emotional abuse as a child.
Reports
being molested. Has been mauled by dogs before with scars over
body.
Family: Has 2 kids with girlfriend (age ___ and ___). They do not
live with him and he does not get to see them.
Family History:
-Mother - intellectually disabled
-Father "cut himself open in front of me and my sister with a
knife to show us his guts". +alcoholism, +depression
Physical Exam:
Admission Physical Exam:
VS: 98 139/88 58 20 95RA
General: somnolent but arousable, responds appropriately, no
acute distress, oriented x3
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, no clubbing, cyanosis or edema. RUE
with induration and tenderness around injection site, no
erythema or warmth.
Neuro: CNs2-12 intact, moving all four extremities.
Discharge Physical Exam
Vitals: 98.0 | 134/88 | 58 | 20 | 95% RA
General: Well nourished man who appears stated age in no acute
distress
HEENT: Moist mucus membranes, stomatitis in right oral crease
CV: RRR, S1, S2 no m/r/g
Lungs: Bibasilar wheezing, otherwise
Abdomen: Soft, discomfort to deep plapation, no guarding
Ext: Trace pitting edema to legs bilaterally
Neuro: Alert oriented moving
Skin: Mildly tender and indurated in right antecubital fossa;
is improving
Psych: continues to endorse suicidal ideation but denies plan
Pertinent Results:
Admission Labs
___ 09:35PM BLOOD WBC-8.4 RBC-4.00* Hgb-11.2* Hct-33.4*
MCV-84 MCH-28.0 MCHC-33.5 RDW-12.3 RDWSD-37.3 Plt ___
___ 09:35PM BLOOD Neuts-58.5 ___ Monos-6.3 Eos-1.1
Baso-0.4 Im ___ AbsNeut-4.94# AbsLymp-2.81 AbsMono-0.53
AbsEos-0.09 AbsBaso-0.03
___ 09:35PM BLOOD Glucose-112* UreaN-14 Creat-1.0 Na-139
K-3.6 Cl-101 HCO3-26 AnGap-16
___ 11:01PM BLOOD Calcium-8.8 Phos-4.3 Mg-1.8
___ 09:25PM URINE Color-Orange Appear-Clear Sp ___
___ 09:25PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 09:25PM URINE RBC-2 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
___ 09:25PM URINE CastHy-5*
___ 09:25PM URINE Mucous-MANY
___ 09:25PM URINE bnzodzp-POS* barbitr-NEG opiates-NEG
cocaine-POS* amphetm-POS* oxycodn-NEG mthdone-NEG
Discharge Labs
___ 08:15AM BLOOD WBC-8.4 RBC-4.45* Hgb-12.4* Hct-38.9*
MCV-87 MCH-27.9 MCHC-31.9* RDW-12.7 RDWSD-40.6 Plt ___
___ 08:15AM BLOOD Glucose-91 UreaN-13 Creat-0.9 Na-138
K-4.8 Cl-103 HCO3-20* AnGap-20
___ 08:15AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0
Microbiology
Urine culture ___ negative
BCx NGTD x5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO BID
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
3. CloNIDine 0.1 mg PO QHS
4. OLANZapine 7.5 mg PO QHS
5. Ondansetron 4 mg PO BID:PRN nausea
6. Prazosin 2 mg PO QHS
7. Pregabalin 100 mg PO TID
Discharge Medications:
1. LORazepam 0.5 mg PO BID:PRN Anxiety
Taper as tolerated
2. Nicotine Patch 21 mg TD DAILY
You cannot smoke while taking this medication.
3. Baclofen 10 mg PO BID
4. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
5. CloNIDine 0.1 mg PO QHS
6. OLANZapine 7.5 mg PO QHS
7. Ondansetron 4 mg PO BID:PRN nausea
8. Prazosin 2 mg PO QHS
9. Pregabalin 100 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
Suicide attempt
Phlebitis
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
INDICATION: ___ w/ polysubstance abuse (including alcohol, opioids, on
suboxone), anxiety, depression, PTTSD, chronic SI with multiple suicide
attempts presenting after suicide attempt with injection of bleach and
cocaine// evaluate RUE for DVT, phlebitis at injection site
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Suicide attempt
Diagnosed with Suicidal ideations, Other psychoactive substance abuse, uncomplicated
temperature: 97.4
heartrate: 107.0
resprate: 14.0
o2sat: 98.0
sbp: 127.0
dbp: 81.0
level of pain: 10
level of acuity: 2.0 | ___ w/ polysubstance abuse (including alcohol, opioids, on
suboxone), anxiety, depression, PTSD, chronic SI with multiple
suicide attempts presenting after suicide attempt with injection
of bleach and cocaine which he has done before. He has been
medically stable since admission.
# Suicide attempt
Pt presenting after suicide attempt with injection of bleach and
cocaine. There is limited literature regarding parental
injection of sodium hypochlorite (bleach). Patient initially
appeared somnolent with induration at the injection site but no
evidence of bradycardia or cardiac arrhythmia. Likely secondary
to benzodiazepine use. On reassessment was placed on ___.
Restarted home psychiatric medications which were well
tolerated. Was kept with one to one sitter.
#Phlebitis
From injection of irritant bleach. ___ possibly contain
superficial thrombus. Pain localized and improved during stay
with hot packs as only treatment.
# Polysubstance abuse
Monitored on ___ without withdrawal. Restarted home suboxone.
# Anemia
Baseline Hemoglobin ___. Was stable in this range |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Bactrim / glucosamine
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
___ - Left hip removal of hardware and open reduction
internal fixation
History of Present Illness:
Patient is a ___ with hx of HLD, fibromyalgia, and osteoprosis
previously on Fosamax for ___ years up until ___, presenting
with fracture of her hip and left gamma nail from a fall today.
Patient had been leaning over to spit when she slipped on the
ice and fell into her left hip. There was no head strike no
LOC, this was a closed isolated injury. She did have left hip
pain in ___nd suffered a left
subtrochanteric fracture, and underwent left gamma nail
fixation. This was a 11 by 300mm nail with 17mm proximal
diameter, and 90mm lag screw, without distal interlocking
performed by Dr. ___ at ___. In ___ she had a
similar subtrochanteric fracture now on the right side and
underwent gamma nailing of the right side. Since that time she
has had persistant pain in the left hip, but she figured this
was normal, and was placed on vicodin for it. She has been
ambulating well until the fall.
Past Medical History:
HLD, Fibromyalgia
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD, AAOx3
LLE: surgical staples c/d/i with no erythema and no drainage;
thich compartment soft and compressible with minimal diffuse
ecchymosis; painless ROM of knee and ankle, mild pain with ROM
of hip; sensation intact to light touch; 2+ dorsalis pedis pulse
Pertinent Results:
___ 05:20AM BLOOD Hct-31.1*
___ 05:05AM BLOOD WBC-12.3* RBC-3.78* Hgb-11.9* Hct-35.4*
MCV-94 MCH-31.5 MCHC-33.6 RDW-14.1 Plt ___
___ 05:07PM BLOOD Neuts-82.2* Lymphs-11.4* Monos-5.8
Eos-0.3 Baso-0.4
___ 05:05AM BLOOD Plt ___
___ 05:05AM BLOOD Glucose-133* UreaN-12 Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-28 AnGap-11
___ 05:05AM BLOOD Calcium-7.5* Phos-2.3*# Mg-1.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO EVERY OTHER DAY
2. Simvastatin 40 mg PO EVERY OTHER DAY
3. Aspirin 81 mg PO EVERY OTHER DAY
Discharge Medications:
1. Simvastatin 20 mg PO EVERY OTHER DAY
2. Acetaminophen 650 mg PO Q6H
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
6. Senna 8.6 mg PO BID
7. Aspirin 81 mg PO EVERY OTHER DAY
8. Simvastatin 40 mg PO EVERY OTHER DAY
9. TraMADOL (Ultram) 50 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left hip periprosthetic 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
HISTORY: Periprosthetic hip fracture, preoperative assessment.
TECHNIQUE: Semi-upright AP view of the chest.
COMPARISON: None.
FINDINGS:
Heart size is top normal. Mediastinal and hilar contours are unremarkable.
Pulmonary vasculature is normal. Apart from minimal atelectasis at the lung
bases, the lungs are clear without focal consolidation. No pleural effusion
or pneumothorax is seen. No acute osseous abnormalities demonstrated.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: Left periprosthetic fracture.
TECHNIQUE: AP view of the pelvis, 2 views of the left femur.
COMPARISON: ___ at 8:05.
FINDINGS:
The patient is status post bilateral intramedullary rod placement with gamma
nail fixation. An oblique, minimally displaced periprosthetic fracture line
is seen involving the left proximal femoral diaphysis. Additionally, a
fracture of the left intramedullary rod is also demonstrated at the level of
the gamma nail. No dislocation is identified. Multiple phleboliths are noted
within the right hemipelvis. There is no diastasis of the pubic symphysis or
sacroiliac joints. The imaged left knee is unremarkable.
IMPRESSION:
Minimally displaced left periprosthetic fracture involving the intramedullary
rod within the proximal femoral diaphysis. There is also a fracture of the
proximal aspect of the intramedullary rod at the level of gamma nail. No
dislocation.
Radiology Report
INDICATION: Periprosthetic left hip fracture.
COMPARISON: Radiograph ___.
TECHNIQUE: MDCT axial images through the left proximal femur were obtained
without the administration of intravenous contrast and displayed with
multiplanar reformats.
FINDINGS: There is proximal nail and intramedullary rod fixation of a healed
left intertrochanteric femur fracture. There is up to 2-mm of lucency
medially about the proximal fixation construct. There is a fracture of
intramedullary rod which is in varus angulation approximately at the level of
the nail. Additionally, there is a spiral fracture through the proximal femur
beginning at the level of the subtrochanteric region extending inferiorly by
approximately 8.6 cm. There is no significant displacement of the fracture
fragments. There is slight varus angulation of the femur.
The femoroacetabular joint is notable for mild narrowing as well.
There are scattered left inguinal lymph nodes, which are not enlarged. The
examination is not dedicated to evaluation of the pelvis, colonic
diverticulosis is moderate in degree.
IMPRESSION:
1. Fracture of the intramedullary rod at the level of proximal nail with
varus angulation of the fixation construct.
2. Spiral periprosthetic fracture of the proximal femur without significant
displacement.
Radiology Report
HISTORY: Hardware removal.
FINDINGS: Images from the operating suite show hardware removal from the left
femur. Further information can be gathered from the operative report.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEFT HIP PAIN
Diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL
temperature: 98.0
heartrate: 89.0
resprate: 18.0
o2sat: 97.0
sbp: 141.0
dbp: 48.0
level of pain: 9
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femur periprosthetic fracture with hardware
failure and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for a
removal of hardware and open reduction/internal fixation, 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 touch down weight bearing in the
left lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ankle pain
Major Surgical or Invasive Procedure:
Open reduction internal fixation of the right ankle
History of Present Illness:
___ female presents with RIGHT trimalleolar fx. Was walking
across the street when she slipped on ice and suffered inversion
ankle injury. Immediate pop. Unable to bear weight. Denies
paresthesias. Endorsing diffuse ___ pain dull aching along
medial, lateral, and posterior mall.
Past Medical History:
CEREBRAL HEMORRHAGE
Social History:
___
Family History:
Non-contributory
Physical Exam:
Gen: NAD
Res: No resp distress
CV: pink/perfused
R ___ ___
Block still with effect
Pulses - WWP
Dressing - C/D/I
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: History: ___ with right ankle pain/swelling s/p slip and fall.//
r/o fracture/dislocation
TECHNIQUE: AP, lateral and oblique view radiographs of the right ankle.
COMPARISON: None.
FINDINGS:
There are nondisplaced fractures through the medial, lateral and posterior
malleoli. There is asymmetric widening of the ankle mortise. Diffuse soft
tissue swelling is seen around the ankle. There is a tibiotalar joint
effusion. There are no significant degenerative changes.
IMPRESSION:
Trimalleolar fracture with widening of the ankle mortise.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with fall pre-op. Evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Lungs are well aerated. No focal consolidation is seen. No large pleural
effusion or pneumothorax. The cardiomediastinal silhouette is within normal
limits.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
INDICATION: ___ with known trimall; OR later this afternoon// Xrays: post
splint/reductionCT: pre op planning
COMPARISON: Prior exam performed earlier today.
FINDINGS:
AP, lateral, oblique views of the right ankle were provided. Post reduction
views of the right ankle popped. There is an overlying plaster splint. In
this patient known to have fractures of the medial, lateral and posterior
malleolar like, the fractures are less conspicuous and the alignment is near
anatomic.
IMPRESSION:
Post reduction views of the right ankle demonstrate near anatomic alignment of
trimalleolar fractures.
Radiology Report
EXAMINATION: CT LOW EXT W/O C RIGHT Q61R
INDICATION: ___ year old woman with known tri-mal// ANKLE ONLY-- tri-mall pre
op planning for ortho from ED
TECHNIQUE: Multiaxial CT images of the right ankle were performed without
intravenous contrast, with sagittal and coronal reformats provided.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.7 s, 16.3 cm; CTDIvol = 14.2 mGy (Body) DLP = 230.2
mGy-cm.
Total DLP (Body) = 230 mGy-cm.
COMPARISON: Radiographs from ___.
FINDINGS:
Redemonstrated is a mildly displaced comminuted intra-articular trimalleolar
fracture. This involves a sagittal oblique bilateral malleolus fracture at
approximately the level of the tibial plafond, an oblique fracture of the
medial malleolus extending into the anteromedial tibial plafond, and a
posterior malleolar fracture involving less than 25% of the posterior
articular surface with cortical step-off of less than 2 mm.
There is severe degenerative changes seen at the first TMT joint with joint
space narrowing and subchondral cyst-like changes.
There is mild the displaced comminuted for fracture of the anterolateral
tibial plafond in the region of the chip its tubercle. There is no evidence
for osteochondral lesion on CT.
There is a small posterior tibiotalar joint effusions.
There is suboptimal evaluation for the ligamentous structures of the ankle on
noncontrast CT.
IMPRESSION:
1. Comminuted, mildly displaced trimalleolar ankle fracture, likely a
supination external rotation, likely ___ supination-external rotation
grade 4.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: Right ankle fracture for ORIF.
TECHNIQUE: Fluoroscopic time 31.4 seconds.
COMPARISON: ___.
FINDINGS:
5 fluoroscopic images without radiologist present.
The images demonstrate ORIF for a trimalleolar right ankle fracture with a
bilateral malleolus plate and screws and K-wire, cerclage wire and screw
fixation of medial malleolar fracture.
IMPRESSION:
Right ankle fracture during ORIF. Please refer to operative report for
details.
Gender: F
Race: ASIAN - KOREAN
Arrive by WALK IN
Chief complaint: L Ankle injury
Diagnosed with Displaced trimalleolar fracture of left lower leg, init, Fall on same level due to ice and snow, initial encounter
temperature: 97.6
heartrate: 74.0
resprate: 14.0
o2sat: 100.0
sbp: 191.0
dbp: 95.0
level of pain: 8
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 right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation
of the right ankle, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Rib Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ with a PMHx of CKD (baseline cr 1.3), HTN,
HLD, osteoporosis, atrial fibrillation (no anticoagulation) who
is presenting with abdominal and right flank pain 2 days after a
fall and a feeling that she was unable to empty her bladder.
She relates that she has been falling with some frequency over
the past several months. She also noted that she has fallen
more frequently over the last several days than she typically
does. She notes that on a recent fall 2 nights ago she hit her
right flank and has had rib pain ever since. She also notes two
episodes of "shaking" over the last ___ days. Additionally,
over the last several weeks she has had to awaken several times
during the night ___ times) to urinate. She endorses low urine
volumes but denies any change in urine appearance, odor,
sensation. Her son notes that he believes she has been
incontinent of urine over night over the last several weeks.
Overall, her son believes that she been on a downward trajectory
in terms of cognition and performance status at home over the
last several weeks to months. He relates that she sometimes
makes comments that are off topic, is much less steady on her
feet even with her walker, and that she is more forgetful than
she was before.
Of note, pt was discharged from ___ on ___
after an admission for a fall at home. During this
hospitalization she also had evidence of a UTI on UA. Her UCx
showed 10,000-50,000 mixed gram positive flora. She received 3
days of levofloxacin but was asymptomatic.
In the ED, initial vitals were: 97.9 110 112/56 16 96% RA
-Exam notable for: TTP over lower abdomen
-Labs notable for: WBC 20.8 (N97, 1 band), Hgb 11.0, Hct 34.3,
Plt 233, Cr 4.3 (from 1.3), HCOe 20, Lactate 1.7, grossly
positive UA.
-Imaging notable for: Bedside ultrasound reportedly revealed
500cc in the bladder and bilateral hydronephrosis. CXR with mild
pulmonary edema and known right 8th rib fracture. CT scan
demonstrated concerning bladder mass and re-confirmed the
hydronephrosis. She was also incidentally found to have a T4
compression fracture as well as concern for
tracheobronchomalacia.
-Patient was given: ceftriaxone 1 gm IV
-Patient was seen by urology who placed a foley catheter,
orthopedic surgery who recommended a TLSO brace and follow up in
___ weeks.
-Decision was made to admit for UTI, obstructive uropathy
On the floor, the pt denies any specific complaints and endorses
a great deal of discomfort from her back brace.
Past Medical History:
Atrial Fibrillation
Depression
Hypothyroidism
Hyperlipidemia
Hypertension
Osteoporosis
Social History:
___
Family History:
Mother had breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 97.9 89 129/75 16 96%RA
Weight: 57.9 kg (bed)
Gen: Patient sitting comfortably in bed with TLSO brace, NAD,
interactive
HEENT: No JVD
CV: Irregular, S1 and S2, murmur on LSB
Pulm: CTAB
Abd: BS+, soft, NT, ND
GU: Foley in place
Ext: Pitting edema to mid shin bilaterally
Skin: Senile purpura on bilateral UEs
Neuro: Grossly intact, voice shaky but fluent
DISCHARGE PHYSICAL EXAM:
==========================
VS: 99.8 ___ 130s-150s/60s-80s ___ 94-98%RA
I/Os: 460/675 24h; sips/275 8h
GENERAL: NAD, laying in bed, interactive, appropriate
HEENT: No JVD
LUNGS: Fine crackles in bilateral lung bases, otherwise CTAB,
moderate inspiratory effort.
HEART: Irreg, S1 and S2, murmur at LSB
ABDOMEN: BS+, soft, NT, ND
EXTREMITIES: Pitting ___ edema to mid shins bilaterally
NEURO: awake, A&Ox3
Pertinent Results:
==ADMISSION LABS==
___ 03:00AM BLOOD WBC-20.8* RBC-3.68* Hgb-11.0* Hct-34.3
MCV-93 MCH-29.9 MCHC-32.1 RDW-15.9* RDWSD-53.9* Plt ___
___ 03:00AM BLOOD Neuts-97* Bands-1 Lymphs-1* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-20.38*
AbsLymp-0.21* AbsMono-0.21 AbsEos-0.00* AbsBaso-0.00*
___ 03:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr-1+
___ 03:00AM BLOOD Glucose-89 UreaN-79* Creat-4.3* Na-133
K-4.9 Cl-96 HCO3-20* AnGap-22*
___ 03:00AM BLOOD ALT-29 AST-45* AlkPhos-118* TotBili-0.7
___ 03:00AM BLOOD Lipase-20
___ 03:00AM BLOOD Albumin-3.4* Calcium-8.9 Phos-4.3 Mg-2.1
___ 03:08AM BLOOD Lactate-1.7
___ 01:20AM URINE Color-Yellow Appear-Hazy Sp ___
___ 01:20AM URINE Blood-LG Nitrite-NEG Protein->300
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-LG
___ 01:20AM URINE ___ Bacteri-MANY
Yeast-NONE ___ 06:46AM URINE WBC Clm-MANY
==DISCHARGE LABS==
___ 05:33AM BLOOD WBC-9.6 RBC-3.36* Hgb-9.8* Hct-31.3*
MCV-93 MCH-29.2 MCHC-31.3* RDW-15.7* RDWSD-54.0* Plt ___
___ 05:33AM BLOOD Glucose-66* UreaN-22* Creat-1.5* Na-136
K-3.8 Cl-105 HCO3-21* AnGap-14
___ 05:33AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.1
==MICROBIOLOGY==
UCx ___
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION
UCx ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
BCx ___ and ___: Pending
Stool C Diff DNA Assay: Negative
==IMAGING==
CXR (___):
1. Moderate cardiomegaly with mild pulmonary edema.
2. Known right 8th rib fracture is better visualized on the
subsequent CT.
CT C-Spine (___):
1. No acute fracture in the cervical spine.
2. Age indeterminate T4 vertebral body compression deformity
with 2 mm retropulsion.
3. 2 mm anterolisthesis of C4 on C5 is almost certainly
degenerative in nature, although should be correlated clinically
if there is concern for ligamentous injury at this level.
CT Head (___):
1. No acute intracranial process on noncontrast head CT.
2. Atrophy and probable chronic small vessel disease.
CT Abdomen (___):
1. No sequela of trauma within the abdomen or pelvis. No free
fluid. 2. Severe right hydroureteronephrosis with unusual
configuration of the right lateral bladder wall near the UVJ
appears chronic and could reflect postoperative change from
prior ureteral implantation. However, mural thickening of the
bladder wall/neoplasm cannot be excluded. This could be further
evaluated with cystoscopy.
3. Colonic diverticulosis, without evidence of acute
diverticulitis.
CT Chest (___):
1. Old bilateral healing rib fractures with an additional right
lateral 8th rib fracture that is age indeterminate.
2. T4 compression deformity with 2-3 mm retropulsion, age
indeterminate.
3. Dilated main pulmonary artery measuring 3.2 cm, which can be
seen in the setting of pulmonary arterial hypertension.
4. Mosaic areas of ground-glass attenuation most likely due to
expiratory air trapping or small airways disease in the absence
of pleural effusion and there is thickening.
5. Nonspecific flattening of the distal trachea, which can be
seen in setting of tracheobronchomalacia. If there is clinical
concern for this entity, non-urgent follow-up CT with dynamic
maneuvers could be obtained.
6. CT abdomen/pelvis dictated separately.
Renal US (___):
Persistent moderate to severe right hydronephrosis. Foley
catheter present within a decompressed bladder.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: NO_PO contrast; History: ___ with abd pain, confusion, hip pain
s/p fallNO_PO contrast // s/p fall with confusion, abdominal pain, bilateral
hip pain - please eval for intracranial process, intraabdominal
trauma/hemoperitoneum, hip/pelvic fracture
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast (due to renal failure). Non-contrast scan has
several limitations in detecting vascular and parenchymal organ abnormalities,
including tumor detection.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was not administered.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 4.1 s, 45.0 cm; CTDIvol = 15.1 mGy (Body) DLP = 680.2
mGy-cm.
4) Spiral Acquisition 0.7 s, 8.0 cm; CTDIvol = 13.1 mGy (Body) DLP = 104.2
mGy-cm.
Total DLP (Body) = 784 mGy-cm.
COMPARISON: None.
FINDINGS:
The study is limited by motion.
LOWER CHEST: There is bibasilar dependent atelectasis. Pleural effusions.
Heart size is top normal, without pericardial effusion. Calcifications are
noted in the coronary arteries and aortic valve.
ABDOMEN:
HEPATOBILIARY: There is a 1 cm simple cyst in segment ___ (2a: 17). The liver
otherwise demonstrates homogeneous attenuation throughout. 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 right kidney is atrophic. There is severe hydronephrosis on the
right. The right ureter is also severely dilated along its entire course,
measuring up to 2.8 cm, both findings appearing chronic. The distal right
ureter, particularly at the ureterovesicular junction is difficult to
visualize due to extensive streak artifact from right hip arthroplasty. There
is a 1.9 cm simple cortical cyst arising from the lower pole of the right
kidney. Left kidney is normal in size, without evidence of focal lesions on
this non-enhanced study. No nephrolithiasis.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. There is scattered colonic
diverticulosis, without evidence of acute diverticulitis. The colon and
rectum are otherwise unremarkable. Normal appendix. No ascites.
PELVIS: The bladder is well distended. There is in unusual concave
configuration of the right lateral bladder wall at the level of the
ureterovesicular junction, with suggestion of possible wall thickening
(2a:59), although further evaluation is severely limited by artifact. This
may reflect postoperative change from prior ureteral implantation, although
underlying neoplasm cannot be excluded. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus contains scattered calcifications.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. Status post right total hip arthroplasty. Multilevel
degenerative changes are noted throughout the lumbar spine, including the
joint arthropathy at L5-S1 bilaterally. There is grade 1 anterolisthesis of
L4 on L5, and grade 1 anterolisthesis of L5 on S1. There is a small fat
containing umbilical hernia. Abdominal and pelvic wall is otherwise within
normal limits.
IMPRESSION:
1. No sequela of trauma within the abdomen or pelvis. No free fluid.
2. Severe right hydroureteronephrosis with unusual configuration of the right
lateral bladder wall near the UVJ appears chronic and could reflect
postoperative change from prior ureteral reimplantation. However, mural
thickening of the bladder wall is present and neoplasm cannot be excluded if
correlative history does not exist. This could be further evaluated with
cystoscopy.
3. Colonic diverticulosis, without evidence of acute diverticulitis.
NOTIFICATION: Updated findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 9:59 AM, 60 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ female presenting with worsening right chest pain
after a fall 2 days ago
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images.
DOSE: DLP: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 3.9 s, 30.1 cm; CTDIvol = 9.9 mGy (Body) DLP = 297.8
mGy-cm.
Total DLP (Body) = 298 mGy-cm.
COMPARISON: Cervical spine CT ___
FINDINGS:
The thyroid gland is homogeneous in appearance. No axillary, supraclavicular,
mediastinal and hilar lymphadenopathy is noted.
There is flattening of the distal trachea (03:19), which is a nonspecific
finding, but can be seen in the setting of tracheobronchomalacia. There is
bibasilar dependent atelectasis. Additional note is made of scattered areas
of mosaic ground-glass attenuation; in the absence of pleural effusion and
interlobular septal thickening, this may reflect expiratory air trapping or
small airways disease. No evidence of pulmonary contusion, laceration or
pneumothorax.
Heart size is moderately enlarged, and contains coronary and aortic valvular
calcifications. The thoracic aorta contains mild atherosclerotic
calcifications, but is normal in caliber. Main pulmonary artery is enlarged
measuring up to 3.2 cm (02:39), which can be seen in the setting of pulmonary
arterial hypertension.
There are old healing fractures of the left third, left fourth and right fifth
ribs. Additional right lateral eighth rib (605b:10) is age indeterminate.
There is greater than 50% loss of height at the T4 vertebral body with 2-3 mm
retropulsion (605b:56), also age indeterminate. No surrounding stranding or
paravertebral hematoma. No other fractures are identified.
Please refer to the separately dictated CT abdomen/pelvis report for details
on subdiaphragmatic findings.
IMPRESSION:
1. Old bilateral healing rib fractures with an additional right lateral ___
rib fracture that is age indeterminate.
2. T4 compression deformity with 2-3 mm retropulsion, age indeterminate.
3. Dilated main pulmonary artery measuring 3.2 cm, which can be seen in the
setting of pulmonary arterial hypertension.
4. Mosaic areas of ground-glass attenuation most likely due to expiratory air
trapping or small airways disease. No pleural effusion.
5. Nonspecific flattening of the distal trachea, which can be seen in setting
of tracheobronchomalacia. If there is clinical concern for this entity,
non-urgent follow-up CT with dynamic maneuvers could be obtained.
6. CT abdomen/pelvis dictated separately.
RECOMMENDATION(S): Consider non-urgent follow-up CT with dynamic maneuvers if
there is clinical concern for tracheobronchomalacia.
NOTIFICATION: Updated findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 9:59 AM, 60 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) BILATERAL
INDICATION: ___ year old woman with bilateral knee pain // ? OA ? OA
IMPRESSION:
On the right there is tricompartmental hypertrophic spurring with narrowing
predominantly involving the medial compartment. Suggestion of meniscal
calcification. On the left, there is tricompartmental spurring with
substantial narrowing in the medial compartment.
No evidence of joint effusion, though there is extensive vascular
calcification on both sides.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with recent stent for hydronephrosis in setting
of ___. // please re-evaluate for hydronephrosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
The right kidney measures 8 cm. The left kidney measures 8.6 cm. Within the
left kidney, there is no hydronephrosis. A small 1.8 x 1.2 x 1.2 cm cyst
projects from the left lower pole. There is moderate to severe hydronephrosis
involving the right kidney with cortical thinning as previously demonstrated
on CT dated ___, not significantly changed. A cyst within the
interpolar region measures approximately 1.7 x 1.4 x 1.5 cm.
A Foley catheter is present within a decompressed bladder.
IMPRESSION:
Persistent moderate to severe right hydronephrosis. Foley catheter present
within a decompressed bladder.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with multiple unwitnessed falls c/o R sided rib pain
// r/o r sided rib fx
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest ___
FINDINGS:
There are scattered bilateral reticular opacities that likely reflect a mild
pulmonary edema. Atelectasis is also present at the lung bases bilaterally.
No confluent consolidation, pleural effusion or pneumothorax. Heart size is
moderately enlarged. Known right 8th rib fracture is better visualized on the
subsequent CT.
IMPRESSION:
1. Moderate cardiomegaly with mild pulmonary edema.
2. Known right 8th rib fracture is better visualized on the subsequent CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ female presenting for evaluation of worsening right
chest pain after falling 2 days ago
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major vascular territorial infarction,
hemorrhage, edema, or mass. There is prominence of the ventricles and sulci
suggestive of involutional changes. Bilateral periventricular and deep white
matter hypodensities are nonspecific, but likely represent a sequela of
chronic small vessel disease. Atherosclerotic calcifications are noted within
the bilateral carotid siphons and intracranial vertebral arteries.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process on noncontrast head CT.
2. Atrophy and probable chronic small vessel disease.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ female with worsening right chest pain after falling
2 days ago
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.6 s, 21.8 cm; CTDIvol = 37.1 mGy (Body) DLP = 811.3
mGy-cm.
Total DLP (Body) = 811 mGy-cm.
COMPARISON: None.
FINDINGS:
The examination is motion degraded. Within these confines:
No acute fractures in the cervical spine. There is a compression deformity
involving greater than 50% loss of height of the T4 vertebral body, with
approximately 2 mm retropulsion (602b:21). 2 mm anterolisthesis of C4 on C5
may be degenerative in nature, although should be correlated clinically if
there is concern for ligamentous injury.
No significant spinal canal or neural foraminal stenosis. There is no
prevertebral soft tissue swelling. Allowing for prominent respiratory motion
artifact, the visualized lung apices are clear. Atherosclerotic calcification
of the bilateral carotid bifurcations are noted. The thyroid gland is
atrophic.
IMPRESSION:
1. No acute fracture in the cervical spine.
2. Age indeterminate T4 vertebral body compression deformity with 2 mm
retropulsion.
3. 2 mm anterolisthesis of C4 on C5 is almost certainly degenerative in
nature, although should be correlated clinically if there is concern for
ligamentous injury at this level.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, R Rib pain
Diagnosed with Unsp fracture of fourth thoracic vertebra, init for clos fx, Fall on same level, unspecified, initial encounter, Unspecified hydronephrosis, Unspecified atrial fibrillation
temperature: 97.9
heartrate: 110.0
resprate: 16.0
o2sat: 96.0
sbp: 112.0
dbp: 56.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ presented with abdominal pain and urinary retention.
She also had flank pain after a traumatic fall. She was found to
have hydronephrosis on imaging and had a foley catheter placed.
She was started on antibiotics for and UTI and pyelonephritis.
She will be discharged on augmentin and will continue this until
___. She was also seen by the spine service for her vertebral
fracture and will follow up with them on an outpatient basis.
# Acute Kidney Injury: Pt presented with acute kidney injury
from obstructive uropathy. This was evidenced by the
pyelonephritis on imaging. Her Cr on admission was 4.3 and her
Cr on discharge was 1.5. Her baseline Cr is approximately 1.3.
She had a foley catheter placed and will be discharged with the
foley catheter and will have follow up with urology on ___.
# UTI, pyelonephritis: The pt had a positive UA and met severe
sepsis criteria on admission. She reported rigors at home
before admission, had a leukocytosis with a left shift, had an
elevated lactate, and had a suspected source (urine).
Obstructive uropathy leading to urinary stasis put Ms. ___ at
increased risk of urinary infection. A foley catheter was
placed to relieve the obstruction and she was treated with
antibiotics. She was initially started on ceftriaxone in the ED
and was broadened to ampicillin/sulbactam on the floor. When
the urine cultures came back, she was transitioned to
amoxicillin/clavulanic acid. She will be discharged on
amoxicillin/clavulanic acid to complete a 14 day course to end
on ___. She will also be discharged with the foley
catheter in place for source control.
# Obstructive Uropathy: The cause of the obstructive uropathy
was not clear. On imaging, bladder wall thickening was seen and
UV junction blockage was suggested. This raises concern for
possible bladder mass. Urology was consulted and recommended
maintaining the foley catheter after discharge for urinary
drainage. She will follow up with urology in clinic on ___.
# Fall: The pt had multiple falls in the time period prior to
presentation. She had a fractured ___ right rib from a fall.
Her pain was managed and she was seen by both physical and
occupational therapy. They recommended that she have continued
outpatient services and that she be observed at all times.
# L4 Fracture: Pt had L4 compression fracture on admission. She
was seen by the orthopedic spine service on the ED. She was
given a TLSO brace for comfort but found it uncomfortable and
did not use it. She will follow up with the orthopedic spine
service in clinic.
# Hypertension
- Continued amlodipine
# Hyperlipidemia
- Continued simvastatin
# Hypothyroid
- Levothyroxine 75 mcg PO daily
# Depression
- Continued fluoxetine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
shellfish derived
Attending: ___
Major Surgical or Invasive Procedure:
___: Single site laparoscopic total abdominal colectomy
with end ileostomy
attach
Pertinent Results:
Micro:
blood cx ___: ngtd
blood cx ___ pending
blood cx ___ pending
___ ucx: ngtd
CT abdomen ___
Procto-pancolitis likely reflective of an acute flare of
ulcerative colitis. There is free fluid in the pelvis, however
no discrete, drainable
organized fluid collection or extraluminal air is identified.
KUB ___:
Interval decrease in the dilated loops of large bowel, now
measuring up to 5.5
cm. No evidence of pneumatosis or free intraperitoneal air.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 30 mg PO DAILY
This is dose # 1 of 3 tapered doses
2. PredniSONE 20 mg PO DAILY
Start: After 30 mg DAILY tapered dose
This is dose # 2 of 3 tapered doses
3. PredniSONE 10 mg PO DAILY
Start: After 20 mg DAILY tapered dose
This is dose # 3 of 3 tapered doses
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Enoxaparin (Prophylaxis) 40 mg SC DAILY
Please take as prescribed
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*21
Syringe Refills:*0
3. Multivitamins W/minerals Chewable 1 TAB PO DAILY
4. TraMADol 50-100 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Do not drink or drive while taking
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
5. PredniSONE 15 mg PO DAILY Duration: 7 Doses
This is dose # 1 of 3 tapered doses
6. PredniSONE 5 mg PO DAILY Duration: 7 Doses
This is dose # 3 of 3 tapered doses
RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
7. PredniSONE 20 mg PO DAILY
This is dose # 2 of 3 tapered doses
RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
8. PredniSONE 10 mg PO DAILY
This is dose # 3 of 3 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ulcerative colitis flare
Acute blood loss anemia
Severe malnutrition
Post-op ileus
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 ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with recent diagnosis of likely UC,
has fever, abdominal pain, anal painNO_PO contrast // ? abscess
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast (VoLumen) was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 20.3 mGy (Body) DLP =
10.1 mGy-cm.
2) Spiral Acquisition 6.1 s, 48.1 cm; CTDIvol = 6.0 mGy (Body) DLP = 289.3
mGy-cm.
Total DLP (Body) = 299 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is diffuse
colonic and rectal wall circumferential thickening, dilatation, loss of
haustra and mucosal hyperenhancement. There are air-fluid levels in the
colon. Free fluid is noted in the pelvis, however there are no organized,
drainable fluid collections, and no extraluminal air. Terminal ileum is
normal appearing. The appendix has mucosal hyperenhancement, contains air and
fluid however is not dilated.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: Mesenteric lymphadenopathy with lymph nodes measure up to 1.2 cm
is likely reactive. There is no retroperitoneal lymphadenopathy. There is no
pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Procto-pancolitis likely reflective of an acute flare of ulcerative
colitis. There is free fluid in the pelvis, however no discrete, drainable
organized fluid collection or extraluminal air is identified.
Radiology Report
INDICATION: ___ year old man with recent UC, worsening abdominal pain // Eval
for free air
TECHNIQUE: Upright AP and supine views of the abdomen
COMPARISON: Same-day CT performed approximately 6 hours earlier
FINDINGS:
The colon demonstrates diffuse gaseous distention. There is a relatively
ahaustral appearance to the colon with thickening of the folds compatible with
known active ulcerative colitis. Contrast from previous CT exam is seen
within the renal collecting systems and urinary bladder. No free
intraperitoneal air, dilated loops of small bowel, or pneumatosis. No acute
osseous abnormality.
IMPRESSION:
No free intraperitoneal air. Redemonstration of ahaustral appearance of the
colon with thickening of the folds compatible with active inflammatory bowel
disease.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with UC flare, now with cough. Has concern for
infx // pneumonia?
TECHNIQUE: Frontal and lateral view radiographs of the chest.
COMPARISON: None.
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities are identified.
IMPRESSION:
No pneumonia or acute cardiopulmonary process.
Radiology Report
INDICATION: ___ year old man with UC flare. Has concern for infx //
perforation?
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiographs ___. CT abdomen and pelvis ___.
FINDINGS:
There has been interval decrease in the size of the dilated loops of large
bowel now measuring up to 5.5 cm. There is redemonstration of the relatively
featureless appearance of the colonic wall with a few small areas of haustral
thickening, which is consistent with ulcerative colitis. There are no
abnormally dilated loops of small bowel. There is no pneumatosis or free
intraperitoneal air. The osseous structures are unremarkable.
IMPRESSION:
Interval decrease in the dilated loops of large bowel, now measuring up to 5.5
cm. No evidence of pneumatosis or free intraperitoneal air.
Radiology Report
INDICATION: ___ year old man with UC flare, now with sudden tachycardia //
eval for perforation
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiographs ___ CT abdomen and pelvis ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. The previously
seen severe distention of the colon with gas is significantly improved.
There is no free intraperitoneal air.
The imaged bones are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Interval improvement in colonic distention, now only measuring up to 4.7 cm.
No evidence of pneumatosis or free intraperitoneal air.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with UC flare with worsening abd pain // eval
for perforation, ___
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
No evidence of subdiaphragmatic free gas. Lungs are fully expanded and clear.
Cardiomediastinal and hilar silhouettes are normal. No vascular congestion. No
pleural effusion or pneumothorax.
IMPRESSION:
No evidence of pneumoperitoneum.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ recent dx of UC p/w severe flare and acute blood loss
anemia. // bilateral chest pain, SOB, eval for underlying cause
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the right PICC projects over the upper right atrium, approximately
3 cm beyond the cavoatrial junction.
There is no focal consolidation, pleural effusion or pneumothorax identified.
The size of the cardiomediastinal silhouette is within normal limits.
IMPRESSION:
No acute cardiopulmonary abnormality.
The tip of the right PICC projects over the right atrium, approximately 3 cm
beyond the cavoatrial junction.
Radiology Report
INDICATION: ___ w/ recent dx of UC p/w severe flare and acute blood loss
anemia. // nausea vomiting
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: ___
FINDINGS:
The several drains project over the abdomen. There are no abnormally dilated
loops of large or small bowel however there is an overall paucity of gas.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ngt // eval ngt placement eval ngt
placement
IMPRESSION:
NG tube tip is in the stomach. Heart size and mediastinum are stable. Lungs
overall clear. There is no appreciable pleural effusion or pneumothorax.
Right PICC line tip is at the cavoatrial junction.
Radiology Report
INDICATION: ___ w/ recent dx of UC p/w severe flare and acute blood loss
anemia s/p laparoscopic TAC, end-ileostomy // Obstruction? Ileus? Free air?
TECHNIQUE: Upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph ___ through ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is a
paucity of bowel gas throughout. The abdomen appears somewhat hazy which may
be indicative underlying small volume ascites.
There is no free intraperitoneal air.
The imaged bones are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies. 2 abdominal drains are unchanged in position.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern. No intraperitoneal free air.
Radiology Report
INDICATION: ___ w/ recent dx of UC p/w severe flare and acute blood loss
anemia s/p laparoscopic TAC, end-ileostomy // Free air? ileus? obstruction?
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiographs ___ through ___
and CT abdomen and pelvis ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is a
paucity of bowel gas throughout.
There is no free intraperitoneal air.
The imaged bones are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies. 2 abdominal drains are stable in position.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern. No evidence of free
intraperitoneal air.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Nausea
temperature: 97.0
heartrate: 104.0
resprate: 14.0
o2sat: 100.0
sbp: 141.0
dbp: 89.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ was initially admitted to the medicine service on
___ with an acute ulcerative colitis flare. The GI service and
colorectal surgery were consulted in the emergency department
for steroid or biologic recommendations and possible colectomy
given concern for fulminant colitis.
#Severe UC Flare
#Acute blood loss anemia
Initially he was treated with Zosyn but per GI recommendations
was switched Rocephin/flagyl. He was also given ganciclovir
empirically for CMV (which later came back negative so
ganciclovir was stopped). On admission he was started on
methylpred 20mg IV q8hrs. Stool samples were sent to rule out
cyclospora, microsporidium, giardia, EHEC, shigella,
campylobacter, salmonella, and c.diff all of which were
negative. He got a daily KUB to monitor for perforation. On
___ overnight he went from little to no blood in bowel
movements to several bloody BMs, heart rate went from ___ to
140s, and his Hgb dropped from 9.9 to 5.9. CRS was called,
abdominal exam is slightly worse but felt no acute surgical
indication. He was transfused 2 units, blood cultures were
drawn, and his antibiotics were broadened back to zosyn. He
reports significant abdominal pain only improved with morphine,
with any motion setting of ___ sharp pain throughout his
abdomen. On ___ the patient had a pre-syncopal episode and
became hemodynamically unstable in the setting of acute blood
loss anemia. His labs were sent and his Hgb/Hct was notable for
___. He was transfused with 3 units of PRBCs and 3 units of
FFP. He was urgently taken to the operating room on ___ for a
laparoscopic total abdominal colectomy with end ileostomy. He
tolerated the procedure well without complications (Please see
operative note for further details). After a brief and
uneventful stay in the PACU, the patient was transferred to the
floor for further post-operative management.
Neuro: Pain was well initially well controlled on IV Tylenol and
a dilaudid PCA for breakthrough pain. Once tolerating oral
intake, the patient was transitioned to oral Tylenol and
tramadol for breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored and the patient
was placed on continuous cardiac monitoring. The patient was
noted to be slightly tachycardic to the low 100's and up to the
150's with ambulation in the immediate post-op period, EKG
obtained and revealed sinus tachycardia. As the patient became
more mobile and active, his tachycardia improved.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. He had good pulmonary
toileting, as early ambulation and incentive spirometry were
encouraged throughout hospitalization.
ID: The patient was given an additional 4 days of Zosyn. He was
closely monitored for signs and symptoms of infection and fever,
of which there was none.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. He was encouraged to get up and ambulate
as early as possible. The patient is being discharged on
prophylactic Lovenox.
#Post-op ileus
The patient was initially kept NPO after the procedure. The
patient was later advanced to a regular diet. On ___, the
patient had an episode of emesis. A KUB was obtained which
showed dilated loops of bowel. A nasogastric tube was placed and
the patient was given IV fluids and IV pain medication the NGT
was removed on ___ due to severe discomfort causing ongoing
tachycardia for the patient. His stoma was thus intubated with a
red rubber catheter. The patient began to have output from his
stoma (both stool and gas) and on ___, he was advanced to a
regular diet which was well tolerated at time of discharge.
Patient's intake and output were closely monitored.
#Acute urinary retention requiring foley replacement:
The patient had a foley catheter in the operating room that was
removed in the PACU. At the time the patient was DTV, he was
bladder scanned for >1L. The foley catheter was replaced on
___ and the patient continued to have good urine output. It
was discontinued on ___ once again and at the time the patient
was DTV, he was bladder scanned for 800cc of urine. A foley was
once again placed on ___ and ultimately removed on ___. The
patient was able to void on his own without difficulty for the
remainder of the hospitalization. Urine output was monitored as
indicated.
#Severe protein calorie Malnutrition
Due to significant weight loss, a nutrition consult was placed.
Initially, due to concern for bacteremia, TPN was held and PPN
was given. Once blood cultures came back negative, a PICC line
was placed on ___ and the patient was started on TPN. The
patient continued on TPN until he was fully tolerating a diet
and TPN was discontinued on ___. The patient will be
discharged home on a multivitamin recommended by nutrition.
#Hyponatremia:
Likely hypovolemic hyponatremia in setting of poor po intake.
TPN adjusted accordingly.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. He will follow-up in the clinic in ___
weeks. This information was communicated to the patient directly
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catherization on ___
History of Present Illness:
___ with hx of DM, HTN, and HLD p/w CP x 1 day. He was in his
usual state ___ until this morning. He lives an active life
style with frequent exercise. He states that his CP started
around 2AM, described as a sudden-onset of pressure sensation
radiating to L arm. Denies SOB, N/V, diaphoresis, PND, or
orthopnea. At OSH, ECG reported to have hyperacute T waves
anteriorly and biphasic T waves inferiorly. He was placed on
heparin gtt and transferred to ___ for further management.
In the ED, VSSAF. Labs notable for TropT 0.02 ___KMB, Cr
1.2 (baseline 1.1), WBC 13.4 (baseline ___ since ___
was given atorvastatin 80, heparin gtt, nitro gtt, methylpred
125 mg IV and sent directly to the cath lab. Cath was notable
for ___ lesion 50-60% occluded with no intervention. After cath,
patient continued to complain of pleuritic chest pain for which
he was admitted.
On arrival to the floor, he had no CP on nitro drip. Denies any
SOB or orthopnea.
Past Medical History:
-HTN
-HLD
-DM
-hx of PNA (hospitalized in ___
-OA
-s/p total hip replacement
-seronegative inflammatory arthritis
-lumbar spinal stenosis
-glaucoma
-night cramps on quinine
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T= 98.4 BP= 124/57 HR= 59 RR= 18 O2 sat=100% RA
GENERAL: Well appearing in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP below clavicle.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
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 c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Right femoral cath site clean, intact, without palpable thrill.
No bruit. Distal pulses 2+ and symmetric with left.
DISCHARGE PHYSICAL EXAM:
VS: T= 98.3 BP= 145/54 HR= 58 RR= 18 O2 sat=100% RA
GENERAL: Well appearing in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP below clavicle.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
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 c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Right femoral cath site clean, intact, without palpable thrill.
No bruit. Distal pulses 2+ and symmetric with left.
Pertinent Results:
Admission Labs:
___ 07:55AM BLOOD WBC-13.4* RBC-3.49* Hgb-10.7* Hct-34.8*
MCV-100* MCH-30.7 MCHC-30.7* RDW-13.6 RDWSD-49.4* Plt ___
___ 07:55AM BLOOD Neuts-68.2 ___ Monos-9.9 Eos-0.0*
Baso-0.5 Im ___ AbsNeut-9.13* AbsLymp-2.79 AbsMono-1.32*
AbsEos-0.00* AbsBaso-0.07
___ 07:55AM BLOOD Glucose-107* UreaN-30* Creat-1.2 Na-141
K-4.4 Cl-109* HCO3-21* AnGap-15
___ 06:05AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
Pertinent labs:
___ 06:05AM BLOOD CK-MB-3 cTropnT-0.02*
___ 10:06AM BLOOD cTropnT-<0.01
___ 07:55AM BLOOD CK-MB-5 cTropnT-0.02*
Discharge labs:
___ 06:05AM BLOOD WBC-12.9* RBC-3.66* Hgb-11.3* Hct-35.8*
MCV-98 MCH-30.9 MCHC-31.6* RDW-13.5 RDWSD-48.4* Plt ___
___ 06:05AM BLOOD Glucose-125* UreaN-29* Creat-1.3* Na-141
K-4.2 Cl-106 HCO3-21* AnGap-18
Studies:
LHC (___):
LAD MLI
___ 60%; ramus 50%
RCA ___ 40%; MLI distally
___ CTPA
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Calcified pleural plaques are noted, possibly from prior
asbestos exposure.
___ TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Methylprednisolone 4 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
7. Quinine Sulfate 324 mg PO QHS
8. Terbinafine 1% Cream 1 Appl TP BID
9. Vitamin D ___ UNIT PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
2. Lisinopril 10 mg PO DAILY
3. Methylprednisolone 4 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
7. Vitamin D ___ UNIT PO DAILY
8. Simvastatin 20 mg PO QPM
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Quinine Sulfate 324 mg PO QHS
11. Terbinafine 1% Cream 1 Appl TP BID
12. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Non-cardiac chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man presents with chest pain and positive cardiac
biomarkers. Cardiac cath w/o culprit lesion. // rule 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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) CT Localizer Radiograph
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8
mGy-cm.
5) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 13.7 mGy (Body) DLP =
6.8 mGy-cm.
6) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 15.2 mGy (Body) DLP =
7.6 mGy-cm.
7) Spiral Acquisition 3.5 s, 27.6 cm; CTDIvol = 14.5 mGy (Body) DLP = 398.6
mGy-cm.
Total DLP (Body) = 414 mGy-cm.
COMPARISON: None
FINDINGS:
Multiple scattered bilateral pleural plaques are identified.
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
Coronary artery and thoracic aorta atherosclerotic calcifications. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES, LUNGS/AIRWAYS: Small bilateral pleural effusions with some
compressive atelectasis. The airways are patent to the level of the segmental
bronchi bilaterally. No pneumothorax.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable. Possibly
replaced right or left hepatic artery, incompletely visualized.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Degenerative changes of the thoracic spine.
Gynecomastia noted.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Calcified pleural plaques are noted, possibly from prior asbestos exposure.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Transfer
Diagnosed with Cardiomyopathy, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 5
level of acuity: 2.0 | ___ with hx of DM, HTN, and HLD p/w CP x 1 day.
# Chest pain: He reports a sudden-onset of pressure sensation
radiating to L arm. Denies SOB, N/V, diaphoresis, PND, or
orthopnea. At OSH, ECG reported to have hyperacute T waves
anteriorly and biphasic T waves inferiorly. He was placed on
heparin gtt and transferred to ___ for further management.
Patient was given atorvastatin 80, heparin gtt, nitro gtt,
methylpred 125 mg IV and sent directly to the cath lab. Cath was
notable for ___ lesion 50-60% occluded with no intervention.
After cath, patient continued to complain of pleuritic chest
pain for which he was admitted. He underwent a CTPA which did
not show any evidence of PE. His pain resolved with rest and
nitro drip. The nitro drip was weaned and his home medications
were restarted without any recurrence of his pain. Pain thought
to be non-cardiopulmonary in nature. He is being discharged on
81mg daily aspirin with PCP follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old M w/ no significant PMH who
presented to ___ with SOB and was found to have a
submassive PE with evidence of right heart strain, transferred
to ___ for further management of submassive PE.
He reports that for the past ___ days he has noticed some subtle
SOB while walking up stairs that he thought was allergies or a
cold coming on. He then was working in his yard this morning
when he felt acutely short of breath. He had some chest
tightness as well with some tingling in his left hand and
bilateral cold sensation in his hands.
His trop at ___ was 0.13 (trop I). He had a CT-PE which
showed "diffuse pulmonary emboli which involve the pulmonary
arteries in all the lobes. Clot in the lobar pulmonary arteries
has extension into a portion of the main pulmonary arteries.
There is a flattening of the intraventricular septum and the
RV/LV ratio is greater than 1, findings consistent with right
heart strain." He was started on heparin gtt and transferred to
___.
In the ED initial vitals were: 97.9 94 144/86 18 99% Nasal
Cannula.
Patient's VS were stable. He was on 3L with hypoxia to high ___
at OSH per EMS.
EKG showed S1Q3T3 present, otherwise no ST depressions or
elevations. Sinus rhythm, normal rate.
Labs/studies notable for: Trop 0.08, BNP 177.
Patient was given: heparin gtt.
Vitals on transfer: 98.1 88 129/87 20 99% Nasal Cannula.
On the floor, the patient reports that he has SOB with walking
to the bathroom and takes him awhile to catch his breath, but
that it is better than earlier in the day. He denies chest pain,
fevers/chills, night sweats, weight loss, cough, urinary
complaints.
He has family history of colon cancer in father (died at age
___, breast cancer in mother (who is still alive in her ___,
and mother who had clot but in the setting of her cancer. No
other family members with blood clots or cancer history.
He reports that he has not smoked cigarettes since ___ years ago.
No recent travel anywhere. Had knee surgery for ACL in ___ but has been very active since then.
Past Medical History:
1. CARDIAC RISK FACTORS: None
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
Low testosterone
history of hernia surgeries
history of ACL surgery
essential tremor
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. He has family history of colon cancer in
father (died at age ___, breast cancer in mother (who is still
alive in her ___, and mother who had clot but in the setting of
her cancer. No other family members with blood clots or cancer
history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: AF, 130s/70s, HR ___, comfortable on RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
Short of breath with talking.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. JVP to mid neck at 60 degrees.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Short
of breath with talking. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. No cords, swelling,
erythema, no tenderness over calf.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
==========================
VS: Tc 97.5, BP 129/89 (110-120s/70-80s), HR 70 (60-70s), sat
95% RA
GENERAL: pleasant man, lying comfortably in bed, alert and
awake, speaking in full sentences, in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. JVP to clavicle at 30 degrees.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Breathing comfortably on room air, no access muscle use. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: +BS, soft, NTND, no rebound, guarding
EXTREMITIES: No c/c/e. No femoral bruits. No cords, edema,
erythema, or tenderness over calf. Left great toe with edema,
tender to palpation, no erythema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:34PM BLOOD WBC-9.5 RBC-5.91 Hgb-17.6* Hct-52.0*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.4 RDWSD-45.1 Plt ___
___ 04:34PM BLOOD Neuts-72.5* ___ Monos-5.7
Eos-0.8* Baso-0.3 Im ___ AbsNeut-6.84* AbsLymp-1.92
AbsMono-0.54 AbsEos-0.08 AbsBaso-0.03
___ 04:34PM BLOOD ___ PTT-150* ___
___ 04:34PM BLOOD Glucose-98 UreaN-17 Creat-1.1 Na-141
K-4.1 Cl-103 HCO3-24 AnGap-18
___ 04:34PM BLOOD proBNP-177
___ 04:34PM BLOOD cTropnT-0.08*
___ 04:48PM BLOOD Lactate-1.9
NOTABLE LABS:
=============
___ 04:34PM BLOOD cTropnT-0.08*
___ 04:34PM BLOOD proBNP-177
DISCHARGE LABS:
================
___ 03:52AM BLOOD WBC-6.8 RBC-5.35 Hgb-16.2 Hct-47.8 MCV-89
MCH-30.3 MCHC-33.9 RDW-14.1 RDWSD-46.1 Plt ___
___ 04:45AM BLOOD ___ PTT-79.4* ___
___ 03:52AM BLOOD Glucose-90 UreaN-18 Creat-1.1 Na-135
K-3.6 Cl-100 HCO3-24 AnGap-15
___ 03:52AM BLOOD Calcium-9.2 Phos-4.4 Mg-1.9
IMAGING:
=========
___ Cardiovascular ECHO
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. 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. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mildly dilated, mildly hypokinetic right ventricle.
Moderate pulmonary artery systolic hypertension. Preserved left
ventricular systolic function. Mildly dilated aortic root.
___ Imaging BILAT LOWER EXT VEINS
1. Deep venous thrombosis extending from the proximal right
femoral vein,
throughout the right popliteal vein, and into 1 of the right
peroneal veins.
2. No evidence of DVT on the left.
Medications on Admission:
The Preadmission Medication list ___ be inaccurate and requires
futher investigation.
1. PrimiDONE 50 mg PO BID
2. Cialis (tadalafil) 20 mg oral PRN
Discharge Medications:
1. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Enoxaparin Sodium 90 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 0.9 mL SC twice a day Disp #*14 Syringe
Refills:*0
3. Propranolol 40 mg PO BID
RX *propranolol 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. PrimiDONE 100 mg PO QHS
RX *primidone 50 mg 2 tablet(s) by mouth at bedtime Disp #*10
Tablet Refills:*0
5. PrimiDONE 50 mg PO QAM
RX *primidone 50 mg 1 tablet(s) by mouth QAM Disp #*3 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Submassive pulmonary embolism
Right ventricle strain
Right lower extremity DVT
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 submassive PE.// eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is complete thrombosis extending from the proximal femoral vein, just
distal to the bifurcation, throughout the popliteal vein and into 1 of the
peroneal veins. The other right peroneal vein is patent. The right posterior
tibial veins are also patent.
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the left posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Deep venous thrombosis extending from the proximal right femoral vein,
throughout the right popliteal vein, and into 1 of the right peroneal veins.
2. No evidence of DVT on the left.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:37 pm, 2 minutes
after discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypoxia, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale
temperature: 97.9
heartrate: 94.0
resprate: 18.0
o2sat: 99.0
sbp: 144.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old M w/ no significant PMH who
presented to ___ with SOB and was found to have a
submassive PE with evidence of right heart strain, transferred
to ___ for further management of submassive PE.
#Submassive PE: Patient presented with acute onset SOB and was
found to have significant clot burden in bilateral pulmonary
arteries with positive troponin and signs of right heart strain
on CTA. Started on heparin gtt and transferred to ___. In the
ED, cardiology was consulted and felt that patient did not have
current indication for thrombectomy or more invasive treatment.
Patient s/p ortho knee surgery ___ with intermittent RLE
swelling. Patient up to date on colonoscopy (next scheduled
___. ___ with DVT extending from proximal right femoral
vein, throughout the right popliteal vein, and into 1 of the
right peroneal veins. TTE with evidence of right heart strain
and elevated pulmonary pressures. He was treated with heparin
gtt and transitioned to Lovenox as bridge to Coumadin. He could
not be on NOAC due to interaction with primidone.
#Gout: patient had new left toe tenderness and edema; per
patient felt similar to prior gout flare. Started colchicine 1.2
mg loading dose with 0.6 mg daily after that.
#Splenomegaly: Seen on CT-A for PE study. Unclear etiology.
Could consider work up if concerned for occult malignancy as
cause of PE.
#Essential tremor: Continued primidone 100 mg qAM and 150 mg qPM
during admission. Discussed with outpatient neurologist Dr.
___ we would like to wean off primidone if possible due
to wanting to put the patient on a NOAC as ultimate
anticoagulation. She agreed with weaning off primidone with 50
mg decrease in dose every 3 days until off the medication.
Started 40 mg propranolol to treat essential tremor with plan to
f/u with neurology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fever, abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of HIV/AIDS (non-adherent to
ARVs, last CD4 147 ___K ___, HTN, HLD, DM2 who
presents with fevers, nausea, vomiting, diarrhea and abdominal
pain. He reports three days of symptoms one week ago that
self-resolved. He then had recurrence of symptoms on the day
prior to admission. He has had ___ non-bloody loose BMs per day
as well as ___ episodes of NBNB emesis. His abdominal pain is
primarily ___ in location.
Patient reports not taking any of his medications for "long
time." He however has been using crystal meth (both smoked and
IV) regularly and reports last use 1 week ago. He does appear
drowsy on exam however denies using any other illicit drug. He
denies any headache, neck stiffness, vision changes, weakness,
numbness, tingling. He also denies any cough, shortness of
breath or chest pain.
In the ED initial vitals were: 99 123 153/99 20 98% RA. He then
spiked a fever to 102.4.
- Labs were significant for WBC 15.3 with 2% bands along with
lactate of 2.9. Chem remarkable for hyponatreia, low phos, low
mag. CT abd/pelvis with diffuse colitis.
- Patient was lorazepam, morphine for pain, vancomycin, zosyn,
and 2L IVF and admitted for further management.
Patient is currently drowsy but arousable. He denies abdominal
pain or nausea currently.
Past Medical History:
-HIV (diagnosed ___, non-compliant with medications, last CD4
147 ___K ___
-DM2 A1c 11.4 ___
-HTN
-HLD
-GERD
-Depression
-Insomnia
-Methamphetamin abuse
-? COPD vs OSA
Social History:
___
Family History:
Father with heart disease, mother with breast cancer.
Physical Exam:
ADMISSION EXAM:
================
VS: T 97.7, BP 95/55, HR 95, RR 18, SaO2
GEN: Drowsy, opens eyes to voice, answers questions, not
tremulous HEENT: NCAT, MMM, EOMI
NECK: Supple, no JVD
CV: RRR, S1+S2, NMRG
RESP: Breathing comfortably, lungs CTAB
ABD: Obese, +BS, soft, nondistended, nontender
GU: No foley
EXT: Cool extremities, 2+ pulses, no edema
NEURO: Oriented x 3, CN III-XII grossly intact, MAE
DISCHARGE EXAM:
================
VS: T 98, HR 69, BP 138/79, RR 18, SaO2 97% RA
GEN: Alert, oriented, no acute distress
NECK: Supple, no JVD
CV: RRR, S1+S2, NMRG
RESP: Breathing comfortably, lungs CTAB
ABD: Obese, +BS, soft, nontender
EXT: Cool extremities, 2+ pulses, bilateral upper extremity
anascarca, no lower extremity edema
NEURO: Oriented x 3, CN III-XII grossly intact, MAE
Pertinent Results:
ADMISSION LABS:
================
___ 01:15AM BLOOD WBC-15.3*# RBC-5.64 Hgb-15.7 Hct-43.1
MCV-77* MCH-27.9 MCHC-36.5* RDW-14.7 Plt ___
___ 01:15AM BLOOD Neuts-69 Bands-2 ___ Monos-10 Eos-0
Baso-0 Atyps-1* ___ Myelos-0
___ 10:53AM BLOOD ___ PTT-32.9 ___
___ 01:15AM BLOOD Glucose-163* UreaN-12 Creat-0.8 Na-129*
K-4.2 Cl-100 HCO3-18* AnGap-15
___ 01:15AM BLOOD ALT-43* AST-42* AlkPhos-130 TotBili-0.8
___ 01:15AM BLOOD Lipase-29
___ 01:15AM BLOOD Albumin-3.4* Calcium-8.1* Phos-1.1*
Mg-1.5*
___ 01:15AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 01:31AM BLOOD Lactate-2.9*
DISCHARGE LABS:
================
___ 05:29AM BLOOD WBC-6.2 RBC-4.72 Hgb-12.9* Hct-36.8*
MCV-78* MCH-27.3 MCHC-35.0 RDW-14.5 Plt ___
___ 05:29AM BLOOD Neuts-69.6 ___ Monos-7.5 Eos-0.5
Baso-0.5
___ 05:29AM BLOOD ___ PTT-30.0 ___
___ 05:29AM BLOOD Glucose-110* UreaN-7 Creat-0.7 Na-136
K-3.7 Cl-106 HCO3-23 AnGap-11
___ 05:29AM BLOOD ALT-27 AST-36 AlkPhos-85 TotBili-0.7
___ 05:29AM BLOOD Calcium-8.0* Phos-1.8* Mg-2.2
OTHER LABS:
============
___ 10:53AM BLOOD Albumin-3.2* Calcium-7.5* Phos-4.5#
Mg-1.8 Iron-15*
___ 10:53AM BLOOD calTIBC-256* Ferritn-185 TRF-197*
___ 05:54AM BLOOD %HbA1c-8.3* eAG-192*
___ 01:15AM BLOOD CRP-24.6*
STUDIES/IMAGING:
=================
CXR (___):
IMPRESSION:
Pulmonary and mediastinal vascular congestion have improved and
yesterday's cardiomegaly has resolved. Lungs are grossly clear.
KUB (___):
FINDINGS:
There is a paucity of bowel gas. No dilated loops of small
bowel are seen. No free air on supine radiograph. Contrast
from prior CT abdomen pelvis is within the bladder. Bony
structures are unremarkable.
CT Abdomen/Pelvis (___):
1. Wall edema, mucosal hyperenhancement, and minimal fat
stranding surrounding the terminal ileum extending into the
ascending and the proximal transverse colon. Etiology include
infectious, inflammatory, or ischemic in origin.
2. Splenomegaly.
CXR (___):
FINDINGS:
No focal consolidations identified. There is mild pulmonary
vascular congestion. The cardiomediastinal silhouette and hilar
contours are normal. There is no pleural effusion or
pneumothorax.
IMPRESSION:
Mild pulmonary vascular congestion. No focal consolidation.
MICROBIOLOGY:
==============
___ 10:34 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___ Reported to and read back by ___ ___ AT
12:30 ___.
FECAL CULTURE (Preliminary):
Reported to and read back by ___. ___ (___)
___ @
4:14 ___.
SHIGELLA FLEXNERI.
Presumptive identification pending confirmation by
___
Laboratory.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SHIGELLA FLEXNERI
|
AMPICILLIN------------ =>32 R
CEFTRIAXONE----------- <=1 S
LEVOFLOXACIN----------<=0.12 S
TRIMETHOPRIM/SULFA---- <=1 S
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
___ Blood cultures x 3 pending
___ Blood cultures x 2 pending
___ Urine culture negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. ClonazePAM 1 mg PO BID:PRN anxiety
4. amlodipine-benazepril ___ mg ORAL DAILY
5. Omeprazole 20 mg PO BID
6. Venlafaxine XR 150 mg PO DAILY
7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
8. Darunavir 800 mg PO DAILY
9. RiTONAvir 100 mg PO DAILY
10. Raltegravir 400 mg PO BID
11. Etravirine 200 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO DAILY
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*52 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
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. Ciprofloxacin HCl 750 mg PO Q24H Duration: 3 Days
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
6. amlodipine-benazepril ___ mg ORAL DAILY
RX *amlodipine-benazepril 10 mg-40 mg 1 capsule(s) by mouth
daily Disp #*30 Capsule Refills:*0
7. ClonazePAM 1 mg PO BID:PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
8. MetFORMIN (Glucophage) 1000 mg PO DAILY
RX *metformin 1,000 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Omeprazole 20 mg PO BID
10. Venlafaxine XR 150 mg PO DAILY
RX *venlafaxine 150 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. Neutra-Phos 2 PKT PO DAILY Duration: 1 Dose
RX *potassium & sodium phosphates [Phos-NaK] 280 mg-160 mg-250
mg 1 powder(s) by mouth daily Disp #*10 Packet Refills:*0
12. Atorvastatin 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Clostridium difficile colitis
Shigella enterocolitis
Abdominal pain
Diarrhea
Secondary:
Hypertension
HIV
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with h/o HIV, non-compliant with vomiting diarrhea distention
and abdominal pain, evaluate for acute cardiopulmonary process.
TECHNIQUE: Single AP portable view of the chest was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
No focal consolidations identified. There is mild pulmonary vascular
congestion. The cardiomediastinal silhouette and hilar contours are normal.
There is no pleural effusion or pneumothorax.
IMPRESSION:
Mild pulmonary vascular congestion. No focal consolidation.
Radiology Report
INDICATION: ___ with h/o HIV, non-compliant with vomiting, diarrhea,
distention and abdominal pain, evaluate for free air, infectious etiologies.
TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis following the
intravenous administration of 150 cc of Omnipaque . Coronal and sagittal
reformatted images were also generated for review.
DOSE: 140 mGy-cm
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis. The visualized portions of
the heart and pericardium are unremarkable.
LIVER: The liver demonstrates decreased attenuation compatible with fatty
infiltration. The appearance of the liver is otherwise normal without
fibrosis or cirrhosis. There is no focal lesions or intrahepatic biliary duct
dilatation. The gallbladder is unremarkable and the portal vein is patent.
PANCREAS: The pancreas does not demonstrate focal lesions or peripancreatic
stranding or fluid collection.
SPLEEN The spleen is homogeneous but enlarged, measuring 16 cm.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys do not show solid or cystic lesions and demonstrate
symmetric nephrograms and excretion of contrast. No pelvicaliceal dilatation
or perinephric abnormalities are present. Note is made of a duplex left
kidney with joining of the upper and lower ureters at the ureteropelvic
junction.
GI TRACT: The stomach and duodenum are within normal limits, without evidence
of wall thickening or obstruction. There is wall edema, mucosal hyper
enhancement, as well as minimal fat stranding surrounding the terminal ileum
extending into the cecum and proximal ascending colon. Fecalized material
seen within the terminal ileum may be related to an incompetent ileocecal
valve. The appendix is visualized and normal. Scattered colonic
diverticulosis is present without evidence of acute diverticulitis.
VASCULAR: The aorta is normal in caliber without aneurysmal dilatation. The
origins of the celiac axis, SMA, bilateral renal arteries, and ___ are patent.
RETROPERITONEUM AND ABDOMEN: There are mildly enlarged common hepatic and
periportal lymph nodes measuring up to 11mm. There is no retroperitoneal
lymphadenopathy. No ascites, free air, or abdominal wall hernias are noted.
PELVIC CT: The urinary bladder and distal ureters are unremarkable. No
pelvic wall or inguinal lymph node enlargement is seen. There is no pelvic
free fluid. There is stranding at the left groin, which is likely related to
previous venous access per discussion with ED physician.
OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy is
present. Bilateral hip osteoarthritic changes are noted.
IMPRESSION:
1. Wall edema, mucosal hyperenhancement, and minimal fat stranding
surrounding the terminal ileum extending into the cecum and very proximal
ascending colon compatible with mostly ileocecitis. Although the etiology is
likely infectious and there are no chronic findings to suggest ___
disease, inflammatory etiology cannot be excluded.
2. Splenomegaly.
3. Hepatic steatosis and mildly enlarged common hepatic and periportal lymph
nodes. Work-up for steatohepatitis or other hepatitides is recommended if not
previously performed.
NOTIFICATION: Updated findings discussed with ___ by Dr. ___
telephone at 9:55am on ___ following attending review.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with severe abd pain in setting of diarrhea,
Bowel distension?
TECHNIQUE: Portable supine abdominal radiograph.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
There is a paucity of bowel gas. No dilated loops of small bowel are seen.
No free air on supine radiograph. Contrast from prior CT abdomen pelvis is
within the bladder. Bony structures are unremarkable.
IMPRESSION:
No bowel distention. No obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with AIDS and new fever // r/o new infiltrate
r/o new infiltrate
COMPARISON: Chest radiographs since ___ most recently ___.
IMPRESSION:
Pulmonary and mediastinal vascular congestion have improved and yesterday's
cardiomegaly has resolved. Lungs are grossly clear.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, n/v/d
Diagnosed with NONINF GASTROENTERIT NEC, DIABETES UNCOMPL ADULT, ASYMPTOMATIC HIV INFECTION
temperature: 99.0
heartrate: 123.0
resprate: 20.0
o2sat: 98.0
sbp: 153.0
dbp: 99.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ with history of HIV/AIDS (non-adherent to
ARVs, last CD4 147 ___K ___, HTN, HLD, DM2 who
presented with fevers, nausea, vomiting, diarrhea, and abdominal
pain who was found to have C. diff colitis and Shigella.
# Severe sepsis secondary to C. diff: Patient presented with
___ SIRS criteria (fever, leukocytosis) and evidence of
end-organ damage (lactate 2.8). He was aggressively fluid
resuscitated. CT A/P revealed ileocecitis and patient stool
studies returned positive for C. diff. Patient was initially
started on broad coverage with IV vancomycin, cefepime, high
dose PO vancomycin, and metronidazole. Once C. diff returned
positive, IV vancomycin and cefepime were discontinued. Patient
remained clinically stable so metronidazole was discontinued and
PO vancomycin dose was decreased to 125 mg q6h (from 500 mg
q6h). Patient's pain was controlled with morphine. His
abdominal pain resolved and his diarrhea improved. He was able
to tolerate a regular diet.
# C. diff: Patient met criteria for severe C. diff (based on
admission ___ of stools/day). Given severe sepsis,
worsening leukocytosis, and rising lactate, he was treated as
severe-complicated initially with high dose vancomycin and IV
metronidazole. Once he clinically improved, metronidazole was
discontinued and vancomycin dose was decreased to 125 mg q6h.
He was discharged on a 14 day course of PO vancomycin.
# Shigella: In addition to C. diff, patient's stool studies
returned positive for Shigella. He was started on ciprofloxacin
and will complete at 7 day course.
# HIV: Last CD4 147 ___K ___. He has not been
adherent to ARVs for several months, possibly years. ARVs were
held and decision to restart should be addressed by his PCP.
Patient was continued on Bactrim for PCP prophylaxis as he has
intermittently been taking this at home.
# Drug abuse: Patient reports using daily methamphetamine. His
withdrawal symptoms were controlled with ___ scale (using
diazepam). He was seen by social work and offered resources for
substance abuse.
# Transaminitis: LFTs on admission notable for ALT/AST 43/42.
CT A/P notable for hepatic steatosis. Review of ___ records
reveals a ?history of (and treatment of) hepatitis C. LFTs
normalized.
# Hypertension: Home amlodipine-benazepril was held initially
in the setting of sepsis. Once he clinically improved, he was
restarted on amlodipine and lisinopril in equivalent doses
(amlodipine-benazepril is not on formulary).
# Diabetes: A1c 8.3. Patient has not been compliant with
metformin. His blood sugar was controlled on a Humalog sliding
scale. He was encouraged to continue metformin on discharge.
# HLD: Patient was restarted on atorvastatin and ASA.
# Depression: Patient's Effexor was held as he has not been
taking it.
# GERD: Held home PPI given C. diff, but restarted on
discharge.
Transitional Issues
- Lung nodule on prior CT in ___, may require follow-up CT
- Please continue to address substance use and medication
non-adherence
- Please discuss re-initiation of HAART with patient when he is
ready to re-start medications
- Please note, patient developed dark scotomata in L eye. Neuro
exam otherwise intact. Urgent Ophthalmology appointment
scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
erythromycin base / amoxicillin / Penicillins
Attending: ___.
Chief Complaint:
FALL
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo F with history of dementia, htn, hld, h/o c diff s/p
colostomy who is admitted s/p mechanical fall, found to have a
humerus fracture for which ortho recommended non operative
management, who is now admitted due to delirium.
Per her caretaker ___, she was released from ___
___ months ago after admission to ___ for sepsis. She
was initially getting 24 hr care, but this was gradually tapered
back to 12 hour care during the day. On the morning of
admission, she slipped in the bathroom (she normally waits for
the asisstant to arrive in the morning to help her to the
bathroom, but for some reason she went on her own without a
walker). She pressed her lifeline and was taken to ___.
Per ___: at baseline she knows the names of the people who
come to the house, but she has severe memory loss (if you feed
her, she won't remember what she ate an hour later). She does
not know the year. She does remember her address and what she
used to do for a living. She was at this baseline up until
admission. She had not been complaining of SOB, cough, sputum,
CP, abdominal pain, dysuria, lightheadedness, dizziness prior to
admission.
At ___, she had extensive imaging w/u including: x ray
right humerus with spiral fracture mid to distal humerus; neg
pelvis and knee x ray, neg CT head and C spine, cxr with no
infiltrate, UA negative. Of note BUN ___ from baseline
___, WBC 14. She was transferred to ___, where Ortho
recommended non operative management. She got morphine 8 mg
total in the ED and became more confused, so she was admitted to
the floor.
This morning, she is complaining of diffuse leg pain and of pain
at the urethral meatus. She still does not know that she had a
fall. She thinks she is at ___.
Past Medical History:
- dementia
- hypertension
- hyperlipidemia
- h/o severe cdiff s/p colostomy
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.5 150s/50s-60s ___ 20 97 RA.
Gen: Pleasant appearing, laying in bed comfortably, breathing
non-labored, right arm in brace and sling.
HEENT: PERRL moist mucous membranes, no elevated JVD.
CV: RRR, soft systolic murmur.
Pulm: Anterior auscultation clear to auscultation with no
wheezes/rales or rhonchi.
Abd: colostomy bag with brown stool in right lower quadrant,
surgical scars from prior
GU: foley in place. urethral meatus non erytehmnatous.
Ext: Trace pedal edema. Right arm in sling
Neuro: Right wrist drop, diminished grip strength in right hand.
Describes slight numbness in her ___ fingers.
Psych: Alert and oriented to person, her birthdate, what she
used to do for a living. States that she is at ___. Unable
to account events of the past 48 hrs. She states that it is
___.
DISCHARGE PHYSICAL EXAM:
=======================
VS: AF ___ 18 96 RA
Gen: Pleasant appearing, laying in bed comfortably, breathing
non-labored, right arm in brace and sling.
HEENT: PERRL moist mucous membranes, no elevated JVD.
CV: RRR, soft systolic murmur.
Pulm: Clear to auscultation with no wheezes/rales or rhonchi.
Abd: colostomy bag with brown stool in right lower quadrant,
surgical scars from prior. Additional ostomy w/ bag w/no output
adjacent to colostomy bag.
GU: no foley
Ext: Trace pedal edema. Right arm in sling
Neuro: Right wrist drop, diminished grip strength in right hand.
Today denies numbness in her hand.
Psych: Alert and oriented to person, her birthdate, what she
used to do for a living. Not oriented to date. Doesn't know
she's in the hospital. Unable to account events of the past 48
hrs.
Pertinent Results:
ADMISSION LABS:
=================
___ 06:00AM BLOOD WBC-6.0 RBC-3.20* Hgb-9.2* Hct-29.1*
MCV-91 MCH-28.8 MCHC-31.6* RDW-13.5 RDWSD-44.9 Plt ___
___ 06:00AM BLOOD Glucose-119* UreaN-28* Creat-1.0 Na-144
K-3.9 Cl-109* HCO3-23 AnGap-16
___ 06:00AM BLOOD CK(CPK)-743*
___ 06:00AM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:00AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.7
PERTINENT RESULTS:
=====================
___ 06:00AM BLOOD WBC-7.1 RBC-3.16* Hgb-9.0* Hct-28.5*
MCV-90 MCH-28.5 MCHC-31.6* RDW-13.3 RDWSD-44.1 Plt ___
___ 06:00AM BLOOD Glucose-117* UreaN-37* Creat-1.1 Na-144
K-3.5 Cl-108 HCO3-21* AnGap-19
POSITIVE UA:
___ 03:50PM URINE CastHy-16*
___ 03:50PM URINE RBC-8* WBC->182* Bacteri-MOD Yeast-NONE
Epi-5 TransE-<1
___ 03:50PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 03:50PM URINE Color-Yellow Appear-Hazy Sp ___
STUDIES:
===============
___ FEMUR A/P LATERAL X RAY
No acute fracture or dislocation. A moderate suprapatellar
joint effusion.
Moderate to severe osteoarthritic changes at the right knee.
___ RIGHT HUMERUS X RAY
Spiral fracture through the midshaft of the right humerus with
mild posterior
displacement of the distal fracture fragment. Significantly
improved
alignment in comparison to the prior examination.
___ RIGHT HUMERUS X RAY
Re- demonstrated spiral fracture of the right humerus with
increased posterior
displacement of the distal fracture fragment.
Mild posterior angulation of distal fracture component.
Likely chronic superior subluxation of the humeral head related
to rotator
cuff tear.
___ CT PELVIS
1. Posterior height loss, subtle cortical step off (best seen on
sagittal
view) and sclerosis at the S1 vertebral body worrisome for
sacral
insufficiency fracture/nondisplaced fracture. No hip fracture.
2. Wide diastases of the rectus abdominus and a wide-mouth
ventral hernia
containing multiple loops of nonobstructed small bowel similar
to the study of
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO BID
2. Vitamin D ___ UNIT PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO BID
2. Calcium Carbonate 500 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Acetaminophen 1000 mg PO Q8H
5. Docusate Sodium 100 mg PO BID
6. Senna 8.6 mg PO BID constipation
hold for loose stools
7. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Right humeral fracture
advanced dementia
SECONDARY DIAGNOSES:
hypertension
colostomy
history of atrial fibrillation
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - always.
Followup Instructions:
___
Radiology Report
EXAMINATION: HUMERUS (AP AND LAT) RIGHT
INDICATION: History: ___ with R humerus fx // eval alignment w/ coaptation
splint with arm in sling eval alignment w/ coaptation splint with arm in
sling
TECHNIQUE: Two views of the right humerus
COMPARISON: Radiograph ___. Chest x-ray ___.
FINDINGS:
There is a spiral fracture through the distal shaft of the right humerus with
posterior and lateral displacement of the distal fracture fragment,
significantly increased in comparison to the prior examination. There is also
some posterior angulation of the distal component. Moderate degenerative
changes noted at the right glenohumeral joint with mild joint space narrowing.
The acromiohumeral interval is likely narrowed suggesting superimposed rotator
cuff tear. Severe acromioclavicular degenerative change.
IMPRESSION:
Re- demonstrated spiral fracture of the right humerus with increased posterior
displacement of the distal fracture fragment.
Mild posterior angulation of distal fracture component.
Likely chronic superior subluxation of the humeral head related to rotator
cuff tear.
Radiology Report
INDICATION: History: ___ with s/p fall // eval for right hip pain
TECHNIQUE: Multidetector CT images of the 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) = 688 mGy-cm.
COMPARISON: Outside CT of the abdomen and pelvis ___
FINDINGS:
PELVIS: There is wide diastases of the rectus abdominus and a wide-mouth
ventral hernia similar to the study of ___ containing multiple
loops of nonobstructed small bowel. Patient is status post colectomy with
exception of the rectum and a portion of the sigmoid. The sigmoid appears to
be within the hernia sac as well possibly anastomosed to small bowel. There
is a diverting ileostomy adjacent to the hernia in the right lower quadrant
(03:24). There is no evidence of bowel obstruction.
The urinary bladder is drained by a Foley catheter. The uterus is grossly
normal. There is no free fluid and no pelvic wall or inguinal
lymphadenopathy. The iliac arteries are normal in caliber.
BONES: There is generalized osteopenia. There are moderate degenerative
changes in bilateral femoroacetabular joints with periacetabular spurring and
spurring about the head neck junction.
There is mild posterior height loss, increased sclerosis and faint
radiolucencies of S1 worrisome for fracture (401B:81). There is no associated
retropulsion. Disc height loss at L5-S1 with posterior disc bulge results in
mild central canal narrowing.
IMPRESSION:
1. Posterior height loss, subtle cortical step off (best seen on sagittal
view) and sclerosis at the S1 vertebral body worrisome for sacral
insufficiency fracture/nondisplaced fracture. No hip fracture.
2. Wide diastases of the rectus abdominus and a wide-mouth ventral hernia
containing multiple loops of nonobstructed small bowel similar to the study of
___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Humerus fracture
Diagnosed with Displaced spiral fx shaft of humerus, right arm, init, Fall on same level, unspecified, initial encounter
temperature: 97.5
heartrate: 94.0
resprate: 16.0
o2sat: 99.0
sbp: 137.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | ___ yo F with history of dementia, htn, hld, h/o c diff s/p
colostomy who is admitted s/p mechanical fall, found to have a
humerus fracture for which ortho recommended non operative
management, who was admitted due to delirium. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Latex / Codeine / Darvocet-N 100 / Influenza Virus
Vacc,Specific
Attending: ___.
Chief Complaint:
vision changes
Major Surgical or Invasive Procedure:
IV steroids
History of Present Illness:
The patient is a ___ year-old right handed woman with a
history of relapsing-remitting MS on ___, migraine
headaches with aura, bipolar depression who presents to the ED
with bilateral vision changes. Neurology is consulted in the
ED.
She was in her USOH until yesterday afternoon, when she noted
gradual darkening of her bilateral vision. She describes this
as
a "tan shading." Over a few hours her vision declined to seeing
only shadows and hard to see colors. However, she was still
able
to use her cell phone and did not have any falls. She tells me
this is previous to prior episodes of "optic neuritis." Her
walking is more cautious than usual as she is scared of her legs
buckling, but she does not have weakness. She continues to walk
with a cane. She has distal hand numbness which is chronic.
She
also has a tremor in her shoulders and head which remains the
same.
With regards to possible infections, she does straight cath 2x
weekly and her urine has been more odorous than usual. No
dysuria
or change in frequency of self cath'ing. She has had runny nose
and sneezing in the past few weeks, but that has improved with
Mucinex.
Regarding her late relapsing remitting MS, she started to have
symptoms in ___ which were mostly motor and sensory symptoms
involving the legs, L>R. Diagnosis made in ___ by Dr. ___
Left INO. She has had evidence of demyelinating plaques on MRI
brain imaging. Per Dr ___ below is her flare and tx
history:
"FLARE HISTORY:
1. ___: poorly described
2. ___: Left INO; no treatment
3. ___: Relapse; treated with steroids
4. ___: LLE weakness, gait disturbance, visual change;
treated with IVMP X2d, left AMA
5. ___: Diffuse weakness; treated with 3d IVMP, then 5d IVMP,
with minimal improvement"
TREATMENT HISTORY:
1. Copaxone - ___ to ___
2. Cytoxan ___, #3: ___
3. Bimontly IV MP ___ (paranoid and anxious)
4. Tysabri ___ restarted ___, missed a
few months, last ___ (JCV antibody positive).
5. Gilenya 0.5 mg daily ___ (brief loss of coverage
for
a week)(pt did not like)
6. Tecfidera ___ (no side effects)"
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies diplopia, vertigo, tinnitus,
hearing difficulty, dysarthria, or dysphagia. Denies focal
muscle
weakness. On general review of systems, the patient denies
fevers, rigors, night sweats, or noticeable weight loss. Denies
chest pain, palpitations, dyspnea, or cough. Denies nausea,
vomiting, diarrhea, constipation, or abdominal pain. No recent
change in bowel or bladder habits. Denies myalgias,
arthralgias,
or rash.
Past Medical History:
1. late RRMS - see above for further details.
2. Depression (Bipolar with hypomania)
3. Migraine-spectrum headaches with visual aura
4. Raynaud's disease
5. Asthma
6. Restless Leg Syndrome
7. Urinary retention requiring intermittent catheterization -
sees urology at ___
8. Cervical spondylosis
Social History:
___
Family History:
Her son may have MRI brain finding of demyelination (MR done for
MVA ___, but he is asymptomatic. Father had a stroke recently.
Physical Exam:
Vitals: 98.4 76 130/82 16 96%
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND,
Extremities: Warm, no edema
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily maintained. Recalls a coherent history. Able to
recite months of year backwards. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. Normal prosody. No dysarthria.
No evidence of hemineglect. No left-right confusion.
- Cranial Nerves - Visual acuity uncorrected ___ ___, corrected
OS ___ -1. Anisocoria with right pupil 3mm and left 4mm. Left
RAPD. Could not visualize fundus. Disconjugate primary gaze,
left exotropia. There is bilateral INO (adduction deficit
without nystagmus) with Left worse than Right. VF full to
finger
wiggle. There is bilateral red desaturation, but confounded by
fact that she tells me colors do not appear normal shades. She
does tell proper color names however. V1-V3 without deficits to
light touch bilaterally. Left NLFF, but symmetric activation.
Hearing intact to finger rub bilaterally, slightly attenuated on
right compared to left. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally, but there is give way on
the right. Tongue midline and strong.
- Motor - Decreased bulk in the left >right palmar hand muscles.
Increased tone in lower extremities. No drift. Postural tremor
and intention tremor of bilateral arms.
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
**She has giveway weakness most notably in these muscle groups,
but on concerted effort, she gives full strength.
- Sensory - There is patchy sensory deficit to pin prick on
right
forearm. No deficits to light touch
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response flexor on left, ? upgoing on right.
- Coordination - No dysmetria with finger to nose testing
bilaterally. There is clear intention tremor. Slowed and
deliberate rapid alternating movements.
- Gait - deferred.
Pertinent Results:
___ 10:27PM BLOOD WBC-8.9 RBC-4.54 Hgb-13.7 Hct-41.5 MCV-91
MCH-30.2 MCHC-33.1 RDW-13.3 Plt ___
___ 10:27PM BLOOD Neuts-64.4 ___ Monos-7.4 Eos-2.9
Baso-1.2
___ 10:27PM BLOOD Glucose-102* UreaN-10 Creat-0.8 Na-143
K-3.6 Cl-103 HCO3-28 AnGap-16
___ 10:27PM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8
___ 10:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ MRI brain
Multiple FLAIR hyperintense and hypointense lesions, in the
cerebral white matter, in the cerebellar peduncles as well as in
the pons felt to represent demyelinating lesions, without
significant change compared to the prior study of ___. No abnormal enhancement; no obvious new lesions. Limited
assessment of the optic nerves is not targeted
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. ClonazePAM ___ mg PO QHS anxiety
3. Tecfidera (dimethyl fumarate) 240 mg oral BID
4. Ibuprofen 600 mg PO Q8H:PRN pain
5. LaMOTrigine 200 mg PO DAILY
6. Gabapentin 400 mg PO DAILY
7. Mirena (levonorgestrel) 20 mcg/24 hr ___ years) intrauterine
___
8. Vitamin D 4000 UNIT PO DAILY
Discharge Medications:
1. OLANZapine 5 mg PO QAM Duration: 10 Days
RX *olanzapine 5 mg 1 tablet(s) by mouth QAM Disp #*10 Tablet
Refills:*0
2. QUEtiapine Fumarate 25 mg PO QHS Duration: 10 Days
RX *quetiapine 25 mg 1 tablet(s) by mouth at bedtime Disp #*10
Tablet Refills:*0
3. ClonazePAM ___ mg PO QHS anxiety
4. Gabapentin 400 mg PO DAILY
5. Ibuprofen 600 mg PO Q8H:PRN pain
6. LaMOTrigine 200 mg PO DAILY
7. Tecfidera (dimethyl fumarate) 240 mg oral BID
8. Vitamin D 4000 UNIT PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
10. Mirena (levonorgestrel) 20 mcg/24 hr ___ years) intrauterine
___
Discharge Disposition:
Home
Discharge Diagnosis:
MS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with likely MS flare and cough.
TECHNIQUE: Chest PA and lateral
COMPARISON: Radiograph dated ___.
FINDINGS:
PA and lateral chest radiograph demonstrates no focal consolidation.
Cardiomediastinal and hilar contours are within normal limits. There is no
pleural effusion or pneumothorax. Visualized osseous structures are
unremarkable. No free air under the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic abnormality.
Radiology Report
INDICATION: ___ year old woman with history of MS presents with new complaints
of vision loss. // concern for MS ___
TECHNIQUE: MRI of the head without and with IV contrast, MS protocol
COMPARISON: MRI of the head ___
FINDINGS:
No acute infarct,, suspicious focus of intracranial hemorrhage, mass effect,
shift of normally midline structures.
There are multiple lesions in the periventricular and subcortical white
matter, which FLAIR hypo and hyperintense signal, extensive in distribution
and similar to the prior study allowing for the technical differences.
A few small foci are noted in the cerebellar peduncles as well as in the pons,
without significant change. Accurate comparison is somewhat difficult given
the number of the lesions; no obvious new lesions are noted.
There is no abnormal enhancement in the brain parenchyma or meninges.
There is mild to moderate dilation of the lateral and third ventricles, along
with mildly prominent sulci can relate to some degree of parenchymal volume
loss.
Postcontrast MPRAGE sequences is somewhat limited due to artifacts. Within
this limitation, no abnormal enhancement noted in these lesions or elsewhere
in the brain parenchyma or meninges.
Limited assessment of the optic nerves as not targeted.
The major intracranial arterial flow voids are noted with a dominant right
vertebral artery.
Small retention cysts in the maxillary sinuses on both sides.
Mild ethmoidal mucosal thickening.
The mastoid air cells are clear.
IMPRESSION:
Multiple FLAIR hyperintense and hypointense lesions, in the cerebral white
matter, in the cerebellar peduncles as well as in the pons felt to represent
demyelinating lesions, without significant change compared to the prior study
of ___.
No abnormal enhancement; no obvious new lesions.
Limited assessment of the optic nerves is not targeted.
Other details as above.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Vision changes
Diagnosed with MULTIPLE SCLEROSIS
temperature: 98.4
heartrate: 76.0
resprate: 16.0
o2sat: 96.0
sbp: 130.0
dbp: 82.0
level of pain: 8
level of acuity: 2.0 | The patient is a ___ year-old right handed woman with a history
of relapsing-remitting MS on ___, migraine headaches with
aura, bipolar depression who presents to the ED with bilateral
vision changes. Her neurological exam was notable for visual
acuity corrected ___, left RAPD, bilateral INO (L worse than
right) and subtle left NLFF. It appears that the patient is
having worsening visual symptoms likley representing an MS
___. She underwent MRI and one dose of IV steroids prior to
___ with plans to continue IV steroids as an out patient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
___ Sigmoidoscopy
___ Low anterior resection converted to abdominoperineal
resection and colostomy
___ paracentesis with 2L removed
History of Present Illness:
___ with stage III cT3N2M0 rectal cancer s/p neoadjuvant
chemradiation w/ ___ ___ and and radiation c/b proctocolitis, afib
( not on coumadin) and recent admission 1 month prior for BRBPR
coming in with BRBPR. The patient was at home when he had 3
bloodly BMs estimated at 50cc blood per BMs. he called his
outpatient oncologist and presented to the ED for evaluation.
Of note he was recently admitted to OMED from ___ for
similar presentation of BRBPR requiring ICU admission. At that
time he was on coumadin for afib with INR of 6. He was
transfused multiple units prbcs, INR reversed w/ vitamin K and
ffp. He had a flex sig which showed deep ulcerations at the
anal verge with deep cratered ulcers with clot and contact
bleeding in the sigmoid colon felt secondary to radiation
colitis with possible ischemic colitis in the setting of GI
bleed. His bleeding stopped on tranfer to OMED without
intervention. He was treated with prednisone 80 mg daily and
flagyl for ? IBD component of sigmoid colitis. His coumadin was
also discontinued in the setting of GI bleed. He has finished
his prednisone taper and flagyl per last onc outpatient note.
Since discharge the patient reports feeling well. He started
excercising, driving, and going out shopping. 1 week prior to
admission he did start taking ibuprofen 400-800 mg daily for
pain with approval from his oncologist, but no other new
medications
In the ED, initial vitals: 97.5 101 123/80 18 97% ra
He had 2 more bloodly BMs and clots about 150ccs each
Labs h/h 10.6/31.6 ( appears at baseline), white count of 3.2
chem notable for Na of 132, INR 1. 2
GI was consulted in the ED who recommend colorectal input to
discuss if bleeding should be managed endoscopically vs
surgically.
He received 40 mg IV protonix, and was started on NS at 250
cc/hr x 1 L.
On arrival to the MICU,the patient continues to have ongoing
bleeding., but denies any abdominal pain, hematemesis, nausea or
vomitting
Past Medical History:
PAST ONCOLOGIC HISTORY (PER MOST RECENT ONC NOTE)
-___ had rectal bleeding and colonoscopy at that time showed 2
polyps, one of which contained a moderately differentiated
adenocarcinoma. Because the lesion was entirely resected he did
not receive any further therapy. Since then he underwent
extensive surveillance including a colonoscopy in ___
which was negative.
-___: difficulty with defecation and some rectal
discomfort. He did not have any rectal bleeding or other
symptoms. This prompted a visit to his PCP who felt ___ mass on
rectal exam.
-___ flex sig showed what appeared to be a mostly extrinsic
mass, there was mucosal irregularity which on biopsy revealed a
moderately well differentiated adenocarcinoma. Subsequent CT
scan
showed a 5.8cm left rectal mass with surrounding adenopathy.
-___ ___hest without metastatic disease
-___ MRI rectum showed transmural rectal tumor with
extension
to and involvement of the mesorectal fascia posterolaterally on
the left, and at least 15cm of superior
extension along the inferior mesenteric vasculature. Inferior
most margin is 6cm from the anal verge. Though there is broad
contact the mesorectal fascia, tumor is not overtly through the
peritoneal reflection. T3dN2M0 by imaging.
-___: MRI liver showed a cirrhotic liver with recanalization
of the umbilical vein, without other signs of significant portal
hypertension. No lesions concerning for metastatic disease
present.
-___: port placed
-___: started neoadjuvant chemoradiation with infusional ___
PAST MEDICAL HISTORY:
-EtOH Cirrhosis, compensated
-Atrial Fibrillation
-GERD
Social History:
___
Family History:
Mother had breast cancer in her ___
Physical Exam:
ON ADMISSION
vs: 97.5 101 123/80 18 97% ra
GENERAL: pale, appears older than stated age.
HEENT: Sclera anicteric, MMM
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: irregularly irregular no m/r/g
ABD: TTP bilateral lower quadrants
Rectal: passing brbpr w/ clots
EXT: no peripheral edema
NEURO:AOx 3
ON DISCHARGE
VS: T 98.5 BP 125/82 HR 97 RR 18 O2 97RA
General: thin appearing male, lying in bed, NAD
HEENT: PERRL, EOMI, MMM, sclera icterus
Neck: supple, no JVD
CV: irregularly, irregular, no murmurs rubs or gallops
Lungs: clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: +BS, soft, NTND, colostomy in place with liquid stool,
periumbilical suture without erythema or drainage
APR wound slighly open this am
Ext: no edema
Neuro: CN II-XII intact, strength ___ throughout
LABORATORY DATA: See below
Pertinent Results:
ADMISSION LABS:
___ 05:25AM NEUTS-73.3* LYMPHS-12.8* MONOS-8.7 EOS-4.6*
BASOS-0.6
___ 05:25AM ALT(SGPT)-23 AST(SGOT)-30 ALK PHOS-107 TOT
BILI-0.7
___ 05:25AM GLUCOSE-91 UREA N-10 CREAT-0.4* SODIUM-132*
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-25 ANION GAP-11
___ 12:54PM PLT COUNT-165
INTERVAL LABS:
___ 12:30PM BLOOD TSH-2.9
___ 12:30PM BLOOD T4-5.4
___ 05:19AM BLOOD Triglyc-94
___ 04:50PM BLOOD PEP-NO SPECIFI
___ 04:30PM URINE U-PEP-NO PROTEIN
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-4.2 RBC-2.78* Hgb-9.1* Hct-28.3*
MCV-102* MCH-32.6* MCHC-32.1 RDW-17.9* Plt ___
___ 06:00AM BLOOD ___ PTT-28.4 ___
___ 06:00AM BLOOD Glucose-94 UreaN-14 Creat-0.3* Na-134
K-3.6 Cl-100 HCO3-25 AnGap-13
___ 06:00AM BLOOD ALT-40 AST-38 AlkPhos-202* TotBili-2.2*
___ 06:00AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.8
IMAGING:
___ ECHO:
IMPRESSION: Normal regional/global left ventricular systolic
function. Right ventricular dilatation with borderline normal
systolic function. Mild thoracic aortic dilatation. Mild mitral
regurgitation. Moderate tricuspid regurgitation.
___ CT A/P with contrast:
1. Patent portal vasculature with no evidence of thrombosis.
Some of the smaller vessels supplying the left medial segment
are not fully opacified, however no focal thrombosis seen.
2. Small amount of intraabdominal free air, in keeping with
recent surgery.
3. Cirrhosis and small volume ascites.
4. Small left sided pleural effusion.
___ RUQ U/S with doppler:
1. Continued nonvisualization of the posterior right portal vein
which is likely occluded.
2. Continued lack of visualized flow in the intrahepatic main
portal vein, unchanged since the prior exam from ___.
This likely represents slow flow; however, thrombus is also
possible. If further evaluation is required recommend CT.
3. Gallbladder sludge
4. Cirrhosis and a small amount of ascites.
___ RUQ U/S:
1. Nodular heterogeneous liver compatible with known history of
cirrhosis. Small amount of ascites.
2. The posterior right portal vein is not visualized and likely
occluded. In review prior imaging including an MRI from ___ and a CT from ___ the right posterior portal
vein branch appears attenuated and suggesting this is a chronic
finding. If further characterization is necessary recommend CT.
Likely slow flow in the main portal vein at the junction of the
right anterior portal vein.
3. Gallbladder sludge.
___ TTE:
IMPRESSION: Suboptimal image quality. Normal global
biventricular systolic function. Mild thoracic aortic
dilatation. Right ventricle not well-visualized. Mild mitral
regurgitation. Moderate pulmonary hypertension.
PATHOLOGY:
___: Colon and Rectum: Resection
1. Sigmoid and rectum, open low anterior resection (___):
Residual adenocarcinoma, low grade, with extensive
lymphovascular and transmural invasion, and extramural tumor
deposits (ypT3); see synoptic report. Three out of ___
regional lymph nodes with involvement by adenocarcinoma
(___) Frozen section of distal margin of this specimen
demonstrates no carcinoma. Submucosal fibrosis and mucosal
ulceration consistent with the patient's history of neoadjuvant
chemoradiotherapy.
2. Left colon, open low anterior resection (2A-2H):
Two unremarkable colonic segments. No carcinoma identified.
3. Anus, open low anterior resection (3A-3E):
Colonic segment with mucosal changes of chronic inactive
colitis, likely secondary to radiation-induced injury. Anus with
focal surface ulceration and fissure formation, subepithelial
fibrosis, and chronic inflammation.
No carcinoma identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO DAILY
2. Lorazepam 0.5-1 mg PO Q6H:PRN nausea
3. Nadolol 20 mg PO BID
4. Ranitidine 150 mg PO HS
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
7. Ibuprofen 400-800 mg PO Q8H:PRN pain
8. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
2. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lorazepam 0.5 mg PO BID:PRN anxiety, nausea
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Ranitidine 150 mg PO HS
7. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Outpatient Lab Work
Labs:
Glucose, BUN, Creat, Na, K, Cl, HCO3, Mg, Phos, Ca
ALT, AST, Alk phos, Tbili
PTT, ___, INR
Please fax results to ___
Attn: Dr. ___
10. Aspirin 81 mg PO DAILY
11. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. TraZODone 12.5 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.25-0.5 tablet(s) by mouth at bedtime as
needed for insomnia Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary: T3N2 rectal cancer complicated by lower GI bleed
secondary to radiation induced protocolitis requiring abdominal
perineal resection with end colostomy
Secondary: decompensated cirrhosis with ascites
A fib with RVR
Secondary bacterial peritonitis
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 (with Doppler.
INDICATION: ___ year old man with adenocarcinoma s/p ___. Elevated Tbili. //
obstruction? Need RUQ with dopplers.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MRI of the abdomen from ___ and CTA of the abdomen and
pelvis from ___
FINDINGS:
LIVER: The hepatic parenchyma is nodular and heterogeneous compatible with
history of cirrhosis. The left lobe is not clearly visualized due to poor
penetration of the ultrasound. There is no focal liver mass. Main portal vein
is patent with hepatopetal flow. There is a small amount of perihepatic
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: There is a large amount of sludge within the gallbladder but
there is no wall edema or pericholecystic fluid to suggest acute inflammation.
PANCREAS: The pancreas is not clearly visualized.
SPLEEN: Normal echogenicity, measuring 9.8 cm.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
DOPPLER: The hepatic artery is patent with a normal waveform. The right and
middle hepatic veins are patent. The left hepatic vein is not visualized. The
left portal vein was not visualized. The main portal vein is patent. Flow void
at the junction of the right portal vein and main portal vein is likely due to
slow flow. The right anterior portal vein is patent. The right posterior
portal vein is not visualized, likely occluded. In comparison to prior imaging
including an MRI from ___ and a CT from ___ the right
posterior portal vein branch appears attenuated.
IMPRESSION:
1. Nodular heterogeneous liver compatible with known history of cirrhosis.
Small amount of ascites.
2. The posterior right portal vein is not visualized and likely occluded. In
review prior imaging including an MRI from ___ and a CT from ___ the right posterior portal vein branch appears attenuated and suggesting
this is a chronic finding. If further characterization is necessary recommend
CT. Likely slow flow in the main portal vein at the junction of the right
anterior portal vein.
3. Gallbladder sludge.
NOTIFICATION: These findings were discussed with ___ by Dr. ___
___ telephone at 17:00 on ___.
Radiology Report
INDICATION: ___ year old man with new R PICC // 48cm R brachial DL PICC -
___ ___ Contact name: ___: ___
COMPARISON: ___
FINDINGS:
Portable frontal supine radiograph of the chest demonstrates the left chest
wall Port-A-Cath in unchanged position ending in the low SVC. A new right PICC
line ends in the mid to lower SVC. There are new bibasilar opacities. There
is a left pleural effusion which also appears new. Multiple healed left-sided
posterior rib fractures are unchanged. No pneumothorax.
IMPRESSION:
1. New right PICC ends in the mid to lower SVC
2. New bibasilar opacities
3. New left pleural effusion
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with rectal CA w LGIB ___ radiation induced
protocolitis, now s/p LAR converted to APR w end colostomy. Pt has
decompesated etoh cirrhosis and had marked elevation of LFTs overnight. //
RUQ US with dopplers to assess for worsening Portal vein thrombosis
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Liver Doppler exam from ___.
FINDINGS:
LIVER: The hepatic parenchyma is nodular and heterogeneous compatible with
history of cirrhosis. The left lobe is better visualized on today's exam
compared to the prior study. There is no focal liver mass. There is a small
amount of perihepatic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: The gallbladder remains distended with a large amount of sludge
but there is no wall edema or pericholecystic fluid to suggest acute
inflammation.
PANCREAS: The pancreas is not clearly visualized.
SPLEEN: Spleen is not imaged appear Cm.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
DOPPLER: The hepatic artery is patent with a normal waveform. The right,
middle and left hepatic veins are patent. The left portal and anterior right
portal veins are patent. The right posterior portal vein is not clearly
visualized. Within the intrahepatic portion of the main portal vein there is
lack of flow, probably related to slow flow. This appearance is unchanged
since ___.
IMPRESSION:
1. Continued nonvisualization of the posterior right portal vein which is
likely occluded.
2. Continued lack of visualized flow in the intrahepatic main portal vein,
unchanged since the prior exam from ___. This likely represents slow
flow; however, thrombus is also possible. If further evaluation is required
recommend CT.
3. Gallbladder sludge
4. Cirrhosis and a small amount of ascites.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___
telephone at 19:25 on ___.
Radiology Report
EXAMINATION: CTV ABDOMEN
INDICATION: ___ year old man with decompensated etoh cirrhosis in s/o
colorectal surgery (POD ___ s/p open LAR converted to APR w/end colostomy). Now
with acutely rising LFTs and doppler RUQ U/S findings showing likely occluded
portal vein. // Assess for patency of portal vasculature Assess for
patency of portal vasculature
TECHNIQUE: Axial MDCT images were obtained through the abdomen after the
uneventful administration of IV contrast as per CTV protocol. No oral
contrast was provided. Sagittal and coronal reformats were generated.
TOTAL EXAM DLP: 311 mGy-cm.
COMPARISON: Right upper quadrant ultrasound from ___.
FINDINGS:
There is a small left-sided pleural effusion and a probable tiny right sided
pleural effusion. There is mild associated atelectasis. There is no
pericardial effusion.
CTV: Contrast time was suboptimal, but there is no evidence of a thrombosed
vessel. The main, left and right portal veins are patent. Although some of
the smaller vessels supplying the left medial segment are not fully opacified,
there is no evidence of focal thrombosis. Additionally, some portal vein
branches appear diminutive, likely from chronic diminutive caliber,
exacerbated by secondary to the timing of the IV contrast bolus injection. The
SMV and splenic veins are grossly unremarkable.
CT of the abdomen: The liver is shrunken and nodular in keeping with known
diagnosis of cirrhosis. The gallbladder appears somewhat distended, but there
are no additional findings to suggest acute ___. The pancreas,
adrenal glands and spleen are normal. There is a 10 mm hypodensity in the
upper pole of the right kidney, likely a cyst. The kidneys excrete contrast
without evidence of hydronephrosis or renal masses. There is a small amount of
intra-abdominal ascites. Small pockets of intraabdominal free air are
expected given recent surgery. An end colostomy is seen in the left lower
quadrant. The stomach and visualized loops of bowel appear grossly
unremarkable. Visualized portions of the intra-abdominal aorta contain
scattered atherosclerotic calcifications.
Osseous structures: No blastic or lytic lesion concerning for malignancy.
IMPRESSION:
1. Patent portal vasculature with no evidence of thrombosis. Some of the
smaller vessels supplying the left medial segment are not fully opacified,
however no focal thrombosis seen.
2. Small amount of intraabdominal free air, in keeping with recent surgery.
3. Cirrhosis and small volume ascites.
4. Small left sided pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with alcoholic cirrhosis, rectal cancer s/p
resection c/b peritonitis, recent CXR with pleural effusion // evaluate for
pna, interval change
COMPARISON: Chest radiographs since ___ most recently ___.
IMPRESSION:
No pneumothorax or appreciable pleural effusion. Mild left basal atelectasis
atelectasis is the only focal pulmonary abnormality. Normal cardiomediastinal
silhouette. No pneumothorax.
Right PIC line extends as far as the origin of the SVC where it is obscured by
the left subclavian line ends in the low SVC semi call on ___ a right
PIC line ended in the mid SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with alcoholic cirrhosis, rectal cancer s/p
resection and colectomy with secondary peritonitis // please perform ONLY
oblique imaging. Determine position of PICC line
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: Plain chest radiograph dated ___. Correlation also
made to chest CT dated ___ and CT abdomen/pelvis dated ___.
FINDINGS:
The tip of a right PICC line projects over the mid SVC. The tip of a left
pectoral power port projects over to the mid SVC. There is no pneumothorax. An
irregularly-shaped opacity at the right lung base corresponds to a focal
consolidation identified on recent CT abdomen/ pelvis, and may be due to
atelectasis, infection or aspiration. Cardiomegaly with left atrial
enlargement is unchanged. Two old healed left rib fractures are incidentally
noted.
IMPRESSION:
No appreciable interval change in focal right middle lobe airspace opacity
which may be due to atelectasis, but infection or aspiration would be
difficult to exclude in the appropriate clinical setting.
Right PICC line in satisfactory position in the mid SVC.
Stable cardiomegaly with left atrial enlargement.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis.
INDICATION: ___ year old man with cirrhosis, afib, rectal cancer status post
abdominal perineal resection with end colostomy complicated by decompensation
and secondary SBP
TECHNIQUE: Ultrasound guided diagnostic and therapeutic. Paracentesis
COMPARISON: None
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a moderate
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 2 L of yellow-coloredfluid was removed and sent for the
requested laboratory analysis.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ attending radiologist, personally supervised the procedure,
subsequently reviewing and has agreed with the preliminary findings.
IMPRESSION:
Uneventful diagnostic and therapeutic paracentesis yielding 2 L of
yellow-colored ascitic fluid.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 97.5
heartrate: 101.0
resprate: 18.0
o2sat: 97.0
sbp: 123.0
dbp: 80.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ M with ETOH cirrhosis (c/b gastric and
rectal varices), afib (not on coumadin since ___, stage
IIIcT3N2M0 rectal cancer s/p neoadjuvant chemoradiation w/ ___ ___
(last ___ C2D1) and radiation therapy stopped prematurely due
to development of severe proctitis c/b GI bleed ultimately
requiring abdominoperineal resection and colostomy with course
complicated by afib with RVR and decompensation of cirrhosis
with ascites and secondary bacterial peritonitis.
# GI bleed: Patient recently had hospital admission for which he
had severe GI bleeding ___ rectosigmoid colitis ___ likely
radiation colitis, erythematous tissue around ca site, and
possible superimposed ischemic colitis during period of GI
bleeding. On admission to hospital and subsequent immediate
transfer to MICU from ED, it was noted that patient likely had
bleeding from prior rectosigmoid site. Patient was transferred
from ED to MICU on ___, and had 8 units of pRBCs, 2 units of
FFP and 1 unit of platelts transfused. Patient had bedside
sigmoidoscopy in MICU on ___ which showed few ulcerations was
noted in the rectosigmoid consistent with prior findings, and a
single oozing clot overlying a presumed ulcer was found in the
above the anal verge, which was subsequently injected with
epinephrine and clipped. After procedure, patient did not have
episodes of further bleeding. His home nadolol was held during
hospitalization, and metoprolol was used for rate control of
Afib with RVR. In the setting of a recent GIB his Coumadin was
held. He was transferred to the floor on ___ in stable
condition, with stable H/H s/p transfusions. However on ___ he
had more BRBPR and received 1u RBCs. He was taken back to GI
suite for flex sig and the clip had fallen out but there was no
intervention able to be undertaken. He had more significant
bleeding the early morning of ___ and required 2u RBCs, 1u
FFP, and had SBP in the ___. He was volume resuscitated also
with 1.5L IVF at that time. HR was controlled also with rate
control see below. He was taken to the OR on ___ (see below)
and had an abdominal perineal resection with end colostomy. His
H/H remained stable and he did not need any transfusions after
the immediate postop period.
# Afib/RVR: Pt with longstanding history of Afib, not currently
on anticoagulation given GI bleed as above. Rate was difficult
to control preoperatively in the setting of large volume active
bleeding. Pt required ongoing transfusions prior to the OR and
was clearly volume depleted. In that setting, combined with
lower BPs on ___, rate control was pursued cautiously, however
on ___ pt finally achieved good control with HRs down to the
___ 100s. This was with 50mg metop q6 po and continued on
dig with 1x extra dose given of 0.125 mg on ___ (for dig level
slightly low at 0.5). His bleeding improved a bit which also
contributed to improvement in volemic status and improved heart
rates. Echo was done that showed very dilated atria and combined
with his interesting but not fully explained history of liver
dysfunction/cirrhosis, cardiology raised the possibility of
amyloidosis. Accordingly, SPEP/UPEP were sent which were
negative. TSH/T4 was normal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
penicillin V / shellfish derived / lisinopril / metformin
Attending: ___
Chief Complaint:
BRBPR, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with PMH DM, HTN, HLD
presenting with BRBPR and weakness x 1 day.
Pt declined translator, and hx is provided by patient and
daughter (HCP) who helps to translate. They report that he began
having blood in his BMs yesterday afternoon but did not tell his
family until this AM, when he continued to have bloody bowel
movements (~5 total) and started feeling dizzy and weak. His
daughter notes that he appears more pale and weak to them, and
that he does not usually complain of feeling unwell, so this is
concerning to them. Daughter saw the stool overnight and reports
that it is maroon colored, not black/not tarry. There is also
bright red blood surrounding the stool in the toilet bowl.
He has had stomach pain for the past 3 weeks with indigestion,
nausea, and occasional vomiting. He has been taking omeprazole
for this.
Had colonoscopy many years ago in ___, reports that it was
normal.
Has never experienced blood in stool before, denies any
black/tarry BMs in past, no hx of hemorrhoids. On ASA 81 daily,
no other AC. No NSAID use.
In the ED:
-Initial vital signs were notable for: T 97, HR 85, BP 109/42,
RR
20, O2 sat 99% on RA
-Exam notable for: dry MM, eyes/lips with pallor, RRR, CTABL,
soft nondistended abdomen with RUQ TTP, DRE with gross blood,
guaiac positive, no masses in rectal vault, no hemorrhoids
noted,
with dried red blood around anus. Skin warm and dry, normal
mentation.
-Labs were notable for:
--CBC: WBC 9.5, Hb 7.4, Hct 22.7, Plt 199
--BMP: Na 140, K 4.5, Cl 106, Bicarb 23, BUN 45, Cr 0.9, Gluc
214, AG 11
--Trop-T <0.01
--Lactate 1.8
-Studies performed include:
--CXR: FINDINGS: Bibasilar atelectasis is seen without definite
focal consolidation. No large pleural effusion or pneumothorax
is
seen. The right costophrenic angle is not entirely included on
the image. There is relative lucency of the upper lung,
suggesting pulmonary emphysema. Cardiac and mediastinal
silhouettes are stable.
IMPRESSION: Bibasilar atelectasis without definite focal
consolidation. Dedicated PA and lateral views may be helpful for
further assessment if/when patient able.
-Patient was given: 1L LR, pantoprazole 40mg, 1u pRBC
-Consults:
--GI: Agree with management thus far. Continue PO PPI (no need
for IV given already on PPI at home), trend Hb, transfuse for
rapid blood loss or Hb<7, fluids, keep NPO pending labs. If
rapid
unstable bleed, please obtain CTA and consult ___. If remains
stable, OK for clears this afternoon for colonoscopy tomorrow.
Vitals on transfer: T 99, HR 77, BP 116/60, RR 18, O2 sat 97% on
2L NC
Upon arrival to the floor, patient and family at bedside agree
with the above history. They note he was having stomach
discomfort and coughing up phlegm/maybe some emesis about 2
weeks
ago and started taking omeprazole daily which did help with the
symptoms. He stopped taking omeprazole a few days ago. Patient
started having hematochezia the afternoon prior to admission,
but
did not tell family until this morning when he was feeling weak.
He had a total of 6 bloody BMs, the last one at 0930 on day of
admission. BMs have been maroon in color with bright red blood
in
the toilet bowel. He denies any history of hemorrhoids or GI
bleeds, and has never had bloody or dark/tarry BMs in the past.
He dose take aspirin daily but did not take it today due to
symptoms. He reports having some nausea earlier today which has
resolved. He has had 2 colonoscopies in the past, with the last
being ___ years ago. Family thinks they were both normal. He
denies any chest pain, dyspnea, nausea, vomiting, headache,
dysuria, weakness or dizziness currently. His last BM was at
0930
on ___. He has also not urinated since that time.
REVIEW OF SYSTEMS: See above as per HPI
Past Medical History:
GLAUCOMA
DIABETES MELLITUS
HYPERTENSION
HYPERLIPIDEMIA
HEALTH MAINTENANCE
AORTIC STENOSIS
Social History:
___
Family History:
brother had lung disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: ___ 1640 Temp: 97.9 PO BP: 173/73 HR: 74 RR: 18 O2
sat: 98% O2 delivery: Ra
GENERAL: Alert and interactive male in NAD.
HEENT: NCAT. PERRL, EOMI. Conjunctival pallor. Sclera anicteric
and without injection. dry MM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing on RA.
ABDOMEN: +BS. Abdomen soft, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Pale. Warm. No rash.
NEUROLOGIC: AOx3. No focal neurologic deficits. CN2-12 intact.
___ strength throughout. Normal sensation. Gait not tested.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 736)
Temp: 98.4 (Tm 98.4), BP: 158/72 (120-166/51-74), HR: 66
(61-75), RR: 18, O2 sat: 97% (92-97), O2 delivery: 1L
GENERAL: alert, NAD
HEENT: Conjunctival pallor, PERRL, EOMI
NECK: supple
CARDIAC: RRR, S1 and S2
LUNGS: coarse breath sounds, no increased work of breathing or
accessory muscle use
ABDOMEN: soft, nontender, nondistended, BS+
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: pale and warm
NEUROLOGIC: AOx3. No focal neurologic deficits
Pertinent Results:
ADMISSION LABS
___ 11:05AM BLOOD WBC-9.5 RBC-2.49* Hgb-7.4* Hct-22.7*
MCV-91 MCH-29.7 MCHC-32.6 RDW-13.6 RDWSD-44.7 Plt ___
___ 11:05AM BLOOD Neuts-72.4* ___ Monos-5.5
Eos-0.9* Baso-0.6 Im ___ AbsNeut-6.91* AbsLymp-1.85
AbsMono-0.52 AbsEos-0.09 AbsBaso-0.06
___ 04:55AM BLOOD ___ PTT-29.0 ___
___ 11:05AM BLOOD Glucose-214* UreaN-45* Creat-0.9 Na-140
K-4.5 Cl-106 HCO3-23 AnGap-11
___ 04:55AM BLOOD Albumin-3.3* Calcium-8.3* Phos-2.9 Mg-2.0
___ 04:55AM BLOOD ALT-14 AST-17 LD(LDH)-186 AlkPhos-56
TotBili-0.3
PERTINENT STUDIES
___ 03:38PM URINE Color-Straw Appear-Clear Sp ___
___ 03:38PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
MICRO
URINE CULTURE COLLECTED ___ (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 11:05AM BLOOD WBC-9.5 RBC-2.49* Hgb-7.4* Hct-22.7*
MCV-91 MCH-29.7 MCHC-32.6 RDW-13.6 RDWSD-44.7 Plt ___
___ 08:10PM BLOOD WBC-9.7 RBC-2.76* Hgb-8.2* Hct-24.9*
MCV-90 MCH-29.7 MCHC-32.9 RDW-14.2 RDWSD-45.7 Plt ___
___ 04:55AM BLOOD WBC-7.3 RBC-2.51* Hgb-7.4* Hct-22.7*
MCV-90 MCH-29.5 MCHC-32.6 RDW-14.5 RDWSD-47.0* Plt ___
___ 05:30PM BLOOD WBC-7.9 RBC-2.51* Hgb-7.5* Hct-23.5*
MCV-94 MCH-29.9 MCHC-31.9* RDW-14.6 RDWSD-49.9* Plt ___
___ 04:55AM BLOOD WBC-10.9* RBC-2.07* Hgb-6.2* Hct-19.2*
MCV-93 MCH-30.0 MCHC-32.3 RDW-14.9 RDWSD-50.0* Plt ___
___ 05:30PM BLOOD WBC-9.0 RBC-2.53* Hgb-7.4* Hct-23.2*
MCV-92 MCH-29.2 MCHC-31.9* RDW-15.7* RDWSD-51.3* Plt ___
___ 06:44AM BLOOD WBC-7.3 RBC-2.57* Hgb-7.5* Hct-23.9*
MCV-93 MCH-29.2 MCHC-31.4* RDW-15.5 RDWSD-51.6* Plt ___
___ 06:28AM BLOOD WBC-6.0 RBC-2.65* Hgb-7.8* Hct-24.3*
MCV-92 MCH-29.4 MCHC-32.1 RDW-15.3 RDWSD-48.7* Plt ___
___ chest xray
FINDINGS:
Bibasilar atelectasis is seen without definite focal
consolidation. No large
pleural effusion or pneumothorax is seen. The right
costophrenic angle is not
entirely included on the image. There is relative lucency of
the upper lung,
suggesting pulmonary emphysema. Cardiac and mediastinal
silhouettes are
stable.
IMPRESSION:
Bibasilar atelectasis without definite focal consolidation.
Dedicated PA and
lateral views may be helpful for further assessment if/when
patient able.
___ COLONOSCOP
Diverticulosis of the sigmoid colon. Normal mucosa in the whole
colon and 10 cm into the terminal ileum. No souce of bleeding or
recent bloo seen in the colon.
___ egd
Normal stomach. Ring in the distal esophagus. Erosions in the
duodenal bulb. Ulcer in the duodenal bulb (Injection, thermal
therapy, endoclip)
DISCHARGE LABS
___ 06:28AM BLOOD WBC-6.0 RBC-2.65* Hgb-7.8* Hct-24.3*
MCV-92 MCH-29.4 MCHC-32.1 RDW-15.3 RDWSD-48.7* Plt ___
___ 06:28AM BLOOD Glucose-118* UreaN-4* Creat-0.6 Na-145
K-3.9 Cl-112* HCO3-23 AnGap-10
___ 06:28AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheezing
2. amLODIPine 10 mg PO DAILY
3. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
4. Lumigan 0.03% Ophth (*NF*) 1 drop Other QHS
5. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) TID
6. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. GlipiZIDE 5 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. Pravastatin 20 mg PO QHS
11. tacrolimus 0.1 % topical BID:PRN
12. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
13. ginkgo biloba 60 mg oral DAILY
14. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN
cough
15. Omeprazole 20 mg PO DAILY
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*16 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheezing
5. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
6. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) TID
7. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN
cough
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. ginkgo biloba 60 mg oral DAILY
11. GlipiZIDE 5 mg PO DAILY
12. Lumigan 0.03% Ophth (*NF*) 1 drop Other QHS
13. Pravastatin 20 mg PO QHS
14. tacrolimus 0.1 % topical BID:PRN
15. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
16. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until instructe to
do so by a physician
___:
Home
Discharge Diagnosis:
Duodenal ulcer
Community acquired pneumonia
Acute blood loss anemia
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 likely LGIB, endorsing some SOB// fluid,
infection
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Bibasilar atelectasis is seen without definite focal consolidation. No large
pleural effusion or pneumothorax is seen. The right costophrenic angle is not
entirely included on the image. There is relative lucency of the upper lung,
suggesting pulmonary emphysema. Cardiac and mediastinal silhouettes are
stable.
IMPRESSION:
Bibasilar atelectasis without definite focal consolidation. Dedicated PA and
lateral views may be helpful for further assessment if/when patient able.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fever after EGD/colonoscopy// please
evaluate for PNA please evaluate for PNA
IMPRESSION:
Heart size is enlarged. Mediastinum is stable. Lungs are overall clear but
there is new left suprahilar opacity that might potentially represent
infectious process.
RECOMMENDATION(S): Followup of the patient in 4 weeks after completion of
antibiotic therapy is recommended for documentation of resolution.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: BRBPR, Weakness
Diagnosed with Melena
temperature: 97.0
heartrate: 85.0
resprate: 20.0
o2sat: 99.0
sbp: 109.0
dbp: 42.0
level of pain: 0
level of acuity: 2.0 | SUMMARY
___ man with PMH DM, HTN, HLD presenting with hematochezia and
weakness x 1 day, s/p ___ which found duodenal ulcer.
Patient received blood transfusions as needed with cauterization
of ulcer, with H. pylori stool antigen pending on discharge. He
was also found to have pneumonia as well as ___ proteus
mirabilis on urine culture and treated with ceftriaxone,
transitioned to cefpodoxime on discharge for total 7 day course,
to end ___, for combined coverage of community acquired
pneumonia/UTI. Azithromycin was discontinued given prolonged QTc
(530) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis of R ___ digit
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with past medical history of drug abuse, EtOH
abuse currently sober, bipolar disorder, aortic aneurysm, DVT,
PE, shingles, anxiety, depression, chronic left hip and back
pain
transferred from ___ for evaluation for
concern
of right third digit tenosynovitis.
Patient states that 2 days ago he had gloves on and was using a
leaf blower which caused irritation to the radial aspect of the
middle finger, this caused an ulceration which he popped 2 days
ago. Yesterday and today he has noticed increased swelling,
significant pain with flexion and extension of the finger, as
well as redness of his right hand. He denied pain in the wrist.
He denied fever or chills, nausea or vomiting.
This morning, he noted worsening swelling of the proximal third
digit as well as worsening pain and was unable to move his
middle
finger completely. He presented to ___ for
further evaluation.
From ___ patient was transferred to ___ for eval of
hand flexor tenosynovitis and hand surgery consult. Vanco and
ceftriaxone were given.
In the ED:
Hand surgery was consulted which believed that he mostly likely
has cellulitis from open blister. There was no c/f deep space
infection or abscess. They recommended admission to medicine,
continuing antibiotics, hand elevation; no splint as issue most
likely caused by irritation and blistering.
Initial vital signs were notable for: 98.0 72 118/99 16 99% RA
Exam notable for: erythema and warmth circumferentially around
the proximal third of the right third digit. Tender to
palpation.
Limited range of motion. There is an open blister with
surrounding erythema along the lateral surface of the finger. No
bleeding.
Labs were notable for:
At ___:
___
------------<105
4.6 26 1.4
Patient was given:
___ 14:47 PO Oxycodone-Acetaminophen (5mg-325mg) 1 TAB
___ 18:27 IV Ampicillin-Sulbactam 3g
Consults:
Hand Surgery Consult
Vitals on transfer: 97.8 76 122/68 20 96% RA
Upon arrival to the floor, the patient reports that his hand and
middle finger feel much better compared to this morning. He is
able to move and bend his middle finger, and he reports pain
___. He denies numbness in his right hand, no changes in
sensation. Has some weakness secondary to pain. He denies
problems with his wrist or the other fingers.
Social History:
___
Family History:
Non-contributory.
Physical Exam:
VITALS:
24 HR Data (last updated ___ @ 429)
Temp: 98.0 (Tm 98.2), BP: 117/74 (117-133/72-74), HR: 72
(72-76), RR: 18, O2 sat: 95% (95-98), O2 delivery: Ra, Wt: 219.5
lb/99.57 kg (219.5-221.8)
Gen: NAD, A&Ox3
HEENT: Normocephalic.
CV: RRR. no murmurs, rubs or gallops
Resp: CTAB, no wheezing, rales or ronchi
Ext: right hand - Warm. 2 second capillary refill in all digit
tips. open blister on ulnar aspect of ___ digit, no erythema
noted. normal right wrist flexion, extension, radial and ulnar
deviation, pronation and supination full. right middle finger
swollen at PIP joint and tender to palpation. MCP and DIP joint
not swollen and not tender to palpation. Sensation grossly
intact
in median, ulnar, and radial distributions.
Sensory: Intact to light touch.
Left Hand: Nontender. No lacerations
Pertinent Results:
IMAGING:
========
Right hand PA, LAT, OBLIQUE Xray
FINDINGS:
No fracture or dislocation is seen. There are severe
degenerative changes in the first carpal metacarpal joint and
mild degenerative changes in first IP joint as well as second
through fourth DIP joints. Degenerative changes in the
triscaphe
joint are mild-to-moderate. No bone erosion or periostitis is
identified. No suspicious lytic or sclerotic lesion is
identified. No soft
tissue calcification or radio-opaque foreign bodies are
detected.
IMPRESSION:
No fracture or dislocation. Osteoarthritis, most pronounced at
the basal joint.
LABS:
=====
___ 05:50AM BLOOD WBC-4.9 RBC-3.56* Hgb-11.2* Hct-33.8*
MCV-95 MCH-31.5 MCHC-33.1 RDW-13.0 RDWSD-45.1 Plt ___
___ 05:50AM BLOOD Glucose-93 UreaN-19 Creat-1.4* Na-142
K-4.7 Cl-105 HCO3-25 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 100 mg PO BID
2. DULoxetine 120 mg PO DAILY
3. ClonazePAM 0.5 mg PO TID:PRN anxiety
4. QUEtiapine Fumarate 600 mg PO QHS
5. rOPINIRole 4 mg PO QPM
6. ARIPiprazole 20 mg PO DAILY
7. TraZODone 150 mg PO QHS:PRN anxiety
8. Docusate Sodium 100 mg PO TID
9. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line
10. Baclofen 10 mg PO TID
11. Tamsulosin 0.8 mg PO QHS
12. Pravastatin 40 mg PO QPM
13. Mirtazapine 45 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Cephalexin 500 mg PO Q6H
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
4. ARIPiprazole 20 mg PO DAILY
5. Baclofen 10 mg PO TID
6. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line
7. ClonazePAM 0.5 mg PO TID:PRN anxiety
8. Docusate Sodium 100 mg PO TID
9. DULoxetine 120 mg PO DAILY
10. LamoTRIgine 100 mg PO BID
11. Mirtazapine 45 mg PO QHS
12. Pravastatin 40 mg PO QPM
13. QUEtiapine Fumarate 600 mg PO QHS
14. rOPINIRole 4 mg PO QPM
15. Tamsulosin 0.8 mg PO QHS
16. TraZODone 150 mg PO QHS:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis of R ___ digit
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT
INDICATION: ___ man with right ___ digit tenosynovitis; evaluate for
bone injury, tenosynovitis.
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right hand.
COMPARISON: No prior imaging is available on PACS at the time of this
dictation.
FINDINGS:
No fracture or dislocation is seen. There are severe degenerative changes in
the first carpal metacarpal joint and mild degenerative changes in first IP
joint as well as second through fourth DIP joints. Degenerative changes in
the triscaphe joint are mild-to-moderate. No bone erosion or periostitis is
identified. No suspicious lytic or sclerotic lesion is identified. No soft
tissue calcification or radio-opaque foreign bodies are detected.
IMPRESSION:
No fracture or dislocation. Osteoarthritis, most pronounced at the basal
joint.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hand pain, Transfer
Diagnosed with Cellulitis of right upper limb
temperature: 98.0
heartrate: 72.0
resprate: 16.0
o2sat: 99.0
sbp: 118.0
dbp: 99.0
level of pain: 7
level of acuity: 3.0 | Information for Outpatient Providers: ___ M R___
p/w ulcer, erythema, and swelling of the ___ digit of his R hand
admitted for management of uncomplicated cellulitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lopid / Zestril / Cozaar / Benicar / hydrochlorothiazide /
amlodipine / Zocor / Pravachol / fish oil / coencyme Q10 / flax
seed oil / Crestor / Effexor / Cymbalta / Gemfibrozil
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
___ h/o hyperlipidemia, depression, presents for eval of
epigastric abdominal pain. Patient states that her pain began
about 2 days prior to presentation, describes it as a sharp
stabbing abdominal pain with radiation to the back constant not
affected by what she ate. No clear trigger for pain. Prior to
this she was in a general state of good health. She endorses
associated nausea and vomiting. She denies any fevers, chills,
dysuria, urinary frequency. He denies any history of prior
abdominal surgery. Denies history of gallstones. Denies
diarrhea. States the pain is constant in nature and unrelenting.
___ pain -> ___ pain worse than labor pain. Seen at outside
hospital where ultrasound shows 6.7 mm dilation of the CBD as
well as 4 mm dilation of the pancreatic duct along with early
intrahepatic ductal dilatation. Discussed with ERCP here,
recommend transfer for MRCP.
===========
In ER: (Triage ___ 45 ___ 97% )
Meds Given: Dilaudid 1 mg x 4, zofran,
Fluids given: NS
Radiology Studies: none
consults called: d/w ERCP who recommended MRCP
======================
.
Currently in ___ pain in the epigastrum which radiates around
to her back.
No weight loss/no sudden visual changes. No change in her bowel
habits.
Her synthyroid was recently increased.
No URI sx
No chest pain or shortness of breath.
No edema
No new MSK sx.
Chronic headaches are well controlled currently,
No easy bruising/bleeding.
No current SI/HI.
PSYCH: [] All Normal
[+/? ] Mood change [-]Suicidal Ideation [ ] Other:
ALLERGY:
[+ ]Several medication allergies
[X]all other systems negative except as noted above
Past Medical History:
- PTSD
- depression
- hypercholesterolemia
- hypertension
- Graves' disease- s/p XRT now with hypothyrioidism followed by
Dr. ___ in ___
- left-sided hearing loss
- arachnoid cyst
- anisocoria
- recent admission for suicidality in ___
Social History:
Per Dr. ___ OMR note in ___
"Her daughter, daughter's husband and ___ granddaughter
are living with
her. The husband is a registered sex offender. The patient
herself has a history of sexual abuse and PTSD and is working
through these issues quite diligently with a psychiatrist and a
therapist"
She tells me that there is a lot of stress at home. She has a 40
pack year history of smoking and currently smokes 1 pack per
day. She tells me that I should be happy that this is all she
does and does not do illicit drugs. She is very involved in
raising her ___ year grand-daughter and derives a lot of pleasure
from this. She works as a ___ and also cleans houses. She drinks
rarely and has never drank heavily.
She also has a son who and has a 10 month old grandson.
She lives with her husband.
Patient with financial stress due to high level of co-insurance
payments required after her recent hospitalization and rehab
stay.
Family History:
Her father died of renal cancer at age ___.
Her sisterd died of an MI at age ___.
She is ___ of 9 siblings.
Her mother is alive with DM.
Physical Exam:
Admission Exam:
AF BP 160-180/70-80 HR 40-60
Gen: Appearing older than stated age, and in discomfort
Lung: CTA B
CV: RRR, no m/r/g
Abd: ++ epigastric tenderness, no rebound or guarding.
Ext: No edema
Pertinent Results:
___ 12:10AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-SM UROBILNGN-2* PH-6.0 LEUK-TR
___ 12:10AM URINE RBC-2 WBC-8* BACTERIA-FEW YEAST-NONE
EPI-5 TRANS EPI-<1
___ 12:10AM URINE MUCOUS-RARE
___ 11:59PM COMMENTS-GREEN TOP
___ 11:59PM LACTATE-1.9
___ 11:30PM GLUCOSE-104* UREA N-24* CREAT-0.9 SODIUM-142
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-28 ANION GAP-15
___ 11:30PM estGFR-Using this
___ 11:30PM ALT(SGPT)-19 AST(SGOT)-17 ALK PHOS-75 TOT
BILI-0.4
___ 11:30PM LIPASE-363*
___ 11:30PM ALBUMIN-4.4 CALCIUM-9.3 PHOSPHATE-4.6*
MAGNESIUM-1.9
___ 11:30PM WBC-17.9* RBC-4.86 HGB-15.2 HCT-47.1 MCV-97
MCH-31.3 MCHC-32.2 RDW-13.3
___ 11:30PM NEUTS-79.7* LYMPHS-14.6* MONOS-4.7 EOS-0.2
BASOS-0.7
___ 11:30PM PLT COUNT-261
___ 11:30PM PLT COUNT-261
RUQ US at ___:
Multiple sonographic sections right upper quadrant the abdomen
were
obtained.
Findings: Gallbladder is somewhat dilated. There is echogenic
fluid
within the gallbladder. This may represent a thick tenacious
bile.
Shadowing gallstone is not seen. There is no gallbladder wall
thickening. Common bile duct measures 6.7 mm in internal
diameter.
In the head of the pancreas the common bile duct measures 7 mm
in
diameter. Pancreatic duct is dilated at 4 mm in internal
diameter.
The liver has questionable early intrahepatic biliary
dilatation.
Inferior vena cava appears normal path through the liver. Right
kidney measures 10.2 cm in greatest sagittal length. It shows
no
mass, cyst, or hydronephrosis. The pancreas shows no obvious
mass or
enlargement. There is no obvious edema type changes. The
dilated
pancreatic duct extends down into the head of the pancreas.
Impressions: Dilated pancreatic duct and common bile duct.
Suggestion of early intrahepatic biliary dilatation. This would
suggest the distal common bile duct obstruction.
Echogenic material within the gallbladder without shadowing.
This
may represent thick tenacious bile. Sand like stones cannot be
excluded. No shadowing stones demonstrated.
INDICATION: ___ woman with acute pancreatitis, with a
dilated CBD and
pancreatic duct seen on outside hospital imaging.
COMPARISON: Reference ultrasound from an outside hospital
___.
TECHNIQUE: Multiplanar T1- and T2-weighted MR images of the
abdomen were
performed prior to and after uneventful intravenous
administration of 6 mL of
Gadovist.
FINDINGS: The liver is normal in signal intensity, without
concerning focal
liver lesions. A 15 x 10 mm T2 hyperintense lesion in the right
hepatic lobe
at the junction of segments V and VI (1103:85) is consistent
with a biliary
hamartoma. There is mild intra and extra hepatic biliary
dilatation, with the
CBD measuring 7 mm. The gallbladder is distended. There is
mild gallbladder
wall edema as well as pericholecystic fluid. No gallstones are
identified.
The pancreas has a diffusely low signal on the pre-contrast
T1-weighted
images, with restricted diffusion seen within the pancreatic
head and neck. A
focal lobulation of pancreas, contiguous with the pancreatic
head, insinuates
between the first and second portion of duodenum (1101:90).
There is marked
duodenal wall edema (involving first and second portions of
duodenum) with
soft tissue inflammation seen along the medial and lateral
aspects of the
duodenum (4:27). Mild prominence of the ampulla (1101:109)
likely relates to
the inflammatory process. A small amount of fluid is seen within
the
pancreaticoduodenal groove. There is homogeneous enhancement
of the
pancreas. The main pancreatic duct is mildly dilated measuring
4 mm at the
level of the pancreatic head. No intraductal obstructing stones
are seen. No
organized peripancreatic fluid collections are seen. The
remainder of the
imaged abdominal loops are normal. Few reactive lymph nodes are
seen in the
porta hepatis (6:30). A 12-mm left adrenal nodule demonstrating
signal drop
on the out-of-phase images, compared to the in-phase images
(5:23) is
consistent with an adrenal adenoma. The right adrenal gland and
left kidney
are unremarkable. Areas of scarring are seen in the upper pole
of right
kidney. The spleen is normal in size, but has a small contour
abnormality
associated with susceptibility artifact consistent with an old
infarct.
The abdominal aorta is normal in caliber. The celiac trunk,
SMA, both renal
arteries are patent. Trace bilateral pleural effusions are
present. The main
portal, splenic and superior mesenteric veins are patent. The
hepatic veins
and IVC are normal. No marrow signal abnormality is seen.
IMPRESSION:
1. Active duodenitis involving the first and second portion of
duodenum,
associated with acute interstitial pancreatitis predominant in
the head/neck, as well as in a focal lobulation insinuating
between the first and second portion of duodenum, which likely
represents a normal lobulation and less likely incomplete
annular pancreas. Distended gallbladder with mild
pericholecystic fluid, likely relates to the extensive
duodenal/pancreatic inflammation.
2. Mild intrahepatic/extra-hepatic bile duct dilation,
pancreatic ductal
dilation associated with a mildly prominent ampulla, likely
relate to
duodenitis.
The above findings were discussed with ___ on ___ at
6:30 P.M.
The study and the report were reviewed by the staff radiologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. colesevelam 625 mg oral Daily
2. Metoprolol Succinate XL 150 mg PO DAILY
3. CloniDINE 0.3 mg PO BID
4. Levothyroxine Sodium 150 mcg PO DAILY
The Preadmission Medication list is accurate and complete.
1. colesevelam 625 mg oral Daily
2. Metoprolol Succinate XL 150 mg PO DAILY
3. CloniDINE 0.3 mg PO BID
4. Levothyroxine Sodium 150 mcg PO DAILY
Discharge Medications:
1. CloniDINE 0.3 mg PO BID
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth daily Disp #*30 Capsule Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN abdominal pain
RX *oxycodone [Oxecta] 5 mg 5 tablet, oral only(s) by mouth
every six hours as needed Disp #*15 Tablet Refills:*0
5. colesevelam 625 mg oral Daily
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Duodenitis
Hypertension
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with acute pancreatitis, with a dilated CBD and
pancreatic duct seen on outside hospital imaging.
COMPARISON: Reference ultrasound from an outside hospital ___.
TECHNIQUE: Multiplanar T1- and T2-weighted MR images of the abdomen were
performed prior to and after uneventful intravenous administration of 6 mL of
Gadovist.
FINDINGS: The liver is normal in signal intensity, without concerning focal
liver lesions. A 15 x 10 mm T2 hyperintense lesion in the right hepatic lobe
at the junction of segments V and VI (1103:85) is consistent with a biliary
hamartoma. There is mild intra and extra hepatic biliary dilatation, with the
CBD measuring 7 mm. The gallbladder is distended. There is mild gallbladder
wall edema as well as pericholecystic fluid. No gallstones are identified.
The pancreas has a diffusely low signal on the pre-contrast T1-weighted
images, with restricted diffusion seen within the pancreatic head and neck. A
focal lobulation of pancreas, contiguous with the pancreatic head, insinuates
between the first and second portion of duodenum (1101:90). There is marked
duodenal wall edema (involving first and second portions of duodenum) with
soft tissue inflammation seen along the medial and lateral aspects of the
duodenum (4:27). Mild prominence of the ampulla (1101:109) likely relates to
the inflammatory process. A small amount of fluid is seen within the
pancreaticoduodenal groove. There is homogeneous enhancement of the
pancreas. The main pancreatic duct is mildly dilated measuring 4 mm at the
level of the pancreatic head. No intraductal obstructing stones are seen. No
organized peripancreatic fluid collections are seen. The remainder of the
imaged abdominal loops are normal. Few reactive lymph nodes are seen in the
porta hepatis (6:30). A 12-mm left adrenal nodule demonstrating signal drop
on the out-of-phase images, compared to the in-phase images (5:23) is
consistent with an adrenal adenoma. The right adrenal gland and left kidney
are unremarkable. Areas of scarring are seen in the upper pole of right
kidney. The spleen is normal in size, but has a small contour abnormality
associated with susceptibility artifact consistent with an old infarct.
The abdominal aorta is normal in caliber. The celiac trunk, SMA, both renal
arteries are patent. Trace bilateral pleural effusions are present. The main
portal, splenic and superior mesenteric veins are patent. The hepatic veins
and IVC are normal. No marrow signal abnormality is seen.
IMPRESSION:
1. Active duodenitis involving the first and second portion of duodenum,
associated with acute interstitial pancreatitis predominant in the head/neck,
as well as in a focal lobulation insinuating between the first and second
portion of duodenum, which likely represents a normal lobulation and less
likely incomplete annular pancreas. Distended gallbladder with mild
pericholecystic fluid, likely relates to the extensive duodenal/pancreatic
inflammation.
2. Mild intrahepatic/extra-hepatic bile duct dilation, pancreatic ductal
dilation associated with a mildly prominent ampulla, likely relate to
duodenitis.
The above findings were discussed with ___ on ___ at 6:30 P.M.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN EPIGASTRIC, OBSTRUCTION OF BILE DUCT
temperature: 97.5
heartrate: 45.0
resprate: 16.0
o2sat: 97.0
sbp: 111.0
dbp: 78.0
level of pain: 8
level of acuity: 2.0 | \The patient is a ___ year old female with h/o depression,
migraines, HLD, smoking history who presents with acute
pancreatitis found to have intrahepatic dilatation, CBD
dilatation and pancreatic ductal dilation concerning for
possible obstruction.
.
Abdominal Pain: Patient with evidence of active pancreatitis
and duodenitis seen on MRCP with clear evidence of ductal
dilation. LFTs normal, but elevated lipase. This clinical
picture may be secondary to a gallstone. No gallstone clearly
seen on MRCP. There was mention of slight ampullary dilation on
MRCP. As such, she needs outpatient f/u with our ERCP staff to
consider ERCP given mention of ampullary dilation. Would
proceed with this workup prior to consideration of
cholecystectomy.
** Patient was discharged with a prescription for oxycodone 5 mg
(15 tabs) but then called the medical floor the day after
discharge to request a new prescription; we told her that we
have strict policies against replacing narcotic prescriptions so
she was not given an additional one.
HTN: Continued on clonidine only given her bradycardia.
Bradycardia: Metoprolol held, and EKG showed sinus arrhythmia.
QTC also prolonged at 480. Needs outpatient recheck and patient
notified not to take any medicines that prolong the qtc. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
EGDx2, colonoscopy
History of Present Illness:
___ M with a history of poorly controlled diabetes, severe
systolic heart failure (EF ___ in ___ secondary to
ischemic cardiomyopathy, history of DVT/PE and LV thrombus on
warfarin and severe peripheral vascular disease s/p right ___
toe amputation with recent bypass procedure due to poor wound
healing who was brought in by ambulance from rehab for BRBPR and
clots. He has been on ASA, Lovenox bridge to Coumadin after his
bypass procedure. After dinner this evening around 6:30pm he
experienced abdominal cramping and massive amounts of bloody
stool with dime sized clots. Rehab called EMS who noted that on
arrival he had SBPs in the ___ but dropped to mid ___ systolic
by the time he arrived in ED. Per EMS over the ten minutes
prior to arrival in the ED he had become much more lethargic and
somnolent.
Mr. ___ was recently admitted on ___ for elective
angiogram due to non-healing ulcer on the right third digit. He
subsequently underwent right third digit amputation. He was then
readmitted on ___ for polymicrobial right foot infection
which was treated with excision, drainage and debridement by
Podiatry and antibiotics, discharged on PO augmentin (guided by
culture data). He was then readmitted from rehab on ___
for foul smelling discharge from non-healing right toe wound.
For this, he underwent right above-knee popliteal to dorsalis
pedis bypass and right foot debridement by Vascular Surgery. He
was discharged on bridging therapy with lovenox since INR was
1.3 on discharge. Renal function at that time had been stable
at 1.6. Of note, he was seen in Cardiology clinic for
orthostatic hypotension on ___ at which time his Torsemide
dose was decreased from 20-->10mg daily.
In the ED, initial vitals: T95, BP 64/44 then up to 89/47, RR
17, SpO2 100% RA. 3 PIVs were placed on arrival. Labs were
notable for: WBC 11.1 with a normal differential, hemoglobin 8.6
(baseline likely in the ___ range), platelets 203. INR 1.1.
Chem panel notable for BUN and creatinine 2.5 (baseline
1.5-2.0). Troponins 0.04. Lactate 1.7. LFTs normal. Albumin 3.0.
VBG was obtained which was 7.33 / 57. His EKG was initially
concerning for ischemic changes but when compared to prior
exams, was similar. A left IJ advanced venous access catheter
was placed. Initially had attempted to place right IJ but
patient was so volume depleted, had difficulty threading the
wire.
The patient was given 4 units of blood, 1unit of FFP, 2300cc of
NS and 40mg IV protonix. GI was consulted about the patient who
thought that most likely this was a lower GI bleed, though
cannot exclude upper GI bleed. His mental status improved after
initial resuscitation and patient was able to give history, was
alert, A&Ox3. Shortly after had another episode of bleeding and
became transiently somnolent. Ultimately bleeding has slowed
down over time that he has been in the ED. There was debate
about pursuing CTA to localize bleeding but patient's renal
function at presentation was significantly worse than baseline
and deferred for now as able to adequately resuscitate in ED.
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:
-SYSTOLIC CHF with EF of ___ on Echo ___ dry weight 94kg
-COCAINE ABUSE - last use ___ per OMR discharge summaries
-MULTIPLE DEEP VENOUS THROMBOPHLEBITIS s/p IVC filter in place,
on chronic warfarin. Complicated by edema/phlebitis.
-DIABETES MELLITUS TYPE II: Last Hgb A1c 9.6 in ___
-CORONARY ARTERY DISEASE s/p anterior ST elevation MI, s/p DES
to the LAD. Had angina led to --> DESx2 to RCA in ___
-HYPERCHOLESTEROLEMIA
-BENIGN PROSTATIC HYPERTROPHY
-HYPERTENSION
-CHRONIC KIDNEY DISEASE (baseline Cr of 1.5-2.0)
-PERIPHERAL VASCULAR DISEASE s/p PTA of the R peroneal artery
and s/p right ___ toe amputation c/b nonhealing amputation site
requiring above-knee popliteal to dorsalis pedis bypass graft
with reverse saphenous vein (___)
-H/O ACUTE PANCREATITIS
-H/O CEREBROVASCULAR ACCIDENT resulting in chronic R leg pain
and weakness
-H/O LV THROMBUS, resolved on warfarin
Social History:
___
Family History:
per OMR:
Mother ___ END STAGE RENAL DISEASE
Father ___ OLD AGE
Sister ___ ___ MYOCARDIAL INFARCTION
Sister ___ CANCER unknown type
Brother ___ LIVER CANCER
Aunt ___ CANCER unknown type
Physical Exam:
EXAM ON ADMISSION:
Vitals: T: 97.7. BP: 133/59. P: 78. R: 13. O2: 100%RA.
GENERAL: Fatigued-appeaing, A&Ox3, mumbling at times
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated; left IJ c/d/i
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi on anterior and lateral exam
CV: Distant heart sounds
ABD: soft, non-distended, hyperactive bowel sounds present; mild
RUQ tenderness, but patient was distractible; no rebound
tenderness or guarding, no organomegaly
EXT: left DP pulse palpable; right leg is bandaged, non-pitting
edema; well-healing scar on right thigh but has multiple
bandaged blood-filled bullae, none of which are actively
draining or bleeding
NEURO: CN II-XII grossly intact, no focal asymmetry; some
residual chronic right leg weakness
EXAM ON DISCHARGE:
VS: T:98.1 102/58 79 19 100RA
GENERAL: pleasant, enjoying breakfast alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation, no w/r/r
HEART: RRR no m/r/g
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP. R foot with clean, dry bandages in place.
Edema on R>L ___. Hemosiderin staining bilaterally. Cannot lift
arm >90 degrees ___ pain. No pain with passive motion.
NEURO: awake, A&Ox3, moves all extremities
Pertinent Results:
ADMISSION LABS:
___ 11:41PM WBC-11.0* RBC-3.21* HGB-9.1* HCT-29.5* MCV-92
MCH-28.3 MCHC-30.8* RDW-15.7* RDWSD-52.7*
___ 11:41PM PLT COUNT-123*
___ 08:33PM ___ PO2-17* PCO2-57* PH-7.33* TOTAL
CO2-31* BASE XS-0
___ 08:33PM LACTATE-1.7
___ 08:15PM GLUCOSE-167* UREA N-71* CREAT-2.5* SODIUM-138
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
___ 08:15PM ALT(SGPT)-15 AST(SGOT)-18 ALK PHOS-116 TOT
BILI-0.1
___ 08:15PM LIPASE-13
___ 08:15PM cTropnT-0.04*
___ 08:15PM CK-MB-2
___ 08:15PM ALBUMIN-3.0*
___ 08:15PM WBC-11.1* RBC-2.94* HGB-8.6* HCT-28.5* MCV-97
MCH-29.3 MCHC-30.2* RDW-14.9 RDWSD-52.8*
___ 08:15PM NEUTS-64.9 ___ MONOS-5.5 EOS-5.4
BASOS-0.1 IM ___ AbsNeut-7.21* AbsLymp-2.59 AbsMono-0.61
AbsEos-0.60* AbsBaso-0.01
___ 08:15PM PLT COUNT-203
___ 08:15PM ___ PTT-33.0 ___
PERTINENT LABS:
___ 04:11AM BLOOD Hgb-7.8* Hct-25.0*
___ 07:27AM BLOOD WBC-11.4* RBC-3.33* Hgb-9.8*# Hct-30.4*
MCV-91 MCH-29.4 MCHC-32.2 RDW-15.8* RDWSD-51.7* Plt Ct-99*
___ 11:04AM BLOOD Hgb-8.5* Hct-26.6*
___ 12:40PM BLOOD Hgb-10.0* Hct-30.8*
___ 04:15PM BLOOD Hgb-10.2* Hct-31.8*
___ 07:49PM BLOOD Hgb-10.2* Hct-31.6*
___ 02:00AM BLOOD WBC-10.7* RBC-3.02* Hgb-8.6* Hct-27.7*
MCV-92 MCH-28.5 MCHC-31.0* RDW-16.2* RDWSD-54.5* Plt ___
___ 04:11AM BLOOD Hgb-7.8* Hct-25.0*
___ 11:04AM BLOOD Hgb-8.5* Hct-26.6*
___ 12:40PM BLOOD Hgb-10.0* Hct-30.8*
___ 02:21PM BLOOD WBC-9.3 RBC-2.92* Hgb-8.6* Hct-26.6*
MCV-91 MCH-29.5 MCHC-32.3 RDW-15.3 RDWSD-50.8* Plt Ct-91*
___ 01:40PM BLOOD Hgb-9.4* Hct-28.1*
___ 10:00PM BLOOD Hgb-9.7* Hct-29.8*
___ 02:00AM BLOOD Glucose-203* UreaN-60* Creat-1.9* Na-139
K-5.7* Cl-110* HCO3-22 AnGap-13
___ 02:21PM BLOOD Glucose-252* UreaN-28* Creat-1.4* Na-136
K-5.2* Cl-107 HCO3-22 AnGap-12
___ 08:40AM BLOOD Glucose-112* UreaN-18 Creat-1.2 Na-136
K-4.0 Cl-105 HCO3-24 AnGap-11
___ 08:40AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.5*
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-8.2 RBC-3.04* Hgb-8.7* Hct-28.6*
MCV-94 MCH-28.6 MCHC-30.4* RDW-15.2 RDWSD-52.1* Plt ___
___ 08:15PM BLOOD Neuts-64.9 ___ Monos-5.5 Eos-5.4
Baso-0.1 Im ___ AbsNeut-7.21* AbsLymp-2.59 AbsMono-0.61
AbsEos-0.60* AbsBaso-0.01
___ 06:00AM BLOOD Glucose-236* UreaN-19 Creat-1.5* Na-137
K-4.7 Cl-101 HCO3-26 AnGap-15
___ 06:00AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.8
MICRO:
IMAGING:
CTA Abd/pelvis ___
IMPRESSION:
1. No active hemorrhage detected.
2. Right-sided diverticulitis at the hepatic flexure (3b:246).
No fluid
collection.
3. Dilated common hepatic duct measuring up to 1.4 cm with
dilation of the
cystic duct and mild intrahepatic biliary ductal dilatation with
a transition
at the level of a calcification in the pancreatic head, possibly
a stone at
the duodenal ampulla (3b:249, 601b:55) but difficult to
distinguish from an
adjacent calcification. This could be further evaluated by ___
if clinically
indicated.
4. Wall thickening of the bladder suggests cystitis, correlate
clinically.
5. Mild wall thickening of the distal sigmoid colon without
adjacent fat
stranding may reflect mild colitis. No associated fluid
collection.
6. Left adrenal mass likely represents an adrenal adenoma but is
indeterminate
on the noncontrast study. Adrenal protocol CT or MRI could be
performed on an
outpatient basis for further characterization if clinically
indicated.
7. Nephrolithiasis.
CXR ___
IMPRESSION:
Left IJ catheter projects over the thoracic inlet. No
pneumothorax visualized
on this supine film.
GI Studies:
___ EGD
Mild esophagitis in distal esophagus with irregular z-line.
Thickened, irregular folds were seen in the gastric body.
Erythematous, nodular appearance of the gastric body-antrum
compatible with possible gastritis. Biopsies were not taken due
to indication of bleeding.
Normal appearing duodenal mucosa.
No fresh or old blood was seen throughout the case.
Otherwise normal EGD to third part of the duodenum
___ EGD
Erythema in the stomach compatible with gastritis (biopsy)
Otherwise normal EGD to third part of the duodenum
___ colonoscopy
Numerous polyps were found throughout the colon including some
with more advanced features and would require emr to remove.
Given his need for anticoagulation none of these were biopsied
or removed.
Otherwise normal colonoscopy to cecum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 3.125 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY
3. Senna 17.2 mg PO QHS
4. solifenacin 10 mg oral DAILY
5. Enoxaparin Sodium 100 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
6. Warfarin 7 mg PO DAILY16
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Omeprazole 20 mg PO DAILY
9. Pancrelipase 5000 1 CAP PO QIDWMHS
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN moderate pain
11. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN Severe pain
12. Guaifenesin 5 mL PO Q6H:PRN cough
13. Acetaminophen 1000 mg PO Q8H:PRN pain, fever
14. Finasteride 5 mg PO DAILY
15. FoLIC Acid 1 mg PO DAILY
16. Gabapentin 300 mg PO TID
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Lisinopril 2.5 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Morphine Sulfate ___ 15 mg PO BID
21. Ascorbic Acid ___ mg PO BID
22. Juven (arginine-glutamine-calcium Hmb) ___ gram oral BID
23. Torsemide 10 mg PO DAILY
24. Aspirin 81 mg PO DAILY
25. Atorvastatin 80 mg PO QPM
26. CarBAMazepine 100 mg PO QHS
27. Docusate Sodium 100 mg PO BID
28. ammonium lactate 12 % topical BID
29. Glargine 22 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain, fever
2. CarBAMazepine 100 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Carvedilol 3.125 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Glargine 22 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN moderate pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*18 Capsule Refills:*0
9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN Severe pain
RX *oxycodone 5 mg 2 capsule(s) by mouth every four (4) hours
Disp #*25 Capsule Refills:*0
10. Pancrelipase 5000 1 CAP PO QIDWMHS
11. Pantoprazole 40 mg PO Q12H
12. ammonium lactate 12 % topical BID
13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
14. Ascorbic Acid ___ mg PO BID
15. Docusate Sodium 100 mg PO BID
16. FoLIC Acid 1 mg PO DAILY
17. Guaifenesin 5 mL PO Q6H:PRN cough
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. Multivitamins 1 TAB PO DAILY
20. Polyethylene Glycol 17 g PO DAILY
21. Senna 17.2 mg PO QHS
22. Gabapentin 600 mg PO QHS
23. Gabapentin 400 mg PO BID
24. Torsemide 10 mg PO DAILY
25. Warfarin 7.5 mg PO DAILY16
26. Juven (arginine-glutamine-calcium Hmb) ___ gram oral BID
27. solifenacin 10 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lower GI bleed, ___, DM2, hx of LV thrombus, diverticulosis,
diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with lower GIB massive blood loss, now s/p L IJ ___ catheter
// confirm L IJ central line placement
TECHNIQUE: Single portable supine view of the chest.
COMPARISON: ___.
FINDINGS:
Prior right IJ central venous catheter is no longer visualized. Left IJ
sheath is in place. Tip projects over the thoracic inlet. There is no
visualized pneumothorax on this supine film. Lung volumes are relatively low
however the lungs remain relatively clear. The cardiomediastinal silhouette
is stable given differences in positioning. No acute osseous abnormalities.
Surgical clips seen in the right upper quadrant.
IMPRESSION:
Left IJ catheter projects over the thoracic inlet. No pneumothorax visualized
on this supine film.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old man with vascular disease, now presenting with BRBPR,
hypotension, now s/p 6u pRBCs in 10 hours, evaluate for any evidence of active
bleeding.
TECHNIQUE: Abdomen CTA without delayed imaging: Non-contrast, arterial, and
portal venous phase images were acquired through the abdomen.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Total DLP (Body) = 2,818 mGy-cm.
IV Contrast: 150 mL of Omnipaque
COMPARISON: Prior CT of the abdomen and pelvis dated ___.
FINDINGS:
VASCULAR:
There is no evidence of active hemorrhage. There is no abdominal aortic
aneurysm. There is moderate calcium burden in the abdominal aorta and great
abdominal arteries. A right iliac vein stent appears patent. An IVC filter
is incidentally noted.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. Mild intrahepatic biliary ductal dilatation
with associated dilatation of the common hepatic duct measuring up to 1.4 cm
(601:51) and the common bile duct measuring up to 1.1 cm (3B:239). Dilatation
terminates abruptly at the level of the calcification in the pancreatic head
which may represent impacted biliary stone in the duodenal ampulla (3B:249;
601:55). There associated mild prominence of the main pancreatic duct. The
gallbladder is is resected.
PANCREAS: The pancreas is diffusely atrophied with scattered calcifications
likely related to prior episodes of pancreatitis. Mild prominence of the main
pancreatic duct as noted above is likely related to a stone at the duodenal
ampulla.
SPLEEN: The spleen and a small accessory spleen show normal size and
attenuation throughout, without evidence of focal lesions.
ADRENALS: A 1.3 x 1.3 cm mass in the left adrenal gland is slightly smaller
than mass seen on the previous CT of ___ and likely represents an adrenal
adenoma. However, this is indeterminate in density on the noncontrast study
and could be further evaluated by dedicated adrenal CT protocol or MRI if
clinically indicated. The right adrenal gland is 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. Multiple small
nonobstructing renal stones are noted. There are no urothelial lesions in the
kidneys or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops
demonstrate normal caliber, wall thickness and enhancement throughout. No
hyperdense material is identified to suggest active hemorrhage. Fluid within
the small bowel measures simple fluid density. Extensive fat stranding and
mild wall thickening is noted in the ascending colon at the level of the
hepatic flexure and area with numerous diverticula consistent with acute
diverticulitis (3B:249). There is no associated fluid collection. There is
no free intraperitoneal air. Mild wall thickening of the distal sigmoid colon
is noted without associated fat stranding, correlate clinically for mild
colitis (3B: 341) Appendix contains air, has normal caliber without evidence
of fat stranding. There is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder is decompressed around a Foley catheter and
demonstrates diffuse wall thickening and mucosal enhancement, correlate
clinically for cystitis (3B:343). There is no evidence of pelvic or inguinal
lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. A small fat containing umbilical
hernia is incidentally noted (3B:291).
IMPRESSION:
1. No active hemorrhage detected.
2. Right-sided diverticulitis at the hepatic flexure (3b:246). No fluid
collection.
3. Dilated common hepatic duct measuring up to 1.4 cm with dilation of the
cystic duct and mild intrahepatic biliary ductal dilatation with a transition
at the level of a calcification in the pancreatic head, possibly a stone at
the duodenal ampulla (3b:249, 601b:55) but difficult to distinguish from an
adjacent calcification. This could be further evaluated by MRCP if clinically
indicated.
4. Wall thickening of the bladder suggests cystitis, correlate clinically.
5. Mild wall thickening of the distal sigmoid colon without adjacent fat
stranding may reflect mild colitis. No associated fluid collection.
6. Left adrenal mass likely represents an adrenal adenoma but is indeterminate
on the noncontrast study. Adrenal protocol CT or MRI could be performed on an
outpatient basis for further characterization if clinically indicated.
7. Nephrolithiasis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 4:50 ___, 40 minutes after the
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ year old man with CHF and GI bleeding. Please capture the
superior portion of advance venous access catheter by the neck // advance
venous access device placement. Please capture the superior portion of it by
the neck
TECHNIQUE: Single frontal view of the neck and upper chest
COMPARISON: ___
IMPRESSION:
Left IJ catheter has two kinks. The tip projects in the junction of the left
IJ and left subclavian veins. The upper lungs are clear.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: GI bleed
Diagnosed with GASTROINTEST HEMORR NOS, LONG TERM USE ANTIGOAGULANT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: 64.0
dbp: 44.0
level of pain: nan
level of acuity: 1.0 | ___ with complicated history of maximally-medically managed
systolic heart failure, severe peripheral vascular disease and
poorly-controlled diabetes who presented from rehabilitation
with BRBPR while on lovenox and coumadin for anticoagulation.
# GI BLEED: Thought to be lower in etiology given history but
could not rule out upper GI bleed on admission. He was
hemodynamically unstable in ED and massive transfusion protocol
was activated. Patient continued to have bleeding in the ICU
requiring additional 3u pRBCs and fluid. He underwent NGT
placement for gastric lavage which was negative. Given his
ongoing bleeding and hemodynamic instability he underwent CTA in
attempt to localize the bleed. This was unfortunately
unrevealing as to source but did show evidence of diverticulitis
in the hepatic flexure. There was also concern for CBD
dilation. Patient underwent EGD per GI which showed evidence of
gastritis but no obvious source of bleeding. A biopsy was not
taken at the time. Had continued slow downtrend in Hct. Became
hypotensive requiring low dose norepinephrine, with marked
improvment by the end of ___ s/p 3U pRBCs and 2L NS. His H/H
then normalized with no further melena or hematechezia. A repeat
EGD and colonoscopy was performed on ___ which showed
intestinal metaplasia in the esopagus and diffuse diverticular
and adenomatous disease in the colon. However, no source of
bleed was clearly located. It was thought that this event likely
represented a brisk diverticular bleed, which spontaneously
resolved. He will need to follow up with gastroenterology as an
outpatient in order to discuss management of adenomatous disease
of colon. GI differed excision during this admission because of
need to anticoaulate given other comorbidities (see below). The
risks and benefits should be discussed with PCP and GI.
# H/O DVT/PE and LV THROMBUS: Anticoagulated with coumadin and
being bridged with lovenox since late ___. INR noted to be
highly variable, from 1.04 to >10 on ___. Was on 7mg warfarin,
last dose ___. In the setting of bleed his anticoagulation was
held. Becuase of his LGIB and ___ it was thought that restarting
lovenox would carry too much risk for further adverse events. He
was therefore started on a heparin drip as a bridge to coumadin.
On day of discharge he is taking 7.5 mg PO daily of coumadin and
his INR is at goal at 2.0 (___). He will need close follow up as
he recently discontinued antibiotics, which could cause
fluctuations in INR.
# ACUTE KIDNEY INJURY: On admission creatinine elevated to 2.5,
baseline appears to be 1.5-2.0, although the patient has
suffered fluctuations over his multiple hospitalizations.
Etiology is likely pre-renal given history of blood loss, and
likely concurrent diuretic use. No evidence of heart failure
exacerbation to suggest cardiorenal etiology. With volume
resuscitation, renal function improved to baseline Cr of
1.2-1.5. Of note, his lisinopril was held for hypotension and
was not restarted in the setting of ___. His BPs have been at
goal but should consider restarting it for renal/cardiac
protective effects.
#Bradyarrhythmia/Hyperkalemia: Patient with single episode of
unclear bradyarrhythmia to ___ caught on monitor late on ___.
Likely wenckebach AV block with intermittent ventricular escape
beats. K that morning had been 5.7. Pt refused lab draws. Pt
treated empirically with 2g IV calcium gluconate. 12 lead EKG
did not capture rhythm or show evidence of acute ischemia. No
further episodes were appreciated during the course, and his
potassium normalized.
#Diverticulitis: CTA on ___ with incidental finding of
uncomplicated diverticulitis. He was treated with intial bowel
rest and a 10 day course of ciprofloxacin and flagyl.
# PERIPHERAL VASCULAR DISEASE: s/p right toe amputation c/b
poor healing and polymicrobial wound infection with recent
bypass surgery from femoral to dorsalis pedis. Vascular surgery
was notified of admission given blood filled bullae at incision
site. His anticoagulation was initially held on admission given
bleed as above (see above). He had a vascular surgery
appointment scheduled during this admission and will therefore
have to reschedule. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
peanut / plum / peach
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
___ MRI brain
IMPRESSION:
1. Study is degraded by motion.
2. No acute intracranial abnormality, with no definite evidence
of acute
infarct.
3. Within limits of study, no definite evidence of lesion or
enhancing
intracranial mass. Please note that this examination is not a
dedicated
seizure protocol, and if continued concern for seizure foci,
consider seizure
MRI for further evaluation.
4. Paranasal sinus disease , as described.
5. Nonspecific prominent nasopharyngeal/adenoid tissues, which
may be
reactive.
Abdominal ultrasound ___
IMPRESSION:
Normal abdominal ultrasound.
LENIs ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___
IMPRESSION:
Study is moderately limited in the setting of motion artifact
and extensive
streak artifact emanating from spinal fixation hardware. Within
these
limitations, no evidence of pulmonary embolism or acute aortic
abnormality
identified.
___ 02:21PM BLOOD WBC-9.2 RBC-4.89 Hgb-11.8 Hct-37.3
MCV-76* MCH-24.1* MCHC-31.6* RDW-14.1 RDWSD-38.6 Plt ___
___ 10:11AM BLOOD WBC-5.8 RBC-4.88 Hgb-11.9 Hct-37.1
MCV-76* MCH-24.4* MCHC-32.1 RDW-13.5 RDWSD-36.9 Plt ___
___ 02:21PM BLOOD ___ PTT-24.7* ___
___ 10:11AM BLOOD Plt ___
___ 02:21PM BLOOD Glucose-159* UreaN-11 Creat-0.8 Na-138
K-4.6 Cl-104 HCO3-19* AnGap-15
___ 10:11AM BLOOD Glucose-140* UreaN-7 Creat-0.8 Na-135
K-4.1 Cl-101 HCO3-21* AnGap-13
___ 02:21PM BLOOD ALT-13 AST-26 AlkPhos-65 TotBili-1.2
___ 11:35PM BLOOD ALT-66* AST-179* LD(LDH)-589*
___ AlkPhos-59 TotBili-1.4
___ 10:11AM BLOOD ALT-50* AST-54* LD(LDH)-275*
CK(CPK)-2597* AlkPhos-57 TotBili-0.6
___ 07:36AM BLOOD T4-12.0
___ 03:30AM BLOOD T4-12.5*
___ 07:36AM BLOOD TSH-1.4
___ 03:30AM BLOOD TSH-2.3
___ 01:30PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 08:57AM BLOOD CRP-2.7
___ 02:21PM BLOOD Lithium-<0.1*
___ 02:21PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:30PM BLOOD HCV Ab-NEG
___ 03:31AM BLOOD ___ pO2-51* pCO2-53* pH-7.30*
calTCO2-27 Base XS-0 Comment-GREEN TOP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 2 mg PO DAILY
2. Sprintec (28) (norgestimate-ethinyl estradiol) 0.25-35 mg-mcg
oral DAILY
Discharge Medications:
1. Sprintec (28) (norgestimate-ethinyl estradiol) 0.25-35
mg-mcg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Bipolar disorder with psychotic features
Volume depletion
Tachycardia
Drug induced liver injury
Rhabdomyolysis
Mild anticholinergic toxicity
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with persistent tachycardia // Rule out pneumonia
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear without consolidation, effusion, or edema.
Cardiomediastinal silhouette is within normal limits. Posterior fixation
thoracolumbar hardware is noted. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with tachycardia, previous anticholinergic
toxicity, and history of bipolar disorder // Syncope and reported seizure
with possible new right sided dysmetria on exam.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.7 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of fracture, infarction,hemorrhage,edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is partial opacification of the left maxillary and right frontal
sinuses. 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. Nonspecific fullness of the nasopharyngeal soft tissues,
predominantly in the adenoids, which could be reactive.
IMPRESSION:
1. No acute intracranial abnormality.
2. Mild sinus disease.
3. Nonspecific fullness of the adenoids may be reactive in the context of
sinus disease. Please correlate for recent upper respiratory infection.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with unexplained tachycardia. Evaluation 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 0.5 s, 1.0 cm; CTDIvol = 1.4 mGy (Body) DLP = 1.4
mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.4 mGy (Body) DLP = 1.4
mGy-cm.
3) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.4 mGy (Body) DLP = 1.4
mGy-cm.
4) Stationary Acquisition 2.0 s, 1.0 cm; CTDIvol = 5.5 mGy (Body) DLP = 5.5
mGy-cm.
5) Spiral Acquisition 8.6 s, 33.1 cm; CTDIvol = 12.0 mGy (Body) DLP = 378.1
mGy-cm.
Total DLP (Body) = 400 mGy-cm.
COMPARISON: No relevant prior imaging for comparison.
FINDINGS:
HEART AND VASCULATURE: Study is moderately limited in the setting of motion
artifact and streak artifact emanating from spinal fixation hardware. Within
these limitations, 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: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. No large pulmonary nodules or interstitial abnormality
identified, within the limitations of a study moderately limited by motion
artifact. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Extensive posterior fixation hardware is seen extending from T5 to the lumbar
spine, beyond the field of view.
IMPRESSION:
Study is moderately limited in the setting of motion artifact and extensive
streak artifact emanating from spinal fixation hardware. Within these
limitations, no evidence of pulmonary embolism or acute aortic abnormality
identified.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with history of bipolar with psychotic
features. Has new transaminitis and has intermittently reported abdominal
pain. Currently unreliable historian due to acute psychosis. Would like to
exclude gallstone pathology and other liver pathologies in order for patient's
psychiatric facility to accept patient. // ? cholelithiasisAnything to
explain newly elevated transaminase
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 2 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.
Spleen length: 7.2 cm
KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in
the kidneys.
Right kidney: 9.4 cm
Left kidney: 11.1 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Normal abdominal ultrasound.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with significantly elevated d-dimer // ? DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with history of BPD with psychotic features and
scoliosis s/p fixation. Now has ne dysmetria of right hand Hardware discussed
and cleared for MRI by MRI tech. // ? cerebellar pathology? seizure foci
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: Head CT dated ___.
FINDINGS:
Study is degraded by motion. Within these confines:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There is no abnormal enhancement after contrast
administration.
There is redemonstration of nonspecific fullness of the nasopharyngeal soft
tissue, predominantly in the adenoids, not substantially changed from prior
study and likely reactive.
Bilateral maxillary sinus and ethmoid air cell mucosal thickening is present.
Limited imaging of the parotid glands demonstrate bilateral subcentimeter
nonspecific probable lymph nodes. Approximately 3 mm pineal cyst is noted.
IMPRESSION:
1. Study is degraded by motion.
2. No acute intracranial abnormality, with no definite evidence of acute
infarct.
3. Within limits of study, no definite evidence of lesion or enhancing
intracranial mass. Please note that this examination is not a dedicated
seizure protocol, and if continued concern for seizure foci, consider seizure
MRI for further evaluation.
4. Paranasal sinus disease , as described.
5. Nonspecific prominent nasopharyngeal/adenoid tissues, which may be
reactive.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hypotension, Lethargy
Diagnosed with Tachycardia, unspecified
temperature: 99.1
heartrate: 115.0
resprate: 12.0
o2sat: 100.0
sbp: 120.0
dbp: 94.0
level of pain: ua
level of acuity: 2.0 | Patient Summary:
===================
___ female with a history of bipolar disorder with
psychotic features. Prior to admission she was admitted to
___. At the facility she was not
reliably taking her prescribed aripiprazole 2 mg/day. She been
complaining of auditory and visual hallucinations and became
increasingly paranoid/agitated. She ended up requiring chemical
sedation at ___ consisting of 200 mg of Thorazine, 100 mg
of Benadryl, and 2 mg of Ativan. She subsequently became
lethargic, hypotensive, and tachycardic so EMS was called. She
was transferred to our emergency department. She was evaluated
by our toxicology department and was found to have minor
anticholinergic toxicity which did not require physostigmine. We
held anticholinergic meds briefly with improvement in her
symptoms. However, she remained significantly tachycardic with
heart rates in the 120s to 140s with activity. We conducted
further work-up to exclude underlying medical disorders which
could be causing tachycardia. Lower extremity Dopplers, and a
CTA chest were negative for DVT/PE. Basic infectious work-up was
negative. While inpatient, the patient continued to struggle
with psychosis. She required as needed Haldol in order to
control her agitation, after receiving Haldol her LFTs were
mildly elevated. She did not complain of any abdominal pain. We
have performed a right upper quadrant ultrasound which was
unrevealing. We performed a hepatitis panel which was
unrevealing. We attributed the patient's transaminitis to
drug-induced liver injury from Haldol. During this time the
patient's CK was also significantly elevated. We reconsulted
toxicology to rule out NMS, and the toxicology department agreed
that she did not have any concerning signs for NMS. We
attributed the CK elevation to rhabdomyolysis from restraints.
She was seen by our neurology department who will work-up
outpatient for possible myositis as well to exclude this as a
cause of her CK elevation.
The patient was sent here on a ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Bactrim / Captopril / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dizziness/ vertigo
Major Surgical or Invasive Procedure:
na
History of Present Illness:
Ms. ___ is a ___ year old lady with history of prior left
frontal stroke, as well as HTN, CHF, CAD who presents with a
sensation of spinning that started yesterday and is persistent
today.
As per the patient, she woke up yesterday and as she turned to
the alarm clock to her right, she developed a feeling of the
room
spinning around her. This lasted 30 minutes and then resolved
spontaneosuly. She then had diarrhea. Over the course of the day
she also experienced bilateral eye floaters.
She had dinner as usual and went to bed around 9pm. At around
0230 today she woke up to use the bathroom and did not
experience
any dizziness as she went to the bathroom. However, at 0530 this
morning she woke up and again turned right to turn off her alarm
clock and experienced the same symptoms. This time the symptoms
were so intense that she was thrown backwards in her bed. She
called her daughter who came over to her apartment. Ms. ___
then had great difficulty getting downstairs and her symptoms
got
so exacerbated by looking downwards that she had to scoot down
each stair on her behind.
She reports that her dizziness feels like the room is spinning
around her and not like she is lightheaded. She reports that it
is worse while coming down the stairs, looking downwards,
movement of her head or with sitting up. It is least bothersome
while lying down. She denies any visual changes, diplopia,
tinnitus, ear pain or difficulty with speech or swallowing. She
does endorse difficulty with gait as a result of her dizziness.
She also endorses nausea but no vomiting.
Ms. ___ received meclizine in ER with significant
improvement in symptoms. However, the minute I attempted to sit
her up or stand her to observe her gait, her symptoms recurred
and she needed to fall back in bed immediately. She expresses a
strong desire to go home and not be admitted inpatient.
Of note, Ms. ___ had a previous frontal infarct in ___ and
was admitted to Neurology at ___. Despite that, she has
minimal
residual deficits, lives alone and leads an independent life.
She
is fiercely protective of her independence.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus. She endorses hearing difficulty for the last
___
year and has a left hearing aid. Denies difficulties producing
or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Endorses 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.
Past Medical History:
History of left frontal infarct in the distribution of the
anterior cerebral artery ___.
Coronary artery disease
Congestive heart failure, systolic
Anemia
Diabetes mellitus, type 2
Hypertension
Hypothyroidism
R blepharism
Social History:
___
Family History:
Sister with BPPV. Brother had h/o TIAs. No other
family members with stroke/seizure
Physical Exam:
Physical Exam:
Vitals: T 98.1 HR 62 BP 190/71 RR 18 SO2 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, R sclear icterus
Neck: Supple. No nuchal rigidity
Abdomen: soft.
Extremities: 1+ bilateral pedal edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. Calculation is intact. 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 confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Slight L facial noted at the L NLF.
VIII: Hearing impaired bilaterally
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri IP Quad Ham TA ___
L 5 ___ 5 5 5 5 5
R 4+ 4+ 4+ ___ 5 5 5
-Sensory: No deficits to light touch or cold sensation. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 2 unable to elicit
R 1 1 2 unable to elicit
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, No dysmetria on FNF
bilaterally. Head tilt test elicits nystagmus but does not
worsen
symptoms.
-Gait:Patient ___ dizzy when she attempts to get up. Unable to
test gait
On discharge patient's exam is overall improved with normal head
impulse test and improved gait - pt is able to climb stairs and
has stable gait with her 4 point walker. otherwise exam remains
unchanged.
Pertinent Results:
___ 11:50AM BLOOD WBC-6.3 RBC-4.15* Hgb-11.7* Hct-34.5*
MCV-83 MCH-28.3 MCHC-34.0 RDW-14.8 Plt ___
___ 11:50AM BLOOD Neuts-72.0* ___ Monos-5.0 Eos-1.9
Baso-0.3
___ 11:50AM BLOOD ___ PTT-27.2 ___
___ 11:50AM BLOOD Glucose-184* UreaN-34* Creat-1.5* Na-144
K-4.0 Cl-110* HCO3-23 AnGap-15
___ 06:55AM BLOOD ALT-14 AST-21 AlkPhos-66 TotBili-0.4
___ 11:50AM BLOOD cTropnT-<0.01
___ 08:00PM BLOOD cTropnT-<0.01
___ 11:50AM BLOOD Calcium-9.5 Phos-3.0 Mg-2.3
___ 06:55AM BLOOD %HbA1c-6.5* eAG-140*
___ 06:55AM BLOOD Triglyc-111 HDL-49 CHOL/HD-3.3 LDLcalc-92
LDLmeas-93
___ 06:55AM BLOOD TSH-1.2
NCHCT ___
No acute intracranial process, or significant change since the
prior head CT dated ___.
MRI/MRA ___. No acute intracranial process. No infarct or mass effect.
2. White matter changes described above compatible small-vessel
ischemic
disease.
3. Allowing for common anatomic variations, essentially
unremarkable MRA of the head.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
5. Simvastatin 40 mg PO QPM
6. Valsartan 160 mg PO DAILY
7. Aspirin EC 81 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. Valsartan 160 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
9. Rolling walker
Prognosis: Good
length of need: 13 Months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Benign paroxysmal positional vertigo
HTN
CHF
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old female with dizziness.
TECHNIQUE: Single AP and lateral view.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
AP upright and lateral chest radiograph demonstrates low lung volumes. Heart
is moderately enlarged. Mediastinal contour is stable when compared to prior
study dated ___. Low lung volumes results in bronchovascular
crowding centrally and atelectasis. There is no pleural effusion. No
pneumothorax or acute osseous abnormality is identified.
IMPRESSION:
Low lung volumes with atelectasis. Cardiomegaly, no pulmonary edema.
Radiology Report
INDICATION: ___ year old female with dizziness.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm-reconstructed images were acquired.
DOSE: DLP: 892 mGy-cm.
CTDIvol: ___ MGy.
COMPARISON: CT from ___ and MR from ___.
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass effect, or vascular
territorial infarction. Prominent ventricles and sulci are likely secondary to
age-related involutional changes. Small hypodensity along the midline left
frontal lobe reflects prior infarct better seen on the MR from ___
(2:22). The basal cisterns appear patent, and there is preservation of normal
gray-white matter differentiation. No fracture is identified, and a calcific
density in the left frontal sinus is again noted. The globes are intact.
IMPRESSION:
No acute intracranial process, or significant change since the prior head CT
dated ___.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN
INDICATION: ___ year old female presenting with dizziness. Please evaluate
for infarct or other process.
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal T1, axial T1, gradient echo, FLAIR, diffusion-weighted and T2 also
performed. Three dimensional maximum intensity projection and segmented images
were generated. This report is based on interpretation of all of these images.
COMPARISON: Head CT dated ___. MRI of the brain dated ___.
FINDINGS:
MRI brain: There is no intra or extra-axial mass effect, acute hemorrhage or
infarct. Sulci, ventricles and cisterns are within expected limits given the
degree of age-appropriate global cerebral volume loss. Periventricular
nonspecific FLAIR white matter hyperintensities are noted, likely representing
small-vessel ischemic disease. The major intracranial flow voids are
preserved. Mild mucosal thickening of the paranasal sinuses is noted. The
orbits are unremarkable. The mastoid air cells are clear.
MRA: There is fetal origin of the right posterior cerebral artery. The right
A1 segment is not visualized, which may be secondary to congenital hypoplasia
or absence. Otherwise, the intracranial ICA, remainder of the ACAS, MCAs and
their major distributions are unremarkable. The vertebral arteries are
codominant and the remainder of the posterior circulation is also
unremarkable. There is no aneurysm larger than 3 mm.
IMPRESSION:
1. No acute intracranial process. No infarct or mass effect.
2. White matter changes described above compatible small-vessel ischemic
disease.
3. Allowing for common anatomic variations, essentially unremarkable MRA of
the head.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with VERTIGO/DIZZINESS
temperature: 97.5
heartrate: 73.0
resprate: 18.0
o2sat: 98.0
sbp: 184.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a delightful and fiercely independent ___ year
old lady with history of prior left frontal stroke, as well as
HTN, CHF, and CAD who presented with vertigo. Her exam was
notable for positive HIT to the left. MRI was negative for acute
infarct. The patient was admitted due to trouble with ambulation
___ her peripheral vertigo. She improved during her stay after
working with ___ she will go home with home ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Lyrica / Flagyl / phentermine
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy
History of Present Illness:
HPI
___ hx CAD s/p PCI, CMP of uncertain etiology (EF 35% on ___ OSH TTE). She developed chest and back pain, was brought to
___ by EMS, and was transferred to ___ ED.
Here, she was found by a circuitous path to have acute
cholecystitis, and is admitted to medicine after a perc biliary
drain.
The patient was in her usual health* (see paragraph about her
CHF symptoms, below) since after her catheterization on
___. In the past week, she suffered a bout of viral
gastroenteritis, first with profuse vomiting and then diarrhea;
states she has lost about 6 lbs (measuring her weight at home
for CHF as instructed. The day prior to admission, she developed
the onset of (1) worsening central chest pressure (similar to
her typical chest pain symptom) without radiation to jaw or
arms; and (2) severe pain across her upper back (not a usual
symptom for her). Both pains were constant, with waxing and
waning quality and not worsened by position or activity.No
diaphoresis, palpitations. She has 100% DAPT adherence. She
called her outpatient cardiologist's office, who directed her to
the ED based on new symptoms and recent stents.
EMS initially brought the pt to ___, where she
received full dose ASA, nitroglycerin (unclear if SLN or IV).
She had no pain relief with these measures, but did develop
nausea with the nitro. She was then transported to ___ ED.
In the ___ ED
- initial VS: 98.9 74 107/69 16 98% RA
- labs: cbc with wbc 11.5, otherwise unremarkable. chemistry
with HCO3 17, BUN/Cr ___, Ca 7.5 Mg 1.5 Phos 2.0. LFTs with
ALT AST 45/49, AP and Tbili normal. Lipase 25. UA without
evidence of UTI.
- CXR initially concerning for pneumomediastinum but CT chest
without any pneumomediastinum. CT did show findings concerning
for acute cholecystitis.
- Cardiology was consulted; recommendations below.
- Thoracic surgery consulted for ? pneumomediastinum; reviewed
films and agrees no evidence of pneumomediastinum.
- ACS was consulted for acute cholecystectomy; they felt CCY
would be higher risk in this patient and recommended PTBD by ___.
- ___ was consulted; the patient was taken for US guided ___ perc
chole. This procedure was notable for a larger quantity of
bloody output than was expected during typical PTBD, so
additional US was performed (see below).
- Other interventions: Plavix, PPI, acetaminophen, GI cocktail,
dilaudid IV, MVI
Admitted to Medicine for further evaluation.
VS were stable on transfer: 98.1 103 ___ 99% RA.
Regarding her PTBD placement:
I spoke to one of the ___ providers (Dr. ___ who
performed her procedure. They performed US-guided perc chole
placement. Initially bile drained. There was some initial blood
in the perc chole tube (which is expected); however, it
continued for a longer time than expected. This could be due to
the pt being on DAPT. However, initial US prior to perc chole
placement showed anechoic GB contents; post-procedure US showed
a decompressed gallbladder with contents having an echotexture
most consistent with blood products. Clinically, there was no
frank hemorrhage from the PTBD. The ___ team performed RUQUS
immediately after tube placement, which did not show any free
fluid or evidence of perihepatic hemorrhage. They waited an
additional ___ minutes and repeated the RUQUS without any
evidence of abdominal free fluid or perihepatic hemorrhage. They
expect that, due to DAPT, it may take several days for the PTBD
drainage to stop being bloody. They would like to get H/H in
next ___.
Regarding her present chest pain, Cardiology consult noted:
"Patient seen and examined. Having central chest/epigastric
pain constant since ___ today. Feels different than prior
angina pain. Patient had 2.5x16 mm Promus Premier DES to mLAD by
Dr. ___ ___. ECG with V5-6 TW flattening/sub-mm
STD. Biomarkers negative.
"CXR initially concerning for pneumomediastinum but CT chest
without any pneumomediastinum. CT did show findings concerning
for acute cholecystitis.
"If cholecystectomy is felt to be indicated, she may proceed to
surgery provided she can continue on aspirin & clopidogrel and
does not miss any doses given she is at high risk for stent
thrombosis without dual antiplatelet therapy. If she is unable
to tolerate PO, would give rectal aspirin and consult cardiology
for likely need for IV Gp IIb/IIIa inhibitor (tirofiban) or
___ inhibitor (cangrelor) gtt.
"Discussed with consult attending Dr. ___
On arrival, patient reports feeling much improved. She continues
to have pain under the R rib margin. She does not have any
nausea or vomiting. She feels thirst. She continues to have a
mild sensation of central chest pressure, but this has been
constant for several weeks-months and was one of the symptoms
that prompted her catheterization by Dr. ___ in ___.
Regarding her cardiac symptoms, she tells me her cath was
prompted by several months of worsening central chest pressure
and dyspnea. She has been told she has a "cardiomyopathy,"
though unclear from what etiology; Dr. ___ has referred
her to ___ for further evaluation, none of which has
occurred as yet. She states she becomes dyspneic with walking
down the hallway at work, and even sometimes with bending over
to put on socks and shoes to get dressed. She has waxing and
waning central chest pressure most of the time (with the
features described above). Denies orthopnea, PND. Denies
palpitations.
Regarding potential risk factors for cardiomyopathy: She drinks
alcohol socially; in particular, states that she goes out
perhaps once a week with friends, and has 3 mixed drinks at the
bar. Does not typically drink at home. Has not used cocaine or
methamphetamines. Previously smoked 1ppd x ___ but now quit.
Does not carry dx of OSA; has poor quality sleep for many years,
but cannot comment on snoring (has no present bed partner). She
does not have personal or family history of autoimmune disease,
and states she's had extensive workup for autoimmune disease at
___ requested by Dr. ___ her CMP. She has no
history of thyroid disease.
Past Medical History:
PMH
-Cardiomyopathy - EF 35% by echo ___ however EF 55% ___
-CAD s/p ___ ___
-Ovarian cysts
-DLD
-Gestational DM
-Depression
-Diverticulitis s/p Sigmoid resection
-Bladder sling
-s/p appendectomy
-Acute Cholecystitis
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS 97.7 PO 109 / 69 86 18 100 ra
Genl: relatively well appearing, NAD
HEENT: PERRLA, no icterus, MMM
Neck: JVP could not be appreciated
Cor: RRR, soft ___ SEM audible throughout precordium but loudest
over the tricuspid and mitral areas
Pulm: breathing comfortably on RA. CTAB.
Abd: soft. perc biliary drain in RUQ with blood-tinged fluid
(not frank blood). ttp around the drain site and in the RUQ. the
remainder of abdomen is soft, ntnd, and without rebound or
guarding.
Neuro: AOX3 without gross focal deficit
MSK: ___ with trc symmetric edema
Skin: warm and dry; no obvious lesions or rashes
Access: PIV
DISCHARGE PHYSICAL EXAM
Vitals- 97.9 | 100/62 | 73 | 18 | 98 RA
___- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, ___ holosytolic
murmur, no rubs
Abdomen- cholecystomoy tube draining mild serosang bilious
output soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly,
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission Labs
=======================
___ 07:44AM BLOOD WBC-11.5* RBC-3.87* Hgb-11.9 Hct-35.6
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.0 RDWSD-39.7 Plt ___
___ 07:44AM BLOOD Neuts-81.9* Lymphs-13.0* Monos-4.4*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-9.41* AbsLymp-1.49
AbsMono-0.51 AbsEos-0.01* AbsBaso-0.03
___ 08:54AM BLOOD ___ PTT-23.8* ___
___ 07:44AM BLOOD Glucose-114* UreaN-13 Creat-0.5 Na-140
K-3.3 Cl-109* HCO3-17* AnGap-17
___ 02:00PM BLOOD ALT-45* AST-49* CK(CPK)-122 AlkPhos-92
TotBili-0.6
___ 07:44AM BLOOD CK(CPK)-121
___ 07:44AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-57
___ 10:46AM BLOOD cTropnT-<0.01
___ 07:44AM BLOOD Calcium-7.5* Phos-2.0* Mg-1.5*
___ 02:00PM BLOOD Albumin-3.8 Iron-68
___ 02:00PM BLOOD calTIBC-308 Ferritn-143 TRF-237
___ 02:00PM BLOOD HBsAg-Negative HBcAb-Negative
___ 02:00PM BLOOD TSH-1.4
___ 06:30AM BLOOD HIV Ab-Negative
___ 09:35PM BLOOD Lactate-0.8
___ 08:41AM URINE Color-Straw Appear-Clear Sp ___
___ 08:41AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 08:41AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 08:41AM URINE UCG-NEGATIVE
___ 08:41AM URINE Mucous-FEW
Pertinent Labs
=======================
___ 07:44AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-57
___ 10:46AM BLOOD cTropnT-<0.01
___ 02:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:15AM BLOOD CK-MB-2 cTropnT-<0.01
Discharge Labs
======================
___ 07:10AM BLOOD WBC-7.6 RBC-3.75* Hgb-11.3 Hct-35.3
MCV-94 MCH-30.1 MCHC-32.0 RDW-12.2 RDWSD-42.2 Plt ___
___ 07:10AM BLOOD ___ PTT-30.3 ___
___ 07:10AM BLOOD Glucose-133* UreaN-9 Creat-0.7 Na-141
K-3.8 Cl-104 HCO3-21* AnGap-20
___ 07:10AM BLOOD ALT-32 AST-26 AlkPhos-80 TotBili-0.5
___ 07:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.1
Imaging
======================
CXR ___
IMPRESSION:
-Heart size at the upper limits of normal or minimally enlarged.
No
significant change in the cardiac silhouette is appreciated
compared with the outside scanned-in chest x-ray from ___ dated
___ at 04:40.
-Stent noted, best correlated with the specifics of the
procedure.
-No acute pulmonary process identified. No CHF or focal
infiltrate. Possible minimal bibasilar atelectasis.
___ CTA Chest
IMPRESSION:
1. No acute abnormality within the chest. No evidence of
pneumomediastinum.
2. Multiple gallstones within a fluid-filled and distended
gallbladder. Rim of enhancement within the surrounding liver
parenchyma (rim sign), which may be perfusional, but raises
suspicion for acute cholecystitis. Right upper quadrant
ultrasound is recommended.
___ RUQ Ultrasound
IMPRESSION:
Gallstones within a distended gallbladder and mild gallbladder
wall edema, likely reflecting early or mild acute cholecystitis.
No intra or extrahepatic biliary dilatation.
___ Ultrasound-guided percutaneous cholecystostomy tube
placement
IMPRESSION:
Successful ultrasound-guided placement of ___ pigtail
catheter into the gallbladder. Samples was sent for microbiology
evaluation.
RECOMMENDATION(S): Q6 hr H&H overnight to evaluate for any
signs of
hemorrhage.
Micro
======================
___ Urine cultre - no growth
___ Bile culture - no growth
___ Blood culture x2 - no growth
___ Blood culture x2 - no growth
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Nexplanon (etonogestrel) 68 mg Other subdermal implant
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
3. Sterile Water for Injection (water for injection, sterile)
10 ml tube flush DAILY
RX *water for injection, sterile [Sterile Water for Injection]
10 ml tube flush Daily Disp #*30 Ampule Refills:*0
4. Syringe without Needle (syringe (disposable)) 1 10cc syringe
miscellaneous DAILY
Please provide patient with 30 10CC syringes
RX *syringe (disposable) [BD Bulk ___ Non-Sterile] 10 mL
Instill 10ml sterile water into tube Daily Disp #*30 Syringe
Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Clopidogrel 75 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Nexplanon (etonogestrel) 68 mg Other subdermal implant
12. Pantoprazole 40 mg PO Q24H
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Acute Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with recent LAD stent 2 wks prior with angina,
dyspnea // eval ? effusion, cardiomegaly
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph with the same date from outside hospital.
FINDINGS:
Heart size is at the upper limits of normal or minimally enlarged.
Cardiomediastinal silhouette otherwise within normal limits. An upside-down
V-shaped density overlying the left heart is thought to represent the stent.
No CHF, focal infiltrate, pleural effusion, or pneumothorax detected.
Possible minimal atelectasis at the left-greater-than-right lung bases.
IMPRESSION:
Heart size at the upper limits of normal or minimally enlarged. No
significant change in the cardiac silhouette is appreciated compared with the
outside scanned-in chest x-ray from ___ dated ___ at 04:40.
Stent noted, best correlated with the specifics of the procedure.
No acute pulmonary process identified. No CHF or focal infiltrate. Possible
minimal bibasilar atelectasis.
Radiology Report
EXAMINATION: CT CHEST WITH CONTRAST
INDICATION: ___ year old woman with cath and stent placement 1.5 weeks ago,
now with chest pain x 8 hours.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 555 mGy-cm.
COMPARISON: Chest radiograph with the same date.
FINDINGS:
HEART AND VASCULATURE: No large central filling defects to suggest pulmonary
embolism. The thoracic aorta is normal in caliber without evidence of
dissection or intramural hematoma. An LAD stent is visualized. Otherwise,
the heart, pericardium, and great vessels are within normal limits. No
pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Minimal paraseptal emphysematous changes within the right
upper lobe. Dependent atelectasis bilaterally. No focal consolidations. No
suspicious lung nodules. The airways are patent to the level of the segmental
bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Multiple gallstones are seen within a fluid-filled and distended
gallbladder. There is a rim of enhancement within the liver parenchyma
surrounding the gallbladder, which may be perfusional, but raises suspicion
for acute cholecystitis (series 2, image 57). Multiple colonic diverticula
are visualized.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No acute abnormality within the chest. No evidence of pneumomediastinum.
2. Multiple gallstones within a fluid-filled and distended gallbladder. Rim
of enhancement within the surrounding liver parenchyma (rim sign), which may
be perfusional, but raises suspicion for acute cholecystitis. Right upper
quadrant ultrasound is recommended.
RECOMMENDATION(S): Right upper quadrant ultrasound is recommended.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___, Patient with RUQ pain, +___ sign, gallstones and
distended gallbladder on CT, suspicion for cholecystitis // Patient with RUQ
pain, +___ sign, gallstones and distended gallbladder on CT, suspicion for
cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT chest with the same date.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There are stones in the distended gallbladder with mild wall
edema.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 9.0 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Gallstones within a distended gallbladder and mild gallbladder wall edema,
likely reflecting early or mild acute cholecystitis. No intra or extrahepatic
biliary dilatation.
Radiology Report
EXAMINATION: Ultrasound-guided percutaneous cholecystostomy tube placement
INDICATION: ___ year old woman with acute cholecystitis and poor surgical
candidate due to anti coagulation. Decision was made to proceed to
intervention despite ASA and Plavix on board given the high risk of septic
decompensation from the cholecystitis.
COMPARISON: Same day right upper quadrant ultrasound
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
OPERATORS: Dr. ___ trainee and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the ultrasound table. Limited
preprocedure imaging was performed to localize the gallbladder. An appropriate
skin entry site was chosen and the site marked. Local anesthesia was
administered with 1% Lidocaine solution.
Using continuous sonographic guidance, an ___ cholecystostomy tube was
advanced via trocar technique into the gallbladder. A sample of fluid was
aspirated, confirming catheter position within the collection. The metal
stiffener was removed. The pigtail was deployed. The position of the pigtail
was confirmed within the collection via ultrasound. Ultrasound images were
stored on PACS.
Approximately 10 cc of bilious fluid was drained with a sample sent for
microbiology evaluation. As aspiration was continued, it was noted that the
fluid was becoming increasing bloody. Therefore, while monitoring the
patient's hemodynamics, we performed sequential ultrasounds immediatley after
placement of the tube, 10 minutes after and 30 minutes after. During this
time, no intraabdominal fluid or hemorrhage was seen. The gallbladder was
noted to be filled with debris, presumed to be some clot. The patient's
hemodynamics remained stable. The catheter was secured by a StatLock. The
catheter was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of
200 mg Versed and 4 mcg fentanyl throughout the total intra-service time of 44
min minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
- Distended gallbladder with gallbladder calculi. Mild gallbladder wall
edema.
- Sequential post procedure ultrasounds immediately following tube placement,
10 minutes and 30 minutes after procedure demonstrated no evidence of
intraabdominal free fluid or hemorrhage. The gallbladder was noted to contain
debris by the end of the procedure. Given the heme aspirated from the
gallbladder, decision was made to monitor the patient closely with serial CBCs
to evaluate for any signs of intraabdominal hemorrhage.
IMPRESSION:
Successful ultrasound-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
RECOMMENDATION(S): Q6 hr H&H overnight to evaluate for any signs of
hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.9
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 107.0
dbp: 69.0
level of pain: 4
level of acuity: 2.0 | ___ year old woman with recent mLAD stent (___) on DAPT and
new diagnosis of cardiomyopathy who presented with chest pain
and was found to have acute cholecystitis, had a percutaneous
c-tube placed, and improved.
# Acute cholecystitis: Initially concerned for ACS or other
cardiac cause given recent diagnosis of cardiomypathy and LAD
stent, however workup was negative. Ultimately found to have
acute cholecystitis on ultrasound with white count of 20K. Not
deemed to be a good surgical candidate because of recent cardiac
issues and current anticoagulation. Percutaneous cholecystostomy
successfully performed though did drain some blood which
continued until discharge in small quanities likely due to dual
anti platelet therapy and HGB dropped from 11.9 on admission and
was 11. 3 on discharge. Started on ceftriaxone. Patient's pain
was much improved, and antibiotics switched to oral amox/clav
for a total of a 5 day course. Will follow up with surgery for
definitive surgical management.
# Cardiomyopathy and heart failure: Patient with new
cardiomyopathy and reported outside EF of ~35% per primary
cardiologist. All troponins negative and no other concerning
findings in cardiac workup. Echo performed and current EF at
55%. Following percutaneous cholecystotmy, chest pain improved.
Patient discussed with outpatient cardiologist and recommended
no additional workup in hospital.
#Pain control - Tylenol and oxycodone 5mg
#GERD- Pantoprazole 40mg daily continued from home medications
Transitional Issues
====================
- Patient is on dual antiplatelet therapy and should remain
until approved by cardiologist to stop treatment.
- Amox/Clav started for 5 day total course of antibiotics to be
completed ___
-Follow up with ___ surgery in 6 weeks for planning ongoing
surgery.
- Follow up with interventional radiology in 6 weeks for
evaluation of cholecysostomy tube.
- Patient's EF on echo in hosptital is >55% which is improved
from prior. Recommend continued workup for cause of heart
failure symptoms and dose adjustment/need for beta-blocker and
ace inhibitor |
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 lower extremity pain
Major Surgical or Invasive Procedure:
1. Left hip joint aspiration ___. Irrigation and debridement with arthrotomy of the left hip
on ___. Girdlestone procedure for femoral head avascular necrosis
and osteomyelitis on ___
History of Present Illness:
___ with hx of uterine cancer s/p radiation presenting with
F/C, and acute onset LLE pain x3 days.
Detailed history is obtained from patient, who is ___ retired ___.
Unfortunately patient's ___ records are not accessible via
Physician ___ portal at this time.
For context, pt was diagnosed with uterine cancer in her ___,
after TAH/BSO for fibroids, with pathology that apparently
revealed endometrial/uterine cancer. She received no further
treatment at that time. Two decades later, in ___ (5
months
after the death of her husband), she developed a L groin mass
that was found to be recurrent endometrial cancer. She underwent
chemotherapy and XRT at ___, and has been in remission since
that time. That process was complicated by iliac vein stricture
(related to compressive effect of mass and XRT), arthritis of L
hip with associated neuropathy, and chronic L foot drop. She has
been maintained on lovenox ___ mg sc for DVT prevention in the
setting of iliac vein stricture, as well as compression
stockings, but denies a history of diagnosed VTE. Her
neuropathic
pain has required management by ___ pain clinic, with
uptitration
of gabapentin, now at 1200 mg q8h. At baseline she ambulates
with
various assistive devices.
With respect to the episode prompting this admission, pt reports
that her first symptom was urinary incontinence, which she
attributes to inability to mobilize to the toilet in time, ___
LLE weakness and pain. Urge incontinence began on ___. She
subsequently discovered LLE pain, which was generalized "muscle
pain," involving L foot. Pain was exacerbated by movement,
although also noted with extended periods at rest. She first
noted fevers and rigors on ___, without associated
headache,
cough, chest pain, SOB, rhinorrhea, sore throat, dysuria,
diarrhea. She denies sick contacts.
Pt was evaluated at ___ for fevers, chills, and LLE pain 3 days
prior to presentation. She reports that workup there was
negative, including influenza, UA, labs, CXR. She returned home,
but LLE pain progressed to the point that she was unable to
mobilize; her PCP advised her to present to ___,
with plan for initial w/u and then consideration of transfer to
___.
Pt presented to ___ as advised, where CT
revealed
"fluid or granulation tissue on the L hip and asymmetric
enlargement fo the L iliacus muscle which is slightly lower in
density diffusely in the right" concerning for infection vs
osteomyelitis. She was also found to have "cellulitis" of
perianal area. She received vancomycin IV. Per ___ notes,
___ was not accepting patients, so patient was redirected to
___.
Past Medical History:
GERD
Hypothyroidism
TIA
Hyperlipidemia
Metastatic uterine cancer
Social History:
___
Family History:
Reviewed and found to be not relevant to this
hospitalization/illness
Physical Exam:
ADMISSION
VS: 99.2 PO 132 / 53 91 18 97 RA
GEN: alert and interactive, comfortable, no acute distress
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes, ears without lesions
or
apparent trauma
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel sounds, no hepatomegaly
EXTREMITIES: edema of L>R, without overlying erythema or TTP.
Active ROM limited by pain. + passive ROM of L hip with
extension>flexion. Passive adduction and abduction not tested
___
pain. R hip flexion, dorsiflexion, and plantarflexion are ___.
Unable to assess L hip flexion ___ pain. L dorsiflexion ___, 2+
plantarflexion.
GU: no foley. No L inguinal or perianal rash
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: Alert and interactive, cranial nerves II-XII intact.
Motor
exam as above
PSYCH: normal mood and affect
Pertinent Results:
ADMISSION
___ 05:23AM BLOOD WBC-9.6 RBC-3.52* Hgb-10.6* Hct-30.6*
MCV-87 MCH-30.1 MCHC-34.6 RDW-13.9 RDWSD-43.7 Plt ___
___ 05:23AM BLOOD Glucose-106* UreaN-10 Creat-0.6 Na-134*
K-4.0 Cl-98 HCO3-20* AnGap-16
___ JOINT FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, BETA
STREPTOCOCCUS GROUP C}
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| BETA STREPTOCOCCUS GROUP
C
| |
CEFTRIAXONE----------- <=0.12 S
CLINDAMYCIN-----------<=0.25 S <=0.25 S
ERYTHROMYCIN---------- =>8 R <=0.12 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
PENICILLIN G---------- <=0.06 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 2 S
IMAGING
MRI Pelvis:
1. Unusual appearances at the left hip with a large joint
effusion with surrounding soft tissue edema but with relative
preservation of the normal bone marrow signal in both the
femoral
head and the acetabulum. There is bony destruction involving the
medial acetabular wall as seen on the prior CT study and
extension of the fluid into the iliacus muscle but with the
peripheral calcified rim. The appearances suggest a chronic
destructive process of the left hip. Potentially a very
indolent
infection could have such an appearance but alternative
etiologies such as inflammatory arthropathy, rheumatoid
arthritis and psoriatic arthritis should also be considered.
2. Multiple insufficiency fractures and apparent bone infarcts
in
the sacral ala.
MRI L spine:
1. Multilevel, multifactorial degenerative changes throughout
the lumbar spine, with irregular contour at the endplates, more
significant at the superior endplate of L2 consistent with
Schmorl's nodes.
2. The signal intensity in the bone marrow is heterogeneous
with
areas of high-signal intensity on the STIR sequence at the
endplates of L1-L2, L2-L3 and L4-5 levels, suggesting bone
edema,
probably degenerative in nature, there is no evidence of
abnormal
enhancement to indicate discitis/osteomyelitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 1200 mg PO TID
2. Levothyroxine Sodium 25 mcg PO 3X/WEEK (___)
3. Simvastatin 20 mg PO QPM
4. Levothyroxine Sodium 50 mcg PO 4X/WEEK (___)
5. Enoxaparin Sodium 100 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
6. Vitamin B Complex 1 CAP PO DAILY
7. Ascorbic Acid ___ mg PO BID
8. Vitamin D 1000 UNIT PO DAILY
9. Vitamin E 400 UNIT PO DAILY
10. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral DAILY
11. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
Plan for ___ weeks, to be determined by ___ ID OPAT Service
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*6 Tablet Refills:*0
3. Ascorbic Acid ___ mg PO BID
4. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral DAILY
5. Enoxaparin Sodium 100 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Gabapentin 1200 mg PO TID
8. Levothyroxine Sodium 25 mcg PO 3X/WEEK (___)
9. Levothyroxine Sodium 50 mcg PO 4X/WEEK (___)
10. Simvastatin 20 mg PO QPM
11. Vitamin B Complex 1 CAP PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# L hip septic arthritis
# Acute L hip osteomyelitis
# Orthostatic hypotension
# Constipation
# Hypothyroidism
# Hyperlipidemia
# History of thromboembolic disease
# Peripheral neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR PELVIS WANDW/O CONTRAST
INDICATION: ___ year old woman with ?osteo of L hip on CT and weakness// eval
for osteo
TECHNIQUE: Imaging performed at 1.5 tesla using the body array coil.
Sequences include coronal T1 and STIR, axial T1 and STIR, axial T1 fat sat pre
and post-contrast.
COMPARISON: CT left hip ___
FINDINGS:
There is a moderately large left hip effusion with extension of fluid through
the medial acetabular wall and an apparent deeper fluid component with
peripheral calcifications seen centered within the iliacus muscle (14:18).
There is remodeling of the bony acetabulum and the femoral head which is
partially collapsed, however the bone marrow is relatively normal in signal
intensity with predominately preservation of the normal T1 signal except for
the area of cortical breakthrough through the medial acetabulum and mild
heterogeneity and bone marrow edema without corresponding T1 signal
abnormality in the femoral head and left iliac bone (11:12, 16). This would
be a very unusual appearance for septic arthritis, the appearances are more
consistent with a chronic slowly progressive process in the joint space.
Differentials would include inflammatory arthropathy such as rheumatoid
arthritis or psoriatic arthropathy.
There is intramuscular edema seen surrounding the hip joint involving the
gluteal muscles, the iliacus muscle and the adductor compartment (11:28, 10).
The remote from the hip joint there is a focal areas of abnormal bone marrow
signal intensity in the posterior left iliac bone (10:12) and right iliac bone
(11:11). Potentially these may reflect sacral insufficiency fractures.
There are triangular abnormalities in the bilateral sacral ala with
alternating hyperintense and hypointense signal intensity on fluid sensitive
sequences (11:9, 09:20) most consistent with bone infarcts.
Probable insufficiency fracture in the left superior pubic ramus (10:20).
Evaluation of the pelvic parenchymal structures is limited. No pelvic
lymphadenopathy seen. There is trace free fluid in the pelvis.
IMPRESSION:
1. Unusual appearances at the left hip with a large joint effusion with
surrounding soft tissue edema but with relative preservation of the normal
bone marrow signal in both the femoral head and the acetabulum. There is bony
destruction involving the medial acetabular wall as seen on the prior CT study
and extension of the fluid into the iliacus muscle but with the peripheral
calcified rim. The appearances suggest a chronic destructive process of the
left hip. Potentially a very indolent infection could have such an appearance
but alternative etiologies such as inflammatory arthropathy, rheumatoid
arthritis and psoriatic arthritis should also be considered.
2. Multiple insufficiency fractures and apparent bone infarcts in the sacral
ala.
Radiology Report
EXAMINATION: MR ___ SPINE WITH CONTRAST
INDICATION: History: ___ with ?osteo of L hip on CT and left leg weakness x2
daysIV contrast to be given at radiologist discretion as clinically needed//
eval for osteomyelitis or cord impingement.
TECHNIQUE: Sagittal T1, T2 and sagittal STIR sequences were obtained through
the lumbar spine, axial T2 weighted images were also obtained. The T1
weighted images were repeated after the intravenous administration of 9 mL of
Gadavist contrast agent.
COMPARISON: CT of the lumbar spine dated ___, from an outside
institution (___).
FINDINGS:
In comparison with the prior CT of the lumbar spine dated ___,
there is unchanged mild retrolisthesis at L3 upon L4, L4-5, and L5 upon S1
levels, likely degenerative in nature. The conus medullaris terminates at the
level of T12-L1 and is unremarkable. There is irregular contour at the
endplates of L1-L2, L2-L3 and L3-L4 levels consistent with Schmorl's nodes,
more prominent at the superior endplate of L2. The signal intensity in the
bone marrow is heterogeneous with areas of high-signal intensity on the STIR
sequence at the endplates of L1-L2, L2-L3 and L4-5 levels, suggesting bone
edema, probably degenerative in nature, there is no evidence of abnormal
enhancement to indicate discitis osteomyelitis.
At T12-L1 level, both neural foramina are patent, there is no evidence of
spinal canal stenosis, there is mild bilateral articular joint facet
hypertrophy and mild ligamentum flavum thickening.
At L1-L2 level, there is posterior spondylosis causing mild anterior thecal
sac deformity, mild right and moderate left neural foraminal narrowing,
additionally there is articular joint facet hypertrophy, more significant on
the left (image 34, series 101).
At L3-L4 level, there is diffuse disc bulge and mild spondylosis, causing mild
anterior thecal sac deformity and bilateral neural foraminal narrowing,
contacting the traversing nerve roots towards the subarticular zones,
additionally there is articular joint facet hypertrophy and ligamentum flavum
thickening resulting in mild spinal canal stenosis (images 44, 45, series
101).
At L4-5 level, there is narrowing of the intervertebral disc space, posterior
spondylosis and mild disc bulge causing mild anterior thecal sac deformity,
and moderate bilateral neural foraminal narrowing, there is mild spinal canal
stenosis, additionally there is mild articular joint facet hypertrophy and
ligamentum flavum thickening.
At L5-S1 level, there is mild spondylosis and disc bulge, causing anterior
thecal sac deformity and moderate left-sided neural foraminal narrowing, there
is moderate articular joint facet hypertrophy and ligamentum flavum
thickening. Sclerotic changes are visualized in the sacral ala on the left
(image 68, series 101), better depicted in the prior CT of the lumbar spine.
The hips are not included in this exam, please correlate with the dedicated
MRI of the pelvis performed concurrently for findings involving the left hip.
IMPRESSION:
1. Multilevel, multifactorial degenerative changes throughout the lumbar
spine, with irregular contour at the endplates, more significant at the
superior endplate of L2 consistent with Schmorl's nodes.
2. The signal intensity in the bone marrow is heterogeneous with areas of
high-signal intensity on the STIR sequence at the endplates of L1-L2, L2-L3
and L4-5 levels, suggesting bone edema, probably degenerative in nature, there
is no evidence of abnormal enhancement to indicate discitis osteomyelitis.
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/FLUORO
INDICATION: ___ year old woman with uterine ca s/p XRT a/w fever, chills, LLE
pain, elevated inflammatory makers, CT hip w/ large L hip effusion concerning
for L hip septic arthritis.// concern for septic arthritis
FINDINGS:
Fluoroscopic documentation of injection procedure. No radiologist was
present.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC// 44 cm R basilic SL
___ ___ Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: None
FINDINGS:
The tip of the right PICC line projects over the distal SVC. There is no
focal consolidation, pleural effusion or pneumothorax identified. The size of
the cardiomediastinal silhouette is within normal limits.
IMPRESSION:
The tip of the right PICC line projects over the distal SVC. No pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Leg weakness, Transfer
Diagnosed with Pain in left hip
temperature: 99.9
heartrate: 95.0
resprate: 17.0
o2sat: 97.0
sbp: 106.0
dbp: 51.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old female with past medical history of
uterine cancer admitted with L hip septic arthritis and acute L
hip osteomyelitis now status post L hip incision and drainage
and L hip girdlestone procedure, course complicated by
constipation, orthostatic hypotension, subsequently improving on
antibiotics and able to be discharged to a rehab facility on
prolonged course of IV antibiotics.
# L hip septic arthritis
# Acute L hip osteomyelitis
Patient was admitted with L hip pain, fever and joint swelling.
Imaging showed a large left hip effusion as well as bony
destruction. ___ guided fluid aspiration revealed joint fluid
with WBC > 50K. Patient was started on empiric antibiotics.
Fluid culture grew coag neg staph and group C strep. She was
seen by orthopedic surgery consult service and infectious
disease consult service, and underwent left hip I&D, girdlestone
procedure on ___. TTE did not reveal signs of endocarditis.
Patient was recommended to complete ___ weeks of IV ceftriaxone,
to be determined by ___ ID OPAT follow-up. Patient had a PICC
line placed, and was able to be discharged to a rehabilitation
facility. At time of discharge, she was using oxycodone prn for
pain.
# ___ course complicated by orthostatic hypotension in
setting of poor PO intake from recent surgical procedure. This
resolved with IV fluid resuscitation and improved PO intake, and
did not recur for the remainder of the admission
# Constipation
Post-operatively patient developed constipation. Resolved with
augmentation of bowel regimen.
# Peripheral neuropathy
Continued home gabapentin
# History of Venous Thromboembolic disease:
The patient has a history of a uterine vein clot ___ ago. She
is on lifelong anticoagulation with lovenox ___ mg daily.
Lovenox was briefly held for her surgical procedure and then
restarted once surgically safe to do so.
# Abnormal MRI Pelvis - Admission MRI read as "Multiple
insufficiency fractures and
apparent bone infarcts in the sacral ala". Discussed this
finding with orthopedics who believe most likely result of her
prior radiation and not concerned re: embolic process--no
additional workup or management was recommended.
# Hypothyroidism:
Continued home levothyroxine
# Hyperlipidemia
Continued statin
Transitional Issues
- Discharged to rehab
- Discharged with PICC in place; would remove PICC on completion
of antibiotic course;
- Planned for ___ week course of IV ceftriaxone to be determined
by ___ ID OPAT follow-up appointment (see below)
- TTE incidentally showed "Mild to moderate tricuspid
regurgitation."; "Possible small asd vs stretched pfo."; Defer
to outpatient regarding potential need for additional workup or
referral.
- MRI incidentally showed "Multilevel, multifactorial
degenerative changes throughout the lumbar spine, with irregular
contour at the endplates, more significant at the superior
endplate of L2 consistent with Schmorl's nodes."; |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Erythromycin Base / Ace Inhibitors
Attending: ___.
Chief Complaint:
Abdominal pain, hematuria, fevers
Major Surgical or Invasive Procedure:
___ Cystoscopy
___ Renal angiogram with coiling 2 non bleeding pseudo
aneurysms and 1 bleeding
History of Present Illness:
Ms. ___ is a ___ woman with a history of HTN, HLD,
DM2, Afib on Coumadin, ADPKD c/b ESRD s/p LRRT (___) c/b graft
failure ___ tacro on HD, and recent admission for PD
catheter infection and colon perforation requiring transverse
colectomy and end colostomy, peritonitis (end date of cipro,
flagyl, dapto, fluconazole ___, new dx afib on warfarin, who
now presents with two days of lower abdominal pain, flank pain,
n/v, hematuria, dysuria, and fevers to 104.
She was discharged to rehab on ___ and states that she did not
have any issues at rehab until 2 nights PTA when she suddenly
developed severe pain primarily in the LLQ and L flank/back. At
that time, she had 1 episode of NBNB emesis and a nurse at her
rehab facility measured her temperature at 104. Over the past
two days, the pain has persisted at a ___ severity and has
migrated from her left now to her RLQ and R flank/back. She no
longer has pain on her left side. She has continued to feel warm
and sweaty with chills mostly at night and has continued to feel
nauseated without further emesis. She also reports loss of
appetite and did not eat for two days at rehab. Of note, she
endorses gross hematuria that began two days PTA associated with
dysuria and decreased urine output. She has had hematuria in the
past with ruptured renal cysts and states that present abdominal
pain is similar to those previous episodes. Colostomy output has
been normal without bloody stools.
In the ED, she continued to have intense pain but was able to
eat a small meal (soup and Jell-O) without vomiting. Vital signs
were notable for a tmax 102.5 and she was hemodynamically stable
(HR 89, BP 165/110). Her exam was notable for generalized
malaise, diaphoresis, somnolence, bilateral CVA tenderness, and
abdominal distension with diffuse tenderness, voluntary
guarding, and rebound tenderness. Ostomy pouch was pink and
vital with a ~4cm of colon prolapse. Labs were notable for WBC
16.1 (80.4% PMNs), Hb 7.2, Hct 22.9, BUN 43, Cr 5.5, INR 2.5,
and tacroFK <2.0. UA revealed large blood, trace leuks, positive
nitrite, RBC>182, WBC>182, and many bacteria. BCx and UCx were
sent and are pending. CT abd/pelvis with PO+IV contrast revaled
small amount of perihepatic and pelvic free fluid of unclear
etiology and a grossly normal transplant kidney. She was given
morphine with minimal improvement in pain. She also received HD
about 30 minutes prior to transfer to the floor. VS on
admission: T 100.4, HR 89, BP 165/110, RR 16, O2 100% RA.
On the floor, patient was able to confirm the history above.
Tmax 103.1, remained HDS, also continued to complain of rigors
and mild headache.
Past Medical History:
ADPKD: renal transplant on ___ c/b failure ___
h/o cyst rupture
Hypertension
Hyperlipidemia
Anemia of renal disease, chronic disease
Diabetes Mellitus type II
Social History:
___
Family History:
Sister and niece have PCKD.
Physical Exam:
Admission physical exam:
Vitals- 102.8 PO 175 / 91 83 18 99 Ra
GENERAL: AOx3, laying down, rigors, diaphoretic, c/o pain
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Oropharynx is clear.
NECK: Supple, no nodules palpated. No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops,
tachycardic. No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
BACK: positive CVA tenderness.
ABDOMEN: hypoactive bowels sounds, right side of abdomen
swollen, warm, non distended, significantly tender to light
palpation diffusely R>L, radiating to the back, + rebound,
+guarding EXTREMITIES: No clubbing, cyanosis, or edema, Pulses
DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia. Gait
defferred.
Discharge physical exam:
Vitals- 98.5 ___ / 92 85 1897 Ra
GENERAL: AOx3, sitting up comfortably
HEENT: No conjunctival pallor or injection, sclera anicteric and
without injection.
NECK: Supple, nontender.
CARDIAC: Regular rhythm, no murmurs/rubs/gallops. No JVD.
LUNGS: Clear to auscultation bilaterally, no wheezes, rhonchi or
crackles.
BACK: R CVA tenderness +.
ABDOMEN: Hypoactive bowels sounds, right side of abdomen remains
mildly swollen, abdomen nondistended, moderately tender to
palpation in R flank and RLQ, minimally tender in suprapubic
region, - rebound, - guarding. Good ostomy output, prolapse is
~8cm w/ pink mucosa.
EXTREMITIES: No clubbing, cyanosis, or edema. Warm and
well-perfused. Palpable DP and ___ pulses bilaterally. No
tenderness along ___ incision.
Pertinent Results:
Admission labs:
===============
___ 09:40PM BLOOD WBC-16.1*# RBC-2.58* Hgb-7.2* Hct-22.9*
MCV-89 MCH-27.9 MCHC-31.4* RDW-15.6* RDWSD-50.6* Plt ___
___ 09:40PM BLOOD Neuts-80.4* Lymphs-8.9* Monos-6.8 Eos-2.9
Baso-0.4 Im ___ AbsNeut-12.94* AbsLymp-1.43 AbsMono-1.10*
AbsEos-0.47 AbsBaso-0.06
___ 09:40PM BLOOD Plt ___
___ 12:09AM BLOOD ___ PTT-41.7* ___
___ 08:00AM BLOOD ___
___ 09:37PM BLOOD Ret Aut-2.3* Abs Ret-0.04
___ 09:40PM BLOOD Glucose-93 UreaN-43* Creat-5.5* Na-135
K-4.7 Cl-91* HCO3-27 AnGap-22*
___ 08:00AM BLOOD ALT-7 AST-17 LD(LDH)-219 AlkPhos-107*
TotBili-0.3
___ 06:17AM BLOOD CK(CPK)-46
___ 09:40PM BLOOD Iron-19*
___ 08:00AM BLOOD Albumin-2.7* Calcium-7.3* Phos-2.0*
Mg-1.8
___ 09:40PM BLOOD calTIBC-156* Ferritn-1724* TRF-120*
___ 06:24AM BLOOD 25VitD-10*
___ 07:00AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 07:00AM BLOOD HCV Ab-Negative
___ 09:28PM BLOOD CMV VL-NOT DETECT
Discharge labs:
===============
___ 07:30AM BLOOD WBC-7.7 RBC-2.96* Hgb-8.5* Hct-26.1*
MCV-88 MCH-28.7 MCHC-32.6 RDW-16.2* RDWSD-52.8* Plt ___
___ 01:25PM BLOOD Neuts-69.8 Lymphs-16.2* Monos-7.4 Eos-5.7
Baso-0.5 Im ___ AbsNeut-5.34 AbsLymp-1.24 AbsMono-0.57
AbsEos-0.44 AbsBaso-0.04
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-106* UreaN-22* Creat-4.9*# Na-139
K-3.7 Cl-104 HCO3-22 AnGap-17
___ 07:30AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.1
Diagnostics:
============
___ CT abdomen and pelvis
1. No evidence of abscess in the abdomen pelvis. No
obstruction.
2. Transplant kidney is grossly normal without hydronephrosis.
There are
multiple subcentimeter hypoattenuating lesions in the transplant
kidney which are too small to characterize but unchanged from ___.
3. Small amount of perihepatic and pelvic free fluid of unclear
etiology.
NOTIFICATION: Free fluid
___ CT abdomen and pelvis
1. Several cysts are seen in the right kidney which have
enlarged since ___ with hyperattenuating internal contents, suggestive
of interval
development of hemorrhagic cysts. Additionally, the right
proximal ureter
appears dilated and hyperattenuating, concerning for clots.
2. Interval increase in bilateral pleural effusions and basilar
atelectasis since ___.
3. Small pockets of gas are seen within the calices of the right
transplant kidney. Although this can be explained by recent
Foley catheter insertion and reflux, emphysematous pyelitis
should be considered, correlation with
urinalysis is recommended. No CT evidence of pyelonephritis or
air within
renal parenchyma.
4. Persistent mild perihepatic and pelvic free fluid without
evidence of
organized fluid collections.
5. Diffuse anasarca.
RECOMMENDATION(S): Correlation with urinalysis and urine
culture is
recommended to rule out a urinary tract infection.
___ Urine instrumentation
SPECIMEN(S) SUBMITTED: URINE, INSTRUMENTATION, # 2 RIGHT RENAL
PELVIC
DIAGNOSIS:
Urine, #2, right renal pelvis:
NEGATIVE FOR HIGH-GRADE UROTHELIAL CARCINOMA
- Abundant blood, histocytes, rare benign-appearing urothelial
cells.
SPECIMEN DESCRIPTION:
Received: 45 ml, bloody fluid.
Prepared: 1 monolayer
___ Cysoscope
SPECIMEN(S) SUBMITTED: CYSTOSCOPE
DIAGNOSIS:
Urine, cystoscopy:
NEGATIVE FOR HIGH-GRADE UROTHELIAL CARCINOMA
- Abundant blood, histiocytes, rare degenerated and reactive
urothelial cells.
SPECIMEN DESCRIPTION:
Received: 10 ml, bloody fluid.
___ Abdomen (supine + erect)
There is no abnormal dilated loops of small large or small
bowel. Contrast is noted in a right abdominal ostomy bag. A
large amount of stool is noted the right abdomen. There is no
evidence for intraperitoneal free air. A right double-J ureteral
stent is noted with partial uncoiling of the proximal pigtail
loop. There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies.
IMPRESSION:
1. No evidence for bowel obstruction.
2. Right double-J ureteral stent with partial uncoiling of the
proximal
pigtail loop.
___ Renal arteriogram
1. Right renal arteriogram demonstrates an ectatic and irregular
superior
segmental right renal artery which comes in close proximity to
the proximal double-J ureteral stent. There is also a
pseudoaneurysm arising from a separate segmental superior right
renal artery. In addition, there is a small pseudoaneurysm
arising from an inferior interlobar right renal artery.
2. Arteriogram from the first targeted superior segment right
renal artery
again demonstrates irregularity and ectasia of the artery which
comes in close proximity to the proximal double-J ureteral
stent.
3. Arteriogram from the separate superior segmental right renal
artery again demonstrates the targeted pseudoaneurysm.
4. Arteriogram from the inferior interlobar right renal artery
again
demonstrates the targeted pseudoaneurysm.
5. Post embolization right renal arteriogram no longer
demonstrates the
targeted bleeding areas described above. There is stasis of
flow in the
inferior segmental right renal artery indicating a small
iatrogenic arterial dissection.
6. Right common femoral arteriogram showed normal anatomy. Of
note, there is a small hematoma in the right groin.
IMPRESSION:
Technically successful coil embolization of three areas of
bleeding seen on right renal arteriogram.
___ Femoral vascular US RIG
In the region of the patient's groin puncture for recent
catheterization,
there is no pseudoaneurysm, fistula or hematoma.
Normal appearing lymph nodes are noted in the right groin.
IMPRESSION: No evidence of pseudoaneurysm, fistula or hematoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cinacalcet 90 mg PO DAILY
2. Omeprazole 40 mg PO BID
3. Acetaminophen 1000 mg PO Q8H
4. Docusate Sodium 100 mg PO BID constipation
5. Fenofibrate 48 mg PO DAILY
6. TraMADol 100 mg PO Q8H:PRN Pain - Moderate
7. Calcium Carbonate 1000 mg PO QID:PRN heartburn
8. Ciprofloxacin HCl 500 mg PO Q24H
9. Daptomycin 240 mg IV 2X/WEEK (MO,WE)
10. Daptomycin 360 mg IV 1X/WEEK (FR)
11. Fluconazole 200 mg PO Q24H
12. Metoprolol Tartrate 37.5 mg PO TID for afib
13. Simethicone 40-80 mg PO QID:PRN gas pain
14. Sucralfate 1 gm PO QID
15. MetroNIDAZOLE 500 mg PO TID
16. TraZODone 25 mg PO QHS:PRN insomnia
17. Warfarin 2.5 mg PO DAILY for afib
18. Zolpidem Tartrate 10 mg PO QHS for insomnia
19. Tacrolimus 4 mg PO Q12H
20. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
21. Senna 8.6 mg PO BID:PRN Constipation
22. Bisacodyl 10 mg PR QHS:PRN constipation
23. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every 8 hours Disp #*90 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
3. Heparin Flush (1000 units/mL) 4000-11,000 UNIT DWELL PRN
line flush
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3
hours as needed for Disp #*120 Tablet Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % 1 patch every day everyday Disp
#*30 Patch Refills:*0
6. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Renal Caps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
7. Oxybutynin 5 mg PO TID
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO BID:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth two times a day as needed Refills:*0
9. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth every day Disp #*30
Capsule Refills:*0
10. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally every day as
needed for constipation Disp #*60 Suppository Refills:*0
11. Calcium Carbonate 1000 mg PO QID:PRN heartburn
12. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
13. Docusate Sodium 100 mg PO BID constipation
14. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day ___
minutes before food Disp #*60 Capsule Refills:*0
15. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [Senexon] 8.6 mg 1 tablet by mouth twice a day
Disp #*60 Tablet Refills:*0
16. Simethicone 40-80 mg PO QID:PRN gas pain
17. Sucralfate 1 gm PO QID
18. Tacrolimus 4 mg PO Q12H
19. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth every
night as needed for insomnia Disp #*30 Tablet Refills:*0
20. HELD- Cinacalcet 90 mg PO DAILY This medication was held.
Do not restart Cinacalcet until you speak to your nephrologist
21. HELD- Fenofibrate 48 mg PO DAILY This medication was held.
Do not restart Fenofibrate until you speak to your doctor
22. HELD- Metoprolol Tartrate 37.5 mg PO TID for afib This
medication was held. Do not restart Metoprolol Tartrate until
you speak with your primary care doctor
23. HELD- Zolpidem Tartrate 10 mg PO QHS for insomnia This
medication was held. Do not restart Zolpidem Tartrate until you
speak to your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
=================
Cyst rupture
Pyelonephritis
Pseudo aneurysm
Secondary diagnosis
====================
Autosomal dominant polycystic kidney disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: +PO contrast; History: ___ with ESRD s/p transplant, recent
colectomy, here with fever and abd/flank pain+PO contrast// assess for
hydronephrosis, renal stone, intraabdominal abscess. Chart review notes that
patient underwent exploratory laparotomy, resection of splenic flexure, and
transverse colostomy on ___.
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) = 803 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: There is subsegmental atelectasis in the bilateral lower lobes.
Mild paraseptal and centrilobular emphysematous changes are noted. Heart is
enlarged. There is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is mild periportal edema, unchanged from CT abdomen pelvis ___.
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. There is normal dilatation the pancreatic duct measuring up to
5 mm in the pancreatic body (02:30), unchanged from ___. Don't
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: Native kidneys are enlarging contain multiple cyst compatible with
polycystic kidney disease. Transplant kidney in the right hemipelvis is
noted. There are multiple subcentimeter hypoattenuating lesions in the
transplant kidney which are too small to characterize but unchanged from ___. There is no hydronephrosis of the transplant kidney.
GASTROINTESTINAL: Enteric tube terminates in the stomach. The stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. Patient is status post transverse colostomy in
the right mid abdomen. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small amount of free fluid the pelvis and perihepatic regions.
REPRODUCTIVE ORGANS: The uterus is normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is diffuse anasarca.
IMPRESSION:
1. No evidence of abscess in the abdomen pelvis. No obstruction.
2. Transplant kidney is grossly normal without hydronephrosis. There are
multiple subcentimeter hypoattenuating lesions in the transplant kidney which
are too small to characterize but unchanged from ___.
3. Small amount of perihepatic and pelvic free fluid of unclear etiology.
NOTIFICATION: Free fluid
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION: Ms. ___ is a ___ woman with a history of HTN, HLD, DM2,
Afib on Coumadin, ADPKD c/b ESRD s/p LRRT (___) c/b graft failure (___) on
tacro on HD, and recent admission for PD catheter infection and colon
perforation requiring transverse colectomy and end colostomy, peritonitis (end
date of cipro, flagyl, dapto, fluconazole ___, who now presents with two days
of lower abdominal pain, flank pain, n/v, hematuria, dysuria, and fevers to
104.// infection, bleed, please do ORAL CONTRAST and IV contrast
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was not administered.
DOSE: Acquisition sequence:
1) Spiral Acquisition 15.1 s, 52.0 cm; CTDIvol = 10.7 mGy (Body) DLP =
542.6 mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 8.5 s, 1.0 cm; CTDIvol = 19.7 mGy (Body) DLP =
19.7 mGy-cm.
4) Spiral Acquisition 14.7 s, 50.5 cm; CTDIvol = 10.9 mGy (Body) DLP =
533.1 mGy-cm.
Total DLP (Body) = 1,109 mGy-cm.
COMPARISON: CT dated ___ and ___
FINDINGS:
LOWER CHEST: There is interval development of atelectasis of the right lower
lobe and increasing mild to moderate right-sided pleural effusion.
Subsegmental atelectasis is seen at the left lung base, adjacent trace pleural
effusion.. The heart is again enlarged. Central line tip in the right
atrium.
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. Mild periportal edema is again noted.
The gallbladder is within normal limits. A small amount of perihepatic free
fluid is again seen, similar to previous. There are no organized fluid
collections.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions. The main pancreatic duct is prominent, similar to previous.
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: Bilateral native kidneys are enlarged contain multiple cysts, in
keeping with polycystic kidney disease. Several cysts in the right kidney
appears enlarged compared to the prior CT scan from ___, with
spontaneously hyperattenuating internal contents, concerning for interval
bleed. Additionally, the right collecting system is dilated and
hyperattenuating, concerning for blood clots within of the right proximal
ureter. Few punctate calcifications along the expected course of the right
ureter are probably similar compared with ___, unlikely to
represent small renal stones, distal right ureter is difficult to follow.
Multiphasic postcontrast imaging was not performed which limits evaluation,
but there is no evidence to suggest active extravasation.
A transplant kidney is again noted in the right lower quadrant and
demonstrates a normal nephrogram. Several tiny subcentimeter cortical
hypodensities are again noted which are too small to characterize but
unchanged compared to ___. Additionally, there is interval
development of small pockets of air within the calices. There is no
hydronephrosis or periureteric stranding.
GASTROINTESTINAL: The stomach appears unremarkable. An enteric tube is in
place. Small bowel loops demonstrate normal caliber, wall thickness, and
enhancement. Residual oral contrast is seen within in the colon.
PELVIS: There is interval placement of a Foley catheter within the bladder.
The bladder is collapsed. A small amount of free fluid is again noted within
the pelvis, similar compared to ___. there is stable presacral,
pelvic mild stranding, indeterminate, possibly from fluid overload.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. The major mesenteric vessels are patent.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is re-demonstration of diffuse anasarca.
IMPRESSION:
1. Several cysts are seen in the right kidney which have enlarged since ___ with hyperattenuating internal contents, suggestive of interval
development of hemorrhagic cysts. Additionally, the right proximal ureter
appears dilated and hyperattenuating, concerning for clots.
2. Interval increase in bilateral pleural effusions and basilar atelectasis
since ___.
3. Small pockets of gas are seen within the calices of the right transplant
kidney. Although this can be explained by recent Foley catheter insertion and
reflux, emphysematous pyelitis should be considered, correlation with
urinalysis is recommended. No CT evidence of pyelonephritis or air within
renal parenchyma.
4. Persistent mild perihepatic and pelvic free fluid without evidence of
organized fluid collections.
5. Diffuse anasarca.
RECOMMENDATION(S): Correlation with urinalysis and urine culture is
recommended to rule out a urinary tract infection.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:17 pm, 20 minutes after discovery
of the findings.
Radiology Report
INDICATION: ___ year old woman with colostomy, Poly cystic kidney disease,
with recent ureteral stent perforation, now with suprapubic pain. Also on
large dose of Dilaudid.//evidence of obstruction
TECHNIQUE: Frontal supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
There is no abnormal dilated loops of small large or small bowel. Contrast is
noted in a right abdominal ostomy bag. A large amount of stool is noted the
right abdomen.
There is no evidence for intraperitoneal free air.
A right double-J ureteral stent is noted with partial uncoiling of the
proximal pigtail loop.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. No evidence for bowel obstruction.
2. Right double-J ureteral stent with partial uncoiling of the proximal
pigtail loop.
Radiology Report
INDICATION: ___ year old woman with ADPKD with continued drop in Hct.//
bleeding source
COMPARISON: CT abdomen and pelvis on ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
150mcg of fentanyl and 1.25 mg of midazolam throughout the total intra-service
time of 90 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl and Versed.
CONTRAST: 80 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 18 min, 266 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Right renal arteriogram.
3. Superior segmental right renal arteriogram.
4. Coil embolization of the superior segmental right renal artery.
5. Separate superior segmental right renal arteriogram.
6. Coil embolization of the separate superior segmental right renal artery.
7. Inferior interlobar right renal arteriogram.
8. Coil embolization of the inferior interlobar right renal artery.
9. Post embolization right renal arteriogram.
10. Right common femoral arteriogram.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. Both groins were
prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A C2 Cobra catheter was advanced over ___ wire into the aorta. The wire
was removed and the right renal artery was selectively cannulated and a small
contrast injection was made to confirm position. A right renal arteriogram was
performed.
Next a renegade ___ microcatheter and double angled Glidewire were used to
select a superior segmental right renal artery. An arteriogram was performed
from this position. Next, a 4 mm x 8 cm Concerto coil and a 3 mm x 6 cm
Concerto coil were placed into this artery. Contrast injection confirmed
stasis. Next, a separate superior segmental right renal artery was then
selected with the microcatheter and micro wire after retracting the catheter
from the existing branch. An arteriogram was performed confirming appropriate
positioning. Next a 4 mm x 8 cm Concerto coil was placed and contrast
injection confirmed stasis. Next, the microcatheter and micro wire were used
to access the targeted inferior interlobar right renal artery after retracting
the catheter from the previous branch. An arteriogram was performed from this
position. Next a 4 mm x 8 cm Concerto coil was then placed followed by a 3 mm
x 4 cm Concerto coil. Contrast injection confirmed stasis. Microcatheter was
removed and a post embolization right renal arteriogram was performed. The
catheter was removed and a right common femoral arteriogram was performed from
the sheath.
The catheter was then removed over the wire and the sheath was removed. An
Angioseal closure device was deployed and manual pressure was held until
hemostasis was achieved. Of note, a small hematoma was noted in the right
groin after Angio-Seal placement, which may be due to patient motion. Sterile
dressings were applied. The patient tolerated the procedure well.
FINDINGS:
1. Right renal arteriogram demonstrates an ectatic and irregular superior
segmental right renal artery which comes in close proximity to the proximal
double-J ureteral stent. There is also a pseudoaneurysm arising from a
separate segmental superior right renal artery. In addition, there is a small
pseudoaneurysm arising from an inferior interlobar right renal artery.
2. Arteriogram from the first targeted superior segment right renal artery
again demonstrates irregularity and ectasia of the artery which comes in close
proximity to the proximal double-J ureteral stent.
3. Arteriogram from the separate superior segmental right renal artery again
demonstrates the targeted pseudoaneurysm.
4. Arteriogram from the inferior interlobar right renal artery again
demonstrates the targeted pseudoaneurysm.
5. Post embolization right renal arteriogram no longer demonstrates the
targeted bleeding areas described above. There is stasis of flow in the
inferior segmental right renal artery indicating a small iatrogenic arterial
dissection.
6. Right common femoral arteriogram showed normal anatomy. Of note, there is
a small hematoma in the right groin.
IMPRESSION:
Technically successful coil embolization of three areas of bleeding seen on
right renal arteriogram.
Radiology Report
EXAMINATION: NON-INVASIVE PERIPHERAL ARTERIAL STUDY
INDICATION: ___ year old woman s/p ___ procedure in right groin with worsening
right ___ pain and some edema// eval for pseudo aneurysm
TECHNIQUE: Grayscale and Doppler ultrasound
COMPARISON: None.
FINDINGS:
In the region of the patient's groin puncture for recent catheterization,
there is no pseudoaneurysm, fistula or hematoma.
Normal appearing lymph nodes are noted in the right groin.
IMPRESSION:
No evidence of pseudoaneurysm, fistula or hematoma.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever, RLQ abdominal pain
Diagnosed with Urinary tract infection, site not specified
temperature: 98.6
heartrate: 83.0
resprate: 20.0
o2sat: 100.0
sbp: 153.0
dbp: 95.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ woman with a history of hypertension,
hyperlipidemia, diabetes, recently diagnosed paroxysmal atrial
fibrillation on Coumadin, autosomal dominant polycystic kidney
disease (ADPKD) complicated by end stage renal disease status
post left renal transplant in ___, complicated by graft failure
in ___ on tacrolimus, now on dialysis and with recent admission
for peritoneal dialysis catheter infection and colon perforation
requiring transverse colectomy and end colostomy, peritonitis
(end date of cipro, flagyl, dapto, fluconazole ___, who
presented on ___ with 2 days of fevers, abdominal pain, and
hematuria despite broad spectrum antibiotics.
#Pyelonephritis: Presented with fevers, chills, rigors.
Infectious work up notable for positive UA, negative cultures to
date, otherwise negative CT abdomen for intraabdominal abscess.
Hematuria and pain consistent with patients presentation of cyst
rupture. Diagnosed with cyst rupture complicated by likely
pyelonephritis, treated with meropenem (___) and micafungin
(___) and then transitioned to daptomycin (___),
ceftazidime (___), and fluconazole (___) with ID
consulted. On ___, patient was febrile to 101.8 and
asymptomatic with negative work up, cultures pending. Decision
was made to monitor closely for 24 hours. No recurrent fevers,
and patient continues to look well so was discharged with close
follow up.
#Ruptured Cyst: Presented with hematuria and abdominal pain. INR
peaked at 4.0, given no afib (likely brought on during last
hospitalization in the setting of infection) and significant
hematuria, warfarin was discontinued. Hematuria and pain
consistent with patients presentation of cyst rupture. Her
course was complicated by recurrent cyst rupture causing
significant hematuria and pain, needing continuous bladder
irrigation and pain management with dilaudid. Patient had a
cystoscopy done which showed old blood in right ureter,
procedure was complicated by a perforation of right ureter
status post stent placement. Given recurrent hematuria with 3
units of RBC transfusion, ___ got involved to find the source of
the bleed through renal angiogram. ___ performed renal
arteriorgram and identified 3 potential sources of bleeding
(pseudoaneurysms) including 1 actively bleeding vessel. All 3
were coiled. Hematuria on discharge still persistent, but
urinating well so CBI discontinued. Patient advised to monitor
for frank blood on urination, and tolerate dark colored urine.
CBC should be monitored at her HD sessions to ensure stability
and not requiring additional pRBC transfusion. On discharge,
pain from PKD cyst rupture and recent ___ procedure was well
controlled on the oral regimen, which should be able to be
tapered down over the course of the next days to weeks.
#Ostomy prolapse: Course complicated by ostomy prolapse,
transplant surgery and ostomy nurse visited often with
instructions to hold cold compress with improvement.
# Nutrition: ___ removed secondary to great PO intake.
Nutrition recs:ensure clear TID, CIB w/ whole milk TID,
nephrocaps, monitor weight post-HD ___.
#Hypocalcemia / Vit D deficiency: Continued Vit D.
#Thrombocytosis: In the setting of sepsis, resolved. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Arm and face numbness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
HPI:
Ms. ___ is a ___ year old female in good health who presents
to the ED because of left arm numbness over the last few days
and
visual distortion noted this morning that has associated nausea
and lightheadedness. She also has noticed worsening of the
tingling to involve her head, face and rim of her tongue.
Ms. ___ states that she has been in her usual state of
health until a few days ago when she started noticing some
numbness in her left arm. She describes this sensation as a
tingling that is most prominent in her thumb and first two
fingers that spreads up the ventral aspect of her arm to her
shoulde but denies any pain or tingling. She says this started
little by little over several days and is intermittent.
Yesterday she also noted some numbness and tingling along the
right occipital portion of her scalp. This morning she woke up
and while in bed realized she was having difficulty focusing on
the wall because of a sense that her vision was shaking
horizontally. She was able to get up and walk without difficulty
and began to get ready for work. When she tried to brush her
teeth she noted that her face was numb (maybe L side > R) and
that she felt she could not open her mouth wide. She is unsure
how long this feeling lasted. About 2 hours after her symptoms
started, she called her friend when she was about to go to work
and told her about what was going on and her friend recommended
she go to the ED. She feels that her vision has improved but is
not back to normal and that her face numbness improved over
about
an hour. Her daughter drove her mother here to ___ and feels
that her mom's face looks a little swollen but has no other
specific concerns.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
focal weakness. 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:
recurrent pancreatitis
osteoporosis
iron deficiency
gastric bypass
dysthmic disorder
Anxiety
ADHD
OSA
Social History:
___
Family History:
Reports significant family history on both sides of strokes, but
typically when older. Father had seizures as a child. No history
of other neurologic problems.
Physical Exam:
Vitals: T:97.1 P:56 R: 15 BP:123/74 SaO2: 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name all objects on ___ stroke card. Able to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages. Visual
Acuity: ___ ___, OS ___
III, IV, VI: EOMI initially with nystagmus on L gaze and up gaze
but normal on repeat exam except some saccadic intrustion.
Normal saccades.
V: Facial sensation intact to light touch but with subjective
tingling
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ ___ 5 5 5 4
R 4 5- ___ ___ ___ 5 5 4
-Sensory: Subjective tingling of left arm, most notably in
median
nerve distribution. Left arm decreased to vibration,
temperature,
pinprick and light touch compared to right. Otherwise intact to
all modalities including propioception. extinguish to DSS
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, slightly slower RAM on Right
hand. No dysmetria on FNF or HKS bilaterally. Slow finger
tapping
on R with less accuracy
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
___ 05:49PM K+-4.3
___ 03:26PM URINE HOURS-RANDOM
___ 03:26PM URINE HOURS-RANDOM
___ 03:26PM URINE UCG-NEG
___ 03:26PM URINE GR HOLD-HOLD
___ 03:26PM K+-9.4*
___ 03:26PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 02:00PM GLUCOSE-72 UREA N-12 CREAT-0.6 SODIUM-137
POTASSIUM-5.6* CHLORIDE-107 TOTAL CO2-20* ANION GAP-16
___ 02:00PM estGFR-Using this
___ 02:00PM WBC-8.8 RBC-3.82* HGB-11.8* HCT-37.2 MCV-97
MCH-30.9 MCHC-31.8 RDW-14.3
___ 02:00PM NEUTS-53.2 ___ MONOS-5.8 EOS-3.0
BASOS-1.1
___ 02:00PM PLT COUNT-283
___ 02:00PM ___ PTT-28.8 ___
CT head:
1. No CT evidence for acute intracranial process.
2. Punctate calcifications along the anterior frontal lobes,
left basal
ganglia, and right temporal lobe. The frontal calcifications
may be
extra-axial, but could be parenchymal. Punctate parenchymal
calcifications are nonspecific and could be seen in
neurocysticercosis or prior infection such as TB or TORCH
infections. Given patient's geographic background, correlation
with serology is recommended.
MRI brain: (prelim) no stroke or mass.
MRI cervical spine (prelim): degenerative changes
Medications on Admission:
- Bupropion 300 mg daily
- Alendronate 70 mg once a week in AM
- Folic acid 1 mg daily
- Ferrous sulfate 325 mg daily
- Vitamin D 1000 units daily
- Vitamin D 50,000 units once weekly
- Calcium carbonate- vitamin D 600 mg (1500 mg) - 400 unit twice
daily
- MVI Daily
Discharge Medications:
- Bupropion 300 mg daily
- Alendronate 70 mg once a week in AM
- Folic acid 1 mg daily
- Ferrous sulfate 325 mg daily
- Vitamin D 1000 units daily
- Vitamin D 50,000 units once weekly
- Calcium carbonate- vitamin D 600 mg (1500 mg) - 400 unit twice
daily
- MVI Daily
2. Outpatient Physical Therapy
DX: Cervical radiculopathy
please evaluate and treat
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical radiculopathy
Discharge Condition:
cranial nerves intact.
Delt Bic Tri WrE FFl IO IP Quad Ham TA ___
L 5- 5- 4+ 5 4+ ___ 5 5 5 5 5
R 4+ 5- 4+ 5 3+ ___ 5 5 5 5 5
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with left face and arm numbness and
dysdiadokinesis of the left arm.
TECHNIQUE: Axial CT images through the head were acquired without intravenous
contrast. Coronal, sagittal, and thin slice bone reconstructed images were
created and reviewed.
COMPARISON: None available.
FINDINGS:
There is no CT evidence for acute intracranial hemorrhage, large mass, mass
effect, edema, or hydrocephalus. There is preservation of gray-white matter
differentiation. The basal cisterns appear patent. The ventricles and sulci
are normal in caliber and configuration for patient's age. Punctate
calcifications are seen along the anterior frontal lobes bilaterally, left
basal ganglia and right temporal lobe. The visualized portions of the
paranasal sinuses and mastoid air cells appear well aerated. No acute bony
abnormality is detected.
IMPRESSION:
1. No CT evidence for acute intracranial process.
2. Punctate calcifications along the anterior frontal lobes, left basal
ganglia, and right temporal lobe. The frontal calcifications may be
extra-axial, but could be parenchymal. Punctate parenchymal calcifications are
nonspecific and could be seen in neurocysticercosis or prior infection such as
TB or TORCH infections. Given patient's geographic background, correlation
with serology is recommended.
Discussed with ___ Brown by ___ by phone at 7:15 p.m. on
___.
Radiology Report
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with multiple symptoms, left upper extremity
numbness, right upper extremity weakness, facial tingling, for further
evaluation to exclude stroke or other abnormalities.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion
axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal
images acquired following the administration of gadolinium. Correlation was
made with the head CT of ___.
FINDINGS: There is no hemorrhage, mass effect, midline shift or
hydrocephalus. There is no evidence of focal signal abnormalities within the
brain or acute infarct. The gray-white matter differentiation maintained.
The ventricles and extra-axial spaces are normal in size. Following
gadolinium, no evidence of abnormal parenchymal, vascular or meningeal
enhancement seen. The visualized sinuses are clear.
IMPRESSION: No significant abnormalities on MRI of the brain with and without
gadolinium.
Radiology Report
HISTORY: Multiple symptoms including left upper extremity numbness, right
upper extremity weakness, facial tingling, slow RAM on right.
COMPARISON: None available.
TECHNIQUE: Routine enhanced ___ MR of the cervical spine was performed
including axial T1 post-gadolinium, T2, gradient echo, as well as sagittal T1,
T2, STIR, and T1 post-gadolinium. Please note that this study became
available for interpretation on PACS on ___, although the original
images were acquired on ___.
FINDINGS: The cervical and upper thoracic vertebral body heights and
alignment are well maintained. No expansile or destructive osseous lesion is
identified. Mild posterior disc protrusions at the levels of C5/6 and C6/7
minimally indent the thecal sac. No significant spinal canal or neural
foraminal stenosis is identified. The spinal cord is normal in size and
signal characteristics. No epidural mass or collection is identified.
IMPRESSION: Mild posterior disc protrusions at C5/6 and C6/7. Otherwise,
unremarkable cervical spine MR.
___ wet read was entered into the system by Dr. ___ on ___ at 9:55 AM.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LEFT ARM AND FACE NUMBNESS
Diagnosed with SKIN SENSATION DISTURB
temperature: 97.1
heartrate: 56.0
resprate: 16.0
o2sat: 97.0
sbp: 123.0
dbp: 74.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a ___ year old female with no
significant stroke risk factors who presents with a subacute
presentation of left arm numbness (tingling) that progressed to
involve the back of her head, her face and tongue. She also had
a
sense of oscillopsia and lightheadedness.
The patient was admitted to the Neurology service. She had a CT
of the head which shows likely old neurocysticercosis infection.
She had an MRI of the brain and cervical cord which showed no
stroke and mild degenerative change. The patient's numbness and
weakness are most likely due to cervical radiculopathy. She was
discharged with outpatient ___ and to follow up in neurology
clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy, liver biopsy
History of Present Illness:
This is a ___ year old female with history of intermittent upper
abdominal pain and known gallstones. She presents after 1 day of
upper abdominal pain and nausea. She states that she had pain
most of the day prior to arrival, worst at 11pm, better at time
of evaluation. She does complain of some nausea that is
described more as stomach upset than feeling as though she will
have emesis. Denies fevers, chills, diarrhea, constipation.
She states she has had similar pain intermittently for the past
___ years but that it usually only lasts for 1 hour. Denies fatty
foods triggering episodes.
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, weakness, paresthesias,
vomiting, hematemesis, bloating, cramping, melena, BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary frequency, urgency
Past Medical History:
Past Medical History:
none
Past Surgical History:
none
Social History:
___
Family History:
Denies liver or gallbladder disease. Denies any cancer.
Physical Exam:
VS: Temp 98.6, HR 74, BP 114/58, RR 16, SpO2 100%RA
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-) LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: Soft, mildly tender to palpation incisionally,
non-distended. Incisions: clean, dry and intact, dressed and
closed with steristrips.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema.
Pertinent Results:
LIVER/GALLBLADDER ULTRASOUND (___):
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
2. Cholelithiasis without sonographic evidence of cholecystitis.
3. Patulous CBD measuring 7 mm though no gallstone is noted
within the
visualized common bile duct.
Medications on Admission:
None
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Doses
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*4 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) 1 mg PO Q6H:PRN pain
RX *hydromorphone 2 mg 0.5 (One half) tablet(s) by mouth every 6
hours Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Ibuprofen 600 mg PO Q8H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Symptomatic cholelithiasis
Transaminitis
Steatosis
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 right upper quadrant pain
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears echogenic. 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 7 mm.
GALLBLADDER: The gallbladder is not distended and does not have wall
thickening. Shadowing gallstones are again seen.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease and
more advanced liver disease including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. Cholelithiasis without sonographic evidence of cholecystitis.
3. Patulous CBD measuring 7 mm though no gallstone is noted within the
visualized common bile duct.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 9:09 AM, following wet-read change.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RUQ abdominal pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 97.4
heartrate: 82.0
resprate: 16.0
o2sat: 100.0
sbp: 137.0
dbp: 71.0
level of pain: 9
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed an echogenic liver
consistent with steatosis, cholelithiasis without sonographic
evidence of cholecystitis and a 7 mm with no gallstone
visualized. Her labwork was significant for transaminitis, which
was also seen ___ years ago.
The patient underwent laparoscopic cholecystectomy and liver
biopsy, 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 a
regular diet, on IV fluids, and oral oxycodone for pain control.
The patient was hemodynamically stable.
Pain was well controlled. The patient voided without problem.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Augmentin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old female who complains of ABD PAIN.
___ past medical history of hypertension presents with right
lower quadrant pain. Patient reports lack of energy and appetite
for several days. Yesterday, she began to develop crampy lower
abdominal pain and nausea. The pain is most severe in her right
lower quadrant. Today, pain improved the patient did develop
fever at home to 101. The patient has not vomited. She has no
chest pain or shortness of breath. Patient came in at ears fever
husband was concerned that she may have appendicitis. She has
not had diarrhea, black stools, bloody stools.
Past Medical History:
Low Ferritin
Hypothyroidism
L Scaphoid Fracture Managed with Casting
Social History:
___
Family History:
noncontributory
Physical Exam:
Temp: 98.2 HR: 95 BP: 128/67 Resp: 16O2 Sat: 98
Constitutional::Comfortable
Head / Eyes::Normocephalic, atraumatic
Chest/Resp::Clear to auscultation
Cardiovascular::Regular Rate and Rhythm, Normal first and second
heart sounds
GI / Abdominal::Soft, Nondistended. TTP in lower abdomen w/ pain
always radiating to RLQ. +guarding on RLQ.
GU/Flank::No costovertebral angle tenderness
Musc/Extr/Back::No cyanosis, clubbing or edema
Skin::No rash, Warm and dry
Neuro::Speech fluent
Psych::Normal mood, Normal mentation
Pertinent Results:
___ 04:40AM BLOOD WBC-10.1 RBC-4.26 Hgb-12.3 Hct-36.6
MCV-86 MCH-28.8 MCHC-33.5 RDW-12.9 Plt ___
___ 05:10AM BLOOD WBC-11.1* RBC-4.33 Hgb-12.7 Hct-37.0
MCV-85 MCH-29.3 MCHC-34.3 RDW-12.9 Plt ___
___ 01:48AM BLOOD WBC-10.1 RBC-3.94* Hgb-11.5* Hct-33.7*
MCV-86 MCH-29.2 MCHC-34.1 RDW-13.0 Plt ___
___ 04:07AM BLOOD WBC-14.2* RBC-4.48 Hgb-13.2 Hct-38.8
MCV-87 MCH-29.5 MCHC-34.1 RDW-13.0 Plt ___
___ 03:10AM BLOOD WBC-18.8*# RBC-5.06 Hgb-14.5 Hct-42.9
MCV-85 MCH-28.6 MCHC-33.8 RDW-13.0 Plt ___
___ 03:10AM BLOOD Neuts-84.2* Lymphs-8.5* Monos-6.7 Eos-0.3
Baso-0.2
___ 04:40AM BLOOD Plt ___
___ 05:10AM BLOOD Plt ___
___ 01:48AM BLOOD Plt ___
___ 01:48AM BLOOD ___ PTT-27.9 ___
___ 04:07AM BLOOD Plt ___
___ 04:40AM BLOOD Glucose-119* UreaN-12 Creat-0.7 Na-137
K-3.8 Cl-101 HCO3-30 AnGap-10
HCO3-27 AnGap-14
___ 04:07AM BLOOD CK(CPK)-22*
___ 03:10AM BLOOD ALT-17 AST-17 AlkPhos-57 TotBili-0.5
___ 04:07AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:40AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Restasis (cycloSPORINE) 0.05 % ___ BID
2. Clotrimazole 1% Vaginal Cream 1 Appl VG HS
3. Tirosint (levothyroxine) 75-100 mcg Oral qd
4. Vivelle-Dot (estradiol) 0.1 mg/24 hr Transdermal EVERY OTHER
DAY
5. Vivelle-Dot (estradiol) 0.0375 mg/24 hr Transdermal EVERY
OTHER DAY
6. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit Oral
tid
Discharge Medications:
1. Clotrimazole 1% Vaginal Cream 1 Appl VG HS
2. Restasis (cycloSPORINE) 0.05 % ___ BID
3. Tirosint (levothyroxine) 75-100 mcg Oral qd
4. Vivelle-Dot (estradiol) 0.1 mg/24 hr Transdermal EVERY OTHER
DAY
5. Vivelle-Dot (estradiol) 0.0375 mg/24 hr TRANSDERMAL EVERY
OTHER DAY
6. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*16 Tablet Refills:*0
8. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl [Cardizem CD] 180 mg 1 capsule,extended
release 24hr(s) by mouth once a day Disp #*30 Capsule Refills:*1
9. Docusate Sodium 100 mg PO BID
10. liothyronine (bulk) 1.2 mcg PO QAM
11. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*24 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 1 TAB PO BID:PRN constipation
14. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
Oral tid
Discharge Disposition:
Home
Discharge Diagnosis:
acute perforated appendicitis
atrial fibrillation with rapid ventricular response
Discharge Condition:
Medically stable
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of right lower quadrant pain, question appendicitis.
COMPARISONS: None.
TECHNIQUE: MDCT axial imaging was obtained from the lung bases to the pubic
symphysis following the administration of intravenous contrast material.
Coronal and sagittal reformats were completed.
DLP: 541.6 mGy-cm.
FINDINGS:
CT ABDOMEN WITH CONTRAST: The lung bases are clear. The visualized heart and
pericardium are unremarkable. The liver enhances homogenously without any
focal lesions or intra- or extra-hepatic 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 or focal lesions. The stomach, small and intra-abdominal
large bowel are unremarkable. The aorta and its major branches are patent.
The aorta is of normal caliber without evidence of aneurysm.
CT PELVIS: The appendix is hyperenhancing, dilated up to 11 mm and fluid
filled consistent with acute appendicitis. There are fecaliths both
proximally (2:53) and distally within the appendix (2:61). There is
significant fluid in the right lower quadrant with thickening of the cecum and
phlegmonous change, concerning for perforation. There is no drainable abscess
at this time.
The bladder, rectum and sigmoid colon are unremarkable. There are multiple
prominent right inguinal lymph nodes measuring up to 2 cm, likely reactive.
Patient is status post hysterectomy.
OSSEOUS STRUCTURES: There are no concerning osseous lesions.
IMPRESSION: Findings consistent with acute appendicitis with significant
phlegmonous change in the right lower quadrant potentially concerning for
early perforation. No drainable collection at this time.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 98.2
heartrate: 95.0
resprate: 16.0
o2sat: 98.0
sbp: 128.0
dbp: 67.0
level of pain: 5
level of acuity: 3.0 | This is an otherwise healthy ___ year old woman who was found in
the emergency department to have acute perforated appendicitis.
She was admited to observation where she was monitored and
treated medically for her abdominal infection. No surgery was
required. She was clinically stable and responded apporpriately
to antibiotics. She was found in the hospital to have no onset
Afib with RVR. The majority of her hospital stay was spent
managing this condition. The patient had low blood pressures at
baseline. We attempted to control her Afib with metroprolol but
it caused asymptomatic hypotension in the patient and it was
held. She was started on diltizem which was able to control her
Afib. Cardiology was consulted who said warfarin was not
required for ___ CHADS of 1. She was started on daily aspirin.
She tolerated diet well and was fully ambulatory and was
clinically able to meet all of her ADLs. She was discharged on
HD7 to home to finish out a 2 week course of antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Left distal tibia fracture
left ___ metatarsal fraction
Major Surgical or Invasive Procedure:
___: L Tibia IMN, ORIF L medial malleolus
History of Present Illness:
Ms. ___ is a ___ year old lady with HTN, MVP s/p repair ___ years
ago, OA s/p R THA admitted with L tibial and ___ metatarsal
fracture after mechanical fall s/p successful ORIF on
___, now with new onset asymptomatic afib with RVR (HR
100-120s).
Pt suffered mechanical fall down ___ steps to her basement on
___. She went to the ED at OSH where L tibial and ___
metatarsal fracture was noted. She was transferred to the ___
for further treatment.
Past Medical History:
PMH/PSH:
Hypertension.
Depression.
Asthma
Duodenal ulcer.
MVP c/b s/p MVR in ___
Osteoarthritis of the right hip s/p replacement.
She had dilatation and curettages in the ___.
Spinal L4-5 fusion in ___.
Right thumb surgery in ___.
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vitals: 98.3, 80, 157/80, 17, 94%RA
General: Unomfortable, no acute distress
HEENT: Normocephalic, atraumatic
Resp: No respiratory distress
CV: Regular Rate and Rhythm
Abd: Nondistended
MSK: No cyanosis, clubbing or edema, ___ ___ strength.
Skin: No rash, Warm and dry, No petechiae
Neuro: Cranial nerves II-XII grossly intact, speech fluent
Psych: Normal mood/mentation
Left lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft thigh and leg. Nontender thigh
- Full, painless AROM/PROM of hip. pain limited PROM of knee,
and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
DISCHARGE PHYSICAL EXAM:
=======================
VS: 98.2 BP:110-110s/67-78 HR: 80-101 R:18 96RA
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM
NECK: JVP difficult to assess ___ obese neck.
LUNGS: Decreased breath sounds left base, otherwise no w/r/r
HEART: irregularly, irregular. Normal s1 and s2.
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: Right ___: WWP, no edema. Left ___: Casted. Normal
sensory and motor.
NEURO: awake, A&Ox4
Pertinent Results:
ADMISSION LABS:
==============
___ 09:20PM GLUCOSE-108* UREA N-17 CREAT-1.0 SODIUM-140
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
___ 09:20PM estGFR-Using this
___ 09:20PM WBC-8.9 RBC-4.55 HGB-14.0 HCT-44.2# MCV-97#
MCH-30.8 MCHC-31.7* RDW-13.2 RDWSD-47.2*
___ 09:20PM NEUTS-73.3* LYMPHS-18.1* MONOS-6.9 EOS-0.8*
BASOS-0.6 IM ___ AbsNeut-6.50* AbsLymp-1.60 AbsMono-0.61
AbsEos-0.07 AbsBaso-0.05
___ 09:20PM PLT COUNT-249
___ 09:20PM ___ PTT-33.0 ___
MIRCO:
=====
UCx ___: Negative
INTERVAL LABS:
==============
___ 01:30PM BLOOD TSH-1.3
___ 01:30PM BLOOD proBNP-6348*
DISCHARGE LABS:
==============
___ 07:51AM BLOOD WBC-7.2 RBC-3.82* Hgb-12.0 Hct-37.6
MCV-98 MCH-31.4 MCHC-31.9* RDW-13.3 RDWSD-48.1* Plt ___
___ 07:51AM BLOOD Plt ___
___ 07:51AM BLOOD ___ PTT-35.5 ___
___ 07:51AM BLOOD Glucose-103* UreaN-15 Creat-0.8 Na-140
K-3.7 Cl-98 HCO3-31 AnGap-15
___ 07:51AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.3
IMAGING:
========
ECHO ___:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The estimated right atrial pressure is ___
mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
estimated cardiac index is normal (>=2.5L/min/m2). 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. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. A mitral valve annuloplasty
ring is present. The mitral annular ring appears well seated
with normal gradient. An eccentric, anteriorly directed jet of
mild (1+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be determined. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
IMPRESSION: Biatrial enlargement. Normal biventricular cavity
sizes with preserved regional and global biventricular systolic
function. Mild mitral regurgitation. Pulmonary artery diastolic
hypertension. Right ventricular free wall hypokinesis.
CXR ___:
IMPRESSION:
In comparison to ___ chest radiograph, cardiomegaly
is
accompanied by mild pulmonary vascular congestion and a
persistent small left pleural effusion. No new or worsening
pulmonary opacities to suggest the presence of ___
___ ___:
1. Spiral comminuted fracture of the distal tibial diaphysis,
subsequent internal fixation has been performed.
2. Vertically-oriented fracture through the medial malleolus
3. Transverse fracture through the base of fifth metatarsal
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PARoxetine 40 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Enoxaparin Sodium 30 mg SC Q12H atrial fibrillation bridge
to warfarin
Start: Today - ___, First Dose: Next Routine Administration
Time
d/c when INR ___
RX *enoxaparin 30 mg/0.3 mL ___very twelve (12) hours
Disp #*14 Syringe Refills:*0
3. Warfarin 2.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Metoprolol Succinate XL 100 mg PO BID
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
6. PARoxetine 40 mg PO DAILY
7.Outpatient Lab Work
Atrial fibrillation
INR draw ___ through ___ services. Please fax INR results to
___ c/o Dr. ___ on ___. Please call
___ (Dr. ___ if any issues with the above
fax number.
8.Rolling Walker
Diagnosis: left tibia fracture, ___ metatarsal fracture
Prognosis: Good
Length of Need: 13 days
9.boot
ICD-10 Diagnoses: S82.202A UNSPECIFIED FRACTURE OF SHAFT OF
LEFT TIBIA, INITIAL ENCOUNTER FOR CLOSED FRACTURE
Services requested: Prefabricated: Aircast Boot (Tall)
Wear brace (duration): 3 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Left tibia fracture
___ metatarsal fracture
Atrial Fibrillation
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: CHEST (PA AND LAT)
INDICATION: ___ with mechanical fall; l distal tibial fx, l ___ metatarsal
fx.
COMPARISON: Prior chest CT exam from ___
FINDINGS:
PA and lateral views of the chest provided. Lung volumes are low. Midline
sternotomy wires are noted. Allowing for low lung volumes, the lungs appear
clear without focal consolidation, large effusion or pneumothorax. No signs
of congestion or edema. The heart is upper limits of normal. Mediastinal
contours unremarkable. No bony abnormalities. No free air below the right
hemidiaphragm.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CT left lower extremity without contrast
INDICATION: ___ year old woman with comminuted left tibial fracture. //
evaluate for Pilon fracture, operative planning
TECHNIQUE: ___ MD CT imaging was performed through the left tibia and
fibula without intravenous contrast. Coronal and sagittal reformats were
produced and reviewed
DOSE: Acquisition sequence:
1) Spiral Acquisition 14.2 s, 30.3 cm; CTDIvol = 20.2 mGy (Body) DLP =
612.4 mGy-cm.
2) Spiral Acquisition 3.7 s, 28.9 cm; CTDIvol = 11.6 mGy (Body) DLP = 334.9
mGy-cm.
Total DLP (Body) = 947 mGy-cm.
COMPARISON: Left tibia and fibula ___. Intraoperative images ___
FINDINGS:
As seen on the prior studies. There is a comminuted fracture of the distal
tibia with a spiral fracture through the distal tibial diaphysis (401b:42)
with a large free fragments along the lateral tibia measuring approximately
6.3 cm craniocaudal dimension. This is minimally displaced. In addition
there is a vertically-oriented fracture through the medial malleolus
(401b:36). This extends the articular surface but does not significantly
displace it. The ankle mortise is congruent. No evidence of an osteochondral
lesion. Small well corticated ossific densities adjacent to the medial
malleolus likely reflect remote avulsion injuries.
There is also a fracture the base of the fifth metatarsal (402b:45), this
appears to be undisplaced.
Reformats of the knee were not performed, however no fracture is seen in the
proximal tibia are distal femur. There is a trace joint effusion. Limited
evaluation of the soft tissue structures does not demonstrate any significant
abnormality except no mild pretibial soft tissue edema.
IMPRESSION:
1. Spiral comminuted fracture of the distal tibial diaphysis, subsequent
internal fixation has been performed.
2. Vertically-oriented fracture through the medial malleolus
3. Transverse fracture through the base of fifth metatarsal
NOTIFICATION: Review of the electronic medical record indicates that the
orthopedic surgery service were where these findings at the time of CT.
Radiology Report
INDICATION: ___ year old woman with hypoxia // evaluate for pulmonary
congestion
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
Lung volumes are slightly low with linear left basilar opacity which is likely
atelectasis. The lungs are otherwise clear. Cardiac silhouette is top-normal
but likely accentuated by AP technique and low lung volumes. Median
sternotomy wires are intact. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: Intra op fluoroscopy, ORIF of left tibial fracture.
TECHNIQUE: Multiple fluoroscopic images obtained in the operating room
without a radiologist present. Total fluoroscopy time 77 seconds. Cumulative
dose 3.1 mGy.
COMPARISON: Correlation made to prior plain films from ___.
FINDINGS:
Orthopedic hardware is seen including intramedullary rod with transfixing
screws. Please see operative report for full details.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with tachycardia // please eval for PNA
IMPRESSION:
In comparison to ___ chest radiograph, cardiomegaly is
accompanied by mild pulmonary vascular congestion and a persistent small left
pleural effusion. No new or worsening pulmonary opacities to suggest the
presence of pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Leg injury, Transfer
Diagnosed with Displaced comminuted fracture of shaft of left tibia, init, Nondisp fx of fifth metatarsal bone, left foot, init, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: 98.3
heartrate: 80.0
resprate: 17.0
o2sat: 94.0
sbp: 157.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ w/ HTN, MVP s/p repair, OA s/p R THA admitted for mechanical
fall with L tibial and ___ metatarsal fracture:
#s/p mechanical fall
#left tibia fracture
#left ___ metatarsal fracture
The patient was found to have a left tibia fracture and was
taken to the operating room on ___ for left tibia IMN and ORIF
L medial malleolus which the patient tolerated well. She was
evaluated by ___ during hospital course and was discharged as
non-weight bearing LLE until re-eval as outpatient with boot
placement. At the time of discharge the patient's pain was well
controlled with oral medications (Tylenol only), incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. 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 ___ care. The patient expressed readiness
for discharge.
#Atrial fibrillation:
On POD 2 patient developed new onset atrial fibrillation with
RVR noted incidentally on telemetry and EKG. She remained
hemodynamically stable without symptoms. Potential causes for
her include volume overload/CHF, which is not unlikely given
cardiomegaly and vascular congestion on imaging, and elevated
proBNP. No current or recent ischemic event (Q waves noted in
the inferior leads in EKG are unchanged from many years prior).
TTE was done which showed biatrial enlargement with normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function. TTE also demonstrated mild
mitral regurgitation, pulmonary artery diastolic hypertension,
and right ventricular free wall hypokinesis. Other risk factors
for afib include obesity w/ likely OSA, hx of MVR, and
catecholamine surge post operatively. TSH normal. She has an
CHADS2-Vasc2 score of ___ (HFpEF, HTN, female, age ___,
making her high risk (4% annual risk of stroke) requiring
anticoagulation. Given her history of GI bleed and recent
surgery, warfarin was initiated for reversibility compared to
NOACs. Patient discharged on warfarin 2.5 mg daily with lovenox
bridge (goal INR ___. Patient will have long term ___ for
INR w/ cardiologist (Dr. ___. Rate control was achieved with
metoprolol mg q6hr and patient was ultimately discharged on
metoprolol XL 100 mg BID.
#Pleural Effusion:
Patient was noted to have left lower lobe pleural effusion on
CXR. This was thought to be ___ volume overload iso HFpEF vs.
___ post-surgical atelectasis. Patient was given 20 mg IV lasix
w/ -2L fluid off. The patient was noted to have normal oxygen
saturation prior to discharge.
#Orthostatic Hypotension: Patient diuresed for c/f for volume
overload iso of cough/desaturation not responsive to
bronchodilators. CXR c/f vascular congestion. Patient given 20
mg IV lasix with -2 L net negative. Upon working with ___ the
following day, she was orthostastic. It was recommended that she
stay in the hospital until this resolved because of the risk of
falls and injuries. She expressed understanding of the risk of
falls and injuries, but still insisted on leaving against
medical advise. Patient agreed to fluids prior to discharge.
Orthostatics vital signs improved, but patient still refused
further monitoring and further fluids. She continued to express
understanding of risks of leaving AMA. Patient was instructed to
avoid stairs, but to have help if she needed to use stairs. She
was also educated regarding using a walker/table to stabilize
herself when going from seated/laying to standing position.
---------------
CHRONIC ISSUES:
---------------
# HTN: Stabilized on metoprolol 100 mg XL by outpatient
cardiologist. Uptitrated to 100 mg XL BID for better rate
control.
#Depression/Anxiety: Patient had anxiety during hospital stay
requiring a dose of Ativan. She has a history of depression
treated with Paroxetine at home; however, this was not restarted
on admission initially. Withdrawal effect from Paroxetine may
have contributed to anxiety. Patient's anxiety was also
exacerbated by a patient sharing the room with her who was
suffering from delirium and agitation. Patient's home Paroxetine
was resumed.
# HLD: Continued Atorvastatin 40 mg PO/NG QPM
-------------------- |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
codeine / Penicillins / Percocet / lidocaine / latex / Demerol /
fentanyl
Attending: ___.
Chief Complaint:
vision changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a ___ year old woman with a history of prior
unruptured brain aneurysm clipping in ___ with subsequent
CSF leak that was repaired, h/o migraine with aura, p/w
transient
visual symptoms. She was at a medical office setting up some
referral appointments and chatting with the receptionist when
she
suddenly had onset of a very abnormal feeling in her L eye. She
describes it as feeling as if she is dizzy or lightheaded INSIDE
her L eye. She also describes that she had flickering of her L
eye vision with light/dark alternation, "like sunshine
flickering
through leaves". This affected her whole vision at once and did
not seem to move from one part of her visual field to another.
This went on for 45 minutes to an hour and then resolved. She
tried covering one eye and then the other, and she said that the
phemonon was only in her L eye, but her R eye vision seemed a
bit
blurry or cloudy.
Since the visual phenomenon the patient has felt somewhat dizzy
and lightheaded, no vertigo. The dizziness comes on when she
sits
up. She also felt somewhat unbalanced associated with the
dizziness.
At the OSH the patient had a headache which came on suddently
when the nurse was trying to place an IV which sounded somewhat
traumatic. The pain was ___ and the patinet got morphine and it
got better. The headache felt like a circle inside her head on
the R side, and was thick and pressure like and constant.
Of note, the patient had some high fevers last week ___ to
103-105 per her report. This occurred after a cervical biopsy.
She was told she might have a UTI and treated with antibiotics.
She was later told she had Hepatitis A. She was briefly
hospitalized on ___ for 13 hours and then discharged. She
says she was given a course of antibiotics but does not remember
what that was and she is now done with it.
Of note the patinet has been experiencing gradually worsening
neck pain and spasms over the last weeks to months and was
schedueld to get an MRA of her neck today.
On neurologic review of systems, the patient Denies difficulty
with producing or comprehending speech.
Denies diplopia, vertigo
Denies muscle weakness.
Denies loss of sensation.
Denies bowel or bladder incontinence or retention, although she
does endorse stress urinary incontinence.
Denies difficulty with gait.
She endorses occasional feelings of de ___, and frequently
being able to smell things that other people cant smell although
she things she just has a sensitive sense of smell. These smells
can be a scent of flowers, or cat litter, or the smell of a dead
animal under her porch.
On general review of systems, the patient says she sometimes
feels flushed and feverish at night,
Denies stiff neck.
Denies chest pain, palpitations, dyspnea, or cough.
Endorses daily vomiting which is her baseline, diarrhea.
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
PMH/PSH: per patient report
- history of prior unruptured brain aneurysm clipping in ___
with subsequent CSF leak that was repaired
- h/o headaches with aura (squiggly lines on both sides of her
vision)
- recently worsening neck pain and spasms in the last several
weeks-months
- Hep A diagnosed on ___
- IBS
- fibromyalgia
- depression, anxiety
- asthma
- episodes of tachycardia, which she says are not afib
- elevated iron levels
- liver nodule
Social History:
___
Family History:
Aunt - brain aneurysm
Physical Exam:
VS 97.6 87 145/81 18 99% RA
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, there is +++ neck spasm and subsequent limited
ROM.
The patient does not otherwise seem meningitic or overly
sensitive to lights.
Abdomen: ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status -
Awake, alert, oriented x 3. Attention to examiner easily
attained
and maintained. Concentration maintained when recalling months
backwards. Recalls a coherent history. Structure of speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No dysarthria.
- Cranial Nerves -
I. not tested
II. L pupil 2 mm with trace irregularity. R pupil 1.75 mm and
circular. Both are reactive to light. It was very difficult to
see her fundus on direct examination due to small pupils. Visual
acuity ___ on the R and ___ on the L. VFF to color
desaturation.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus.
V. facial sensation was intact, muscles of mastication with full
strength
VII. face was symmetric with full strength of facial muscles.
There is mild L NLF flattening but the patient says this is her
baseline when looking in a mirror.
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Muscule bulk and tone were normal. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR FExt Fflx IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Intact to light touch and proprioception throughout.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response flexor bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally. Good speed
and intact cadence with rapid alternating movements.
- Gait -
Gait is hesitant. + Rhomberg
Discharge exam:
Improved gait otherwise exam as above
Pertinent Results:
___ 01:10PM BLOOD WBC-6.6 RBC-3.81* Hgb-12.7 Hct-40.5
MCV-106* MCH-33.4* MCHC-31.4 RDW-13.9 Plt ___
___ 05:05PM BLOOD WBC-6.1 RBC-3.54* Hgb-11.6* Hct-37.3
MCV-106* MCH-32.8* MCHC-31.1 RDW-14.0 Plt ___
___ 01:10PM BLOOD ___ PTT-31.7 ___
___ 01:10PM BLOOD ACA IgG-PND ACA IgM-PND
___ 01:10PM BLOOD AT-119 ProtCFn-PND ProtSFn-PND
___ 01:10PM BLOOD Lupus-PND
___ 01:10PM BLOOD Glucose-101* UreaN-9 Creat-0.5 Na-137
K-4.9 Cl-103 HCO3-26 AnGap-13
___ 05:05PM BLOOD ALT-66* AST-54* AlkPhos-235* TotBili-0.4
___ 12:00PM BLOOD ALT-71* AST-54* AlkPhos-239* TotBili-0.6
___ 05:05PM BLOOD Calcium-9.0 Phos-4.9* Mg-1.7 Cholest-164
___ 05:05PM BLOOD %HbA1c-5.7 eAG-117
___ 05:05PM BLOOD Triglyc-115 HDL-44 CHOL/HD-3.7 LDLcalc-97
___ 05:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:10PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
MRI brain with and without contrast
FINDINGS:
There is a right para clinoid aneurysm clip. There is mild
gliosis in the
right temporal lobe which may be related to prior surgery or
ischemia. There
are changes on the right pterional craniotomy. No pathologic
enhancement is
noted. There is no evidence for acute ischemia or hydrocephalus.
Intracranial flow voids are maintained. Visualized paranasal
sinuses and
mastoid air cells are clear.
IMPRESSION:
No acute changes. Sequela of prior presumed aneurysm surgery.
TTE: The left atrium is elongated. 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 thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
Medications on Admission:
per atrius records. Patient reports she takes paxil
20 and dilt 240 BID but this conflicts with atrius records. Also
patient does not seem to know the names of her medications very
well. Need to reconfirm with pharamcy in the AM.
- diazepam 5 mg Oral tablet Take ___ tablets as need for
anxiety/sleep
- PARoxetine 30 mg Oral tablet Take 1 tablet daily do not stop
without consulting clinician
- lidocaine (LIDODERM) 5 %(700 mg/patch) Topical Adhesive Patch,
Medicated Apply 1 patch daily to painful area for up to a
maximum
of 12 hours per day
- diltiazem (CARDIZEM CD) 240 mg Oral capsule,extended release
24hr SR 24 Hr Take 1 capsule daily PRESCRIBED BY CARDIOLOGY
- omeprazole (PRILOSEC) 20 mg Oral capsule,delayed
___
Take 1 capsule daily 30 minutes before first meal of day
- Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Inhalation Solution
for Nebulization Use 1 ampule (3mL) every four to six hours as
needed for asthma symptoms
- Budesonide-Formoterol (SYMBICORT) 160-4.5 mcg/actuation
Inhalation HFA Aerosol Inhaler Use 2 inhalations twice daily and
rinse your mouth thoroughly afterward
- Epinephrine (EPIPEN) 0.3 mg/0.3 mL Intramuscular Pen Injector
use as needed for life threatening nut allergy
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour Apply patch daily daily Disp #*14
Patch Refills:*0
4. Paroxetine 30 mg PO DAILY
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache/pain Duration: 10
Days
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hr Disp #*15
Tablet Refills:*0
6. Cyclobenzaprine 10 mg PO ONCE neck pain Duration: 1 Dose
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth every 6hr Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Retinal Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with amaurosis fugax // ?stroke
TECHNIQUE: Routine MRI of the brain without and with intravenous gadolinium.
COMPARISON: ___
FINDINGS:
There is a right para clinoid aneurysm clip. There is mild gliosis in the
right temporal lobe which may be related to prior surgery or ischemia. There
are changes on the right pterional craniotomy. No pathologic enhancement is
noted. There is no evidence for acute ischemia or hydrocephalus.
Intracranial flow voids are maintained. Visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION:
No acute changes. Sequela of prior presumed aneurysm surgery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Vision changes, Neck pain
Diagnosed with VISUAL DISTURBANCES NEC
temperature: 97.6
heartrate: 87.0
resprate: 18.0
o2sat: 99.0
sbp: 145.0
dbp: 81.0
level of pain: 5
level of acuity: 2.0 | Upon further interviewing during the hospitalization, the
following information was obtained by Dr. ___. "She was at a
medical office when she
noticed a dark shade come down over her left eye's field of
vision from the top to the bottom. This shade descended over
seconds and stayed for several seconds. She is not clear on the
pattern with which the shade went away. She did close one eye at
a time and confirmed that it was the left eye that was affeted.
Once her vision returned, she also had a sensation of a black
area closing in on her left eye's field of vision. There was a
pressure and "lightheadedness" behind her left eye.
The temporary loss of vision of the left eye due to a shade
descending occurred eight to ten times. It happened ___ times
while she was walking down the hallway of the office, and then
again several times while she was sitting down. These episodes
occurred over one hour."
She was not considered to be at risk for temporal arteritis. ESR
and CRP were within normal limits. She had intact temporal
artery pulses bilaterally. Optho was consulted and she was found
to have a normal exam without evidence of intraocular pathology.
Her vision disturbances were not thought to be related to the
right paraclinoid ICA aneurysm. Neurosurgery was also consulted
regarding this right paraclinoid ICA aneurysm but no
intervention was needed. MRI brain did not show evidence of a
stroke. Echo did not show evidence of PFO or cause for emboli to
cause a TIA. A limited hypercoagulable panel and sent and was
still pending at the time of hospital discharge. Overall it was
felt that the transient loss of vision of the left eye could be
a retinal migraine. Transient monocular vision loss due to
thrombosis was thought to be less likely.
She was recommended to continue aspirin 81mg daily for now for
protection against the possibility of thrombosis and TMVL. She
was encouraged to cease smoking cigarettes. She was given a
nicotine patch.
She had right sided severe neck pain that was non radiating.
This neck pain may possibly due to degenerative cervical disc
disease and muscle spasm. She was given tramadol, flexeril, and
a lidocaine patch which were helpful. She did not feel that a
soft cervical collar was helpful. She should follow up with her
outpatient provider for continued evaluation and management of
the right sided neck pain and to obtain rescheduling of her MRI
cervical spine. |
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, abd pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o female recently diagnosed with infectious mononucleosis
presenting with fevers, abdominal pain and weakness.
Ms. ___ states that her symptoms started with a headache 6
days ago, which improved with Excedrin migraine. On the
following
day, she noted a fever and began feeling generally unwell. Then
4
days ago she developed additional symptoms of fluctuating fever
___ highest measured at home) with chills, night sweats, sore
throat, fatigue with weakness, and nausea and vomiting. She
states that for the past 2 days she has had difficult keeping
food down and has vomited 4 times. The vomit looks like whatever
she recently tried eating. Around the same time, Ms. ___
developed abdominal pain which she localizes to the
infra-umbilical region and describes as a ___ dull pain.
Nothing
makes this pain better and pushing on it makes it worse. Denies
any recent trauma to the abdomen. She went to partners urgent
care 2 days ago where she was diagnosed with infectious
mononucleosis. She states that one of her roommates was
diagnosed
with mono in ___.
On arrival to the ED, pt was febrile to 102, tachy to 125, SBP
of
95 and Sats 100% on RA. Labs were notable for leukopenia and
thrombocytopenia to ___, AST/ALT in 500s, Tbili of 3.8 and
lactate of 2.3. Pt was given ___ of IVF, Tylenol, Toradol and
underwent a RUQ u/s that did not reveal any biliary dilation and
showed a decompressed GB with mild wall thickening. Monospot
returned positive and repeat labs show drop in hgb from 13.9
->11.8. Lactate came down to 1.3. Repeat LFTs notable for LDH
of 753. Tbili of 3.3, D bili 2.8 and haptoglobin pending.
ROS: Positive for constipation- patient states last bowel
movement was 5 days ago and describes her normal as ___ bowel
movements daily. Denies any difficultly breathing, recent
changes
in weight or burning with urination. 10 point ROS reviewed and
otherwise negative.
Past Medical History:
Factor V Leiden (diagnosed with genetic screen after an uncle
experienced complications during an operation)
Home Medications:
Nexplanon implant
Allergies: NKDA
Social Hx:
Third year health ___ major at ___.
Lives with two female roommates in an off-campus apartment
Endorses ___ drinks ___ per week.
Denies tobacco use
Endorses infrequent marijuana use. No other recreational drugs.
Currently sexually active with last sexually activity ___
months ago. Endorses regularly using condoms. Denies any history
of STIs, but states that she recently went to the dermatologist
to have what may be a wart removed, but said the diagnosis has
yet to be confirmed. Counseled on safe sex practices.
Family Hx
Uncle and Father with Factor V ___.
Mother and ___ Grandmother with ___ syndrome.
ADMISSION PE:
VITALS: ___ 0827 Temp: 99.1 BP: 101/70 HR: 106 RR: 18 O2
sat: 95% O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Oropharynx with cobbling and erythema. Tonsils are enlarged
bilaterally with exudate.
CV: Heart regular rate; normal perfusion
RESP: Symmetric breathing pattern with no stridor. Breathing is
non-labored. Clear to auscultation bilaterally.
GI: Abdomen soft, non-distended, liver is palpable below the rib
margin. Tenderness to light and deep palpation in the left lower
quadrant and intra-umbilical region. Negative Murphys sign.
MSK: Neck supple, normal muscle bulk and tone
SKIN: No rashes or ulcerations noted. No petechiae.
NEURO: Alert, oriented, face symmetric speech fluent, moves all
limbs, sensation to light touch grossly intact throughout
PSYCH: normal thought content, logical thought process,
appropriate affect
Past Medical History:
See HPI
Social History:
___
Family History:
See HPI
Physical Exam:
DISCHARGE:
=========
Temp: 99.9 PO BP: 95/59 HR: 112 RR: 18 O2 sat: 96% O2 delivery:
RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Oropharynx with cobbling and erythema. Tonsils are enlarged
bilaterally with exudate.
CV: Heart regular rate; normal perfusion
RESP: Symmetric breathing pattern with no stridor. Breathing is
non-labored. Clear to auscultation bilaterally.
GI: Abdomen soft, non-distended, liver is palpable below the rib
margin. Tenderness to light and deep palpation in the left lower
quadrant and intra-umbilical region. Negative Murphys sign.
MSK: Neck supple, normal muscle bulk and tone
SKIN: No rashes or ulcerations noted. No petechiae.
NEURO: Alert, oriented, face symmetric speech fluent, moves all
limbs, sensation to light touch grossly intact throughout
PSYCH: normal thought content, logical thought process,
appropriate affect
Pertinent Results:
ADMISSION LABS:
=============
WBC 3.5 (50% neuts) Hbg 11.8 Hct 35.5 Plt 71
BUN 4 Creat 0.7 Na 137 K 3.9 Cl 106 HCO3 19 AnGap 12
___ 13.6 PTT 21.0 INR 1.3
ALT 408 AST 461 AP 262 LDH 753 T bili 3.3 Dbili 2.8 Alb 3.0
TIBC 151 Hapto ___ Ferritin 1038 TRF 116
Lactate 2.3-->1.3
MICRO:
=====
Monospot: Positive
Urine Analysis: Negative for blood, nitrites, and leuks.
Positive for Ketones (10).
IMAGING/OTHER STUDIES:
====================
RUQ u/s 1. No evidence of gallstones or
intrahepatic/extrahepatic biliary ductal dilatation.
2. Markedly decompressed gallbladder demonstrating mild wall
thickening.
LABS ON DISCHARGE:
================
___ 06:44AM BLOOD WBC-6.9 RBC-3.92 Hgb-11.9 Hct-34.6 MCV-88
MCH-30.4 MCHC-34.4 RDW-13.4 RDWSD-43.5 Plt Ct-97*
___ 06:44AM BLOOD Glucose-88 UreaN-5* Creat-0.8 Na-133*
K-4.2 Cl-98 HCO3-25 AnGap-10
___ 06:44AM BLOOD ALT-480* AST-408* AlkPhos-348*
TotBili-4.6*
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# acute EBV Mononucleosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SPLEEN ULTRASOUND
INDICATION: ___ year old woman with infectious mononucleosis complaining of
left lower quadrant pain.// Is there evidence of splenomegaly?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the spleen were
obtained.
COMPARISON: Ultrasound abdomen from yesterday.
FINDINGS:
Limited examination of the spleen was performed. The parenchyma is
homogeneous and within normal limits. The spleen measures up to 13.4 cm and
appears mildly bulbous. This is likely unchanged from yesterday allowing for
slight differences in measurement technique.
IMPRESSION:
Spleen is mildly enlarged.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Fever
Diagnosed with Infectious mononucleosis, unspecified without complication
temperature: 102.1
heartrate: 125.0
resprate: 17.0
o2sat: 99.0
sbp: 95.0
dbp: 81.0
level of pain: 5
level of acuity: 3.0 | ___ with acute EBV presenting with fever and abdominal pain,
admitted for ongoing supportive care.
# Acute EBV "Mononucleosis"
Presented with fever, Abdominal Pain Sore throat and fatigue
with positive monospot and contact with roommate who recently
had mono. No concern for major complications such as splenic
rupture or airway compromise from tonsilitis. Noted to have
cholestatic hepatitis . Treated with supportive care including
IVF and antipyretics. Patients able to tolerate PO prior to
discharge.
# Abnormal LFTs:
Cholestatic hepatitis due to acute EBV infection. RUQ-US without
stones or biliary obstruction. No concern for acute liver
failure. LFTs elevated but stable at time of discharge.
> 30 mins spent in discharge planning. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Trilisate / vancomycin / ciprofloxacin
Attending: ___.
Chief Complaint:
non-healing ulcer
Major Surgical or Invasive Procedure:
Bone Biopsy ___
History of Present Illness:
___ M with quadriplegia, DM2, non-healing R decubital ulcer
found to have osteomyelitis on CT ___ in context of rising
ESR/CRP, admitted for further workup. Nursing home contacted ID
here who recommended deep culture from pelvic bone, possible
debridement, flap closure by plastic surgery, prolonged
antibiotic(s). Patient reports that this ulcer has been an issue
for the past ___ years.
Of note, patient admitted ___ with GBS bactermia and
discharged on 6 week course of penicillin G.
In the ED initial vitals were: 97.2 78 118/62 16 97% RA
- Labs were significant for WBC 2.2 (4.4% eos), Plts 39, ESR
109, CRP 17.7. Lactate 2.1. FSG 415->323.
- Patient was given 1L NS.
On the floor, patient denies fevers, chills, nightsweats. Does
report cough which he attributes to post-nasal drip.
Past Medical History:
# Quadraplegia, C4/C5 work related injury ___ years ago
# Constipation, chronic
# h/o Heart failure, echo ___ with EF 75%, likely diastolic
# SCC lung (poorly differentiated carcinoma with squamous
differentiation of the left upper lobe of the lung - s/p
Cyberknife therapy)
# COPD
# DM2
# EtOH abuse, none for ___ years
# Cirrhosis w/ occassional ascites, splenomegaly and
thrombocytopenia
# Suprapubic cath-h/o MRSA uti and pseudomonas UTI
# h/o SBO ___, conservatively managed per
surgery(NGT/NPO/enemas)
# h/o peritonitis years ago s/p laparotomy/washout, complicated
extended course (liver/renal/pulm failure)
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals - T: 98.4 BP: 156/71 HR: 100 RR: 16 02 sat: 98%/RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition,
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended but soft, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly appreciated
EXTREMITIES: contractures of bilateral upper extremities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: ecchymosis of second toe on L foot. 2cm deep ulceration
with packing material of R ischial area. some surrounding
hyperpigmentation, but no warmth, does not appear cellulitic.
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98.3 120-140s/40-60s (127/50) 80-90s (83) 18 98/RA
I&Os: ___
GENERAL: Elderly male, lying in bed in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended/obese but soft, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
appreciated
EXTREMITIES: Contractures of bilateral upper extremities, no
c/c/e
NEURO: A&Ox3, CN II-XII grossly intact
SKIN: Ecchymosis of second toe on L foot. Bandage of ulcer site
appears c/d/i. Some surrounding hyperpigmentation wound site,
but no warmth or erythema to suggest cellulitis
Pertinent Results:
ADMISSION LABS:
===============
___ 06:00AM BLOOD WBC-3.1* RBC-4.08* Hgb-12.2* Hct-40.4
MCV-99* MCH-29.9 MCHC-30.2* RDW-15.9* Plt Ct-46*
___ 04:50AM BLOOD WBC-2.6* RBC-3.96* Hgb-11.9* Hct-38.7*
MCV-98 MCH-30.1 MCHC-30.8* RDW-15.7* Plt Ct-45*
___ 12:30PM BLOOD WBC-2.2* RBC-4.03* Hgb-12.2* Hct-38.8*
MCV-96 MCH-30.4 MCHC-31.5 RDW-15.5 Plt Ct-39*
___ 04:50AM BLOOD ___ PTT-35.0 ___
___ 06:00AM BLOOD ___ PTT-32.9 ___
___ 12:30PM BLOOD ESR-109*
___ 12:30PM BLOOD Glucose-396* UreaN-29* Creat-0.6 Na-133
K-4.7 Cl-98 HCO3-27 AnGap-13
___ 04:50AM BLOOD Glucose-415* UreaN-27* Creat-0.7 Na-129*
K-4.3 Cl-97 HCO3-27 AnGap-9
___ 06:00AM BLOOD Glucose-227* UreaN-25* Creat-0.7 Na-137
K-4.2 Cl-103 HCO3-27 AnGap-11
___ 04:50AM BLOOD ALT-39 AST-60* AlkPhos-87 TotBili-0.4
___ 04:50AM BLOOD Albumin-3.0* Calcium-8.9 Phos-3.1 Mg-1.9
___ 06:00AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0
___ 05:58AM BLOOD %HbA1c-9.2* eAG-217*
___ 12:30PM BLOOD Acetone-NEGATIVE
___ 12:30PM BLOOD CRP-17.7*
___ 12:43PM BLOOD Lactate-2.1* Na-133 K-4.6 Cl-96
calHCO3-26
DISCHARGE LABS:
===============
___ 06:00AM BLOOD WBC-2.7* RBC-3.68* Hgb-11.0* Hct-36.1*
MCV-98 MCH-29.8 MCHC-30.4* RDW-15.7* Plt Ct-45*
___ 06:00AM BLOOD Plt Ct-45*
___ 06:00AM BLOOD Glucose-195* UreaN-15 Creat-0.5 Na-135
K-3.8 Cl-103 HCO3-25 AnGap-11
IMAGING:
========
X-ray Pelvis (___)
Erosive changes centered at the right ischial tuberosity similar
to CT scan from one week prior concerning for osteomyelitis.
CT Pelvis (___)
Again noted is a large decubitus ulcer with phlegmonous change
and multiple air locules extending from the right buttock up to
the right ischium. The area soft tissue abnormality has mildly
increased in size since ___, now measuring 3.8 x 3.3 cm
(previously 3.8 x 2.7 cm). Interval increase since ___ in
hair-on-end periosteal new bone formation along the anterior
ischium (04:109) with cortical disruption and irregularity along
the posterior ischium with associated ischial sclerosis and
erosive destruction concerning for acute on chronic
osteomyelitis. This is seen been recent bony debridement to
account for the absence of cortex along the posterior surface of
the ischial tuberosity. Note is made of a small focus of
moderate the calcification to the right of the phlegmon (4:113).
Calcifications posterior to the left SI joint presumably
represent injection granulomas are noted (4: 53). Dystrophic
calcifications are also seen about the left hip --? Within it
(4:86, 4:93). Moderate to severe degenerative
changes is seen at the hip joints and lower lumbar spine.
Limited assessment of the abdomen is grossly unremarkable.
Visualized small
bowel and colon are within normal limits without mucosal
thickening, fat stranding, or obstruction. The appendix is
normal without evidence of acute appendicitis. Partially
visualized right kidney is notable for interval increase in
right lower pole 3.4 x 3.2 cm (previously 2.3 x 2.4 cm) cystic
lesion. Dense atherosclerotic calcification is seen throughout
the abdominal aorta and iliac arteries bilaterally. Again seen
is a suprapubic catheter with balloon in the fundus of urinary
bladder. No free fluid or free air in the pelvis. No pelvic
sidewall or inguinal lymph known enlargement by cross-sectional
imaging criteria.
IMPRESSION:
1. Findings concerning for acute on chronic right ischium
osteomyelitis with mild increase in phlegmonous change with air
loculations from a large right buttock to ischium decubitus
ulcer. Has there been a recent history of debridement that could
account for the bony defect along the posterior edge of the
right ischium? No separate subcutaneous emphysema.
MICROBIOLOGY:
==============
___ 4:00 pm TISSUE SOURCE: RIGHT ISCHIUM BIOPSY.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Preliminary):
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Preliminary):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID pain/fever
2. Baclofen 10 mg PO QAM
3. Baclofen 20 mg PO Q6PM
4. Baclofen 30 mg PO HS
5. Baclofen 40 mg PO QNOON
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO EVERY OTHER DAY
8. Miconazole Powder 2% 1 Appl TP BID
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
10. Ascorbic Acid ___ mg PO BID
11. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral daily
12. Carbamide Peroxide 6.5% 4 DROP AU TWICE WEEKLY
13. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 140-100 mg oral daily
14. Diazepam 5 mg PO HS
15. Fluticasone Propionate NASAL 1 SPRY NU HS
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Natural Balance (artificial tear (hypromellose)) 0.4 %
ophthalmic daily
18. Omeprazole 20 mg PO DAILY
19. Prochlorperazine 10 mg PO Q8H:PRN nausea
20. Senna 17.2 mg PO EVERY OTHER DAY
21. TraMADOL (Ultram) 50 mg PO BID:PRN pain
22. Vitamin A 10,000 UNIT PO DAILY
23. Glargine 70 Units Bedtime
novolog 22 Units Breakfast
novolog 22 Units Lunch
novolog 22 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
24. Bisacodyl 10 mg PR HS
25. Ranitidine 150 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO BID pain/fever
2. Ascorbic Acid ___ mg PO BID
3. Baclofen 10 mg PO QAM
4. Baclofen 20 mg PO Q6PM
5. Baclofen 30 mg PO HS
6. Baclofen 40 mg PO QNOON
7. Bisacodyl 10 mg PR HS
8. Diazepam 5 mg PO HS
9. Fluticasone Propionate NASAL 1 SPRY NU HS
10. Glargine 70 Units Bedtime
novolog 22 Units Breakfast
novolog 22 Units Lunch
novolog 22 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. Prochlorperazine 10 mg PO Q8H:PRN nausea
15. Senna 8.6 mg PO EVERY OTHER DAY
16. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
17. TraMADOL (Ultram) 50 mg PO BID:PRN pain
18. Vitamin A 10,000 UNIT PO DAILY
19. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral daily
20. Carbamide Peroxide 6.5% 4 DROP AU TWICE WEEKLY
21. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 140-100 mg oral daily
22. Miconazole Powder 2% 1 Appl TP BID
23. Natural Balance (artificial tear (hypromellose)) 0.4 %
ophthalmic daily
24. Senna 17.2 mg PO EVERY OTHER DAY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right Ischial Ulcer
Type 2 Diabetes
Right Calf Lesion concerning for Squamous Cell Carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
PELVIS AND RIGHT HIP FILMS: ___
HISTORY: ___ male with chronic right ischial ulcer. Question
osteomyelitis.
FINDINGS: AP view of the pelvis and AP and frogleg views of the right hip.
Comparison is made to CT pelvis from ___.
Exam is limited secondary to patient's body habitus and diffuse osteopenia.
However, when compared to most recent CT scan, again seen is mixed sclerosis
with erosive changes centered at the right ischial tuberosity concerning for
osteomyelitis. Severe bilateral degenerative changes seen at the
femoroacetabular joints. Pubic symphysis is unremarkable. SI joints are not
well assessed. Calcifications projecting over the sacrum on the left were
seen in the posterior soft tissues on prior CT scan.
IMPRESSION: Erosive changes centered at the right ischial tuberosity similar
to CT scan from one week prior concerning for osteomyelitis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hyperglycemia
Diagnosed with AC OSTEOMYELITIS-PELVIS
temperature: 97.2
heartrate: 78.0
resprate: 16.0
o2sat: 97.0
sbp: 118.0
dbp: 62.0
level of pain: 13
level of acuity: 2.0 | ___ y/o M with quadriplegia, cirrhosis, DM2, history of
osteomyelitis admitted with recent CT imaging indicating
possible acute on chronic osteomyelitis for planned bone biopsy
with further management to be coordinated with ID and plastic
surgery as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension and hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with history of DM2, hypothyroidism,
HTN, DVT LLE ___, IBD s/p distant colectomy, abscess ___
___ s/p repeat colectomy and small bowel resection at ___
___ bleed, PICC-associated DVT's and PE's who presented
for hypotension and hypoglycemia.
She was recently admitted to the ___ service from ___ for
purulent drainage from her midline incision, which grew MRSA.
She was transitioned from Vancomycin to Bactrim to Cephalexin
with plan for an additional 11 days of treatment after
discharge. She had urinary retention >600 requiring that
persisted despite straight cath x 2 and she ultimately required
a foley.
During this admission she grew E. coli from the urine on ___,
MSSA from the blood on ___, and mixed bacterial flora and MRSA
from the wound on ___.
Since discharge she has been at ___ at ___.
History is difficult to obtain from the patient. She responds "I
hurt all over" when asked about pain.
___ the ED, initial vitals 97.4, 114, 72/39, 18, 99% RA.
Labs were significant for FSBG 66 on presentation, INR 6.8, K
5.8, UA with >182 WBC with negative nitrites, leukocytosis to
34.
Imaging was significant for: CT abdomen pelvis with 1. Right
lower lobe pneumonia; 2. Interval opening of a abscess ___ the
subcutaneous tissues of the lower anterior abdominal wall, with
no significant residual fluid; 3. Cholelithiasis, with no
evidence of acute cholecystitis; 4. Trace pericardial effusion
is slightly increased from prior; 5. Diffuse anasarca.
Past Medical History:
PMH:
IBD (unclear UC vs. Crohns ___ years ago), DM2, Hypothyroid, HTN
DVT LLE ___
PSH:
___ (OSH) - ___ for large bowel obstruction due to IBD
___ (OSH) - Reanastamosis (ostomy takedown) (OSH)
___ (___) - Sigmoid perforation with abscess,
___
Social History:
___
Family History:
h/o colon ca
Physical Exam:
ADMISSION PHYSICAL
====================
Vitals: T: 97.3 BP:109/78 P:109 R:28 O2:93% on RA
FSBG 44
GENERAL: ___ word answers, appears lethargic. After dextrose,
talks ___ full sentances
HEENT: Sclera anicteric, MM dry, poor oral hygiene
NECK: supple, JVP flat, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-distended, bowel sounds present; large abdominal
incision with defect and packing ___ inferior aspect. No
drainage, or foul odor.
GU: Foley ___ place
EXT: cool feet below ankles, <2 sec cap refill. pulses easily
dopplerable,
SKIN: dry, flaking skin throughout. Diffuse maceration of
buttocks with a ~2cm sacral decub with white slough, no purulent
drainage
NEURO: A&O x2.
MSK: Extreme pain to palpation of left thigh and knee.
ACCESS: PIVs (no central access)
DISCHARGE PHYSICAL
==================
VS: Temp 97.8 BP 155/75 HR 106 RR 18 97%Ra
GENERAL: No acute distress
HEENT: Sclera anicteric, MMs dry
LUNGS: Regular work of breathing
CV: Tachycardic; ___ ejection murmur heard best at L ___
interspace, No murmurs, rubs, or gallops appreciated
ABD: Soft, non-distended, non-tender; Large abdominal incision
with no drainage or foul odor; Ostomy ___ place with watery
stool, erythematous stoma
GU: Foley ___ place draining clear yellow urine
EXT: Warm; No edema; Bilateral swelling of knees--no erythema or
warmth
NEURO: A&Ox3, CN's grossly intact
Skin: Chronic venous stasis discoloration bilaterally over shins
bilaterally. Multiple sacral lesions on buttocks and posterior
thighs with areas of ulceration , purulence and active bleeding
GU: Rectal exam ___ with watered down blood, creamy discharge
Pertinent Results:
ADMISSION LABS:
=====================
___ 04:08PM PLT COUNT-423*
___ 10:00AM GLUCOSE-52* UREA N-42* CREAT-1.9* SODIUM-133
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-17* ANION GAP-19
___ 10:00AM CK-MB-19* cTropnT-0.05*
___ 10:00AM CALCIUM-8.0* PHOSPHATE-4.5 MAGNESIUM-1.6
___ 10:00AM TSH-1.6
___ 06:10AM GLUCOSE-68* UREA N-43* CREAT-2.0* SODIUM-133
POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-15* ANION GAP-22*
___ 04:00AM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 04:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 04:00AM URINE RBC-57* WBC->182* BACTERIA-MANY
YEAST-MOD EPI-6
___ 02:56AM LACTATE-1.8 K+-5.8*
___ 02:50AM ALT(SGPT)-19 AST(SGOT)-41* CK(CPK)-716* ALK
PHOS-127* TOT BILI-0.2
___ 02:50AM LIPASE-16
___ 02:50AM cTropnT-0.07*
___ 02:50AM CK-MB-13* MB INDX-1.8
___ 02:50AM ALBUMIN-2.5* CALCIUM-8.5 PHOSPHATE-4.9*
MAGNESIUM-1.8
___ 02:50AM WBC-34.0*# RBC-2.81* HGB-7.3* HCT-23.1*
MCV-82 MCH-26.0 MCHC-31.6* RDW-19.9* RDWSD-58.8*
___ 02:50AM NEUTS-90* BANDS-0 LYMPHS-1* MONOS-8 EOS-0
BASOS-0 ___ METAS-1* MYELOS-0 AbsNeut-30.60* AbsLymp-0.34*
AbsMono-2.72* AbsEos-0.00* AbsBaso-0.00*
MICROBIOLOGY
============
___ 5:11 am BLOOD CULTURE Source: Line-R midline.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:07 am BLOOD CULTURE Source: Line-r midline.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:56 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 11:56 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
Time Taken Not Noted ___ Date/Time: ___ 4:55 pm
SWAB Source: Vaginal.
**FINAL REPORT ___
SMEAR FOR BACTERIAL VAGINOSIS (Final ___:
GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS.
YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR
YEAST.
__________________________________________________________
Time Taken Not Noted ___ Date/Time: ___ 4:55 pm
ANORECTAL/VAGINAL Source: Vaginal.
**FINAL REPORT ___
R/O GROUP B BETA STREP (Final ___:
NEGATIVE FOR GROUP B BETA STREP.
__________________________________________________________
___ 2:43 pm SWAB Source: sacral wound.
**FINAL REPORT ___
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final ___:
HERPES SIMPLEX VIRUS TYPE 2.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
VARICELLA-ZOSTER CULTURE (Final ___:
Refer to Herpes simplex viral culture for further
information.
__________________________________________________________
___ 2:43 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
Source: sacral wound.
**FINAL REPORT ___
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
___:
UNINTERPRETABLE DUE TO INADEQUATE SPECIMEN.
Refer to culture results for further information.
Reported to and read back by ___ ___ ON ___ @
10:38AM.
__________________________________________________________
___ 11:30 am SWAB Source: Sacrum area.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
PSEUDOMONAS AERUGINOSA.
SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 4 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
__________________________________________________________
___ 4:45 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
__________________________________________________________
___ 1:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:30 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
__________________________________________________________
___ 10:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:07 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:07 am BLOOD CULTURE SET#2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:25 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:20 am BLOOD CULTURE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:41 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:00 am BLOOD CULTURE Source: Venipuncture #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:10 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/STUDIES
=====================
MR PELVIS ___
Exam is very limited and was terminated early. Only motion
degraded T2
weighted images were obtained. Of note the bowel wall of the
___ pouch
is not appear to be grossly thickened or edematous
ECG ___
Clinical indication for EKG: I47.1 - Supraventricular
tachycardia
Sinus tachycardia. Diffuse ST-T wave abnormalities. No major
change from
prior.
Read by: ___.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
134 ___ 421 37 18 -176
TTE ___
The left atrium is normal ___ size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is a small circumferential pericardial
effusion best seen ___ subcostal images.
IMPRESSION: Small circumferential pericardial effusion. Normal
biventricular cavity sizes with preserved global biventricular
systolic function.
Compared with the report of the prior study (images unavailable
for review) of ___, the effusion is slightly larger.
CT A/P with contrast ___
IMPRESSION:
1. No evidence of acute intra-abdominal or intrapelvic process.
2. No evidence of fluid collections, abscess or alternative
source of
infection within the abdomen or pelvis.
3. Post partial colectomy with end colostomy and ___
pouch.
4. Please refer to separate report of CT chest performed on the
same day for
description of the thoracic findings.
TTE ___
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF = 62 %). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. There is borderline pulmonary artery systolic
hypertension. There is a very small pericardial effusion.
IMPRESSION: No valvular pathology or pathologic flow
identified.Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function.
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.
CXR ___
Right lower lobe pneumonia.
CT Abdomen/Pelvis ___
IMPRESSION:
1. Right lower and middle lobe pneumonia.
2. Interval decompression of an abscess ___ the subcutaneous
tissues of the
lower anterior abdominal wall, with no significant residual
fluid.
3. Cholelithiasis, with no evidence of acute cholecystitis.
4. Trace pericardial effusion is slightly increased from prior.
5. Hypoattenuation of the blood pool relative to the myocardium
is suggestive of anemia.
L hip XR ___
No fractures seen on this single AP view
TTE ___
No valvular pathology or pathologic flow identified.Normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function.
NOTABLE LABS
===========
___ 12:45PM BLOOD ZINC-Test
___ 12:45PM BLOOD COPPER (SERUM)-Test
___ 07:20AM BLOOD COPPER (SERUM)-Test
___ 03:57PM BLOOD Lactate-2.5*
___ 01:49PM BLOOD Lactate-2.8*
___ 10:07AM BLOOD calTIBC-90* ___ Ferritn-418*
TRF-69*
___ 10:07AM BLOOD D-Dimer-784*
___ 05:18AM BLOOD Hapto-102
___ 10:00AM BLOOD TSH-1.6
___ 02:50AM BLOOD cTropnT-0.07*
___ 10:00AM BLOOD CK-MB-19* cTropnT-0.05*
___ 02:50AM BLOOD Lipase-16
DISCHARGE LABS
==============
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Levothyroxine Sodium 100 mcg PO DAILY
3. OxyCODONE (Immediate Release) 2.5 mg PO BID
4. Pantoprazole 40 mg PO Q12H
5. Warfarin 3 mg PO DAILY16
6. Ascorbic Acid ___ mg PO DAILY
7. Gabapentin 100 mg PO BID
8. Zinc Sulfate 220 mg PO DAILY
9. Lisinopril 20 mg PO DAILY
10. GlipiZIDE 5 mg PO DAILY
11. Furosemide 20 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Mirtazapine 15 mg PO QHS
15. Cephalexin 500 mg PO Q6H
16. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
18. Docusate Sodium 100 mg PO BID:PRN constipation
19. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
20. Calcium Carbonate 500 mg PO BID
21. Salonpas (camphor-methyl salicyl-menthol;<br>methyl
salicylate-menthol) ___ % topical DAILY
22. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
Discharge Medications:
1. Acyclovir 200 mg PO 5X/D Duration: 10 Days
RX *acyclovir 200 mg 1 capsule(s) by mouth five times a day Disp
#*20 Capsule Refills:*0
2. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
3. Hydrocortisone Acetate 10% Foam ___ID
RX *hydrocortisone acetate [Cortifoam] 10 % 1 foam(s) rectally
twice a day Refills:*0
4. Lidocaine 5% Patch 2 PTCH TD QAM Please apply 1 patch to
each knee
RX *lidocaine 5 % apply to both affected knees daily Disp #*60
Patch Refills:*0
5. Psyllium Powder 1 PKT PO BID
RX *psyllium husk (aspartame) [Fiber (with aspartame)] 3.4
gram/5.8 gram 1 powder(s) by mouth twice a day Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
7. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg/2.5 mL 1 syringe(s) by mouth every six (6)
hours Disp #*12 Syringe Refills:*0
8. Gabapentin 200 mg PO BID
9. Lisinopril 5 mg PO DAILY
10. OxyCODONE (Immediate Release) 2.5 mg PO TID
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth three times
a day Disp #*3 Tablet Refills:*0
11. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN
BREAKTHROUGH PAIN
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours as needed Disp #*6 Tablet Refills:*0
12. Acetaminophen 1000 mg PO Q8H
13. Ascorbic Acid ___ mg PO DAILY
14. Calcium Carbonate 500 mg PO BID
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Levothyroxine Sodium 100 mcg PO DAILY
17. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
18. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
19. Mirtazapine 15 mg PO QHS
20. Multivitamins W/minerals 1 TAB PO DAILY
21. Pantoprazole 40 mg PO Q12H
22. Salonpas (camphor-methyl salicyl-menthol;<br>methyl
salicylate-menthol) ___ % topical DAILY
23. HELD- GlipiZIDE 5 mg PO DAILY This medication was held. Do
not restart GlipiZIDE until discussing with your primary care
doctor
24. HELD- Tamsulosin 0.4 mg PO QHS This medication was held. Do
not restart Tamsulosin until discussing with your primary care
doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
=======
Sepsis
Severe clostridium difficile colitis
Persistent leukocytosis
Sinus tachycardia
Sacral wound herpes simplex 2 infection
Diversion Colitis
Chronic malnutrition
Hypoglycemia
Demand ischemia
Acute kidney injury
Anemia
Secondary
=========
History of pulmonary embolism
Inflammatory bowel disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypoglycemia, altered mental status// evaluate
for pneumonia
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph on ___
FINDINGS:
Compared with ___, there is a new opacity at the right lung base.
Cardiac size is normal. There is no pneumothorax or pleural effusion.
IMPRESSION:
Right lower lobe pneumonia.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: NO_PO contrast; History: ___ with sepsisNO_PO contrast// evaluate
for intraabominal infection
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) = 711 mGy-cm.
COMPARISON: CT abdomen and pelvis on ___
FINDINGS:
LOWER CHEST: There is new consolidation at the right lung base. A trace
pericardial effusion is increased from prior. Incidental note is made of
lipomatous hypertrophy of the intra-atrial septum. Aortic valvular
calcifications are noted. Hypoattenuation of the blood pool relative the
myocardium is suggestive of anemia.
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 distended and contains gallstones without wall
thickening or evidence of inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Patient is status post partial
colectomy and left lower quadrant colostomy. Small bowel loops are normal in
caliber without wall thickening or evidence of obstruction. ___ pouch
is re-identified. There is a lipoma in the rectum, unchanged.
PELVIS: A Foley catheter is present in the decompressed flatter. The distal
ureters are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Compared with ___, and abscess in the subcutaneous
tissues of the lower anterior abdominal wall, just in the right of the
midline, has been opened, with no significant residual fluid (2:70). There is
diffuse anasarca.
IMPRESSION:
1. Right lower and middle lobe pneumonia.
2. Interval decompression of an abscess in the subcutaneous tissues of the
lower anterior abdominal wall, with no significant residual fluid.
3. Cholelithiasis, with no evidence of acute cholecystitis.
4. Trace pericardial effusion is slightly increased from prior.
5. Hypoattenuation of the blood pool relative to the myocardium is suggestive
of anemia.
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: ___ year old woman with left hip pain// r/o fracture r/o
fracture
TECHNIQUE: Portable supine radiograph of the left hip.
COMPARISON: CT of the abdomen pelvis dated ___.
FINDINGS:
No fracture or dislocations seen on this single frontal view. Mild
degenerative changes are noted involving the femoroacetabular joint. Surgical
sutures project over the left hemipelvis.
IMPRESSION:
No fractures seen on this single AP view
Radiology Report
INDICATION: ___ year old woman with history of Crohn Disease, colectomy with
multiple revisions and subcutaneous abscesses in past, being treated for c
diff colitis with rising leukocytosis and reactive thrombocytosis this morning
concerning for alternate source of infection// Interval change in known
abscess; other infectious source?
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) = 1,065 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains gallstones
without wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The patient is status post partial colectomy with an end
colostomy in the left lower quadrant without signs of bowel obstruction. The
stomach is unremarkable. There is an some oasis of small-bowel loops in the
left lower quadrant which are mildly dilated containing layering debris and
contrast material but is overall similar morphology to prior exam (3:77).
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. A ___ pouch is re-demonstrated. A lipoma in the rectal
wall is unchanged.
PELVIS: A Foley catheter is seen within the bladder. Otherwise, the urinary
bladder and 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. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is a stable right-sided abdominal wall defect containing
large and small bowel without signs of herniation or strangulation.
IMPRESSION:
1. No evidence of acute intra-abdominal or intrapelvic process.
2. No evidence of fluid collections, abscess or alternative source of
infection within the abdomen or pelvis.
3. Post partial colectomy with end colostomy and ___ pouch.
4. Please refer to separate report of CT chest performed on the same day for
description of the thoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ woman with history of Crohn's disease, status post
colectomy with multiple revisions and subcutaneous abscess in the past, being
treated for C diff colitis with rising leukocytosis and reactive
thrombocytosis, concerning for alternative source of infection. Evaluate for
infectious source.
TECHNIQUE: MDCT axial images of the chest were obtained after administration
of IV contrast. Multiplanar oblique reformats and axial maximal intensity
projections were obtained and reviewed on PACs.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.5 s, 56.2 cm; CTDIvol = 18.7 mGy (Body) DLP =
1,050.7 mGy-cm.
2) Stationary Acquisition 5.1 s, 0.5 cm; CTDIvol = 27.9 mGy (Body) DLP =
14.0 mGy-cm.
Total DLP (Body) = 1,065 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: CT chest from ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Due to positioning of the patient,
direct comparisons of the previously demonstrated thyroid hypodensities are
difficult. However, right lobe hypodensity appear overall similar, measuring
up to 2.5 cm (03:12). There is no supraclavicular or axillary lymphadenopathy
by CT size criteria. Scattered supraclavicular lymph nodes measure up to 6
mm. There are multiple dense and linear calcifications in the bilateral
breasts, incompletely imaged and suboptimally evaluated on the current
modality. There are multiple enhancing soft tissue nodules in the
subcutaneous tissue of the left forearm, the largest measuring 17 x 10 mm
(03:23). There is diffuse stranding in the subcutaneous tissue, which may be
related to volume overload.
UPPER ABDOMEN: Please refer to the dedicated CT abdomen and pelvis from the
dated same day for details on subdiaphragmatic findings.
MEDIASTINUM: There is no mediastinal lymphadenopathy by CT size criteria. The
largest lymph node in the lower pretracheal station measures up to 7 mm
(03:16).
HILA: There is no hilar lymphadenopathy by CT size criteria.
HEART and PERICARDIUM: The heart is mildly enlarged. New since ___, there is asymmetric thickening of the posterior pericardium, measuring
up to 1.4 cm with fluid density and mild enhancement of the periphery, may
represent loculated pericardial effusion. There is mild coronary artery
calcifications. Aortic valve calcifications are mild.
PLEURA: Decreased since ___, there is persistent small, dependent
left nonhemorrhagic pleural effusion and small to trace right nonhemorrhagic
layering pleural effusion.
LUNG:
1. PARENCHYMA: There are no suspicious lung nodules that require follow-up.
Compared to prior exam on ___, there is increased consolidation
in the right lower lobe with diffuse ground-glass opacities in the right lung,
worse in the right lower lobe, which may be a combination of atelectasis and
breathing motion. On left, there is mild atelectasis in the left lower lobe.
The lingula is clear.
2. AIRWAYS: The airways are patent to the subsegmental levels.
3. VESSELS: The ascending and descending aorta are normal in caliber. The
main and right pulmonary arteries are normal in caliber. Moderate
calcifications at the aortic arch is seen. There is common origin of the
innominate and left common carotid artery, which is mildly dilated, measuring
up to 16 mm, grossly unchanged from prior exam. While this exam is not
tailored for evaluation of pulmonary embolism, no large filling defects are
seen in the central pulmonary arteries.
CHEST CAGE: There are no worrisome osseous lesions for infection or
malignancy. No acute fracture is seen. Multilevel degenerative changes of
the cervical, thoracic and sternoclavicular joint are noted.
IMPRESSION:
-Pericardial effusion with enhancing pericardium. Possible pericarditis. No
evidence of cardiac tamponade. Further evaluation with echocardiogram is
recommended.
-Bibasilar atelectasis and pleural effusions, decreased from prior.
Persistent lymphovascular congestion of the right lower lobe.
-Right thyroid hypodensity measuring up to 2.5 cm. Dedicated ultrasound is
recommended on nonurgent basis.
-Left upper arm nodule. Clinical exam of this area is recommended.
RECOMMENDATION(S): Echocardiogram for pericardial effusion.
Right thyroid hypodensity measuring up to 2.5 cm. Dedicated ultrasound is
recommended on nonurgent basis.
Left upper arm nodule. Clinical exam of this area is recommended.
NOTIFICATION: The findings were discussed with BROWN, ___, M.D.
by ___, M.D. on the telephone on ___ at 4:08 pm, 20 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old woman with hx of IBD p/w leuko/monocytosis, rectal
lipoma on CT pelvis and scant rectal bleeding, ? IBD flair// Rule out
infection/fistula. signs of inflammation. source of bleed?
TECHNIQUE: Limited exam. Only scout images, sagittal, coronal, and axial T2
weighted images were obtained. These are motion degraded.
COMPARISON: CT from ___
FINDINGS:
Limited and essentially nondiagnostic exam. The bowel wall of the ___
pouch does not appear thickened or edematous.
Bladder is decompressed around a Foley catheter.
There is a trace amount of free pelvic fluid.
Diffuse muscular atrophy.
IMPRESSION:
Exam is very limited and was terminated early. Only motion degraded T2
weighted images were obtained. Of note the bowel wall of the ___ pouch
is not appear to be grossly thickened or edematous
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hypoglycemia, Hypotension
Diagnosed with Sepsis, unspecified organism, Non-ST elevation (NSTEMI) myocardial infarction, Acute kidney failure, unspecified
temperature: 97.4
heartrate: 114.0
resprate: 18.0
o2sat: 99.0
sbp: 72.0
dbp: 39.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a very pleasant ___ yo woman with history of NIDDM,
DVT/PEs (on Coumadin), HTN, IBD (s/p distant colectomy c/b
abscess then repeat colectomy and small bowel resection
(___) w/ recent admission for purulent drainage from midline
incision c/b MSSA bacteremia who was admitted to ___ with
sepsis physiology, was initially treated for HAP and then
developed c diff and persistent leukocytosis. Over the course of
her hospital stay, the following issues were addressed:
# Goals of Care. Patient's healthcare proxy and nephew ___
___ expressed
concern that she Ms. ___ has been chronically ill for a long
time and had
reached a point where he was more concerned about her overall
well-being. Ms. ___ expressed being tired of hospitalizations
and invasive diagnostic testing/intervention multiple times
throughout hospital stay. Patient was followed by our palliative
care team and several goals of care discussions were initiated
___. ___ was connected with home hospice liaisons.
Eventually plan was decided to start Hospice at home, and
patient had MOLST filled out stating she was DNR/DNI.
# Sepsis. Hypotensive ___ ED to systolic ___, but fluid
responsive and never required pressor. CXR showed RLL pneumonia.
UA with pyuria, hematuria, and many bacteria though culture
showed polymicrobial growth. Denied respiratory symptoms and was
not hypoxic. Difficult to determine other symptomatology as she
said "I hurt all over." MRSA swab negative. Treated with
Vanc/zosyn and rapidly narrowed to vanc/cefepime (day ___.
Due to lack of symptoms and no improvement ___ leukocytosis with
initiation of abx and the fact that patient was discovered to be
C. Diff positive, the source of her leukocytosis was more
consistent with C. Diff colitis and vancomycin and cefepime were
stopped on ___ after 6 days of antibiotics. Transferred from
MICU to floor on ___.
#C. Diff Colitis. Stool tested positive for C. Diff. Stool
output was variable throughout stay and patient remained
afebrile and hemodynamically stable. However, significant
leukocytosis >15 and serum albumin <3 indicative of severe
disease. She was maintained on PO Vancomycin 125 mg Q6h (start
date ___ IV flagyl was added from ___ due to transient
decrease ___ stool output (with concern for developing ileus) and
persistent leukocytosis as below. Ceftriaxone was administered
___ to ___ and Vancomycin was extended until ___ to cover 7
days after all other antibiotics (start date ___ | projected
end date ___.
# Leukocytosis & intermittent monocytosis. Patient was noted to
have a persistent leukocytosis from ___ for entire length of
hospital stay as well as intermittent monocytosis (15% ___ and
16% ___. No improvement on treatment of c diff as above. UA
with 33 RBC's, 22 WBC's, yeast, but negative for bacteria and
nitrates. No coughing, SOB, fever, and CT does not not show
evidence of pulmonary infiltrate suggestive of pneumonia. No
change ___ collapsed abscess or new abscess formation on repeat
CT. Patient had purulent, beefy red sacral ulcers over back
entire hospital stay which eventually tested positive for HSV 2.
Leukocytosis began downtrending on administration of acyclovir
and rectal hydrocortisone below.
# Sacral Ulcers
# HSV 2. Patient presented with areas of macerated skin over
thighs and sacrum and developed further desquamation with areas
of ulceration on gluteals and posterior thights with exudate.
She was treated with ceftriaxone from ___ to ___ with some
improvement ___ leukocytosis. Eventually grew HSV 2 from wound
swab culture (confirmed with DFA). No discrete ulcers noted on
vaginal exam or vesicles noted over sacrum but certainly
possible that this is contributing to patient's leukocytosis and
even to her urinary retention (rare extravaginal complication).
Started acyclovir 200 mg five times per day for 10 days (start
___ | projected end date ___. She also grew pseudomonas from
these wounds but these were felt to be colonizers.
# Diversion Colitis. Patient with persistent leukocytosis and
oozing blood per rectum noted ___ concerning for diversion
colitis of ___ pouch vs IBD flare ___ rectal stumpy.
Flexible sigmoidoscopy of rectal remnant was attempted but
patient refused. Due to patient's underlying IBD, Hydrocortisone
Acetate 10% Foam ___ID was initiated (start ___. She
will need to be on this medication BID for 2 weeks, and then
every other day for 1 week and then twice a week for 2 weeks and
then stop.
# Bacterial PNA: Patient initially presented with tachycardia,
leukocytosis and hypotension. Found to have right lower and
middle lobe infiltrates on imaging and started empirically on
vancomycin and zosyn for suspected pneumonia, then transitioned
to vancomycin and cefepime(D1= ___. Patient had no respiratory
symptoms and no improvement ___ leukocytosis with initiation of
abx. GPC's ___ clusters on blood culture from ___ were likely
contaminants. MRSA swab negative. ___ light of this, and the fact
that patient was discovered to be C. Diff positive, the source
of her leukocytosis was more consistent with C. Diff colitis and
vancomycin and cefepime were stopped on ___.
# Bilateral knee pain and back pain. Chronic, secondary to
osteoarthritis. Significant cause of pain. Pain regimen was
titrated with aid of pain and palliative consult service. Final
regimen: Lidocaine 5% Patch 2 PTCH TD QAM Please apply 1 patch
to each knee, OxyCODONE (Immediate Release) 2.5 mg PO/NG TID,
Gabapentin 200 mg PO/NG BID, acetaminophen 1 g Q8H, OxyCODONE
(Immediate Release) 2.5 mg PO/NG Q4H:PRN BREAKTHROUGH PAIN.
# History of DVT/PE. Patient had initial LLE DVT at ___
___, placed on lovenox to warfarin bridge with goal INR of
___. Patient represented to ___ ___ with GIB during which
time warfarin and heparin were held. She subsequently developed
right UE PICC-associated DVT and later ___ that hospital stay had
CT angiogram of the chest performed and was found to have
multiple subsegmental PEs. She has thus been on coumadin for 4
continuous months, with all INRs ___ our system ___ the
therapeutic to supratherpeutic range. INR was reversed ___
but was labile and increased above ___ several times during
hospital stay despite administration of both PO and IV vitamin
K. She was first maintained on a heparin drip and then
transitioned to apixaban 2.5 mg BID (originally on 5 mg BID but
dose-reduced to 2.5 mg BID due to patient's weight and concern
for bleeding).
# Severe Malnutrition. Ms. ___ had poor PO intake throughout
hospital stay, with ongoing coagulopathy and poor wound healing.
She was given multivitamin with minerals and nutritional
supplements. Nutrition recommended supplementation with tube
feeds but patient refused placement of Dobhof tube. Zinc and
copper levels were within normal limits.
# Hypoglycemia. Per collateral from ___, FSBS ___ on
metformin and glipizide. Likely due to sepsis and glipizide.
Treated with IV D5W on day 1 and quickly dc'd with stable BS
throughout hospital course.
# ___. Creatinine 2.4 on admission from baseline 0.7. Likely
pre-renal/ATN from sepsis. Improved to baseline with IVF and
antibiotics.
# Type II NSTEMI. Troponin T elevated to 0.07 on admission, and
subsequently downtrended. No chest pain or ischemic EKG changes.
# Anemia: Hypoproliferative, normocytic anemia. Pattern of
down-trending Hgb following pRBC transfusions. Low Fe, low TIBC,
normal haptoglobin, increased ferritin, and decreased
transferrin portray anemia of chronic disease. Consistent with
hx of IBD and multiple bowel resections. Elevated D-dimer and
fibrinogen reassuring that patient was not ___ DIC. Has a hx of
UGI bleed ___ setting of previous supratherapeutic INR and
anastomosis. Less suspicious for current GI bleed given that she
has not had any episodes of hemoptysis, melena from ostomy site,
and is remaining normotensive. Hb was labile and patient
received a total of 4 units pRBCs ___ due to downdrifting
Hb below 7. Only clinical sign of bleeding was scant rectal
bleeding from rectal pouch as described above. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___
Chief Complaint:
abdominal distension, dark stools
Major Surgical or Invasive Procedure:
___ - EGD
___ - Diagnostic/therapeutic paracentesis, 2L
___ - Diagnostic/therapeutic paracentesis, 2L
___ - Diagnostic paracentesis
___ - Diagnostic/therapeutic paracentesis, 3L
History of Present Illness:
___ with history of alcohol use disorder and recent left knee
(meniscal) and hand injury who presents with several weeks of
black stools and blood spotting after bowel movements without
blood in the stool itself. She has had worsening abdominal
distention for about 2 months. She endorses some abdominal pain
after eating. She denies fevers, shortness of breath, chest
pain,
dizziness, headaches, changes to urinary function. She has
20-pack-year history and currently still smokes half pack per
day. She previously drank 30 alcoholic drink per week, her last
drink was 2 weeks ago. She denies any illicit drug use.
Past Medical History:
Alcohol use disorder
Tobacco use disorder
Social History:
___
Family History:
No history of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
___ 0012 Temp: 98.4 PO BP: 112/76 HR: 102 RR: 18 O2 sat:
95%
O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No 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.
ABDOMEN: Normal bowels sounds, distended and mildly tender.
EXTREMITIES: 1+ edema to mid shins.
SKIN: Warm. Palmar erythema, spider telangiectasias over cheeks
and upper chest.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. No asterixis
DISCHARGE PHYSICAL EXAM:
VS: 24 HR Data (last updated ___ @ 652)
Temp: 99.2 (Tm 100.2), BP: 111/71 (111-124/64-75), HR: 107
(83-107), RR: 20 (___), O2 sat: 94% (94-97), O2 delivery: Ra,
Wt: 141.8 lb/64.32 kg
GENERAL: Middle aged woman in no acute distress.
HEENT: EOMI, MMM
NECK: supple, normal range of motion
CARDIAC: RRR, normal S1/S2, no m/r/g
LUNGS: no respiratory distress. CTAB
ABDOMEN: soft, NT, moderately distended
EXT: 3+ edema to mid shins b/l, tender when pressed. WWP.
NEURO: alert and oriented, exam grossly intact. Normal strength
and sensation. Steady gait
Pertinent Results:
ADMISSION LABS:
___ 04:42PM BLOOD WBC-11.9* RBC-3.16* Hgb-10.1* Hct-30.8*
MCV-98 MCH-32.0 MCHC-32.8 RDW-14.2 RDWSD-50.9* Plt ___
___ 04:42PM BLOOD Neuts-73.5* Lymphs-12.0* Monos-12.8
Eos-0.7* Baso-0.3 Im ___ AbsNeut-8.75* AbsLymp-1.43
AbsMono-1.53* AbsEos-0.08 AbsBaso-0.04
___ 04:42PM BLOOD ___ PTT-32.3 ___
___ 04:42PM BLOOD Glucose-99 UreaN-3* Creat-0.4 Na-128*
K-3.0* Cl-88* HCO3-26 AnGap-14
___ 04:42PM BLOOD ALT-14 AST-83* AlkPhos-196* TotBili-2.2*
___ 04:42PM BLOOD Lipase-70*
___ 04:42PM BLOOD Albumin-2.9* Calcium-8.1* Phos-2.5*
Mg-1.6 Iron-32
___ 04:42PM BLOOD calTIBC-228* VitB12-574 Folate-6
Ferritn-64 TRF-175*
___ 05:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:30AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 05:30AM BLOOD ___
___ 05:30AM BLOOD IgG-729 IgA-548* IgM-40
___ 04:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:30AM BLOOD HCV Ab-NEG
___ 05:00PM BLOOD K-2.6*
DISCHARGE LABS:
___ 05:31AM BLOOD WBC-11.1* RBC-2.58* Hgb-7.6* Hct-23.8*
MCV-92 MCH-29.5 MCHC-31.9* RDW-15.6* RDWSD-51.9* Plt ___
___ 05:54AM BLOOD Neuts-71.2* Lymphs-13.6* Monos-10.6
Eos-3.2 Baso-0.7 Im ___ AbsNeut-8.43* AbsLymp-1.61
AbsMono-1.25* AbsEos-0.38 AbsBaso-0.08
___ 05:31AM BLOOD ___
___ 05:31AM BLOOD Glucose-118* UreaN-17 Creat-1.2* Na-135
K-4.5 Cl-101 HCO3-21* AnGap-13
___ 05:31AM BLOOD ALT-7 AST-32 AlkPhos-70 TotBili-0.9
___ 05:31AM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.5 Mg-1.9
___ 04:42PM BLOOD calTIBC-228* VitB12-574 Folate-6
Ferritn-64 TRF-175*
___ 09:31AM BLOOD IgM HAV-NEG
___ 05:15AM BLOOD HAV Ab-POS*
___ 05:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 03:33PM BLOOD HIV Ab-NEG
IMAGING:
LIVER OR GALLBLADDER US ___ IMPRESSION:
1. Cirrhotic liver with moderate volume ascites.
2. Patent portal vein with to and fro flow.
3. Unremarkable gall bladder.
ECG NSR
CHEST (PA & LAT) ___ IMPRESSION:
No previous images. Cardiac silhouette is within normal limits
and there is no vascular congestion, pleural effusion, or acute
focal pneumonia.
MICRO:
Urine: MIXED BACTERIAL FLORA CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
___ 9:31 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
___ Blood cx: no growth
___ 2:28 pm PERITONEAL FLUID PERITONEAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 1:30 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 1:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
___ 5:01 am URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
YEAST. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
___ 6:04 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
___ 4:35 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
___ 4:35 pm PERITONEAL FLUID
PERITONEAL FLUID PURPLE TOP BEING USED FOR GST.
Hematology/Chemistry specimen, possibly contaminated.
INTERPRET RESULTS WITH CAUTION.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
Medications on Admission:
None
Discharge Medications:
1. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
This medication can be constipating and can make your stools
dark. Take every other day.
RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by
mouth every other day Disp #*30 Tablet 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. Midodrine 5 mg PO TID
RX *midodrine 5 mg 1 tablet(s) by mouth three times a day Disp
#*21 Tablet Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
tablet(s) by mouth once a day Disp #*30 Capsule Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. 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
7.Outpatient Lab Work
Please obtain BMP, Cr, BUN, Na, K, Cl, HCO3.
Fax results to ___ , attention ___.7
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
-Alcoholic cirrhosis decompensated with ascites and esophageal
varices
-Acute kidney injury
Secondary diagnosis: alcohol use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with new dx of all cirrhosis, now with
fevers.// New fevers, eval for PNA, crackles at right base
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear without consolidation or edema. Blunting of the right
lateral costophrenic angle may be due to pleural thickening, no evidence of
pleural effusion on the lateral view. Cardiac silhouette is top-normal. No
acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ with history of alcohol use disorder presenting withabdominal
distension and dark stools, found to have cirrhosis and moderate volume
ascites, on ppx CTX s/p ___ EGD found to have stage I varices and solitary
esophageal polyp removal, now with 2L removed on iagnostic/therapeutic
paracentesis ___, course c/b fever of unknown source, currently on
vanc/cefepime. Less likely respiratory as no respiratory symptoms, and urine
cultures have been clean.// eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None available.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST ___
INDICATION: ___ year old woman with fever, ___// ? infectious process
TECHNIQUE: Multidetector CT images of the abdomen were obtained without oral
or intravenous contrast. Sagittal and coronal reformations were also
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 71.2 cm; CTDIvol = 14.3 mGy (Body) DLP =
1,017.8 mGy-cm.
Total DLP (Body) = 1,018 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT CHEST
W/O CONTRAST)
COMPARISON: Ultrasound is available from ___.
FINDINGS:
Chest is reported separately.
The liver demonstrates heterogeneous fatty infiltration. As perhaps better
depicted on the prior ultrasound, the liver has a nodular outer contour also
highly suggestive of cirrhosis. This protocol, performed without intravenous
contrast, is not suitable to evaluate for focal liver lesions, particularly in
the setting of cirrhosis, although none are identified on this examination.
Small stones are identified in the gallbladder. There is no biliary
dilatation. The spleen is normal in size and appearance. Pancreas
demonstrates a few probably postinflammatory calcifications consistent with
chronic pancreatitis. Adrenals appear normal. No evidence for stones or
hydronephrosis involving either kidney. Neither renal cortex appears thinned.
Kidneys appear normal in size.
The stomach shows moderate distension. Pylorus is patent, open at the time of
the examination. Small bowel is not dilated. Large bowel is also
unremarkable.
Bladder is mostly empty and difficult to assess. Uterus appears normal.
Bilateral tubal ligation clips are identified bilaterally. No adnexal masses
are found. Vascular calcification is moderate. The aorta is normal in
caliber. There is no lymphadenopathy.
Quantity of ascites is moderate to large, similar to increased relative to the
prior ultrasound although detailed comparison is difficult due to differences
in modality.
There are no suspicious bone lesions. Bones are probably demineralized.
IMPRESSION:
1. Moderate to large ascites.
2. Fatty liver with features suggesting cirrhosis; overall findings are most
consistent with acute on chronic liver disease.
3. Nonspecific moderate gastric distension.
4. Cholelithiasis.
5. Findings consistent with chronic pancreatitis.
6. No hydronephrosis. Neither renal cortex appears thinned.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: cirrhosis w/ ___// eval for obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Liver gallbladder ultrasound dated ___.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Right kidney: 12.1 cm
Left kidney: 11.8 cm
The bladder is not identified.
The visualized liver is cirrhotic which is better demonstrated on the liver
gallbladder ultrasound dated ___. Moderate ascites noted in the
pelvis, grossly unchanged as well.
IMPRESSION:
No hydronephrosis or obstructing stones demonstrated.
Free-fluid in the pelvis as seen on recent abdominal ultrasound.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST Q411
INDICATION: ___ year old woman with fever, ___// ? infectious process
TECHNIQUE: Multidetector CT images of the chest were obtained without
intravenous contrast. Sagittal and coronal reformations were also performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 71.2 cm; CTDIvol = 14.3 mGy (Body) DLP =
1,017.8 mGy-cm.
Total DLP (Body) = 1,018 mGy-cm.
COMPARISON: Radiographs of the chest are available from ___.
FINDINGS:
The heart is borderline in size. Aortic annulus is partly calcified. Mild
coronary artery calcification. Aorta is normal in caliber with mild mural
calcification. Central pulmonary arteries are normal in caliber.
There is a small right-sided pleural effusion, but none on the left. No
pericardial effusion. No enlarged lymph nodes.
Asymmetric calcification along the left vocal cord.
Although predominantly dependent, right lower lobe opacities as well as less
extensive right middle lobe opacities may represent atelectasis versus
pneumonia or aspiration. Few thickened interlobular septa in the right lung
suggest mild asymmetric pulmonary edema. In the right middle lobe a 5 mm
nodule is observed (302:123).
The abdomen is reported separately.
There are no suspicious bone lesions. Bones appear demineralized.
IMPRESSION:
1. Small right-sided pleural effusion with the basilar opacities that may be
due to atelectasis in conjunction with mild asymmetric pulmonary edema.
Presence of pneumonia is possible, however.
2. Asymmetric calcification along the vocal cord, possibly post inflammatory.
Correlation with direct inspection is recommended in followup.
3. Small right middle lobe nodule measuring 5 mm. If there are risk factors
such as smoking, occupational exposure or family history of pulmonary
malignancy, then followup chest CT might be considered in one year.
Abdomen is reported separately.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with ruq pain, ascited,// new onset cirrhosis//PVT?
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. The contour of the
liver is smooth. There is no focal liver mass. Simple hepatic cysts measuring
up to 1.2 cm. The main portal vein is patent with to and fro flow. There is
moderate ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 3 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 11.3 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.6 cm
Left kidney: 10.7 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with moderate volume ascites.
2. Patent portal vein with to and fro flow.
3. Unremarkable gall bladder.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with decompensated cirrhosis// r/o pneumonia
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits and there is
no vascular congestion, pleural effusion, or acute focal pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs, BRBPR
Diagnosed with Alcoholic cirrhosis of liver with ascites
temperature: 97.7
heartrate: 109.0
resprate: 16.0
o2sat: 96.0
sbp: 108.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ with history of alcohol use disorder p/w abdominal
distension and dark stools, found to have cirrhosis and moderate
volume ascites, with diagnostic/therapeutic paracentesis on
___, and ___ negative for SBP. Her hospital course
c/b initially worsening ___ c/f HRS vs sepsis vs volume
overload, and fever of unknown source s/p Zosyn (___).
Her Cr and urine output began to improve after a week of albumin
challenge, octreotide, and maximum dose midodrine.
TRANSITIONAL ISSUES
===================
[] Noted to have low grade temperatures during week of
discharge, most recently 100.2, no source of infection found
after multiple paracentesis and asymptomatic. Would continue to
monitor for true fever and evaluate if concern for infection
[] Evaluate abdominal ascites at next appt- may need
paracentesis
[] She is being discharged off diuretics due to recent profound
kidney injury, concerning for HRS now improved.
[] Will need outpatient GI ___ w/ hepatology after D/C within
one month
[] Will need PCP ___ after D/C in ___ wks
[] Has iron deficiency anemia, will need iron supplementation
[] Had duodenal polyp removed, will need follow-up upper
endoscopy in 6 months (___) for eval of adenoma removal and
foveolar metaplasia eval
[] Discharge creatinine 1.2
[] Discharge weight 141.8 lbs
[] Patient has not had routine healthcare screening and has had
limited access to healthcare prior to this hospitalization. It
will be very important for this patient to have all
age-appropriate routine screening (mammography, colonoscopy, pap
smear) so that she can be further considered for a liver
transplant in the future.
[] Patient needs hepatitis B immunization |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman w/ PMHx of SLE on
hydroxychloroquine, depression, hypothyroidism, who presents
with increased pain on the internal side of her right hip.
Per patient report, she was seen by her rheumatologist on ___
and at that time she complained of left shoulder pain. She was
given colchicine which improved her shoulder pain. Then
starting from ___, patient has developed progressive pain in
her right hip to the point that she was not able to walk in the
past couple of days. Patient reports the pain was located in the
right inguinal area, on the internal side of her right hip
joint, ___ in severity and worsened by any movement of her
right hip. ___ radiation down her R leg. ___ pain or change in
mobility in her left hip. ___ fever or chills.
In the ED, patient had an X-ray of hip and pelvis which did not
show any fracture or any osseous change or soft tissue change.
Patient was admitted for further eval and treatment.
ROS: 14 points ROS negative except as above.
Past Medical History:
Breast Cyst
Depression
Endometriosis
Gastroesophageal Reflux Disease
Glaucoma
Hypothyroidism
Mitral Regurgitation
Pulmonary Hypertension
Raynaud's
Systemic Lupus Erythematous
History of Uterine Bleeding
Past Surgical History:
D&C: immediately post-partum, ___ retained placenta
LTL: ___
Laparoscopy for endometriosis
Cystectomy during surgery for endometriosis
Social History:
___
Family History:
Mother - history of hypertension and hypothyroidism. History of
CABG in her ___.
Father - died of an MI at age ___.
Brother - diabetes.
Physical Exam:
GEN: NAD, AAOx3.
HEENT: PERRL, EOMi, MMM.
Neck: ___ JVD, ___ carotid bruit, ___ thyromegaly.
CV: RRR, nl S1/S2, ___ m/r/g.
Lungs: CTA ___, ___ wheezes.
Abdomen: NT, ND, BS active.
Ext: tenderness and limited ROM on the internal side of R hip,
___ local swelling noted; tenderness on the superior side of L
shoulder (improving).
Neuro: CN II-XII grossly.
DISCHARGE:
Gen: well appearing, NAD
HEENT: NCAT, oropharynx clear
CV: RRR, ___ mrg
Resp: CTA ___
Abd: soft, nt, nd, ___ organomegaly
Ext: ___ CCE, ___ impaired range of motion, ___ pain with palpation
at pubic ramus through the ASIS
Neuro: ___ focal deficits, ___ facial droop
Pertinent Results:
___ 08:15PM WBC-3.3* RBC-4.38 HGB-11.3 HCT-35.5 MCV-81*
MCH-25.8* MCHC-31.8* RDW-14.0 RDWSD-40.8
___ 08:15PM GLUCOSE-80 UREA N-8 CREAT-0.7 SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16
___ 05:30PM URINE HOURS-RANDOM
___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
DISCHARGE:
___ 07:00AM BLOOD WBC-3.0* RBC-4.00 Hgb-10.2* Hct-32.5*
MCV-81* MCH-25.5* MCHC-31.4* RDW-13.7 RDWSD-40.5 Plt ___
___ 07:00AM BLOOD Glucose-82 UreaN-7 Creat-0.7 Na-140 K-3.5
Cl-107 HCO3-26 AnGap-11
MRI PELVIS WET READ:
___ evidence of a fracture. ___ joint effusion or abnormal
enhancement to
suggest infection. ___ abnormal signal in the surrounding
musculature. Please followup final read to be completed ___
AM. Right external iliac chain inguinal lymph nodes are
slightly prominent, though do not meet size criteria for
pathologic enlargement, and are nonspecific. Incidentally noted
Bartholin gland cyst.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Colchicine 0.6 mg PO DAILY
4. Desonide 0.05% Cream 1 Appl TP Q12H:PRN itching
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Hydroxychloroquine Sulfate 200 mg PO ONCE ON ODD DAY, TWICE
ON EVEN DAY
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Hydroxychloroquine Sulfate 200 mg PO ONCE ON ODD DAY, TWICE
ON EVEN DAY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
9. Colchicine 0.6 mg PO DAILY
10. Desonide 0.05% Cream 1 Appl TP Q12H:PRN itching
Discharge Disposition:
Home
Discharge Diagnosis:
Hip Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI MSK PELVIS WANDW/O CONTRAST
INDICATION: ___ year old woman with progressive right hip pain x 1 week. X-ray
negative. unable to walk. // etiology of right hip pain review of OMR
gives a history of SLE and hypothyroidism.
TECHNIQUE: Multi sequence and multiplanar imaging of the right hip was
performed with and without intravenous contrast on a 1.5 tesla MRI.
Subtraction or pre and postcontrast images was performed, but resultant images
are limited by motion artifact.
COMPARISON: Pelvic and hip radiograph ___
FINDINGS:
Incidental note is made of postoperative changes in right inguinal region hand
susceptibility artifact in the posterior pelvis which may relate to prior
surgery .
There is increased signal and size of the rectus femoris tendon at the
attachment on the anterior inferior iliac spine, consistent with tendinosis.
In addition, there is mild to moderate surrounding edema. Findings could
represent tendinosis, calcific tendinitis, or partial tear of the recurrent
head of the rectus femoris tendon.
No hip joint joint effusion.No avascular necrosis. No occult fracture. Mild
chondral thinning noted on the superior femoral head. Small rounded high T2
focus in the femoral head neck junction posteriorly (10:18, 06:17) likely
represents a small synovial herniation pit
There is mild edema at the right greater trochanteric bursa.
Remaining visualized tendons are intact. Note made of tendinosis in the
right hamstring tendon origin. Muscles are normal signal and bulk.
Prominent external iliac chain and inguinal lymph nodes are seen, measuring
up to 2.7 x 0.9 x 2.3 cm (series 8, image 11).
Limited assessment of intrapelvic soft tissue structures reveal several
incidental findings.
There is a 2.4 x 0.9 cm ovoid cystic structure in the perineum on the left,
the most likely represents a Bartholin gland cyst.
There is an 11 x 10 mm STIR mildly hyperintense lesion in the uterus -- this
is not fully characterized, but likely represents a small nabothian cyst or
less likely a fibroid. There is a small amount of free fluid in the pelvis,
within physiologic limits.
On the coronal STIR images, there is a lobulated, well-circumscribed 14.7 x
17.9 mm high T2 signal structure abutting abutting sacrum, to the immediate
left of midline. . This is only partially visualized (series 8, image 27),
but does not appear to enhance on the post-contrast images (11:27) and
statistically most likely represents a perineural or Tarlov cyst.
IMPRESSION:
1. Increased signal and size of the rectus femoris tendon at the attachment on
the anterior inferior iliac spine, consistent with tendinosis, with
surrounding soft tissue edema . When correlated to radiograph there is
suggestion of small soft tissue calcification in this area. Findings may
represent calcific tendinitis versus partial tear of the recurrent head
tendon. The straight head of the tendon appears intact, without tear.
2. Mild degenerative changes of the right hip joint. No evidence of fracture
or AVN.
3. Right iliac lymph nodes, that are borderline enlarged, of uncertain
etiology or significance. Clinical correlation is required.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: R Inguinal pain
Diagnosed with Pain in right hip
temperature: 97.7
heartrate: 62.0
resprate: 16.0
o2sat: 100.0
sbp: 148.0
dbp: 87.0
level of pain: 3
level of acuity: 3.0 | Ms. ___ is a ___ yo woman w/ PMHx of SLE on
hydroxychloroquine, depression, hypothyroidism, who presents
with increased pain on the internal side of her right hip.
# Right hip pain: patient is on hydroxychloroquine and given her
SLE would question whether avascular necrosis or a septic
arthritis is possible. Patient has not had fever, CRP is wnl
making septic arthritis less likely. MRI showed ___ acute
abnormality and patient's pain was resolved. Recommend she
follow up with her PCP for further work up.
-cont colchicine for pseudogout in shoulder per rheumatologist
# SLE
- Continue hydroxychloroquine.
# Hypothyroidism
- Continue levothyroxine.
# Asthma
-patient reports taking advair only as needed, which seems
incorrect. On albuterol as well.
#GERD: cont home medications
[] Code: Full.
[] Dispo: pending results of MRI
[x] Discharge documentation reviewed, pt is stable for
discharge
[ ] >30 minutes was spent on day of discharge on coordination
of care and counseling
Electronically signed by ___, MD, pager ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Shellfish / Iodine Containing
Agents Classifier / Codeine / Morphine / Heparin Agents /
Levaquin in D5W
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx chronic pancreatitis, ESRD on HD, CAD, PVD, and diabetes
who presents with acute epigastric pain radiating to the back.
States that she went to dialysis yesterday and did fine,
afterwards ate a meatball sub and developed acute epigastric
pain afterwards. Characterizes this pain as exactly like her
previous abdominal pain admissions. The pain was associated with
nausea, vomiting and diarrhea, exactly like her previous episode
1 week prior. She has had multiple hospitalizations for
epigastric pain of unclear etiology.
.
RECENT COURSE:
___
Patient has had several admissions for abd pain. Presented on
___ with "normal" abdominal pain. She was treated with IV
dilaudid for pain and IV zofran for nausea and patient's pain
and nausea resolved following a brief stay with supportive care.
___
thrombosed LUE AV graft, s/p revision
___
LUE AV graft thrombectomy
___
AV graft occlusion s/p AV graft thrombectomy on ___
Abdominal pain after dialysis, treated symptomatically
.
In the ED, initial VS were 89 187/82 32 100%. She triggered for
RR 32 and her oxygen sat on room air was 88. Her pain was
typical of her pancreatitis flares and was reproducible on
palpation. She was given SL NTG x3, a full dose aspirin, zofran
and dilaudid.
.
Upon transfer to the floor, vitals were 98po 86 17 168/79 100%
3L nc
Past Medical History:
- Numerous hospitalizations over the past ___ years for
epigastric pain of unclear etiology. Carries a diagnosis of
chronic pancreatitis, though unconfirmed. Pancreas bx ___
negative for evidence of chronic pancreatitis. Negative EUS/EGD
___, CTA ___, negative gastric emptying study ___.
- ESRD on HD since ___ ( ___
- CAD - s/p MI in ___ (received stent to RCA and PDA at ___)
- PVD
- History of DVT and clots in aorto-femoral bypass
- chronic mesenteric ischemia with known occlusion of inferior
mesenteric artery.
- COPD
- Schizoaffective disorder
- Hypertension
- Hyperlipidemia
- diabetes mellitus type II
- Lumbar disc disease
- Gastroesophageal reflux/gastritis ___ EGD)
- Heparin-induced thrombocytopenia ___ (positive antibody)
- Exploratory laparotomy for pancreas divisum with
sphincterectomy of minor duct in ___
- Benign pelvic mass, s/p R oophorectomy and hysterectomy
- s/p cholecystectomy
- s/p arthroscopy of right knee and medial meniscectomy in ___
- s/p aorto-femoral bypass with
atherectomy in ___ after near total occlusion; multiple
revisions of her aorto-bifemoral and cross femoral grafts
Social History:
___
Family History:
Apparently mother and sister with chronic abdominal pain of
unclear etiology.
Physical Exam:
PHYSICAL EXAM:
VS - 98.8 120/70 73 18 96RA
GEN - NAD, appears comfortable today sitting upright in the
chair
CV - rrr, s1/s2, -m/r/g
R - cta b/l, -w/r/r
A - +BS soft, ND, mildly ttp epigastric
Ext - -c/c/e
Pertinent Results:
___ 05:10AM BLOOD WBC-15.4*# RBC-4.33 Hgb-10.7* Hct-34.9*
MCV-81* MCH-24.7* MCHC-30.6* RDW-17.8* Plt Ct-82*
___ 05:58PM BLOOD WBC-9.0 RBC-4.45 Hgb-11.0* Hct-36.0
MCV-81* MCH-24.6* MCHC-30.5* RDW-17.7* Plt Ct-85*
___ 10:45AM BLOOD WBC-9.0 RBC-4.17* Hgb-10.3* Hct-33.8*
MCV-81* MCH-24.7* MCHC-30.4* RDW-17.6* Plt ___
___ 06:00AM BLOOD WBC-7.9 RBC-4.01* Hgb-9.8* Hct-32.7*
MCV-82 MCH-24.5* MCHC-30.0* RDW-17.6* Plt ___
___ 07:19AM BLOOD WBC-10.2 RBC-3.78* Hgb-9.5* Hct-30.5*
MCV-81* MCH-25.2* MCHC-31.2 RDW-17.5* Plt ___
___ 05:55AM BLOOD WBC-6.1 RBC-4.02* Hgb-10.2* Hct-32.5*
MCV-81* MCH-25.4* MCHC-31.4 RDW-17.6* Plt ___
___ 06:00AM BLOOD Neuts-70 Bands-1 Lymphs-12* Monos-12*
Eos-5* Baso-0 ___ Myelos-0
___ 05:55AM BLOOD Neuts-50 Bands-0 ___ Monos-13*
Eos-6* Baso-0 ___ Myelos-0
___ 05:10AM BLOOD Glucose-181* UreaN-24* Creat-5.0*#
Na-125* K-GREATER TH Cl-88* HCO3-26
___ 05:58PM BLOOD Glucose-89 UreaN-29* Creat-6.2*# Na-134
K-5.7* Cl-93* HCO3-25 AnGap-22*
___ 10:45AM BLOOD Glucose-61* UreaN-35* Creat-6.9* Na-130*
K-5.2* Cl-89* HCO3-23 AnGap-23*
___ 06:00AM BLOOD Glucose-153* UreaN-48* Creat-8.2*#
Na-130* K-5.5* Cl-92* HCO3-20* AnGap-24*
___ 07:19AM BLOOD Glucose-186* UreaN-48* Creat-8.3* Na-131*
K-5.2* Cl-93* HCO3-22 AnGap-21*
___ 05:55AM BLOOD Glucose-67* UreaN-12 Creat-4.6*# Na-136
K-3.8 Cl-89* HCO3-31 AnGap-20
___ 05:10AM BLOOD ALT-26 AST-171* AlkPhos-163* TotBili-0.3
___ 05:58PM BLOOD ALT-10 AST-18 CK(CPK)-22* AlkPhos-181*
Amylase-88 TotBili-0.2
___ 05:10AM BLOOD Lipase-47
___ 05:58PM BLOOD GGT-34
___ 05:10AM BLOOD ___
___ 05:10AM BLOOD cTropnT-0.06*
___ 05:55AM BLOOD Calcium-8.1* Phos-4.0# Mg-2.0
___ 05:58PM BLOOD %HbA1c-6.1* eAG-128*
___ 05:55AM BLOOD T4-6.6 Free T4-1.1
___ 05:55AM BLOOD TSH-1.4
___ 05:55AM BLOOD Cortsol-7.6
___ 07:19AM BLOOD BETA-HYDROXYBUTYRATE-PND
___ 07:19AM BLOOD INSULIN-PND
___ 07:19AM BLOOD C-PEPTIDE-PND
Radiology Report
INDICATION: Shortness of breath.
TECHNIQUE: Single frontal radiograph of the chest.
COMPARISON: Multiple prior examinations, most recent dated ___.
FINDINGS: No focal opacity to suggest pneumonia is seen. No pleural effusion
or pneumothorax is present. Mild interstitial prominence is similar to prior
examinations. The heart size is normal. A large bore dual-lumen right-sided
central venous catheter is unchanged with the distal tip reaching the right
atrium.
IMPRESSION: No evidence of pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SHORTNESS OF BREATH/ABD PAIN
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, END STAGE RENAL DISEASE
temperature: nan
heartrate: 89.0
resprate: 32.0
o2sat: 100.0
sbp: 187.0
dbp: 82.0
level of pain: nan
level of acuity: 1.0 | ___ hx ESRD on HD, CAD s/p MI, HIT, COPD and schizoaffective
disorder who presents approximately 1.5 weeks after discharge
with recurrent epigastric abdominal pain radiating to her back,
consistent with prior episodes of her chronic abdominal pain.
.
#Abd pain: pt states exactly like her previous episodes of
chronic abdominal pain thought to be chronic pancreatitis, which
were also a/w n/v/d like this episode. Lipase wnl. Has had
extensive w/u for this in the past including EGDs with biopsies.
EUS ___ showed some changes consistent with chronic
pancreatitis but not enough to declare a diagnosis. Treated per
her usual care for chronic pancreatitis with NPO, IVF and IV
pain medications. At the time of discharge, she was tolerating
PO well without pain or nausea/vomiting.
.
#hypoglycemia: unclear etiology for persistent hypoglycemia.
Per pt report, has had episodes of hypoglycemia at home over the
recent past as well. Not receiving insulin or other
hypoglycemic medications. Was found to have glucose of ~40 on
multiple occasions throughout her hospitalization while NPO.
Combination with new thrombocytopenia suggests possible liver
etiology, however this is unlikely in this woman who has minimal
risk factors for liver pathology with has normal LFTs. It is
possible that she has reduced glucagon secretion from her
chronic pancreatitis. Other etiologies include thyroid related
illness versus adrenal related versus insulinoma vs IGF-1
overproduction. During the admission, she also had some
hyponatremia that suggested possible adrenal cause but her
fasting AM cortisol was within normal limits. She had
c-peptide, insulin and beta-hydroxybutyrate levels drawn which
will be followed up as an outpatient. She has been scheduled to
see endocrinology as an outpatient for followup.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Keflex / Sulfa (Sulfonamide Antibiotics) / Erythromycin Base /
Penicillins / Methotrexate / Macrolide Antibiotics / Avelox
Attending: ___.
Chief Complaint:
vertigo, direction changing nystagmus
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ F with h/o SLE, HTN, prior
cerebellar infarct and antiphospholipid syndrome with positive
anti-cardiolipin antibody on coumadin who presents with sudden
onset vertigo 3 days prior to presentation. The patient was at
home watching television when she suddenly felt dizzy. The
dizziness is described as feeling off balance and having a
sensation that she is spinning when she is not moving. The
dizziness has been persistent and unchanged since onset. She has
had some feelings of unsteadiness while walking, but has not
fallen and has not noticed that she falls to one side or the
other more frequently. Her INR is supratherapeutic today at 3.4.
She was noted to be orthostatic at an OSH and had worsening of
her symptoms with standing.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
SLE
- Since ___
- Chronic low C3 and elevanted dsDNA
- Lupus anticoagulant and anticardiolipin ab
Membranous glomerulonephritis ___ renal bx at ___ with
macrovascular thrombosis, sp cytoxan and imuran; on Coumadin)
HTN
Osteoporosis
h/o avascular necrosis
Fibromyalgia
___ lacunar stroke
___ pyoderma gangrenosum
Social History:
___
Family History:
SLE
Fibromyalgia
Discoid lupus
Hypertension
Melanoma
Physical Exam:
ADMISSION EXAM:
EXAM:
Vitals:
98.9 100 100/70 18 100%
GEN: Awake, cooperative, NAD.
HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx
NECK: Supple, no carotid bruits.
RESP: CTAB no w/r/r
CV: RRR, no m/r/g
ABD: soft, NT/ND
EXT: No edema, no cyanosis
SKIN: no rashes or lesions noted.
NEURO EXAM:
MS:
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.
Speech was not dysarthric.
Pt was able to name both high and low frequency objects.
Able to follow both midline and appendicular commands.
Good knowledge of current events.
No evidence of apraxia or neglect.
CN:
II:
Right pupil is 2.5mm-->1.5mm, brisk; left pupil is 2mm-->1mm,
brisk
VFF to confrontation.
III, IV, VI: EOMI, There is sustained nystagmus with lateral
gaze
and upward gaze. Beats to left when looking left, to right when
looking right and up when looking up.
V: Sensation intact to LT.
VII: Facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate rise symmetric.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue protrudes midline.
Motor:
Normal bulk, tone throughout. No pronator drift bilaterally.
No adventitious movements. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ ___ 5 5
R ___ ___ ___ ___ 5 5
Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
Reflexes:
Bi Tri ___ Pat Ach
L ___ 3 2
R ___ 2 2
left toe up, right toe down
DISCHARGE EXAM:
VS - T97.9, BP135-153/92-95, HR51-81, RR18, SpO2 92-98% on RA
General physical exam is unremarkable.
Neurological exam
MS - A&Ox3, no deficits
CN - R beating nystagmus on R gaze, L beating nystagmus on L
gaze, no nystagmus on up gaze; symmetric facial muscle
activation
Motor/Sensation - grossly intact
Coordination - some past pointing w B/L uppers
Gait - mildly unsteady, but greatly improved
Pertinent Results:
CBC w diff
___ 04:23PM BLOOD WBC-1.7* RBC-3.61* Hgb-9.9* Hct-30.5*
MCV-85 MCH-27.5 MCHC-32.5 RDW-16.5* Plt ___
___ 06:35AM BLOOD WBC-1.1* RBC-3.05* Hgb-8.7* Hct-26.0*
MCV-85 MCH-28.3 MCHC-33.3 RDW-16.4* Plt ___
___ 06:38AM BLOOD WBC-1.0* RBC-3.19* Hgb-8.8* Hct-26.6*
MCV-83 MCH-27.7 MCHC-33.2 RDW-16.1* Plt ___
___ 06:00AM BLOOD WBC-1.9*# RBC-3.30* Hgb-9.2* Hct-28.0*
MCV-85 MCH-28.0 MCHC-33.0 RDW-16.3* Plt ___
___ 05:40AM BLOOD WBC-2.2* RBC-3.51* Hgb-9.7* Hct-29.8*
MCV-85 MCH-27.7 MCHC-32.7 RDW-16.4* Plt ___
___ 07:40AM BLOOD WBC-5.6# RBC-3.75* Hgb-10.5* Hct-32.2*
MCV-86 MCH-28.1 MCHC-32.8 RDW-16.5* Plt ___
INR
___ 04:23PM BLOOD ___ PTT-43.7* ___
___ 05:50PM BLOOD ___ PTT-44.8* ___
___ 06:38AM BLOOD ___ PTT-44.5* ___
___ 06:00AM BLOOD ___ PTT-79.8* ___
___ 01:00PM BLOOD ___ PTT-49.8* ___
___ 05:40AM BLOOD ___ PTT-48.0* ___
___ 07:40AM BLOOD ___ PTT-45.4* ___
MRI HEAD W/O CONTRAST (___)
1. No acute intracranial process. No acute infarct.
2. Single nonspecific FLAIR white matter hyperintensity of the
right frontal
lobe, which may be seen the setting of chronic migraine or small
vessel
ischemic disease.
In retrospect, there is also a focus of FLAIR hyperintensity
along the right medulla extending to the facial colliculus,
compatible with sequela of remote infarct.
MRI HEAD W/ AND W/O CONTRAST (___)
IMPRESSION:
Ill-defined area of FLAIR signal abnormality in the right
posterior
pontomedullary junction. The appearance is nonspecific but given
the absence of mass effect and the clinical history of lupus, it
may be a vasculitic lesion. It is not significantly changed in
appearance from prior MRI four days ago given differences in
technique. Another small focus of FLAIR signal abnormality in
the right frontal subcortical white matter is also unchanged and
may be due to the same process. Follow-up imaging is suggested
at an interval to be determined based on the patient's clinical
scenario.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms
3. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID chest rash
4. Dapsone 100 mg PO DAILY
5. Warfarin 10 mg PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
7. Hydroxychloroquine Sulfate 200 mg PO MWFSU
8. Hydroxychloroquine Sulfate 400 mg PO TTHSAT
9. Duloxetine 60 mg PO DAILY
10. Nortriptyline 10 mg PO HS
11. Hydrochlorothiazide 25 mg PO DAILY
12. irbesartan 300 mg oral daily
Discharge Medications:
1. Dapsone 100 mg PO DAILY
RX *dapsone 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Duloxetine 60 mg PO DAILY
3. Hydroxychloroquine Sulfate 200 mg PO MWFSU
4. Hydroxychloroquine Sulfate 400 mg PO TTHSAT
5. Nortriptyline 10 mg PO HS
6. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID chest rash
RX *triamcinolone acetonide 0.1 % Apply to affected area twice a
day Refills:*0
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
8. Gabapentin 200 mg PO TID
9. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms
10. Hydrochlorothiazide 25 mg PO DAILY
11. irbesartan 300 mg oral daily
12. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
13. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Secondary Diagnosis: lupus, +lupus anticoagulant antibodies,
+anti-cardiolipin antibodies
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 dizziness/orthostasis // Eval for cardiopulmonary
process
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear. The cardiomediastinal silhouette is stable. Compression
deformities in the thoracic and lumbar spine are unchanged. Surgical clips
seen in the right upper quadrant.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with nystagmus, vertigo, h/o antiphospholipid ab
syndrome // Eval for arterial stenosis/thrombosis
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion of 70 cc of Omnipaque
intravenous contrast material. Images were processed on a separate workstation
with display of curved reformats, 3D volume redendered images, and maximum
intensity projection images.
DOSE: DLP: 2522.05mGy-cm;
COMPARISON: CT head are contrast of ___.
FINDINGS:
Head CT: Intra or extra-axial mass, acute hemorrhage or infarct. Gray-white
differentiation is preserved. The sulci, ventricles and cisterns are within
expected limits. The visualized paranasal sinuses are clear. The orbits are
remarkable. The mastoid air cells and middle ear cavities are well
pneumatized and clear. The left stapes is not visualized, consistent with
given clinical history of prior stapiectomy. Skull and extra-cranial soft
tissues are unremarkable.
CTA head: The right intracranial internal carotid artery is asymmetrically
smaller compared to the left, likely congenital given the appropriate
corresponding size of the petrous carotid canal. In addition, he right A1
segment is hypoplastic or congenitally absent. Otherwise, he intracranial
internal carotid artery, remainder of be ACA, MCA and are major branches are
on remarkable. The left intracranial prevertebral artery is dominant.
Otherwise the posterior circulation is unremarkable. Small left posterior
communicating artery is noted. The right posterior communicating artery is
not seen. No intracranial aneurysm larger than 3mm.
CTA Neck: The right common carotid and extracranial internal carotid arteries
are asymmetrically smaller compared to the left, likely congenital.
Otherwise, the carotid and vertebral arteries and their major branches are
patent with no evidence of stenoses. The distal cervical internal carotid
arteries measure 8.0 mm in diameter on the left and 7.3 mm in diameter on the
right. No significant internal carotid arteries stenosis by NASCET criteria.
There is no evidence of aneurysm formation or other vascular abnormality.
Visualized aerodigestive track is unremarkable. No cervical lymphadenopathy
by CT size criteria. The visualized lung apices are clear.
IMPRESSION:
1. No acute intracranial process.
2. Allowing for anatomic variations, essentially unremarkable CTA of the head
and neck.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with left cerebellar hypodensity on CT //
stroke?
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images .
COMPARISON: CT head without contrast of ___, CTA head and neck of ___.
FINDINGS:
There is no intra or extra-axial mass, acute hemorrhage or infarct. Sulci,
ventricles and cisterns are within expected limits. There is a single FLAIR
right frontal subcortical hyperintensity, which is nonspecific, but may be
seen a wide variety of settings, including chronic small vessel ischemic
disease or migraine. The major flow voids are preserved. No gradient echo
susceptibility artifacts. The paranasal sinuses are essentially clear. The
orbits are unremarkable. Overlying the paramedian posterior left parietal
skull and the soft tissues is a 1 cm presumed rounded epidermal inclusion
cyst.
IMPRESSION:
1. No acute intracranial process. No acute infarct.
2. Single nonspecific FLAIR white matter hyperintensity of the right frontal
lobe, which may be seen the setting of chronic migraine or small vessel
ischemic disease.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with SLE, APAS presents w direction changing
nystagmus and unsteadiness // demyelinating process vs infarct, evolution of R
medullary lesion
TECHNIQUE: MRI of the head was performed without and with intravenous
contrast. 6 cc of Gadavist was administered intravenously.
COMPARISON: MRI head ___.
FINDINGS:
There is an ill-defined area of FLAIR hyperintensity within the right
posterior aspect of the pontomedullary junction (series 4, image 8). There is
no enhancement or abnormally slowed diffusion within this region. There is no
mass effect. The lesion abuts the anterior wall of the fourth ventricle. There
is no mass effect. The fourth ventricle is normal in size and configuration.
This FLAIR hyperintense lesion does not appear significantly changed from MRI
on ___ given differences in technique and patient motion. There is a
smaller focus of FLAIR hyperintensity within the right posterior frontal
subcortical white matter, unchanged (series 4 image 18). This lesion is also
nonenhancing and does not demonstrate abnormally slowed diffusion.
There is no acute intracranial hemorrhage or evidence of chronic blood product
deposition. There is no extra-axial fluid collection. The ventricles, sulci,
and basal cisterns are normal. Major intravascular flow voids are preserved.
The osseous structures are normal. The paranasal sinuses and mastoid air cells
are clear. The orbits are normal. The round, well-circumscribed, nonenhancing
lesion of the high left parietal scalp is unchanged (series 9, image 24).
IMPRESSION:
Ill-defined area of FLAIR signal abnormality in the right posterior
pontomedullary junction. The appearance is nonspecific but given the absence
of mass effect and the clinical history of lupus, it may be a vasculitic
lesion. It is not significantly changed in appearance from prior MRI four days
ago given differences in technique. Another small focus of FLAIR signal
abnormality in the right frontal subcortical white matter is also unchanged
and may be due to the same process. Follow-up imaging is suggested at an
interval to be determined based on the patient's clinical scenario.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Hypotension, Dizziness
Diagnosed with VERTIGO/DIZZINESS
temperature: 98.9
heartrate: 100.0
resprate: 18.0
o2sat: 100.0
sbp: 100.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ F w PMHx SLE ___ years, +lupus anticoagulant and
+anti-cardiolipin antibody (on home coumadin), membranous GN
with vascular occlusion in ___ (seen on kidney biopsy), HTN,
and prior cerebellar infarct presents with sudden onset vertigo
beginning 3 days prior to presentation. Her exam is notable for
direction changing nystagmus evoked with lateral and superior
gaze. CTA preliminary read is without abnormality. MRI brain w/o
contrast: focus of FLAIR hyperintensity along the right medulla
extending to the facial colliculus, that could be compatible
with sequela of remote infarct. Pt discussed w outside
___, Dr. ___ recommended ___
Rheumatology consultation. ___ Rheumatology consult
recommended solumedrol 1g IV x3d. Pt reported signficant
improvement in subjective well being after steroid course. Her
neuro Repeat MRI Brain W/ and W/O contrast on ___ showed an
ill-defined area of FLAIR signal abnormality in the right
posterior pontomedullary junction. The appearance is nonspecific
but given the absence of mass effect and the clinical history of
lupus, it may be a vasculitic lesion. It is not significantly
changed in appearance from prior MRI four days ago given
differences in technique. It was considered less likely that
this lesion was a chronic ischemic infarct. Another small focus
of FLAIR signal abnormality in the right frontal subcortical
white matter is also unchanged and may be a
vasculitic/demyelinating lesion secondary to lupus. She should
follow up with her outpatient Rheumatolgist Dr. ___
determination of the appropriate long term therapy for her
lupus. As pt had significant clinical improvement in the inteval
between her MRI studies, decision was made to discharge with
suggested imaging follow up (MRI brain with and without
contrast) at one month, but will defer to her outpatient
neurologist Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever & chills/1 wk
Major Surgical or Invasive Procedure:
___ ___ placement of 8 ___ drain into hepatic abscess
History of Present Illness:
___ history of poorly controlled diabetes, HTN, and
HLD presents to the emergency room for evaluation of fever
chills
and general malaise. Patient states that he had periumbilical
abdominal pain for one day approximately one week ago that then
resolved without any treatment. Then over the course of the
week
he was unable to leave his house and could barely leave his bed
to go to the bathroom. Has not showered ___ over 1 wk. He was
feeling very lightheaded when he stood up and also c/o fever and
chills. He suspected food poisoning, but had not traveled
anywhere recently or eaten anything suspect. He was not having
any vomiting. He did have loose BMs, but only 1-2/day. They
were
not bloody or acholic. FSBS ___ 460s at the outside hospital
where
a CT showed e/o acute cholecystitis with possible underlying
mass. RUQ US was suspicious for a perforated gallbladder. He
also had an incidental finding of a lung nodule, and this had
been seen on a prior CXR. He was found to have transaminitis
and
elevated alk phos. The surgery team at the OSH felt he was too
complex and recommended transfer to a tertiary care center. wbc
16.9, creatine 2.1 at OSH. Known to have elevated cr/CKD at
baseline.
ROS: + for dyspnea with exertion past several mo, subjective f/c
past week, diarrhea x 1 day and stomach upset/loose stools with
milk products - for wt loss, jaundice, acholic stools, emesis,
bloody/black BMs.
Past Medical History:
PMH: DMT2, lumbar disc herniation, HLD, HTN, right bundle branch
block, last colonoscopy ___ yrs ago per patient no significant
findings due ___ next few years for another
PSH: pedi tonsillectomy
Social History:
___
Family History:
fa died colon ca age ___
Physical Exam:
PE: VS T 99.3 HR 87 BP 174/66 RR 18 SaO2 95% RA
GEN: A&Ox3, NAD, caucasian elderly male
HEENT: PERRL, MMM
CV: RRR, no r/m/g, nl S1/S2
P: CTAB, no respiratory distress
ABD: morbidly obese, nontender abdomen
EXTREM: bilateral ___ edema, e/o chronic venous stasis, no open
wounds, warm and well perfused
LYMPH: no cervical, allixary, inguinal LAD
LABS:
___ 00:24 UA with proteinuria
___ 23:09 Lactate:1.1
___ 22:55
135 104 70 352 AGap=17
5.2 19 1.9
estGFR: 35/42 (click for details)
Ca: 8.7 Mg: 1.7 P: 3.1
ALT: 185 AP: 281 Tbili: 0.5 Alb: 3.0
AST: 53 LDH: Dbili: TProt:
___: Lip: 24
14.8 > 8.8/27.2 < 279
N:82 Band:0 ___ M:8 E:0 ___ Metas: 1 Absneut: 12.14 Abslymp:
1.33 Absmono: 1.18 Abseos: 0.00 Absbaso: 0.00
Hypochr: 1+ Poiklo: 1+ Ovalocy: 1+
Plt-Est: Normal
___: 14.5 PTT: 30.6 INR: 1.3
IMAGING:
OSH RUQ US
? mass ___ the gallbladder versus acute cholecystitis
OSH CT torso
1.3 cm nodule ___ the right apex with periphal calicfaction
subcentimeter subpleural nodules 7.5 mm. Ill defined right lobe
liver fluid collection measuring 5 cm ?liver abscess ___ to
cholecystitis
___ RUQ US
Focused ultrasound ___ the right upper quadrant was performed to
assess the liver and gallbladder given findings on outside
hospital CT and ultrasound. There is a complex irregular fluid
collection within the right hepatic lobe abutting the
gallbladder
which measures approximately 6.5 x 3.3 cm. There is wide open
communication between the gallbladder and this collection
raising
concern for perforated acute cholecystitis with intrahepatic
abscess. No vascularity seen within this collection.
Gallstones
are seen within the neck of the gallbladder. The CBD is
nondilated. Main portal vein is patent. No perihepatic
ascites.
Pertinent Results:
___ 10:55PM BLOOD WBC-14.8*# RBC-2.99* Hgb-8.8*# Hct-27.2*
MCV-91 MCH-29.4 MCHC-32.4 RDW-13.3 RDWSD-44.0 Plt ___
___ 10:55PM BLOOD ___ PTT-30.6 ___
___ 10:55PM BLOOD Glucose-352* UreaN-70* Creat-1.9* Na-135
K-5.2* Cl-104 HCO3-19* AnGap-17
___ 10:55PM BLOOD ALT-185* AST-53* AlkPhos-281* TotBili-0.5
___ 06:15AM BLOOD ALT-122* AST-35 AlkPhos-236* TotBili-0.5
___ 06:15AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.7
___ 06:08AM BLOOD %HbA1c-8.2* eAG-189*
___ 10:27AM BLOOD CEA-5.0* AFP-0.6
___ and ___ Blood cultures:
pending
___ 2:14 pm ABSCESS LIVER ABSCESS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Preliminary):
GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Simvastatin 80 mg PO QPM
5. Pioglitazone 15 mg PO DAILY
6. GlipiZIDE XL 20 mg PO DAILY
7. Labetalol 300 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Labetalol 300 mg PO BID
2. Allopurinol ___ mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Acetaminophen 650 mg PO TID
do not take more than 2000mg per day
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 by mouth at bedtime Disp #*60
Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Weeks
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
10. Aspirin 81 mg PO DAILY
11. GlipiZIDE XL 20 mg PO DAILY
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [OneTouch Verio] one ___ times daily
Disp #*1 Box Refills:*5
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 17
Units QID per sliding scale Disp #*2 Syringe Refills:*2
RX *lancets [OneTouch Delica Lancets] 33 gauge one ___ times
daily Disp #*1 Box Refills:*5
13. Pioglitazone 15 mg PO DAILY
14. Insulin Pen Needles
32 G, ___ (4mm Nano)
Use to inject insulin 4 times daily
Supply: #100
Refills: 2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hepatic abscess/perforated gallbladder
cholelithiasis
DM, uncontrolled
Lung Nodules
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: Liver abscess. Evaluate for underlying mass.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 15 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Fluid collection drainage from ___. Right upper
quadrant ultrasound from ___. CT of the chest from ___.
FINDINGS:
Lower Thorax: There is mild bibasilar atelectasis and a very trace right
pleural effusion. Within the limitations of MRI, the lung bases are otherwise
clear. The base of the heart is normal in size. There is no pericardial
effusion.
Hepatobiliary: The liver is normal in shape and contour. There are no
morphologic features of cirrhosis. There is no background hepatic steatosis.
In the left lobe of the liver, there is a 8 mm T2 hyperintense which
demonstrates arterial nodular enhancement that fills in on the delayed phases
(8, 21 and 19, 35). This is most consistent with a hemangioma. In the dome
of the liver, there is a 8 mm focus of arterial hyperenhancement that has no
correlate on other sequences. This is likely a transient hepatic intensity
difference. Several similar sub-5 mm enhancing foci are also noted in the
periphery of both lobes of the liver, and also likely perfusional.
The superior wall of the gallbladder is discontinuous and in direct
communication with the fluid collection in the adjacent liver parenchyma. The
fluid collection measures 45 x 30 x 35 mm (19, 65 and 7, 12). There is some
finger-like projections of fluid in the surrounding parenchyma, as well,
though they all appear to be communicating. This has the appearance of a
perforated gallbladder with associated hepatic abscess. There is diffuse
surrounding arterial hyperenhancement, which is likely inflammatory. No
obvious mass is identified. The gallbladder is not distended. There is a
stone in the neck (7, 18). Since the prior exam, the fluid collection in the
liver appears of slightly decreased in size. A percutaneous drain has been
placed. The drain is not well evaluated by MRI, though appears to terminate
within the main intrahepatic collection (7:9).
There is mild dilation of the intrahepatic bile ducts. Additionally, there is
mild dilation of the common bile duct, measuring up to 10 mm. Just superior
to the ampulla, there is a 5 mm filling defect, compatible with a stone.
Several other smaller stones are noted just upstream to this obstructing
stone. There is no abnormal enhancement around the ducts to suggest
cholangitis.
There is a replaced right hepatic artery from the SMA. The portal veins are
patent. A branch of the middle hepatic vein which courses adjacent to the
abscess is thrombosed (21, 48). The remainder of the hepatic veins are
patent.
Pancreas: The pancreatic parenchyma is normal in signal and enhances
homogeneously. There is no duct dilation or mass.
Spleen: The spleen is borderline enlarged, measuring 13.7 cm. There are no
focal lesions.
Adrenal Glands: The bilateral adrenal glands are normal.
Kidneys: The kidneys are normal in size. There are few punctate simple cysts.
There are no worrisome renal lesions, hydronephrosis, or perinephric
abnormalities.
Gastrointestinal Tract: The stomach and small bowel are normal in course and
caliber. There is no evidence of obstruction. The imaged portions of the
large bowel are normal. There is no ascites.
Lymph Nodes: There are few prominent periportal lymph nodes measuring up to 10
mm. These are presumably reactive. There is no retroperitoneal or mesenteric
lymphadenopathy.
Vasculature: The abdominal aorta is normal in caliber without evidence of an
aneurysm or significant atherosclerotic plaque.
Osseous and Soft Tissue Structures: There are no concerning osseous lesions.
Moderate to severe multilevel degenerative changes are noted throughout the
spine. The soft tissues are unremarkable.
IMPRESSION:
1. Hepatic abscess in direct continuity with a perforated gallbladder, as
described above. No definite mass is identified. Follow-up after treatment
is recommended to exclude a subtle underlying lesion which may be obscured by
the surrounding inflammatory changes.
2. Bland thrombus within the peripheral aspect of the middle hepatic vein
which courses through the inflamed region.
3. Choledocholithiasis with a 5 mm stone at the ampulla and several smaller
stones upstream. There is associated mild intra and extrahepatic biliary duct
dilation.
4. Borderline splenomegaly.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:59 AM, 25 minutes
after discovery of the findings.
Radiology Report
EXAMINATION:
Ultrasound-guided hepatic collection drainage
INDICATION: ___ year old man with collection on imaging // ?drainage
COMPARISON: Ultrasound from ___
PROCEDURE: Ultrasound-guided drainage of hepatic collection.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agree with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the drain placement
was chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the collection. A sample of fluid was
aspirated, confirming catheter position within the collection. The pigtail
was deployed. The position of the pigtail was confirmed within the collection
via ultrasound.
Approximately 200 cc of purulent fluid was drained with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 15
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Preprocedure ultrasound demonstrated an enlarged, distended gallbladder with
complex echogenic internal material, in addition to a 6.5 x 6.0 cm hepatic
collection adjacent to the gallbladder fossa. There was visible disruption in
the gallbladder wall measuring up to 2.2 cm. The findings are highly
suggestive of perforated cholecystitis with associated liver abscess.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the
collection. Samples was sent for microbiology evaluation.
RECOMMENDATION(S): Short-term follow-up ultrasound in 48-72 hr is recommended
to reassess the status of the gallbladder and the hepatic collection and to
ensure that both entities are being adequately drained.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, N/V
Diagnosed with Perforation of gallbladder
temperature: 98.7
heartrate: 78.0
resprate: 16.0
o2sat: 97.0
sbp: 148.0
dbp: 78.0
level of pain: 5
level of acuity: 3.0 | ___ M with one month h/o RUQ pain, fevers, found to have right
lobe abscess adjacent to the gallbladder. He was pan-cultured
and started on IV antibiotics then underwent ___ drainage on
___. Ultrasound demonstrated an enlarged, distended gallbladder
with complex echogenic internal material, ___ addition to a 6.5 x
6.0 cm hepatic collection adjacent to the gallbladder fossa.
There was visible disruption ___ the gallbladder wall measuring
up to 2.2 cm. The findings were highly
suggestive of perforated cholecystitis with associated liver
abscess. An 8 ___ drain was placed into the collection that
appeared purulent and a sample sent to microbiology. Micro
isolated no pmns, 2+GPC, 2+GNR, 1+GPR and sparse growth GPC. IV
Unasyn continued pending finalization of abscess culture. An MRI
was done to assess whether abscess represented a perforated
cholecystitis or an underlying tumor. MRI was done on ___ that
demonstrated the following:
1. Hepatic abscess ___ direct continuity with a perforated
gallbladder, as
described above. No definite mass is identified. Follow-up
after treatment
is recommended to exclude a subtle underlying lesion which may
be obscured by
the surrounding inflammatory changes.
2. Bland thrombus within the peripheral aspect of the middle
hepatic vein
which courses through the inflamed region.
3. Choledocholithiasis with a 5 mm stone at the ampulla and
several smaller
stones upstream. There is associated mild intra and
extrahepatic biliary duct
dilation.
4. Borderline splenomegaly
Tumor markers were sent off. CEA was elevated at 5.0 and AFP was
0.6. CA ___ was 27.
Upon learing MRI findings, ERCP was consulted and on ___, he
underwent ERCP with the following note:
note of small filling defects ___ the lower bile duct suggestive
of sludge/stone. There was mild diffuse biliary dilation,
including mild saccular dilation of the lower CBD. The cystic
duct was filled with contrast, and the intrahepatics were
well-visualized and only mildly dilated. A sphincterotomy was
performed and a moderate amount of sludge was extracted.
Completion cholangiogram was normal. Otherwise normal ERCP to
___ portion of duodenum.
Post ERCP, he received IV fluid hydration. Labs were improved
and diet was resumed and tolerated.
He was hyperglycemic. Sliding scale insulin was used to control
his glucoses. HgA1c was elevated at 8.2. A ___ consult was
obtained and insulin was adjusted with improved control. At time
of discharge to home, home meds (actos/glipizide)were resumed.
He was instructed to hold his Januvia for a week and f/u with
his PCP for DM management. A Humalog sliding scale was
recommended for home. The ___ DM educator reviewed glucometer
teaching and injection with an insulin pen. He was provided with
scripts for Humalog pen with pen needles, strips, lancets.
A time of discharge, antibiotics were switched to Augmentin for
2 weeks from drain placement. Drain output was averaging 570cc.
___ was arranged to see him at home to assess management.
Of note, he will see Dr. ___ consult)for
evaluation of pulmonary nodules that were noted on OSH CT scan
uploaded on ___ imaging(1.3cm nodule ___ the right apex with
small peripheral calcification and adjacent scarlike opacity,
7.5mm supleural nodule ___ the right lung base, 5mm subpleural
nodule ___ the right middle lobe and 5mm subpleural nodule ___ the
left upper lobe posteriorly). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
aspirin
Attending: ___
Chief Complaint:
Headache, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ otherwise healthy presents from ___ for brain mass.
He began having a gradually worsening frontal, throbbing
headache
last night. This morning he began having nausea and vomiting. He
went to ___ where he was given Reglan and Morphine and MRI
showed a 1.4cm x 1.7cm sella mass. His headache and nausea are
currently improved. No vision changes, weakness, numbness.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
AVSS
Gen: WD/WN, comfortable, NAD.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Awake, alert, oriented x3
follows commands throughout
PERRL, EOMI, FSTM
No drift
MAE ___
sensation intact to light touch throughout
visual fields full on confrontation
Pertinent Results:
___ CXR:
No evidence of mass, mild cardiomegaly
MRI OF THE HEAD: ___
A 1.7x2.4x1.7cm heterogeneous lesion in the sella with cystic/
necrotic and solid components, extending into the suprasellar
region as described above with indentation on the optic chiasm
and compression/ encasement of the infundibulum and possible
minimal extension into the cavernous sinuses. DDx incudes
macroadenoma, craniopharyngioma, etc.
CTA brain (pre-op mapping) ___
IMPRESSION:
1. Lesion in the pituitary gland, extending into the
suprasellar location, better assessed on the recent MRI
pituitary study. Please see details on that report.
2. Patent major intra cranial and upper cervical arteries as
described above.
3. Cavernous carotid segments and the right ICA para clinoid
segment in
proximity to the sellar lesion without encasement or narrowing.
4. Mild thinning of the dorsum sella.
CT Head ___:
Unchanged pituitary lesion extending into the suprasellar area,
better
assessed on recent MRI pituitary. No acute intracranial process.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every six (6) hours Disp #*60 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary macroadenoma
Pituitary Appoplexy
Hypokalemia
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with Brain Mass // ? Mass
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate low lung volumes
which results in bronchovascular crowding. The heart is mildly enlarged. The
hilar contours are unremarkable. There is no pneumothorax, pleural effusion,
mass or consolidation.
IMPRESSION:
1. No evidence of mass.
2. Mild cardiomegaly.
Radiology Report
EXAMINATION: MR ___ ___ CONTRAST
INDICATION: ___ year old man with pituitary mass on head CT // ___ year old
man with pituitary mass on head CT severe headache, low hormones based
on Careweb details
TECHNIQUE: MRI of the pituitary without and with IV contrast including axial
FLAIR and axial T1 postcontrast sequences through the brain
COMPARISON: CT head from ___ done on ___
FINDINGS:
There is enlargement of the sella, with a heterogeneous lesion in the sella,
extending into the suprasellar region. The pituitary gland is not separately
identifiable.
The lesion measures approximately 1.7 cm transverse, 2.4 cm CC and 1.7 cm AP
___.
It has a heterogeneous appearance on the postcontrast images, with enhancing
as well as nonenhancing cystic/necrotic components and a slightly thick
enhancing rim.
A small focus superiorly has a slightly T1 precontrast appearance and may
relate to small amount of blood products or mineralization likely chronic, as
the recent CT does not demonstrate any dense focus to suggest acute hemorrhage
within.
There is possible minimal extension towards or into the cavernous sinus on
either side series 5, image 7.
The cavernous carotid flow voids are noted.
The optic chiasm is draped by the lesion and indented ; plane of cleavage is
difficult to identify.
The infundibulum is not seen except for a very small portion superiorly
indented by the lesion and the rest of it is either compressed or encased by
the lesion. Series 6, image 9
Enhancement in the cavernous sinuses is not well seen. Likely mild proptosis
left more than right; however assessment limited due to rotated positioning on
routine study.
Correlate clinically.
On the postcontrast sequences of the brain, no abnormal enhancement is noted
in the brain parenchyma or meninges.
Left vertebral artery is dominant with diminutive right vertebral artery.
Ventricles, extra-axial CSF spaces on the sulci are unremarkable.
Right transverse sinus is dominant and left is diminutive.
Increased signal intensity on the FLAIR sequence at the foramen series 8,
image 4, 5, 6 magnum margins, is of uncertain etiology and significance,
question vascular.
The pineal gland and the craniocervical junction regions are unremarkable.
There is mild to moderate ethmoidal and sphenoidal mucosal thickening.
Retention cyst in the right maxillary sinus with slightly dense contents
within.
IMPRESSION:
A 1.7x2.4x1.7cm heterogeneous lesion in the sella with cystic/ necrotic and
solid components, extending into the suprasellar region as described above
with indentation on the optic chiasm and compression/ encasement of the
infundibulum and possible minimal extension into the cavernous sinuses.
DDx incudes macroadenoma, craniopharyngioma, etc.
Other details as above
Radiology Report
EXAMINATION:
CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ year old man with pituitary macroadenoma. Pre-op mapping/ EEA
protocol // Pre-op mapping; pls do EEA protocol per Dr. ___
___: CT head without IV contrast, CT angiogram of the head with IV
contrast; 2D and 3D reformations of the intracranial arteries
DOSE: DLP: ___ MGy-cm; CTDI: 130 mGy
COMPARISON: MRI of the pituitary ___
FINDINGS:
CT HEAD
No acute intracranial hemorrhage or mass effect.
Enlarged sella with lesion in the sella extending into the suprasellar
location, better assessed on the recent MRI of the pituitary.
The ventricles, extra-axial CSF spaces on the sulci are unremarkable.
No suspicious osseous lesions.
Mild thinning of the dorsum sella, seen on the prior CT head study from
outside hospital
Mild ethmoidal and sphenoidal mucosal thickening.
Retention cysts in the right maxillary sinus.
The mastoid air cells are clear.
Pneumatization of the petrous apices on both sides.
The included orbits are unremarkable.
CT ANGIO HEAD
The major intracranial arteries of the anterior and the posterior circulation
are patent, without focal flow-limiting stenosis or occlusion or obvious
aneurysm more than 3 mm within the resolution.
Minimal calcifications and contour irregularity noted in the cavernous carotid
segments and in close proximity to the lesion in the sella.
The para/ supraclinoid segment of the right internal carotid artery is also in
close proximity to the lesion in the sella.
No arterial encasement or narrowing noted.
The anterior and the posterior communicating arteries are faintly seen.
Left vertebral artery is dominant.
Right vertebral artery is diminutive, and not seen after the origin of the
right posterior inferior cerebellar artery, with effective ___ termination.
The posterior inferior cerebellar arteries are slightly tortuous in course.
The anterior inferior cerebellar arteries are faintly seen.
The included cervical portions of the common carotid, internal carotid
arteries and the vertebral arteries are patent without focal flow-limiting
stenosis or occlusion.
A few small nodes in the upper neck, not enlarged by size criteria.
IMPRESSION:
1. Lesion in the pituitary gland, extending into the suprasellar location,
better assessed on the recent MRI pituitary study. Please see details on that
report.
2. Patent major intra cranial and upper cervical arteries as described above.
3. Cavernous carotid segments and the right ICA para clinoid segment in
proximity to the sellar lesion without encasement or narrowing.
4. Mild thinning of the dorsum sella.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with pituitary macroadenoma with an episode of
syncope // Eval for hemorrhage
TECHNIQUE: Contiguous axial CT 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: DLP: 891 mGy-cm
CTDI: 55
COMPARISON: CT head on ___ and pituitary MRI on ___
FINDINGS:
Again seen is an enlarged sella with a dense lesion within the sella extending
into the suprasellar area, previously characterized as macroadenoma on recent
MRI of the pituitary gland. There is no evidence of hemorrhage, edema, mass
effect, or infarction. The ventricles and sulci are normal in size and
configuration. The basal cisterns appear patent and there is preservation of
gray-white matter differentiation.
The visualized bony structures are grossly unremarkable. There is mucosal
thickening of the sphenoid sinus. The remainder of the paranasal sinuses are
clear. The mastoid air cells are clear.The globes are unremarkable.
IMPRESSION:
Unchanged pituitary lesion extending into the suprasellar area, better
assessed on recent MRI pituitary. No acute intracranial process.
Gender: M
Race: ASIAN - ASIAN INDIAN
Arrive by AMBULANCE
Chief complaint: Headache, MASS
Diagnosed with BRAIN CONDITION NOS
temperature: 99.0
heartrate: 72.0
resprate: 16.0
o2sat: 96.0
sbp: 135.0
dbp: 75.0
level of pain: 5
level of acuity: 2.0 | Patient was seen and evalauted in the emergency department as a
transfer from an outside hospital on the evening of ___.
Iamging had revealed a sellar lesion. Workup was initiated to
assess if tumor was causing abnormal secretion of hormones and a
dedicated Pituitary MRI was obtained. On ___, the patient
remained neurologically stable and waiting for the MRI of the
brain. On ___, the patient's MRI of the brain was completed
confirmed a pituitary macroadenoma. The endocraine service was
consulted to follow along for the suprasellar mass. Prolactin
was normal. Dr ___ met with the patient and his wife on
___ to discuss surgical options. The plan was made for the
patient to return the following week for surgery. Pre-op testing
and mapping would be done during this admission and the patient
will dc home ___.
On ___, patient reported an episode of LOC while in the
bathroom and came to on the floor with a small laceration to his
left cheek. Patient was evaluated and was neurologically intact.
A STAT CT head was performed and showed more blood within the
lesion. Dr ___ was made aware, the patient was transferred
to the SDU. Given no deficits he will continue to be monitored
and DC was cancelled. An EKG showed no changes and labs were
sent. His K was mildly low and repleted. His NA is trending up
compared to 129. The midlevel spoke to his wife to update her.
___, the patient was discharged home in stable condition with
instructions to return for visual field testing and a planned
resection. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Bee sting
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ yo male who presents w/ 1-day history of
abdominal pain severe enough to prevent sleeping. It began as a
periumbilical pain around ___ p.m. Pt denies migration of the
pain overnight. Claims it felt like stomach cramps different
from
the pain he associated w/ his previous cholecystitis and GERD.
Endorses intermittent vomiting throughout the night, along w/
loose stools. Pt denies recent fevers or chills, though
developed
sweats during the night. The pain is mild ___ ___ut
movement causes moderate pain and palpation severe pain. Pt has
only had scattered sips since ___ p.m.
Past Medical History:
hepatitis - ? HAV
Social History:
___
Family History:
Father with h/o gallstones and some sort of subsequent CA from
which he died in his ___. Half-brother who is healthy. ___
descent. No IBD. No autoimmune ds.
Physical Exam:
EXAM: upon admission: ___:
VS - T97.5 HR87 BP130/79 RR19 O2 sat 100% RA
GEN - NAD, lying in bed
HEENT - NCAT, EOMI, no scleral icterus, MMM
___ - RRR
PULM - no increased WOB, CTAB, no w/r/r
ABD - well-healed laparoscopic incisions c/w prior
cholecystecomy. soft, nondistended, moderate to severe TTP in
the
RLQ extending up to the periumbilical area without rebound or
guarding. Equivocal Rovsing's/Obturator signs.
EXTREM - warm, well-perfused; no peripheral edema
Discharge physical exam: ___
VS: 98.2 62 120/68 18 99RA
Gen: NAD, lying in bed
HEENT: nonicteric, EMOI, MMM
Card: S1/S2, RRR
Pulm: no respiratory distress
Abd: soft, mildly distended, nontender, no rebound/guarding,
port incision dressing clean
Ext: warm, well perfused, no cyanosis, no edema
Pertinent Results:
___ 02:30AM BLOOD WBC-17.0*# RBC-4.96 Hgb-15.4 Hct-40.6
MCV-82 MCH-31.1 MCHC-38.0* RDW-13.0 Plt ___
___ 02:30AM BLOOD Neuts-74.2* ___ Monos-4.4 Eos-1.2
Baso-0.2
___ 02:30AM BLOOD Glucose-128* UreaN-17 Creat-0.9 Na-140
K-3.8 Cl-101 HCO3-24 AnGap-19
___ 02:30AM BLOOD ALT-40 AST-26 AlkPhos-61 TotBili-0.3'
___: cat scan of abdomen and pelvis:
Acute appendicitis, with the tip of the appendix dilated to
1.4-cm and
Preliminary Reportperiappendiceal stranding. No evidence of an
adjacent abscess or rupture.
Medications on Admission:
flovent Flovent HFA 110 mcg/actuation aerosol
inhaler. 1 puffs(s) twice a day, albuterol inhaler, prevacid
ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs(s) po four
times a day as needed for sob/wheezing - OMEPRAZOLE - omeprazole
20 mg capsule,delayed release. 1 capsule(s) by mouth once a day
for acid reflux
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 8 hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
may cause dizziness, do no drive while on this medicaiton
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20
Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. Omeprazole 20 mg PO DAILY
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
qid
Discharge Disposition:
Home
Discharge Diagnosis:
laparoscopic appendectomy
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: History right lower quadrant pain. Please evaluate for
appendicitis.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous administration of 130cc of Omnipaque. Coronal and
sagittal reformations were performed.
DOSE: DLP: 645 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST: The bases of the lungs are clear.
ABDOMEN: The liver is normal without evidence of focal lesions or
intrahepatic biliary ductal dilatation. The patient is status post
cholecystectomy. The portal vein is patent. The splenic vein is patent. The
SMV is patent. The adrenal glands bilaterally are normal. An 8 mm hypodensity
in the midpole the left kidney is too small to characterize by CT but likely
secondary to a simple renal cyst. The kidneys otherwise bilaterally are normal
without evidence of focal lesions concerning for malignancy or hydronephrosis.
The pancreas is normal without evidence of focal lesions or pancreatic duct
dilatation.
The stomach, duodenum, and small bowel are normal without evidence of wall
thickening or obstruction. There is no retroperitoneal or mesenteric
lymphadenopathy.
The tip of the appendix is dilated, measuring up to 1.4 cm series 601b, image
31. There is periappendiceal fat stranding as well as prominent local lymph
nodes, although none are enlarged by CT size criteria. The colon is normal.
There is no evidence of an adjacent abscess or rupture.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
BONES AND SOFT TISSUES: There is no evidence of worrisome lesions.
IMPRESSION:
Acute appendicitis, with the tip of the appendix dilated to 1.4-cm and
periappendiceal stranding. No evidence of an adjacent abscess or rupture.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V, Abd pain
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 97.5
heartrate: 87.0
resprate: 19.0
o2sat: 100.0
sbp: 130.0
dbp: 79.0
level of pain: 5
level of acuity: 3.0 | The patient was admitted to the hospital with right lower
quadrant abdominal pain and an elevated white blood cell count.
He was made NPO, given intravenous fluids, and underwent
imaging. A cat scan of the abdomen showed acute appendicitis.
Based on these findings, the patient was taken to the operating
room on HD #1 where he underwent a laparoscopic appendectomy.
The operative course was stable with minimal blood loss. The
patient was extubated after the procedure and monitored in the
recovery room. His post-operative course was stable. He was
started on a regular diet. His incisional pain was controlled
with oral analgesia. He was voiding without difficulty. On the
operative day, the patient was discharged home in stable
condition. An appointment for follow-up was made with the acute
care service. |
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 PMHx diastolic CHF, dementia, who presents to the ED
after a unwitnessed fall. Pt is ___ speaking only. History
was obtained with help of her daughter.
Pt was found down at 2pm on ___ at home by her helper. Pt was
conscious when found. She stated that she felt dizzy prior to
the fall. It is unclear whether pt lost consciousness during the
event, and pt could not recall chest pain or any prodromal
symptoms.
Of note, this is the ___ fall in the past month for Ms.
___. She had a fall a couple weeks ago, and crawled on the
floor for an extended period of time, resulting in multiple
bruises over her legs. Pt received 10 days amoxicillin and
doxycycline, that were finished about one week ago. Per family,
pt denies F/C, CP, SOB, cough, appetite, N/V/D, dysuria. Pt has
good appetite, and her last BM was yesterday, unclear form or
color. family reported that pt gained 12 lbs in the past month.
At baseline, pt needs help with ADL. She lives along with helper
visiting daily.
In the ED, initial VS was 98 83 118/53 20 98%. Hip X-ray showed
small nondisplaced ramus fracture. CXR showed possible increased
opacity in RLL. CT head could not be completed as pt was not
cooperative. Labs were not available at the time of transfer
because of access issues. Pt was given 1 gram Vancomycin for
cellulitis.
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:
CHRONIC BILATERAL PLEURAL EFFUSIONS, S/P TALC PLEURODESIS ___
HYPERTENSION
HYPERLIPIDEMIA
HYPOTHYROIDISM
Gastritis - per EGD ___
H/O NEPHROLITHIASIS
H/O BASAL CELL CARCINOMA ___
CHRONIC CONSTIPATION
URINARY INCONTINENCE
OSTEOPOROSIS
CHRONIC UTI on methenamine
- ___: admitted to ___ for Coombs
positive hemolytic anemia, treated with Solumedrol IV
- ___: bone marrow biopsy with hypercellular marrow with
erythroid hyperplasia and mild non-diagnostic lymphocytosis
- ___: relapsed and was treated with IVIG
- ___: s/p splenectomy by Dr. ___ at ___
___
- ___: hospitalized at ___ for autoimmune hemolytic anemia
with cold agglutinins, received 4 units PRBCs
Social History:
___
Family History:
Mother had hypertension.
Physical Exam:
VS - Temp 97.4F, BP 145/55, HR 78, R 20, O2-sat 96% RA
GENERAL - frail and pale appearing woman in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD at clavicle, no carotid
bruits
LUNGS - RLL crackles, no wheeze or rhonchi
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, mildly distended, umbilical hernia, ND on
palpation, no masses or HSM, no rebound/guarding
EXTREMITIES - 1+ pitting edema bilaterally, ___ not palpable,
tender on palpation over left hip
SKIN - multiple shallow ulcers over bilateral shins, mild
erythematous area over right lower leg
NEURO - awake, A&Ox2 (not hospital name), muscle strength ___ in
four extremities, moving both legs well.
VS - 98 130/50 68 17 95%RA
GENERAL - elderly woman, NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, edentulous
NECK - supple, no thyromegaly, JVD at clavicle, no carotid
bruits
LUNGS - CTAB, no wheeze or rhonchi
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, moderately distended, umbilical hernia, ND
on palpation, no masses or HSM, no rebound/guarding
EXTREMITIES - 1+ pitting edema bilaterally, ___ not palpable,
tender on palpation over left hip. R arm and hand with 1+ edema
SKIN - multiple shallow ulcers over bilateral shins, mild
erythematous area over right lower leg, R heel with some
cracking, no obvious ulceration
NEURO - awake, A&Ox3, muscle strength ___ in four extremities,
moving both legs well.
Pertinent Results:
___ 11:00PM BLOOD WBC-7.2 RBC-2.19* Hgb-7.6*# Hct-23.6*
MCV-108* MCH-34.5* MCHC-32.1 RDW-14.2 Plt ___
___ 07:00AM BLOOD WBC-7.1 RBC-2.80* Hgb-9.5* Hct-28.2*
MCV-101* MCH-33.7* MCHC-33.6 RDW-19.0* Plt ___
___ 11:00PM BLOOD Glucose-99 UreaN-103* Creat-1.6* Na-135
K-4.6 Cl-100 HCO3-23 AnGap-17
___ 07:00AM BLOOD Glucose-82 UreaN-95* Creat-1.4* Na-138
K-4.1 Cl-107 HCO3-23 AnGap-12
___:23AM BLOOD LD(LDH)-258*
___ 05:10AM BLOOD proBNP-2283*
___ 05:10AM BLOOD VitB12-GREATER TH
___ 07:23AM BLOOD Hapto-<5*
___ 08:50AM BLOOD Folate-8.2
___ 07:00AM BLOOD TSH-7.0*
___ 07:00AM BLOOD Free T4-0.91*
___ EKG: Sinus rhythm with premature atrial contractions.
Tracing is otherwise within normal limits. Compared to the
previous tracing of ___ the heart rate is increased and the
P-R interval is shortened. Premature atrial contractions are now
noted.
___ ECG: Atrial fibrillation with a rapid ventricular
response. Non-specific ST-T wave changes. Compared to the
previous tracing of ___ atrial fibrillation is new.
___ Hip xray: Possible nondisplaced fracture of the left
superior pubic ramus.
___ CXR: Moderate size right and small left pleural
effusions. Worsening opacification in the right lung base could
reflect compressive atelectasis though infection is difficult to
exclude. Retrocardiac atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4-6H SOB
per ___, rarely uses
2. fenofibrate nanocrystallized *NF* 145 mg Oral qd
3. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
per ___, uses rarely.
4. Furosemide 60 mg PO BID
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Losartan Potassium 50 mg PO DAILY
7. NIFEdipine CR 90 mg PO DAILY
please hold for SBP < 100 or HR < 60
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Senna 1 TAB PO BID:PRN constipation
12. Acetaminophen 500 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4-6H SOB
per ___, rarely uses
3. Aspirin 81 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
per ___, uses rarely.
5. Furosemide 60 mg PO BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Simvastatin 40 mg PO DAILY
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. Docusate Sodium 100 mg PO BID
12. Enoxaparin Sodium 30 mg SC Q24H
please continue while at rehab. Can discontinue once pt
discharged to home.
13. FoLIC Acid 1 mg PO DAILY
14. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
15. Polyethylene Glycol 17 g PO DAILY:PRN constipatino
16. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
17. NIFEdipine CR 90 mg PO DAILY
please hold for SBP < 100 or HR < 60
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
s/p fall
anemia
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Hip pain after fall.
TECHNIQUE: AP view of the pelvis, 2 views of the left hip.
COMPARISON: None.
FINDINGS:
Diffuse demineralization of the osseous structures limits the detection of
subtle fractures. A subtle area of cortical irregularity is seen involving
the superior left pubic ramus suspicious for a nondisplaced fracture. There
is no diastasis of the pubic symphysis or sacroiliac joints, with degenerative
changes noted in these joints. Mild to moderate degenerative changes with
joint space narrowing are also noted involving both hips. No focal lytic or
sclerotic osseous abnormalities are identified. There are scattered vascular
calcifications.
IMPRESSION:
Possible nondisplaced fracture of the left superior pubic ramus.
Radiology Report
HISTORY: Diastolic congestive heart failure with chronic pleural effusions,
recent weight gain weakness.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Moderate to severe cardiomegaly is unchanged. The mediastinal and hilar
contours are stable. There is no pulmonary vascular engorgement. Moderate
size right pleural effusion is relatively unchanged compared to the prior
study with a trace left pleural effusion also again noted. There is worsening
opacification in the right lung base, which could reflect atelectasis though
infection cannot be excluded. Retrocardiac atelectasis is also be
demonstrated. No pneumothorax is identified.
IMPRESSION:
Moderate size right and small left pleural effusions. Worsening opacification
in the right lung base could reflect compressive atelectasis though infection
is difficult to exclude. Retrocardiac atelectasis.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: LEFT HIP PAIN
Diagnosed with CELLULITIS OF LEG
temperature: 98.0
heartrate: 83.0
resprate: 20.0
o2sat: 98.0
sbp: 118.0
dbp: 53.0
level of pain: 7
level of acuity: 3.0 | ___ with PMHx diastolic CHF, hemolytic anemia, who presents to
the ED after a unwitnessed fall, found to have hemolytic anemia.
# ___: Pt presented with Cr. 1.6 from baseline of 0.7-1. FeUrea
16%, peaked at 2.1, now 1.4. Initially thought ___ anemia and
hypovolemia from increased lasix, however pt appeared volume
overloaded and creatinine worsened with IVF and holding
diuretics. Renal spun urine and saw some yeast and acanthocytes,
wanted to consult, however repeat spin showed only one
acanthocyte, per renal no e/o vasculitis. The pt was restarted
on her home lasix 60mg PO BID and her cr downtrended. On day of
discharge cr was 1.4.
# Weakness: Likely multifactorial, due to deconditioning,
anemia, accidentally doubling her medications at home. Anemia
managed as stated below. ___ worked with pt and felt she would
benefit from rehab. Of note, TSH was elevated at 7 and free T4
0.91. PCP was notified and will follow-up as an outpt.
# Paroxysmal Afib: Pt with baseline sinus rhythm, found to have
afib with RVR for several hours. The pt was started on metop
12.5mg BID with good rate controle, however subsequent reverted
to sinus braycardia. Metoprolol was dced and the pt remained in
normal sinus. Given pt was asymptomatic with afib with rvr,
unclear if this was an isolated event or if she has ongoing
paroxysmal afib. Given the pt's CHADS2 score of 2,
anticoagulation was consider, but felt to be contraindicated in
the setting of her frequent falls. High dose aspirin was also
considered, however pt also with hx of esophageal ulcerations
and ongoing issues with anemia. Pt was continued on aspirin 81mg
daily.
# Anemia: The pt presented with a macrocytic anemia with HCT 23
from baseline of ___, down to 20. The pt has an extensive hx
of hemolytic anemia, and was found to have LDH elevated, hapto
<5, +DAT. GUAIAC negative. She was very difficult to crossmatch
but received 2u prbc with bump to 28. Hemonc was consulted, and
felt she should f/u as an outpatient given her hcts stabilized.
Vitamin B12 greater than assay, folate wnl, however folate 1g
daily started per hem recs.
# s/p fall: Per pt history, likely mechanical, and ___ weakness
from extra medication and anemia. Management of anemia as above.
___ recommended rehab.
# Possible nondisplaced fracture of the left superior pubic
ramus. Pt comfortable, able to ambulate, full ROM. ___ as above.
Should continue lovenox 30mg q24h for DVT ppx while in rehab.
# Funguria: Presented with significant pyuria. Ucx ___. Pt
treated with diflucan 150mg PO x1 per renal recs.
# Heel pain: On day of discharge pt complained of worsening R
heel pain, which, per grandson, has been ongoing for a few
months. Pt has spent a lot of time in bed, and heels appear
slightly cracked and tender, likely applying more pressure than
at baseline. Wound care recs below. Tramadol prn pain. If pain
worsens, can consider outpt eval by podiatry or xray foot.
# Diastolic heart failure: continued home meds. Losartan was
held due to decreased creatinine clearance. Should be restarted
as pt renal function improves, as tolerated by BPs.
# BLE traumatic ulcerations: chronic from crawling on the floor
after prior fall. Wound care evaluated, recs below.
# Asthma: continued home meds
# Hypothyroidism: continued home meds. Of note, TSH was elevated
at 7 and free T4 0.91. PCP was notified and will follow-up as an
outpt.
# HLD: continued home meds |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Codeine / Ciprofloxacin
Attending: ___.
Chief Complaint:
Abdominal pain
Hematemesis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
Mr. ___ is a ___ with h/o Etoh cirrhosis c/b esophageal
varices s/p banding and ascites who p/w abdominal pain c/w
previous flares of chronic pancreatitis, as well as hematemesis.
He was admitted most recently for acute-on-chronic pancreatitis
from ___, during which time he received IVF and pain
control and was tolerating POs by the time of discharge. He
reports that he was in his USOH until the day PTA, when he
developed constant, throbbing epigastric pain, ___ in
intensity, radiating to the back, and entirely c/w past acute
exacerbations of his chronic pancreatitis. Unlike in the setting
of prior exacerbations, however, he experienced hematemesis x1,
filling ___ cups, on the day of admission; it is not clear as to
whether he was coughing or retching prior to vomiting. He
emphasizes that he has had no recurrent hematemesis since the
time of his variceal bleeds in ___. He endorses heavy EtOH
use (1 pint ___ daily) since discharge, as well as
chills over the same period. He denies subjective fevers,
lightheadedness, CP, diarrhea/constipation, or melena/BRBPR,
though he does note that his stools were guiac-positive in the
ED.
In the ED, initial VS were as follows: Afebrile, 63, 104/65, 16,
95% RA. He received a total of 1.5mg IV Dilaudid, as well as 1L
IVNS before transfer to the floor.
Past Medical History:
EtoH cirrhosis
Esophageal Varices
- Grade II and s/p banding procedures
- s/p multiple variceal bleeds, 6 episodes from ___ to ___
s/p multiple bandings
- ___ EGD: 1 cord of grade 2 varices, 2 cords of grade 1
varices were seen in the lower third of the esophagus; changes
consistent with ___
Chronic pancreatitis
EtOH abuse
Bipolar disorder
S/p CCY in ___
S/p Right ACL replacement and meniscectomy in ___
Social History:
___
Family History:
Known h/o alcoholism. Paternal grandfather with prostate cancer.
Maternal grandmother with MI. Father with h/o kidney cancer. No
other known h/o malignancy or cardiovascular disease.
Physical Exam:
On admission:
AVSS.
GENERAL - thin man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, + TTP in the epigastic region, no masses or HSM,
no rebound/guarding, no ascites
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no asterixis
SKIN - no rashes or lesions, no cutaneous stigmata of cirrhosis
NEURO - awake, A&Ox3, CNs II-XII grossly intact
At discharge:
AVSS. No TTP in epigastric region, otherwise unchanged.
Pertinent Results:
On admission:
CBC: ___
Lytes: ___ 8.9/1.7/2.3
LFTs: ___
Coags: 14.7/1.___.6
Other: lipase 9, lactate 2.4
At discharge:
CBC: 2.___
Lytes: ___ ___
Portable CXR (___): No acute findings, specifically no free air
below the diaphragm.
EGD (___):
Severe Esophagitis
Several lesions c/w ___
Grade 1 nonbleeding varices
Mild Portal Gastropathy of gastric body
Normal duodenum
Otherwise normal sigmoidoscopy to splenic flexure
Medications on Admission:
1. Nadolol 20 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Nadolol 20 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
Hold for sedation, RR<12
5. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute-on-chronic pancreatitis
Esophagitis
Discharge Condition:
Discharge condition: Improved, abdominal pain-free, tolerating
solid foods
Mental status: A0x3, appropriately interactive
Ambulatory status: Independent
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Increasing abdominal pain, assess for free air below the
right hemidiaphragm.
FINDINGS: Portable AP upright chest radiograph obtained. Lungs are clear
bilaterally. No free air below the right hemidiaphragm. No pleural effusion
or pneumothorax. Cardiomediastinal silhouette appears normal. Bony
structures appear intact.
IMPRESSION: No acute findings, specifically no free air below the diaphragm.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ALCOHOL ABUSE-UNSPEC, ABDOMINAL PAIN GENERALIZED, NAUSEA WITH VOMITING, ACUTE PANCREATITIS
temperature: 96.8
heartrate: 85.0
resprate: 15.0
o2sat: 96.0
sbp: 104.0
dbp: 73.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ with h/o Etoh cirrhosis c/b esophageal
varices s/p banding and ascites who p/w abdominal pain c/w
previous flares of chronic pancreatitis, as well as hematemesis.
#Hematemesis: Patient with known h/o esophageal varices s/p
banding p/w single episode of hematemesis without active signs
of bleeding or HD instability on admission. EGD ___ demonstrated
severe esophagitis, nonbleeding grade 1 varices, lesions c/w
___, and mild portal gastropathy, for which he was treated
with IV pantoprazole, transitioned to PO at discharge. He
remained HD stable throughout admission without recurrent
hematemesis. From 40.4 on admission, Hct remained stable at
34-35, with initial decline likely at least partially
dilutional.
#Abdominal pain: Patient with known h/o chronic EtOH
pancreatitis p/w epigastric pain radiating to the back, entirely
c/w past episodes of acute-on-chronic pancreatitis. Abdominal
exam was notable for epigastric TTP without peritoneal signs.
LFTs were at baseline, and lipase was within normal limits on
admission. There was no e/o free air on CXR. He was treated
initially with IV Dilaudid, with transition to PO Dilaudid once
tolerating clears. He was tolerating solids by the time of
discharge.
#EtOH dependence: Patient continues to drink heavily despite
explicit knowledge that his EtOH use leads to recurrent
admissions. He remained HD stable without signs of withdrawal or
benzodiazepine requirement throughout admission.
#EtOH cirrhosis: Patient with known h/o EtOH cirrhosis c/b
varices and ascites in the past. There was no e/o
encephalopathy, ascites, or asterixis on admission, and LFTS,
platelets, and INR were c/w baseline. Home nadolol was
continued.
#Bipolar disorder: Patient with known h/o bipolar disorder
without manic or depressive symptoms or SI/HI on admission. He
reported taking Seroquel, trazodone, and an antidepressant,
identity unknown to him, in the past, but also indicated that he
had not been seen by a psychiatrist for some time. Psychiatric
medications were held on the last admission concluding ___,
given reports that his psychiatrist had discontinued his
medications due to drug-seeking behavior, and continued to be
held on the current admission.
#Transitional issues:
- Patient will need GI follow-up for esophagitis, discharged on
pantoprazole, and EtOH cirrhosis, continued on nadolol. It was
unclear as to whether he had been seeing a GI provider at an
outside location, given his h/o visiting multiple providers and
hospitals with similar complaints.
- Patient readily acknowledged heavy EtOH use and received some
counseling from medical team, but was not amenable to further
discussion on this admission, noting that he had taken part
in/continues to take part in programs without success. He should
continue to be encouraged to seek counseling, detoxification,
and will be discharged to ___ House.
- Patient's current psychiatric medication regimen was not
clear, and he will need psychiatric follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Zosyn
Attending: ___.
Chief Complaint:
URI, unresponsiveness
Major Surgical or Invasive Procedure:
Cardiopulmonary resuscitation
History of Present Illness:
___ is a ___ year-old female with metastatic rectal
adenocarcinoma on FOLFOX therapy C2D17 (last dose ___ c/b
bowel obstruction resulting in sigmoid diverting colostomy
___, Hx L tibia osteosarcoma (s/p ___
resection/reconstruction and ___ wide excision of recurrence),
and sickle cell disease (c/b splenic infarction, acute chest
syndrome, pulm infarction, AVN), who presented from ___
clinic on ___ with URI symptoms, course complicated by
unresponsiveness and possible cardiac arrest caused by Zosyn
infusion, now called out from ___ for further management of URI
and post-anyphylactoid reaction care.
The patient had several weeks of URI symptoms including
productive cough, rhinorrhea, and subjective fevers (highest
temp
at home 100.3). She presented to ___ clinic on ___ and
was
felt to be unwell enough to receive chemo due to extreme
fatigue,
productive cough, and temp 100.7. Basic labs, BCx, UA/UCx, CXR,
flu swab/resp viral Cx were obtained and she was directed to ED
for infectious workup and treatment.
While in the ED, she was started on IVF and Zosyn. Soon after
Zosyn infusion began, she felt unwell and had trouble breathing,
then saw stars and passed out. She was noted to be pulseness and
apneic, and she underwent CPR for 2 mins and epi 1 mg x1 was
administered. She was not intubated. She obtained ROSC and there
was no post-ictal period. No s/s airway swelling, rash, or GI
Sx.
HR was noted to be 140s-150s and reportedly sinus. She had
bilateral hip pain c/w sickle cell crisis and was given fluids.
Abx were changed to cefepime/vanco. Bedside echo was nl. She was
transferred to ___, where vanco was stopped and she was
continued on cefepime and azithromycin. She was given 1 u pRBCs
for Hgb 7.1. Her plts were noted to have dropped acutely from
404
to 29, now 77, potentially due to epi. She was noted to be
stable
and was called out to floor for further management.
On transfer to OMED service, she reports she is having some
sternal chest pain since she received chest compressions, and it
hurts to cough. She is also having bilateral hip pain consistent
with her sickle cell crisis pain. Her URI symptoms are improved.
She continues to have some voice hoarseness. She denies current
shortness of breath, abdominal pain, leg swelling.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- High-grade osteosarcoma of the left Tibia, s/p ___
resection/reconstruction and ___ wide excision of recurrence
- ___: Diagnosed with metastatic rectal adenocarcinoma. Ms.
___ presented with abdominal pain, constipation and
hematochezia and has been diagnosed with metastatic rectal
adenocarcinoma. Her PET-CT in hospital demonstrated 5.4cm rectal
mass and diffuse FDG-avid lymphadenopathy c/f metastatic
disease.
- ___, she underwent L pelvic node biopsy positive for
adenocarcinoma though unfortunately this was a regional node and
does not prove metastatic disease. She subsequently
underwent biopsy of a left cervical lymph node with pathology
consistent with metastatic adenocarcinoma IHC similar to prior
pathology. She had no additional sites of visceral involvement.
Port was placed ___.
- ___: C1D1 modified FOLFOX
- ___: laparoscopic sigmoid diverting colostomy for large
bowel obstruction secondary to rectosigmoid stenosis from tumor
- ___: C2D1 modified FOLFOX
PMH/PSH:
-Rectal carcinoma dx ___
-High-grade osteosarcoma of left tibia, dx ___, s/p resection
___ treated with chemotherapy
-Sickle cell disease
-GERD
-Hepatitis C- Genotype 1B s/p Harvoni with SVR, no evidence of
cirrhosis
-Diverting colostomy ___
-S/p cholecystectomy for gallstones in ___
-S/p Appendectomy in ___
Social History:
___
Family History:
No family history of ___
Dad with prostate cancer at age ___
Mom had breast cancer diagnosed at age ___, passed away age ___
Aunt with ovarian cancer, diagnosed in ___
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 98.6 HR 94 BP 109/73 RR 16 O2 sat 100% RA
GEN: no acute distress, appears stated age
EYES: No scleral icterus, PERRL
CV: regular rate and rhythm, no m/r/g
RESP: Lungs clear to auscultation b/l, no adventitious sounds
GI: Abdomen soft, nontender, nondistended. Ostomy bag in place
LLQ. No organomegaly.
SKIN: No rashes or lesions noted.
NEURO: Moving all extremities, no focal deficits.
ACCESS: Port-O-Cath
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 707)
Temp: 98.4 (Tm 99.3), BP: 100/60 (91-120/60-77), HR: 103
(98-107), RR: 18, O2 sat: 98% (98-99), O2 delivery: RA
GEN: no acute distress, appears stated age
EYES: No scleral icterus, EOMI.
CV: regular rate and rhythm, no m/r/g
RESP: Lungs clear to auscultation b/l, no adventitious sounds
GI: Abdomen soft, nontender, nondistended. Ostomy bag in place
LLQ. No organomegaly.
SKIN: No rashes or lesions noted.
NEURO: Moving all extremities, no focal deficits.
ACCESS: Port-O-Cath
Pertinent Results:
ADMISSION LABS
===============
___ 12:37PM BLOOD WBC-17.3* RBC-2.62* Hgb-8.2* Hct-24.1*
MCV-92 MCH-31.3 MCHC-34.0 RDW-20.0* RDWSD-64.8* Plt ___
___ 12:37PM BLOOD Neuts-66 Bands-0 ___ Monos-10 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-11.42* AbsLymp-4.15*
AbsMono-1.73* AbsEos-0.00* AbsBaso-0.00*
___ 12:37PM BLOOD Hypochr-NORMAL Anisocy-2+* Poiklo-2+*
Macrocy-NORMAL Microcy-NORMAL Polychr-1+* Ovalocy-1+* Target-2+*
Schisto-OCCASIONAL Tear ___
Ellipto-OCCASIONAL
___ 12:37PM BLOOD Plt Smr-NORMAL Plt ___
___ 08:40PM BLOOD ___ PTT-29.4 ___
___ 12:38AM BLOOD ___
___ 05:35PM BLOOD Ret Man-10.6* Abs Ret-Unable to
___ 12:37PM BLOOD UreaN-10 Creat-0.8 Na-141 K-4.0 Cl-98
HCO3-28 AnGap-15
___ 08:40PM BLOOD Glucose-146* UreaN-12 Creat-0.8 Na-144
K-3.5 Cl-104 HCO3-26 AnGap-14
___ 12:37PM BLOOD ALT-7 AST-19 AlkPhos-112* TotBili-1.0
___ 08:40PM BLOOD proBNP-350*
___ 12:37PM BLOOD Albumin-3.3* Calcium-9.4 Phos-3.2 Mg-1.4*
___ 12:38AM BLOOD Hapto-<10*
___ 12:37PM BLOOD CEA-29.4*
___ 12:37PM BLOOD ASA-NEG Acetmnp-10 Tricycl-NEG
___ 08:47PM BLOOD ___ pO2-42* pCO2-46* pH-7.45
calTCO2-33* Base XS-6
___ 08:47PM BLOOD Lactate-2.3*
___ 07:02AM BLOOD Lactate-3.0*
___ 07:00AM BLOOD Lactate-1.3
DISCHARGE LABS
==============
___ 04:42AM BLOOD WBC-10.9* RBC-2.43* Hgb-7.4* Hct-22.3*
MCV-92 MCH-30.5 MCHC-33.2 RDW-20.4* RDWSD-67.0* Plt ___
___ 04:42AM BLOOD Glucose-110* UreaN-8 Creat-0.7 Na-139
K-3.8 Cl-101 HCO3-29 AnGap-9*
___ 04:42AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.6
MICRO
=====
___ blood cultures - negative
___ urine culture - negative
___ RVP x2 - inadequate samples
IMAGING AND STUDIES
===================
___ CXR
Possible mild interstitial pulmonary edema; more confluent area
in the right mid lung may relate to vascular congestion, but a
small focus of infection is difficult to exclude.
___ TTE
Normal biventricular cavity sizes, regional/global systolic
function. Mild mitral regurgitation.
___ CXR
Right Port-A-Cath catheter tip is at the level of lower SVC.
Heart size and mediastinum are stable. Lungs overall clear.
There is no appreciable pleural effusion. There is no
pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. HYDROmorphone (Dilaudid) ___ mg IM Q6H:PRN Pain - Severe
4. FoLIC Acid 5 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Prochlorperazine 10 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Levofloxacin 750 mg PO DAILY Duration: 1 Day
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
4. FoLIC Acid 5 mg PO DAILY
5. HYDROmorphone (Dilaudid) ___ mg IM Q6H:PRN Pain - Severe
6. Lisinopril 2.5 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Upper respiratory tract infection
Metastatic rectal carcinoma
Anemia
Thrombocytopenia
Secondary Diagnoses:
Sickle cell disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ year old woman with cough fever// r/o infection
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Right-sided Port-A-Cath terminates in the low SVC without evidence of
pneumothorax.There is mild interstitial pulmonary edema. A subtle small more
confluent area in the lateral right mid lung may relate to vascular
congestion, but a small focus of infection is difficult to exclude. No
pleural effusion or evidence of pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable and stable.
IMPRESSION:
Possible mild interstitial pulmonary edema; more confluent area in the right
mid lung may relate to vascular congestion, but a small focus of infection is
difficult to exclude.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ female with short period unresponsiveness and CPR
after zosyn. Evaluate for intrathoracic abnormality.
TECHNIQUE: Portable AP view radiograph the chest.
COMPARISON: Chest radiograph ___ 16:09
FINDINGS:
Right-sided Port-A-Cath terminates in the low SVC. There is mild interstitial
edema, grossly unchanged as compared to most recent chest radiograph. There
is central vascular congestion. There is no pleural effusion pneumothorax.
Cardiomediastinal silhouette is stable.
IMPRESSION:
Mild pulmonary edema and central vascular congestion is grossly unchanged as
compared to most recent chest radiograph.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ female with sudden unresponsiveness after getting
zosyn. Evaluate for intracranial abnormality.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Ventricles and sulci are within normal limits.
There is almost complete opacification of the bilateral maxillary sinuses and
partial opacification of the bilateral ethmoid air cells, both sphenoid
sinuses, and both frontal sinuses. The globes are unremarkable. The patient
is rotated and only the left parotid gland is visualized. The left parotid
gland is borderline prominent.
There are mild atherosclerotic calcifications of bilateral carotid siphons and
minimal calcifications of the V4 portions of the left vertebral artery.
IMPRESSION:
1. No acute intracranial abnormality.
2. There is opacification of multiple paranasal sinuses. Clinical correlation
for sinusitis is recommended.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ Pass is a ___ year-old female with metastatic rectal
adenocarcinoma on FOLFOX therapy C2D17 (last dose ___ c/b bowel
obstruction resulting in sigmoid diverting colostomy ___, Hx L tibia
osteosarcoma (s/p ___ resection/reconstruction and ___ wide excision of
recurrence), and sickle cell disease (c/b splenic infarction, acute chest
syndrome, pulm infarction, AVN), who presented from ___ clinic on ___
with URI symptoms, course complicated by unresponsiveness and possible cardiac
arrest caused by Zosyn infusion, now called out from FICU for further
management of URI andevaluate for fracture in sternum or ribs
IMPRESSION:
Right Port-A-Cath catheter tip is at the level of lower SVC. Heart size and
mediastinum are stable. Lungs overall clear. There is no appreciable pleural
effusion. There is no pneumothorax.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Cough, Fever
Diagnosed with Fever, unspecified, Tachycardia, unspecified
temperature: 100.7
heartrate: 106.0
resprate: 16.0
o2sat: 100.0
sbp: 107.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | SUMMARY
=========
___ is a ___ year-old female with metastatic rectal
adenocarcinoma on FOLFOX therapy C2D18 (last dose ___ c/b
bowel obstruction resulting in diverting colostomy, Hx L tibia
osteosarcoma (s/p ___ resection/reconstruction and ___ wide
excision of recurrence), and sickle cell disease (c/b splenic
infarction, acute chest syndrome, pulm infarction, AVN), who
presented from ___ clinic on ___ with URI symptoms,
course complicated by unresponsiveness and pulselessness caused
by Zosyn infusion, now called out from ___ for further
management of URI and post-anyphylactoid reaction care.
ACUTE ISSUES
============
# Unresponsiveness
# Cardiac arrest
She became unresponsive, apneic, and rigid and her pulse could
not be detected after brief administration of zosyn. ROSC was
obtained after 2 minutes CPR and epi 1 mg x1. Unknown rhythm
before/during this episode, reportedly sinus tach (140s-150s)
following ROSC. Ddx for this episode includes anaphylactoid
reaction to Zosyn causing hypotension/syncope, and vasovagal
reaction. Bedside TTE in ED without RHC to suggest PE or other
obvious abnormalities. Seizure was felt to be unlikely as she
had no post-ictal period. Formal TTE unremarkable except for
mild MR. ___ was monitored in the ICU following this episode and
lidocaine 5% patch was applied to chest for sternal pain. She
was subsequently called out to the floor for further monitoring.
She was monitored on telemetry and electrolytes were monitored
and repleted as needed. Pain was controlled with IV and PO
dilaudid and Tylenol.
# Anemia
# Thrombocytopenia - improving
Cell count derangements were noted in the setting of malignancy
(currently C2D19 on FOLFOX) and probable sequestration. The
patient's Hgb was noted to be 7.1, and she was given 1 u pRBCs
with appropriate response. Her platelets were noted to be 29
following cardiac arrest episode, an abrupt decrease from plts
404 noted 8 hours prior, raising concern for epinephrine
mediated thrombocytopenia. However her platelet count up trended
and she had no signs of bleeding during the hospitalization.
Concern for immune mediated destruction process given patient's
reaction to zosyn and marked acute thrombocytopenia and worsened
anemia. Hemolysis labs remarkable for low hapto, high LDH, high
indirect bili c/w hemolytic process. She was monitored with a
daily CBC and active T&S was maintained. When her platelets rose
above 50, she was anticoagulated with subcutaneous heparin for
DVT prophylaxis.
# URI
# Leukocytosis
Patient presented from ___ clinic with 2 weeks of fatigue,
pharyngitis, rhinorrhea, productive cough, and myalgias c/w
viral vs. bacterial URI, in setting of immunocompromised state.
CXR reassuring but cannot r/o small focus of consolidation. No
s/s acute chest syndrome. Flu negative. Blood and urine cultures
were drawn, and a respiratory viral screen was obtained.
Leukocytosis downtrended. Following admission to ICU, cefepime
and azithromycin were started, which was switched to
levofloxacin following transfer to medicine floor. She was given
IV fluids as needed during the hospitalization. Her symptoms
improved during the admission. She was instructed to complete a
7 day course of levofloxacin for community acquired URI
(___).
# Metastatic rectal carcinoma
Diagnosed in ___. Complicated by large bowel obstruction
resulting in sigmoid diverting colostomy. Currently undergoing
treatment with FOLFOX C1D1 ___. Last treatment ___.
# Hypophosphatemia
# Hypomagnesemia
Electrolytes were monitored with a daily CMP and electrolyte
sliding scales and phos repletion were used as needed.
# Sickle cell disease
Previously complicated by splenic infarction, acute chest
syndrome, pulmonary infarction, AVN. Not currently on
hydroxyurea secondary to thrombocytopenia expected from
chemotherapy. During this admission she had hip pain consistent
with her pain crises. Anemia and thrombocytopenia were treated
as above. Her home folic acid was continued. Her pain was
controlled with IV Dilaudid and Tylenol, which was converted to
a PO Dilaudid regimen prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / omeprazole / Cefadroxil / Augmentin
Attending: ___.
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a pleasant ___ w/ stage IA breast cancer and
stage IIIB lung adenocarcinoma diagnosed in ___,
with CNS metastasis confirmed by biopsy, s/p WBRT now on
protocol
___ ___ w/ alectinib 600 mg BID, who p/w nausea, abdominal
pain, and increased weakness and dizziness on standing. Several
days ago while in the shower she felt faint and fell onto her
right shoulder but no head trauma nor LOC.
In ED: received 2L IV NS, 4 mg IV Zofran, 5 mg Morphine. She was
found to be orthostatic with SBP dropping to 88/37 and HR bumped
from 83 to 132. CT Abd/Pelv, CXR were neg for any acute process.
On arrival to OMED, pt was in significant abdominal pain. She
received 4 mg IV Morphine and nearly immediately started to have
vomiting and noted that was common for her. History was limited
due to her vomiting persistently.
REVIEW OF SYSTEMS:
10 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
PAST ONCOLOGIC HISTORY:
1. Stage IA right breast cancer ___, with right axillary
recurrence ___
a) S/p R mastectomy/implant ___,
b) Tamoxifen ___
c) Herceptin x ___ year, ___
2. Stage IIIB left lung adenocarcinoma, ALK + ___, no with
disease recurrence in the brain ___.
a) Crizotinib ___ - ___
b) Alectinib 600mg twice a day started on ___
PAST MEDICAL HISTORY:
1. Metastatic adenocarcinoma of the lung, ALK+
2. Stage IA right breast cancer ___, with right axillary
recurrence ___
3. Pulmonary embolism status post IVC filter placement.
4. Migraines
5. Radiculopathy
6. GERD
7. Nephrolithiasis
PAST SURGICAL HISTORY:
1. ___: Midline suboccipital craniotomy, excision brain
tumor
2. ___: Craniotomy for pfossa decompression and clot
evacuation
3. ___: IVC filter placement
4. ___: Right VP shunt placement (nonprogrammable)
5. Pancreatic cyst excision in ___
6. Right mastectomy ___
7. Left supraclavicular LN biopsy in ___
Social History:
___
Family History:
The patient has had BRCA testing and was negative for mutation.
She has no family history of cancer.
Physical Exam:
ADMISSION PHYSICAL
General: NAD, Resting in bed vomiting frequently
VITAL SIGNS: Tc 97.7, Tm 97.8, BP 92-94/62, HR 58-72, 98% RA
HEENT: PERRL, EOMI, no nystagmus, sclera anicteric, orpharynx
with dry mucus membranes
CV: normal S1 and S2, RRR, no murmurs
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, SNT/ND, + abdominal scar from prior pancreatic
surgery
LIMBS: WWP, no ___, + tremors
SKIN: No rashes on the extremities
NEURO: CNII-XII grossly intact, no pronator drift, ___ ___
strength, sensation intact to soft touch, normal coordination,
normal FNF, toes down b/l
DISCHARGE PHYSICAL
PHYSICAL EXAM:
VITAL SIGNS: Tm 98.2, BP 96-118/50s-70s, HR 75-103, 96-98% RA
HEENT: PERRL, EOMI, no nystagmus, sclera anicteric, orpharynx
wnl
CV: normal S1 and S2, RRR, no murmurs
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, ND, minimal LUQ ttp, + abdominal scar from prior
pancreatic surgery
LIMBS: WWP, no ___
SKIN: No rashes on the extremities
NEURO: CNII-XII grossly intact, no pronator drift, ___ ___
strength, sensation intact to soft touch
Pertinent Results:
ADMISSION LABS
___ 02:25PM BLOOD WBC-9.1 RBC-4.29 Hgb-10.4* Hct-33.1*
MCV-77* MCH-24.2* MCHC-31.4* RDW-19.2* RDWSD-53.3* Plt ___
___ 02:25PM BLOOD ___ PTT-23.6* ___
___ 02:25PM BLOOD Glucose-95 UreaN-8 Creat-0.7 Na-137 K-4.1
Cl-100 HCO3-22 AnGap-19
___ 02:25PM BLOOD ALT-24 AST-21 AlkPhos-127* TotBili-1.1
___ 02:25PM BLOOD ALT-24 AST-21 AlkPhos-127* TotBili-1.1
___ 02:25PM BLOOD Albumin-4.2
___ 09:13AM BLOOD Albumin-3.7 Calcium-9.3 Phos-4.9* Mg-2.0
___ 09:13AM BLOOD Cortsol-38.4*
___ 07:00AM BLOOD HCG-<5
___ 02:28PM BLOOD Lactate-1.___BDOMEN
1. Ventriculoperitoneal shunt terminating in the midline of the
pelvis, with a
small amount of associated free fluid.
2. No evidence of bowel obstruction.
3. Mild stranding of the right anterior abdominal wall in the
region of prior
postsurgical changes from ventriculoperitoneal shunt revision in
___.
4. Infrarenal IVC filter.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Cyclobenzaprine 10 mg PO TID:PRN neck pain
2. Docusate Sodium 100 mg PO BID constipation
3. Enoxaparin Sodium 130 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
4. Simethicone 40-80 mg PO QID:PRN gas pain
5. Pantoprazole 40 mg PO Q24H
6. Ferrous Sulfate 325 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Hydrocortisone 20 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
2. Simethicone 40-80 mg PO QID:PRN gas pain
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
stomach discomfort
RX *alum-mag hydroxide-simeth [Antacid] 200 mg-200 mg-20 mg/5 mL
___ mL by mouth four times a day Refills:*3
4. Ibuprofen 800 mg PO Q8H:PRN pain
5. Ascorbic Acid ___ mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Cyclobenzaprine 10 mg PO TID:PRN neck pain
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*24 Tablet Refills:*3
11. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*3
12. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet(s) by
mouth daily Disp #*30 Packet Refills:*6
13. Docusate Sodium 100 mg PO BID constipation
14. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
15. Ondansetron 8 mg PO Q8H:PRN nausea
oral dissolving tablet
RX *ondansetron [___] 8 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*60 Tablet Refills:*3
16. Enoxaparin Sodium 130 mg SC Q24H
Start: Today - ___, First Dose: First Routine
Administration Time
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: orthostasis
Secondary diagnosis: nausea, vomiting, lung cancer,
constipation, dysuria/increased urinary frequency, vaginal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with metastatic NSCLC currently on clinical
trial // eval for interval change, staging
TECHNIQUE: VOLUMETRIC CT ACQUISITIONS OVER THE ENTIRE THORAX IN INSPIRATION,
ADMINISTRATION OF INTRAVENOUS CONTRAST MATERIAL, MULTIPLANAR RECONSTRUCTIONS.
DOSE: DLP: mGy-cm
COMPARISON: ___
FINDINGS:
The examination is compared to ___.
Unchanged 3 mm hypodense right thyroid nodule. No supraclavicular,
infraclavicular or axillary lymphadenopathy. All lymph nodes in these regions
are normal in size. Unchanged morphology of the VP shunt and of the right
breast implant.
The previously massive mediastinal lymphadenopathy has substantially improved.
1 large reference lesion in pre bronchial location on the right (2, 21)
measures 8 x 9 mm, as compared to 20 x 28 mm on the previous examination.
Likewise, a right para aortic lymph node (2, 21) measures 4 x 4 mm on today's
examination, as compared to 11 x 10 mm on the previous examination. There is
no evidence of new or growing lymph nodes.
Unchanged morphology of the large mediastinal vessels. The pre-existing
embolic changes in both lower lobes are no longer visible. Unchanged
appearance of the heart. No pericardial effusion. Unchanged fatty liver. A
previously described hyperenhancing lesion in the right lobe of the liver is
no longer clearly visualized.
No osteolytic lesions at the level of the ribs, the sternum or the vertebral
bodies.
Minimal bilateral apical scarring, unchanged as compared to the previous
study. Also unchanged is the larger right apical scar in subpleural location
(5, 65). A previously described left lower lobe scar (5, 156) is unchanged in
extent and severity. The more proximal nodular lesion located adjacent to the
scar (previous examination series 3, image 116) has almost completely
resolved. Unchanged areas of bilateral atelectasis in the dependent lung
regions as well as minimal scarring at the bases of the lingular. No new or
growing lung nodules. No pleural effusions. The airways are patent.
IMPRESSION:
Substantial decrease in size of pre-existing, previously enlarged mediastinal
lymph nodes.
Near complete resolution of a nodular component of scarring in the left lower
lobe.
No new or growing nodules or lymph nodes.
The pre-existing bilateral lower lobe emboli are no longer visible.
Unchanged areas of parenchymal scarring, notably in the right upper lobe.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, MAL NEO BRONCH/LUNG NOS
temperature: 96.0
heartrate: 49.0
resprate: 16.0
o2sat: 96.0
sbp: 96.0
dbp: 72.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a pleasant ___ w/ stage IA breast cancer and
stage IIIB lung adenocarcinoma diagnosed in ___,
with CNS metastasis s/p resection and VP shunt placement, s/p
WBRT and crizotinib, now on protocol ___ ___ w/ alectinib
600 mg BID who presented with nausea, vomiting, and orthostasis.
# Orthostasis: likely ___ dehydration in the setting of
significant nausea and poor PO intake. TSH checked in ___ was
wnl and B12 was wnl. Adrenal insufficiency was on the
differential however cortisol/cosyntropin stimulation test was
wnl. Patient received IV hydration and her symptoms improved.
# Nausea/vomiting: etiology was unclear but was initially
attributed to her study drug. During her last admission she had
an extensive workup which consisted of an MRI brain and EGD.
Patient was recently on a steroid taper (which she completed at
home) however states that steroids made her symptoms worse and
therefore steroids were not continued during this
hospitalization. A CT abdomen/pelvis was performed and did not
show an acute process that would explain her symptoms. Her neuro
exam was non-focal and she did not complain of symptoms
suggestive of elevated ICP. Neurosurgery was contacted to
discuss her case and they felt a VP shunt series was not
necessary at this time. Neuro-Oncology was consulted and they
felt that patient may benefit from a LP as an out patient to
evaluate for leptomeningeal carcinomatosis as well as
paraneoplastic syndromes. Patient did not want LP in house as
she was feeling better upon day of discharge. Patient may follow
up with Neurology as an out patient to obtain LP if desired.
# Dysuria/increased frequency: UA negative for infection, Urine
culture ___ negative, chronic. ? interstitial cystitis vs.
autonomic dysregulation. Patient will follow up with uro-gyn as
an out patient.
# Vaginal pain, likely ___ pain as patient does not
have abnormal vaginal discharge or other symptoms/signs
suggestive of infection
-ibuprofen PRN
-phenazopyridine 100mg tid
-pelvic exam as out patient
# h/o PE: continued home lovenox ___ mg daily |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim DS
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
Joint fluid aspiration
History of Present Illness:
This is a ___ year-old with a PMH significant hypertension,
hyperlipidemia, depression and anxiety, GERD, degenerative joint
disease and congenital hip dislocation who was recently admitted
on ___ with altered sensorium found to have high grade MSSA
bacteremia with a left thigh abscess, right iliacus and SI joint
abscess, epidural abscess and aortic valve endocarditis who
underwent multiple joint washouts and drainage procedures and
discharged on a prolonged course of IV cefazolin who now
re-presents with persistent left hip pain.
The patient was discharged to a rehabilitation facility on
___ on longterm IV cefazolin given her recent high grade MSSA
bacteremia with seeded joints. While at rehab, she denies
participation in physical therapy secondary to pain. She has
been taking Oxycontin and Dilaudid for breakthrough without
significant relief. She denies recent fevers or chills.
She notes that over the last several days she has participated
in increasing occupational and physical therapy exercises with
worsening pain that is not relieved by her oral narcotics. The
pain has now exceeded her mobility limits and occurs at rest;
she reports a ___ pain on admission. She says that she has
only been able to transfer to the commode and get to the edge of
the bed and that causes significant pain. Even touching the
overlying skin is painful for her. She denies erythema, warmth
or overling skin changes around her incision. She denies fevers,
chills or nightsweats. Of note, she was recently seen in ___
clinic on ___ and was continued on Cefazolin with the
addition of Rifampin. Interestinlgy, her inflammatory markers
were recently checked and were markedly elevated.
In the ED initial VS, 98.8 91 158/92 18 100% RA. Labs notable
for WBC 4.4, HCT 25.6%, PLT 337. INR 2.7. Creatinine 0.5.
Potassium 3.1. She had a pelvic CT while in the ED. She received
IV Dilaudid and Lorazepam 2 mg IV while in the ED.
On arrival to the floor, she is complaining of left hip pain.
Past Medical History:
hypertension
osteoarthritis -neck, lower back, hips
DJD
spinal stenosis s/p cervical laminectomy and lumbar spinal
fusion
cervical radiculitis
GERD
peripheral edema -since ___. Worst in left arm and left leg
fractured L knee in ___, splinted for 1 month
vocal cord polyps
Depression
anxiety
alopecia
hyperlipidemia
microhematuria
fibroid uterus s/p hysterectomy
s/p Breast reduction ___ c/b post op infxn. Day surgery -no
overnight stay in hospital.
hx of congenital hip dx s/p hip replacement left x 2, in ___
PSH:
Patient is s/p multiple back surgeries, most recent one was an
L1-L2 discectomy, laminectomy, and fusion at L1-L2, Revision on
___. Past surgical history is also significant for left
abdominal hernia repair on ___, bilateral breast reduction
in ___, and a left hip replacement.
Social History:
___
Family History:
MI, CAD, hyperlipidemia, and HTN in both patient's mother and
father.
Physical Exam:
ADMISSION:
VITALS: 99.1 154/74 84 18 100% RA
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing. Frail-appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist with plaques or exudates.
NECK: supple. JVP not elevated.
___: Regular rate and rhythm, III/VI early systolic murmur at
___, no rubs or gallops. S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses; left
hip incisions appear clean, dry and well-approximated. No
overlying skin warmth or erythema was noted.
NEURO: Alert and oriented x 3. Strength ___ bilaterally,
sensation grossly intact. Gait deferred.
DISCHARGE:
VITALS: 99.0 99.0 146/71 85 18 100%RA Pain ___
I/O: 580/850
GENERAL: Appears comfortable. Alert and interactive. Well
nourished appearing. Frail-appearing. OOB to chair.
HEENT: Normocephalic, atraumatic. EOMI. Mucous membranes moist
without plaques or exudates.
NECK: supple. JVP not elevated.
___: Regular rate and rhythm, III/VI early systolic murmur at
LUSB, I/VI diastolic murmur at LUSB. no rubs or gallops. S1 and
S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses; left
hip incisions appear clean, dry and well-approximated. There is
firmness around the incision, but no exudate or flatuence. No
overlying skin warmth or erythema was noted. There is better
active ROM, but not full ROM.
NEURO: Alert and oriented x 3. Sensation grossly intact. Gait
deferred.
Pertinent Results:
ADMISSION LABS:
___ 10:15AM BLOOD WBC-4.4 RBC-3.12* Hgb-8.4* Hct-25.6*
MCV-82 MCH-26.8* MCHC-32.7 RDW-14.5 Plt ___
___ 10:15AM BLOOD Neuts-75.4* Lymphs-17.9* Monos-5.4
Eos-0.9 Baso-0.4
___ 10:15AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL
Macrocy-1+ Microcy-1+ Polychr-1+
___ 10:15AM BLOOD ___ PTT-56.2* ___
___ 09:44AM BLOOD ___
___ 06:35AM BLOOD ESR-138*
___ 10:15AM BLOOD Glucose-94 UreaN-10 Creat-0.5 Na-139
K-3.1* Cl-102 HCO3-26 AnGap-14
___ 06:35AM BLOOD ALT-6 AST-11 LD(LDH)-168 AlkPhos-188*
TotBili-0.2
___ 10:15AM BLOOD Calcium-8.4 Phos-4.9* Mg-1.6
___ 06:35AM BLOOD ALT-6 AST-11 LD(LDH)-168 AlkPhos-188*
TotBili-0.2
___ 06:35AM BLOOD Hapto-382*
___ 06:00AM BLOOD CRP-109.6*
___ 06:35AM BLOOD CRP-135.0*
DISCHARGE LABS:
___ 06:41AM BLOOD WBC-3.5* RBC-2.99* Hgb-8.2* Hct-24.7*
MCV-83 MCH-27.3 MCHC-33.0 RDW-15.2 Plt ___
___ 06:41AM BLOOD ___ PTT-42.9* ___
___ 06:41AM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-140
K-3.4 Cl-101 HCO3-30 AnGap-12
___ 06:41AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.8
MICROBIOLOGY:
___ 3:15 pm JOINT FLUID LEFT HIP JOINT FLUID.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
NO GROWTH AS OF ___.
DUE TO LABORATORY ERROR, UNABLE TO CONTINUE PROCESSING.
ANAEROBES ARE SCREENED FOR IN THE FLUID CULTURE.
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
IMAGING:
___ PELVIS (AP ONLY) - Extensive post-surgical change
consistent with spinal surgery and Girdlestone procedure. No
definite acute change.
___ CT PELVIS W/CONTRAST - Rim enhancing fluid collection
within the left thigh is smaller than ___ and is
likely postsurgical, although, an underlying infection is not
excluded. No rim enhancing fluid collection within the right
iliacus muscle.
___ at 9:08:09 AM TTE (Complete)
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened at the juncture of the left and noncoronary
cusp, and vegetation cannot definitively be excluded. There is
systolic doming of the aortic valve leaflets. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Moderate (2+)
aortic regurgitation is seen. Physiologic mitral regurgitation
is seen (within normal limits). There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. BuPROPion 200 mg PO QAM
3. BuPROPion 250 mg PO QPM
4. Citalopram 40 mg PO DAILY
5. Gabapentin 400 mg PO HS
6. Omeprazole 40 mg PO BID
7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
8. Pravastatin 20 mg PO DAILY
9. Ranitidine 300 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral DAILY
12. Estradiol 0.5 mg PO DAILY
13. MedroxyPROGESTERone Acetate 2.5 mg PO DAILY
14. Vesicare *NF* (solifenacin) 10 mg Oral DAILY
15. CefazoLIN 2 g IV Q8H
until ___
16. Heparin 5000 UNIT SC TID
17. celecoxib *NF* 400 mg Oral DAILY
18. Acetaminophen 650 mg PO Q6H:PRN pain, fever
19. Bisacodyl 10 mg PO DAILY
20. Docusate Sodium 200 mg PO BID
21. Polyethylene Glycol 17 g PO DAILY:PRN constipation
22. Senna 2 TAB PO BID
23. Ondansetron 4 mg IV Q8H:PRN nausea
24. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
25. Maalox/Diphenhydramine/Lidocaine 30 mL PO TID mouth sores
Discharge Medications:
1. CefazoLIN 2 g IV Q8H
Through ___
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV q8 hours
Disp #*90 Unit Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain, fever
3. Atenolol 25 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY
5. BuPROPion 200 mg PO QAM
6. BuPROPion 250 mg PO QPM
7. Citalopram 40 mg PO DAILY
8. Docusate Sodium 200 mg PO BID
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
10. Maalox/Diphenhydramine/Lidocaine 30 mL PO TID mouth sores
11. Omeprazole 40 mg PO BID
12. Gabapentin 400 mg PO HS
13. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
RX *oxycodone [OxyContin] 40 mg 1 tablet extended release 12
hr(s) by mouth twice a day Disp #*60 Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Pravastatin 20 mg PO DAILY
16. Ranitidine 300 mg PO DAILY
17. Senna 2 TAB PO BID
18. Vitamin D 1000 UNIT PO DAILY
19. ClonazePAM 0.25 mg PO TID:PRN anxiety
RX *clonazepam 0.5 mg ___ (one half) tablet(s) by mouth three
times a day Disp #*60 Tablet Refills:*0
20. Rifampin 450 mg PO Q12H
Through ___
RX *rifampin 150 mg 1 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
RX *rifampin 300 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
21. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral DAILY
22. Celecoxib *NF* 400 mg ORAL DAILY
23. Estradiol 0.5 mg PO DAILY
24. MedroxyPROGESTERone Acetate 2.5 mg PO DAILY
25. Vesicare *NF* (solifenacin) 10 mg Oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. Hip pain
Secondary Diagnosis:
1. hx of MSSA bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Recent pelvic, obturator and iliacus abscess presenting with severe
left hip pain. Evaluate for fracture or recurrent abscess.
TECHNIQUE: MDCT axial images were acquired from the iliac crests to the mid
thighs after the uneventful administration of 100 mL of Omnipaque. Coronal
and sagittal reformations were provided and reviewed.
DLP: 325.19 mGy/cm.
COMPARISON: CT pelvis ___ and ___. Pelvic
MRI ___.
FINDINGS: There is a severely fragmented and disorganized left proximal femur
and left iliac wing after orthopedic hardware removal consistent with
osteomyleitis. A rim enhancing fluid collection within this area appears
smaller than ___, extending from the level of the acetabulum,
measuring 6 x 3.5 cm, and inferiorly to the mid femur where it measures 5.2 x
2.4 cm. The collection involves the quadriceps femoris and lateral muscles of
the left thigh. There is no adjacent lymphadenopathy.
The right hip is unremarkable. There is no rim enhancing fluid collection
seen within the right iliacus muscle, although a collapsed collection
measuring 1.6 x 1.2 cm is present after recent drain removal. Extensive
postoperative changes are seen in the lower lumbar spine. Spacer device is
again seen between L5 and S1. The right sacroiliac joint is fragmented,
consistent with prior osteomyelitis. There is no new fracture.
The imaged portions of the liver, gallbladder, spleen, kidneys and pancreas
are unremarkable. Mesh is noted in the aterior abdominal wall. There is no
bowel wall thickening or obstruction seen within the pelvic loops of bowel.
The bladder, rectum and sigmoid are normal. There is no free pelvic fluid or
air. Injection granulomas are seen over the anterior abdomen.
IMPRESSION: Rim enhancing fluid collection within the left thigh and hip is
smaller than ___ and may represent postsurgical seroma, although an
underlying infection is not excluded. Collapsed residua of previous fluid
collection within the right iliacus muscle following drainage.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Tip of left PICC terminates in the mid superior vena cava.
Cardiomediastinal contours are stable in appearance allowing for differences
in positioning and lung volumes. Patchy and linear areas of atelectasis
and/or scarring are present at the lung bases with otherwise clear lungs.
Radiology Report
PROCEDURE: ULTRASOUND-GUIDED ASPIRATION OF FLUID COLLECTION FROM THE LEFT HIP
JOINT.
INDICATION: ___ female with history of left developmental dysplasia,
status post prior left total hip arthroplasty at age ___, and multiple
subsequent infections of the left hip, treated with surgical washouts. The
most recent hip washout was performed by Dr. ___ on ___.
Patient presenting with left hip pain and found to have fluid collection
within the left hip on recent CT scan. The patient presented for aspiration
of this fluid for evaluation for infection.
COMPARISON: CT of the pelvis from ___.
PROCEDURE: The procedure to be performed was explained to the patient
including risks, benefits and alternatives. Subsequently, recent signed
informed consent was obtained.
The patient was then placed in the right lateral decubitus position on the
bed, and images of the left hip joint region was obtained, showing complex
fluid collection with septations. Area above this collection was marked(with
mark placed on the skin). A timeout was then performed using three patient
identifiers. Using standard aseptic technique, the skin was sterilized, and
surgical draped placed. 1% lidocaine was used to anesthetize the skin above
the fluid collection and deeper into the subcutaneous tissues. Subsequently,
under ultrasound guidance, a 20-gauge spinal needle was advanced into the
fluid collection and approximately 45 mL of serosanguineous/cloudy fluid was
aspirated from the fluid pocket within the left hip joint region. After
aspiration, needle was removed and pressure applied to the skin and
subcutaneous tissue for hemostasis. Hemostasis was achieved.
The patient tolerated the procedure well and no immediate procedural
complications.
FINDINGS: Sonographic images of the left hip joint showed complex fluid
collection with internal debris within the left hip joint region,
corresponding to fluid collections seen on a CT scan.
IMPRESSION:
1. Successful ultrasound-guided aspiration of fluid collection within the
left hip joint pocket. 45 mL of serosanguineous/cloudy fluid was aspirated
and sent to the lab for microbiology and fluid analysis.
2. Moderate-to-large fluid collection within the left hip joint space may
represent postsurgical seroma and/or abscess. Followup with pathology is
recommended.
Dr. ___, the attending radiologist, was present and supervised
the entire procedure.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: LEFT HIP PAIN
Diagnosed with JOINT PAIN-PELVIS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ with a PMH significant for hypertension, hyperlipidemia,
depression and anxiety, GERD, degenerative joint disease and
congenital hip dislocation who was recently admitted on ___
with altered sensorium found to have high grade MSSA bacteremia
with a left thigh abscess, right iliacus and SI joint abscess,
epidural abscess and aortic valve endocarditis who underwent
multiple joint washouts and drainage procedures and discharged
on a prolonged course of IV cefazolin who now re-presents with
persistent left hip pain. Her pain is much better controlled
today. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, Ostomy Output
Major Surgical or Invasive Procedure:
___ Percutaneous Nephrostomy Tube placement
History of Present Illness:
Mr. ___ is a ___ male with a history of rectal and
prostate cancer, status post end ileostomy ___, who presented
with fever, bloody output from his ostomy, and gas. In the ED,
he
was initially febrile to 101.1 and tachycardic to 120 with BP
119/52 and nonfocal exam. He was subsequently found to be
hypotensive to 81/41, HR 110 temperature of 101.8. He received
2L
IVF fluid, cipro, flagyl, vanc. His blood pressures improved
though he was found to be anemic and thrombocytopenic. Heme was
consulted and he received 1 unit PRBCs and 2 units of platelets.
A CT abdomen/pelvis was obtained to evaluate for source of
sepsis
and found a 6mm obstructing stone in the mid distal ureter with
moderate to severe left hydroureteronephrosis. Urology, ___, and
colorectal surgery were consulted, ___ placed a perc nephrostomy
tube and urology will follow.
After his perc nephrostomy he was transferred to the FICU where
he arrived in stable condition, not on pressors.
In the ED,
- Initial Vitals: 101.1, 120, 119/52, 19, 99%RA
- Exam:
Radiation wound to the lower back without associated erythema or
drainage. Ostomy appears to be somewhat bulging. There is a
small
amount of serosanguineous drainage. No surrounding erythema. No
meningismus. Neurologically intact. Question of possible small
amount of swelling to the left ankle as compared to the right.
Con: In no acute distress, non-toxic
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact. No meningismus or
neck TTP. No lymphadenopathy. Oropharynx benign.
Resp: Clear to auscultation, normal work of breathing
CV: Regular rate and rhythm, normal ___ and ___ heart sounds, 2+
distal pulses in arms and legs. Capillary refill less than 2
seconds. No clinically significant murmur.
Abd: Soft, Nontender, Nondistended. No masses or overlying skin
changes. No organomegaly.
GU: No costovertebral angle tenderness
MSK: No deformity or edema. No back TTP.
Skin: No rash, Warm and dry
Neuro: No lateralizing signs, cranial nerves II-XII grossly
intact, strength and sensation grossly intact all ext
Psych: Normal mood/mentation
- Labs: WBC 5.5, Hgb 6.6, Plt 24, Na 131, Cr 2.5, lactate 1.6
- Imaging:
CT ABD/Pelvis ___
1. 6 mm obstructing stone in the mid distal ureter with
moderate-to-severe left hydroureteronephrosis. A second 9 mm
nonobstructing stone in lower pole of the left kidney is also
noted. Slightly higher density material layering dependently in
the lower pole renal calices and upper ureter suggesting
underlying complexity within the urine potentially due to
infection, less likely hemorrhage.
2. Known hepatic metastases are better evaluated on recent CT
abdomen and pelvis with contrast on ___.
3. Redemonstration of gastrohepatic lymphadenopathy, rectal
mass,
and
sclerotic metastases within the lumbar spine.
4. Cholelithiasis, without evidence of acute cholecystitis.
5. Splenomegaly.
CXR ___
1. No definite acute cardiopulmonary process.
- Consults: ___, Urology, Heme
- Interventions: Perc nephrostomy
Past Medical History:
BILATERAL CATARACTS
ERECTILE DYSFUNCTION
GLAUCOMA
HYPERTENSION
OBESITY
PANIC DISORDER
VITAMIN D DEFICIENCY
GOUT
PSORIASIS
KNEE ARTHRITIS
PROSTATE CANCER
RECTAL CANCER
Social History:
___
Family History:
No history of prostate cancer. Father had colon
cancer at age ___ and CLL. His cousin has breast cancer BRCA
mutation.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 101.2, 117, 171/77, 94% on RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI.
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.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Ostomy noted
EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. Cap
refill <2s. No rash.
NEUROLOGIC: CN2-12 grossly intact.
DISCHARGE PHYSICAL EXAM
========================
VS: 98.9 PO 160 / 79 68 20 100 RA
Constitutional: NAD, sitting at edge of bed, awake and alert
HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM
without exudate
CV: RRR, II/VI SEM w/o rads
Resp: CTAB
GI: NABS, ostomy pink w moderate prolapse, no bloody stool
GU: no foley, L PCN site cdi, drainage serosanguinous
Ext: wwp, neg edema in BLEs
Skin: no rash grossly visible
Neuro: A&Ox3, DOWB w ease, MOYB with ease, CNs grossly intact
Psych: normal affect, pleasant
Pertinent Results:
ADMISSION LABS
===============
___ 02:20PM BLOOD WBC-5.5 RBC-1.97* Hgb-6.6* Hct-21.0*
MCV-107* MCH-33.5* MCHC-31.4* RDW-16.3* RDWSD-63.3* Plt Ct-24*
___ 02:20PM BLOOD Neuts-88* Bands-2 Lymphs-1* Monos-9
Eos-0* Baso-0 AbsNeut-4.95 AbsLymp-0.06* AbsMono-0.50
AbsEos-0.00* AbsBaso-0.00*
___ 02:20PM BLOOD ___ PTT-29.3 ___
___ 02:20PM BLOOD Glucose-106* UreaN-38* Creat-2.5*#
Na-131* K-4.1 Cl-98 HCO3-21* AnGap-12
___ 02:20PM BLOOD ALT-10 AST-28 AlkPhos-137* TotBili-0.6
___ 02:20PM BLOOD Albumin-2.4* Calcium-7.7* Phos-2.7 Mg-1.8
DISCHARGE LABS
===============
___ 05:28AM BLOOD WBC-2.8* RBC-2.29* Hgb-7.4* Hct-23.9*
MCV-104* MCH-32.3* MCHC-31.0* RDW-19.9* RDWSD-75.1* Plt Ct-41*
___ 05:28AM BLOOD Neuts-52.2 ___ Monos-21.5*
Eos-5.5 Baso-0.4 AbsNeut-1.44* AbsLymp-0.53* AbsMono-0.59
AbsEos-0.15 AbsBaso-0.01
___ 05:28AM BLOOD Glucose-81 UreaN-27* Creat-1.4* Na-146
K-3.7 Cl-113* HCO3-21* AnGap-12
REPORTS
========
___ CT A/P w/o Contrast
1. 6 mm obstructing stone in the mid distal ureter with
moderate-to-severe
left hydroureteronephrosis. A second 9 mm nonobstructing stone
in lower pole of the left kidney is also noted. Slightly higher
density material layering dependently in the lower pole renal
calices and upper ureter suggesting underlying complexity within
the urine potentially due to infection, less likely hemorrhage.
2. Known hepatic metastases are better evaluated on recent CT
abdomen and
pelvis with contrast on ___.
3. Redemonstration of gastrohepatic lymphadenopathy, rectal
mass, and
sclerotic metastases within the lumbar spine.
4. Cholelithiasis, without evidence of acute cholecystitis.
5. Splenomegaly.
___ L LENIs
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ Renal U/S
1. Bilateral nephrolithiasis without hydronephrosis.
2. Partially imaged left percutaneous nephrostomy tube.
3. Ureteral jets demonstrated on the right, not demonstrated on
the left.
========
MICRO:
___ 5:52 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ 10:07 pm URINE,KIDNEY Source: Kidney.
FLUID CULTURE (Final ___:
ENTEROCOCCUS SP.. >10,000 CFU/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Morphine Sulfate ___ 15 mg PO Q8H:PRN Pain - Moderate
2. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
3. MorphaBond ER (morphine) 15 mg oral BID:PRN
4. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
5. ClonazePAM 1 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
7. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
Discharge Medications:
1. Ampicillin 500 mg PO Q6H
RX *ampicillin 500 mg 1 capsule(s) by mouth four times a day
Disp #*100 Capsule Refills:*0
2. Senna 17.2 mg PO BID
3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
4. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
5. ClonazePAM 1 mg PO BID
6. MorphaBond ER (morphine) 15 mg oral BID:PRN
7. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
septic shock
nephrolithiasis
obstructive uropathy
acute kidney injury
anemia
thrombocytopenia
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 W/O CONTRAST
INDICATION: ___ with sepsisNO_PO contrast// eval for acute infectious
pathology
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.3 s, 57.6 cm; CTDIvol = 27.8 mGy (Body) DLP =
1,599.5 mGy-cm.
Total DLP (Body) = 1,600 mGy-cm.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
LOWER CHEST: Multiple pulmonary nodules bilaterally are similar prior and
better evaluated on recent CT chest from ___. There is no evidence
of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Known hepatic metastases are better evaluated on recent CT
abdomen and pelvis with contrast from ___. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder contains
gallstones without wall thickening or evidence of inflammation.
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 is enlarged measuring 17 cm AP with homogeneous attenuation
throughout, without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is a 6 mm obstructing stone in the mid to distal left ureter
with moderate-to-severe left hydroureteronephrosis. There is questionable
higher density material layering in the lower pole dilated calices and
proximal ureter which could be due to debris. A second 9 mm nonobstructing
stone is noted in the lower pole of left kidney. There is slightly asymmetric
left perinephric stranding without discrete fluid collection. Redemonstration
of 3.9 cm left upper pole simple cyst. There is no hydronephrosis in the
right kidney. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Left parasagittal diverting
colostomy appears similar. Few scattered colonic diverticula, without a focal
area of fat stranding or wall thickening to suggest acute diverticulitis.
Known anorectal mass is partially image.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis. Presacral edema is unchanged.
REPRODUCTIVE ORGANS: Fiducial seeds are again seen in the prostate.
LYMPH NODES: Redemonstration of a 1.3 cm gastrohepatic lymph node (series 2,
image 26). A 1.1 cm retroperitoneal lymph node additional prominent
para-aortic lymph nodes are noted, some of which may be reactive. No pelvic
or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Sclerotic appearance of the L5 vertebral body, right iliac bone, and
right L4 pedicle are unchanged from prior and likely represent sclerotic
metastasis from known prostate cancer. L5 laminectomy changes are again
noted.
SOFT TISSUES: Other than the aforementioned diverting colostomy, the abdominal
and pelvic wall is within normal limits.
IMPRESSION:
1. 6 mm obstructing stone in the mid distal ureter with moderate-to-severe
left hydroureteronephrosis. A second 9 mm nonobstructing stone in lower pole
of the left kidney is also noted. Slightly higher density material layering
dependently in the lower pole renal calices and upper ureter suggesting
underlying complexity within the urine potentially due to infection, less
likely hemorrhage.
2. Known hepatic metastases are better evaluated on recent CT abdomen and
pelvis with contrast on ___.
3. Redemonstration of gastrohepatic lymphadenopathy, rectal mass, and
sclerotic metastases within the lumbar spine.
4. Cholelithiasis, without evidence of acute cholecystitis.
5. Splenomegaly.
Radiology Report
INDICATION: ___ with sepsis// eval for pneumonia
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___. Chest CT from ___.
FINDINGS:
Right chest wall port is again seen the catheter tip is obscured by posterior
spinal fixation hardware. The lungs are grossly clear without consolidation.
Pulmonary nodules seen on prior CT are not clearly delineated. No significant
effusion noting that the bilateral costophrenic angles are excluded from the
field of view. Cardiac silhouette is accentuated by lordotic positioning and
low lung volumes though is not likely changed. Thoracic spine laminectomy
changes and posterior fixation hardware is identified.
IMPRESSION:
No definite acute cardiopulmonary process.
Radiology Report
INDICATION: ___ year old man with left hydro and 6 mm obstructing stone// Left
hydro
COMPARISON: CT of the abdomen pelvis dated ___.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___, Interventional Radiology fellow performed the procedure. Dr.
___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 15 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 1 g of cefazolin
CONTRAST: 15 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 7 minutes, 45 mGy
PROCEDURE:
1. Left ultrasound guided renal collecting system access.
2. Left nephrostogram.
3. 8 nephrostomy tube placement.
4. Upsized 10 ___ nephrostomy tube placement.
5. Cone beam CT nephrostogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
prone on the exam table. A pre-procedure time-out was performed per ___
protocol. The left flank was prepped and draped in the usual sterile fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the left renal collecting system was accessed through a posterior lower pole
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. Prompt return of urine confirmed
appropriate positioning. Injection of a small amount of contrast outlined a
dilated renal collecting system. Under fluoroscopic guidance, a Nitinol wire
was advanced into the renal collecting system. After a skin ___, the needle
was exchanged for an Accustick sheath. Once the tip of the sheath was in the
collecting system; the sheath was advanced over the wire, inner dilator and
metallic stiffener. The wire and inner dilator were then removed and diluted
contrast was injected into the collecting system to confirm position. A ___
wire was advanced through the sheath and coiled in the collecting system. The
sheath was then removed and a 8 ___ nephrostomy tube was advanced into the
renal collecting system. The wire was then removed and the pigtail was formed
in the collecting system. Contrast injection confirmed appropriate
positioning. The catheter was then flushed, 0 silk stay sutures applied and
the catheter was secured with a Stat Lock device and sterile dressings. The
catheter was attached to a bag. However minimal drainage was noted. Contrast
was injected confirming appropriate positioning however demonstrating multiple
filling defects indicating thick purulent material. The dressing was removed,
the catheter was cut and the stay sutures were released and a wire was
advanced. The drain was removed. A ___ catheter was advanced over the
wire. Contrast was injected confirming appropriate positioning. An Amplatz
wire was advanced. The Kumpe catheter was removed and a new 10 ___
nephrostomy tube was flushed and advanced over the metal stiffener. The drain
was advanced into the proximal ureter and the pigtail was formed and placed in
the renal collecting system. Catheter and wire were removed. Pigtail was
locked. Contrast was injected confirming appropriate positioning. Number the
urine output was noted. However output then diminished.
Decision was made to perform a cone beam CT. Rotational cone-beam CT
angiography was performed to help delineate the anatomy. Multiplanar CT
images were reconstructed and 3D volume-rendered images of the renal anatomy
required post-processing on an independent workstation under direct physician
___. These images were used in the interpretation, decision making
for intervention and reporting of this procedure.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the left renal collecting system. The catheter was then flushed, 0 silk stay
sutures applied and the catheter was secured with a Stat Lock device and
sterile dressings. The catheter was attached to a bag. Patient tolerated the
procedure well and returned to the emergency department.
FINDINGS:
1. Ultrasound images of the left kidney demonstrates moderate severe
hydronephrosis.
2. Needle nephrostogram demonstrates opacification of the left lower pole
calyx.
3. Antegrade nephrostogram through the Accustick sheath demonstrates
appropriate positioning and hydronephrosis.
4. Final fluoroscopic image of the 8 and 10 ___ percutaneous nephrostomy
tubes demonstrate appropriate positioning.
IMPRESSION:
Successful placement of left 10 ___ nephrostomy tube.
Radiology Report
EXAMINATION: VENOUS DUP EXT UNI (MAP/DVT) LEFT
INDICATION: ___ w/ cancer, left lower extremity swelling; r/o DVT// DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the left
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with prostate and rectal ca w LUE weakness x
months// r/o bleed, cva, metastasis
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP =
940.0 mGy-cm.
Total DLP (Head) = 940 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
mass.
There is a chronic lacunar infarct in the right caudate body. Additional
hypodensity in the right lentiform nucleus may represent a lacunar infarct or
prominent perivascular space. There are mild hypodensities in the
periventricular white matter, which are nonspecific, but most likely represent
chronic microangiopathic changes. There are atherosclerotic calcifications of
the intracranial internal carotid arteries and vertebral arteries.
The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. There is a large retention cyst within the
right maxillary sinus. An additional retention cyst within the right
frontoethmoidal recess is noted. There is partial opacification of the right
mastoid air cells. The left mastoid air cells and bilateral middle ear
cavities are clear. There are bilateral lens replacements. Otherwise, the
orbits are unremarkable.
IMPRESSION:
No evidence of acute territorial infarction, hemorrhage or mass. Chronic
lacunar infarct in the right caudate body. Additional hypodensity in the right
lentiform nucleus may represent a lacunar infarct of indeterminate chronicity
or a prominent perivascular space. If there is high clinical concern for an
infarct or intracranial metastases, further evaluation may be performed with
MRI brain.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with recent hydro and pcn for obstructing stone,
cr still rising// r/o persistent hydro
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Renal ultrasound from ___. Abdominopelvic CT from ___ was also reviewed.
FINDINGS:
Right kidney: 13.8 cm
Several small echogenic foci with twinkle artifact in the upper pole of the
right kidney likely represent small stones. There is a 3.7 cm simple cyst in
the upper pole, also seen on prior CT. There is no hydronephrosis.
Corticomedullary differentiation is maintained. No masses are identified.
Left kidney: 15.4 cm
At least 2 renal cysts, largest measuring up to 4.2 cm in the upper pole. 7
mm echogenic focus with posterior shadowing in the inferior pole likely
represents a stone seen on prior CT. There is no hydronephrosis. There is a
percutaneous nephrostomy tube which is partially imaged. Corticomedullary
differentiation is maintained.
The bladder is moderately well distended and normal in appearance. A ureteral
jet is demonstrated on the right, none demonstrated on the left.
IMPRESSION:
1. Bilateral nephrolithiasis without hydronephrosis.
2. Partially imaged left percutaneous nephrostomy tube.
3. Ureteral jets demonstrated on the right, not demonstrated on the left.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Fever
Diagnosed with Sepsis, unspecified organism, Tachycardia, unspecified, Altered mental status, unspecified
temperature: 101.1
heartrate: 120.0
resprate: 19.0
o2sat: 99.0
sbp: 119.0
dbp: 52.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ male w/ rectal and prostate cancer,
status post end ileostomy ___, who initially presented with
septic shock ___ to genitourinary infection in s/o obstruction
requiring FICU admission, now s/p percutaneous nephrostomy w/
improvement in hemodynamics, transferred to medicine.
Subsequently had resolving ___, toxic metabolic encephalopathy,
as well as anemia/thrombocytopenia.
# UTI, pyelonephritis
# septic shock
# nephrolithiasis
# hydronephrosis
Presented in septic shock. Started on vanc/cefepime empirically
(___), narrowed to ampicillin after cultures returned
sensitive enterococcus. Underwent percutaneous nephrostomy by ___
with return of pus, also growing sensitive enterococcus. Urology
followed and recommended outpatient follow up with them for
definitive stone management and/or stent placement. Will
continue abx until definitive stone management or at least 14
days from PCN placement (ie until ___, whichever is later.
# ___
# obstructive nephropathy
# hydronephrosis
# nephrolithiasis
Initial cr 1.1 (baseline), quickly rose to 2.5 which was likely
a combination of obstructive nephropathy and ATN. Plateaued at
that level and eventually came down with resolution of
obstruction, IVF and time. Repeat u/s showed no more
hydronephrosis. Meds were renally dosed (including switching
morphine on transfer out of ICU to oxycodone). Plan per urology
for nephrostomy to remain in place on discharge until urology
follow up. Cr 1.4 on discharge.
#Toxic metabolic encephalopathy: likely ___ combination of
sepsis and medications in renal failure as well as renal failure
itself. Other than baseline LUE weakness, exam was non-focal. He
continued to improve with time and especially with renal
improvement and reductions in meds (switched morphine to
oxycodone/reduction in clonazepam on transfer from ICU to
floor). On discharge mental status had resolved back to
baseline.
# LUE weakness: pt reports baseline, but at risk for both mets
or bleeding. Unlikely acute. CT with old lacunar infarcts but
these would not explain the weakness. Will eventually need MRI.
# Serosanguinous drainage from nephrostomy in ba: in setting of
low platelets, had some thicker sanguinous drainage when
platelets were particularly low, never with clots. But with
platelets and time this improved, was having light red tinged
urine on discharge.
#LLE swelling: negative ___
#Thombocytopenia, anemia likely ___ chemotherapy. No
schistocytes seen on smear. Per outpatient oncologist, he may
take longer than normal to respond, particularly given the
infection. Was transfused several units of PRBCs (goal >7) and
plts (goal >50 given serosanguinous drainage in PCN bag. Ostomy
without any bleeding. Discussed with oncologist, will get labs
two days after discharge and decision on neulasta at that point.
#Rectal cancer, prostate cancer: recently received FOLFOX. Pain
was controlled with oxycodone in place of morphine given ___ as
above. Chemo on hold until renal issues are resolved.
#Anxiety: on long-standing clonazepam, would not want to stop
this abruptly for risk of withdrawal. Decreased home clonazepam
to 0.5mg po BID for now.
#Stoma prolapse: does not appear incarcerated but given prolapse
could be at risk of such. Was seen by colorectal surgery who
reduced the prolapse. No acute surgical plan given that he's a
poor surgical candidate with comorbidities. ___ RN saw him,
gave him and wife new appliances, taught how to use the
equipment. Ostomy nurse to come see him at home.
#Hyponatremia: On admission due to hypovolemia, resolved with
IVF.
TRANSITIONAL ISSUES
========================
- Will need to continue antibiotics until definitive stone
management or at least 14 days from PCN placement (ie until
___, whichever is later. Has follow-up for KUB on ___ and
urology on ___
- Patient currently does not have PCP because his is on medical
leave and then retiring. He has been instructed to set up with
new PCP, which he will find locally in ___
- PCP: MRI brain w/wo as o/p once creatinine is back to normal
- needs follow up with ___ in ___ weeks, which ___ is planning to
arrange
- nephrostomy to stay in place until definitive treatment of
kidney stones by urology
- repeat labs including creatinine and CBC w/ diff within one
week after 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:
Fatigue, abdominal pain
Major Surgical or Invasive Procedure:
EGD ___
Colonoscopy ___
History of Present Illness:
___ with hep b infection on tenofovir presenting with fatigue,
abd pain. Patient states he stopped taking tenofovir approx 9
months ago thinking that he no longer needed it (lfts normalized
and vl suppressed). 25 days ago his mother passed away and he
flew to ___ for the funeral. He began to feel fatigued while
there, and 15 days days ago developed progressively worsening
RUQ pain and nausea. Had labs checked ___ with worsenign
transaminitis. Resumed his tenofovir about a week ago. Has had
worsening poor PO intake progessively since his return from
___.
Denies f/c/sick contacts. No hematemesis/melena/hematochezia.
In the ED, initial vitals were: 97.2 65 114/65 14 99% RA
- Labs were significant for alt 1873, ast 118, T bili 19.2, plt
124, inr 1.6
- Imaging revealed no ascites on RUQ U/S, no abnormality on cxr
- The patient was given 1L NS, 5 mg IV morphine x 1, 4 mg IV
zofran x 1.
Vitals prior to transfer were: 60 101/62 16 97% RA
Upon arrival to the floor, patient recounts above history. Pain
somewhat improved.
Past Medical History:
Hepatitis B infection
Social History:
___
Family History:
Mother and brother with Hep B cirrhosis
Physical Exam:
ADMISSION EXAM:
====================
Vitals: 98.6 102/63 57 18 98 RA
General: Alert, oriented, no acute distress, jaundiced
HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding, ruq minimally tender,
negative ___, no fluid wave.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: AAOx3, no asterixis, cn2-12 intact, strenght and
sensation intact b/l upper and lower extremity
DISCHARGE EXAM:
====================
Vitals: Tm98.3 BP92-111/50s-60s HR60s-70s RR18 O298 RA
General: alert, oriented, NAD, diffusely jaundiced
HEENT: NCAT, sclera icteric, OP clear, good dentition
CV: RRR, normal s1/s2, no m/r/g
RESP: clear to auscultation bilaterally
ABD: soft, NDNT, no hepatosplenomegaly or masses, normoactive
bowel sounds
EXT: WWP, no edema
SKIN: jaundiced, no rash
NEURO: AOx3, moves all 4 extremities equally, no asterixis
Pertinent Results:
=================
ADMISSION LABS:
=================
___ 06:53PM BLOOD WBC-4.0 RBC-4.70 Hgb-15.6 Hct-45.9 MCV-98
MCH-33.2* MCHC-34.0 RDW-13.0 RDWSD-47.2* Plt ___
___ 09:50PM BLOOD Neuts-59.0 ___ Monos-12.1
Eos-0.9* Baso-0.7 Im ___ AbsNeut-2.52 AbsLymp-1.16*
AbsMono-0.52 AbsEos-0.04 AbsBaso-0.03
___ 06:53PM BLOOD ___
___ 06:53PM BLOOD Plt ___
___ 09:50PM BLOOD Glucose-95 UreaN-12 Creat-0.9 Na-136
K-3.7 Cl-99 HCO3-27 AnGap-14
___ 09:50PM BLOOD Albumin-3.6 Calcium-9.2 Phos-2.7 Mg-1.9
___ 06:53PM BLOOD ALT-1834* AST-1049* AlkPhos-97
TotBili-19.2* DirBili-14.2* IndBili-5.0
==================
PERTINENT LABS:
==================
___ 09:26AM BLOOD ___ pO2-250* pCO2-42 pH-7.39
calTCO2-26 Base XS-0
___ 05:43AM BLOOD HIV Ab-Negative
___ 05:43AM BLOOD IgG-1691* IgA-360 IgM-113
___ 05:43AM BLOOD CEA-1.4 PSA-0.2 AFP-164.0*
___ 05:43AM BLOOD AMA-NEGATIVE
___ 05:29AM BLOOD HBsAg-POSITIVE* HBsAb-NEGATIVE
HBcAb-POSITIVE
___ 04:20PM BLOOD HAV Ab-NEGATIVE
___ 05:43AM BLOOD 25VitD-19*
___ 09:20AM BLOOD Triglyc-201* HDL-LESS THAN LDLmeas-LESS
THAN
___ 05:43AM BLOOD calTIBC-129* Ferritn-3451* TRF-99*
___ 05:36AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 05:36AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln->12 pH-7.0 Leuks-NEG
====================
MICROBIOLOGY:
====================
HBV Genotype (___): C; no resistance predicted
====
HBV Viral Load (___): 837,000 IU/mL.
HBV Viral Load (___): 551,000 IU/mL.
HBV Viral Load (___): 10,100 IU/ml
HBV Viral Load (___): 1,730 IU/mL.
HBV Viral Load (___): 682 IU/mL.
===
RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE.
RUBELLA IgG SEROLOGY (Final ___: POSITIVE BY EIA.
VARICELLA-ZOSTER IgG SEROLOGY (Final ___: POSITIVE BY EIA.
CMV IgG ANTIBODY (Final ___: POSITIVE FOR CMV IgG ANTIBODY
BY EIA.
___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1:10
BY IFA.
TOXOPLASMA IgG ANTIBODY (Final ___: NEGATIVE FOR
TOXOPLASMA IgG ANTIBODY BY EIA.
===============
IMAGING:
===============
___ RUQ US: Unremarkable right upper quadrant ultrasound.
===
___ Chest PA/lat: No definite acute cardiopulmonary process.
===
___ CT abd w/ and w/o contrast:
1. Hepatic steatosis. No suspicious focal hepatic lesion
identified.
2. Gallbladder wall thickening and mucosal hyper enhancement,
likely reactive to the overlying hepatitis.
3. Few ___ nodules seen in the left lingula, query
underlying viral
bronchitis.
4. Incidental horseshoe kidneys.
5. Liver volumes will be dictated as an addendum when they are
available.
===
___ MRE:
1. Increased stiffness of the liver, consistent with stage F4,
or maybe F3
fibrosis with a nodular liver suggesting cirrhosis.
2. No hepatic steatosis or significant iron deposition.
3. No focal liver lesion.
4. Evidence of portal hypertension with mild splenomegaly,
varices, and trace ascites.
5. Gallbladder wall edema is nonspecific, though likely related
to the
chronic liver disease.
6. Horseshoe kidney.
===
EGD ___: No varices were seen. A small clean-based
ulceration was seen in the esophagus, likely from NJT friction.
Erythema and mosaic appearance in the stomach compatible with
portal hypertensive gastropathy. Gastric erosion. Duodenal
erosion. Otherwise normal EGD to third part of the duodenum.
===
Colonoscopy (___): Normal mucosa in the whole colon
Normal retroflexion. Medium sized nonthrombosed external
hemorrhoids.
Otherwise normal colonoscopy to cecum.
=================
DISCHARGE LABS:
=================
___ 05:27AM BLOOD WBC-3.9* RBC-2.45* Hgb-9.6* Hct-27.7*
MCV-113* MCH-39.2* MCHC-34.7 RDW-18.3* RDWSD-74.2* Plt ___
___ 05:27AM BLOOD ___ PTT-78.3* ___
___ 05:27AM BLOOD Glucose-136* UreaN-9 Creat-0.7 Na-135
K-3.4 Cl-101 HCO3-27 AnGap-10
___ 05:27AM BLOOD ALT-102* AST-126* AlkPhos-153*
TotBili-26.1*
___ 10:19 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.
HBV Viral Load (Final ___:
672 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test v2.0.
Linear range of quantification: 20 IU/mL - 170 million
IU/mL.
Limit of detection: 20 IU/mL.
Radiology Report
INDICATION: ___ with weakness // PNA
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: None.
FINDINGS:
There is focal opacity silhouetting the left ventricular apex localizing to
the region of the fissure on the lateral view. This is felt most likely to
represent a prominent fat pad. Lungs are otherwise clear. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No definite acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with liver failure
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized due to overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 11.4 cm.
KIDNEYS: The right kidney measures 10 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen. There is no hydronephrosis.
IMPRESSION:
Unremarkable right upper quadrant ultrasound.
Radiology Report
EXAMINATION: CT scan of the abdomen and pelvis
INDICATION: ___ year old man with history of chronic hepatitis now with
reactivation hepatitis in the setting of medication non-compliance. // Liver
transplant work-up with liver volumes
TECHNIQUE: Multiphasic Liver: Multidetector CT of the abdomen was done
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 was scanned in the early arterial phase, followed by a scan of the
abdomen and pelvis in the portal venous phase, followed by a scan of the
abdomen in equilibrium phase (3-min delay). IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 8.6 s, 29.4 cm; CTDIvol = 6.9 mGy (Body) DLP = 193.4
mGy-cm.
4) Spiral Acquisition 8.0 s, 24.6 cm; CTDIvol = 6.6 mGy (Body) DLP = 153.3
mGy-cm.
5) Spiral Acquisition 9.5 s, 29.1 cm; CTDIvol = 5.2 mGy (Body) DLP = 144.1
mGy-cm.
6) Spiral Acquisition 8.1 s, 24.8 cm; CTDIvol = 6.6 mGy (Body) DLP = 154.7
mGy-cm.
Total DLP (Body) = 657 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Few ___ type nodules are seen in the left lingula, query
underlying viral bronchiolitis.
Small amount of bibasilar atelectatic change.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous low density relative to the
spleen on the noncontrast images, compatible with steatosis. There is no
evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder demonstrates for enhancement
and edematous wall thickening. These changes are likely reactive to the
overlying hepatitis.
There is a small amount of ascites in the right upper quadrant.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Spleen measures 12.5 cm, upper limits of normal. No suspicious
splenic lesions are identified.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Horseshoe kidneys are noted. No suspicious focal renal lesions
identified. No hydronephrosis. No evidence of nephrolithiasis. Incidental
note is made of solitary retro aortic left renal vein.
GASTROINTESTINAL: There are extensive periesophageal and perigastric
collaterals/varices. The partially visualized small and large bowel loops are
within normal limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. Hepatic arterial branching pattern is anatomic. The left gastric
artery arises directly from the aorta. Incidental solitary left retro aortic
renal vein. The portal vein is patent.
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. Hepatic steatosis. No suspicious focal hepatic lesion identified.
2. Gallbladder wall thickening and mucosal hyper enhancement, likely reactive
to the overlying hepatitis.
3. Few ___ nodules seen in the left lingula, query underlying viral
bronchitis.
4. Incidental horseshoe kidneys.
5. Liver volumes will be dictated as an addendum when they are available.
Radiology Report
EXAMINATION: MR ___
INDICATION: Hepatitis-B reactivation. Evaluate for liver steatosis,
fibrosis, cirrhosis, or concerning focal liver lesion.
TECHNIQUE: T1 and T2 weighted images were obtained within a 1.5 T magnet.
___ and iron quantification protocols were also performed.
IV contrast: 7 mL Gadavist.
COMPARISON: CT of the abdomen and pelvis from ___. Right upper
quadrant ultrasound from ___.
FINDINGS:
LOWER THORAX: There is mild bibasilar atelectasis and a trace left pleural
effusion. The base of the heart is normal in size. There is no pericardial
effusion.
LIVER: The liver is normal in size. There is a subtle nodular contour of the
anterior capsule (14, 14), which may suggest cirrhosis. There is no focal
liver lesion. The hepatic arterial anatomy is conventional. The portal and
hepatic veins are patent. There is moderate periportal edema.
Hepatic steatosis: None.
Average liver stiffness: Between 7 and 8 kiloPascals. This degree of
stiffness is most often seen in significant chronic liver disease, stage F4 or
maybe F3. Given the morphologic features in the liver, this is highly
suggestive of cirrhosis.
Iron level: 35 (+/- 20) micromol/g (normal is < 35 micromol/g). No
appreciable iron overload.
BILIARY: There is no intra or extrahepatic biliary duct dilation. The
gallbladder is mildly distended. There is minimal wall edema and
pericholecystic fluid, which is nonspecific, though likely related to the
underlying liver disease.
SPLEEN: The spleen is mildly enlarged, measuring 13.2 cm in the cranial caudal
dimension.
PANCREAS: The pancreatic parenchyma is normal in signal and enhances
homogeneously. There is no duct dilation or mass.
ADRENAL GLANDS: The bilateral adrenal glands are normal.
KIDNEYS: There is a horseshoe kidney. The entire kidney is not included in
the field of view. The imaged upper poles are normal without evidence of a
mass or hydronephrosis.
GASTROINTESTINAL TRACT: The stomach and small bowel are normal in course and
caliber. There is no evidence of obstruction. The imaged portions of the
large bowel are normal. There is trace perihepatic and perisplenic ascites.
LYMPH NODES:Prominent periportal lymph nodes are noted, and most likely
reactive. There is no retroperitoneal or mesenteric lymphadenopathy.
VASCULATURE:The abdominal aorta is normal in caliber without evidence of an
aneurysm or significant atherosclerotic plaque. The left gastric artery
origin is directly from the aorta. Incidentally noted is a retro aortic left
renal vein. There is a recanalized paraumbilical vein and esophageal and
gastric varices, suggesting portal hypertension.
OSSEOUS STRUCTURES AND SOFT TISSUES: There are no concerning osseous lesions.
The soft tissues are unremarkable.
IMPRESSION:
1. Increased stiffness of the liver, consistent with stage F4, or maybe F3
fibrosis with a nodular liver suggesting cirrhosis.
2. No hepatic steatosis or significant iron deposition.
3. No focal liver lesion.
4. Evidence of portal hypertension with mild splenomegaly, varices, and trace
ascites.
5. Gallbladder wall edema is nonspecific, though likely related to the
chronic liver disease.
6. Horseshoe kidney.
Radiology Report
EXAMINATION: NASOINTESTINAL TUBE PLACEMENT WITH FLUORO
INDICATION: ___ year old man with reactivation HBV, malnutrition, needs
___ Dobhoff. // Please advance Dobhoff tube ___.
DOSE: Fluoro time: 3 min 9 seconds
COMPARISON: None.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, ___ feeding tube was advanced into the
stomach and then post-pylorically using a guidewire.
10 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the type of the feeding tube in the
third portion of the duodenum.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Successful placement of ___ feeding tube. The tube
is ready to use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new Dobhoff. // Evaluate Dobhoff placement.
Evaluate Dobhoff placement.
COMPARISON: Chest radiographs ___ one.
IMPRESSION:
Feeding tube with the wire stylet in place ends in the mid stomach. Lungs
clear. Heart size normal. No pleural abnormality.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE ONLY)
INDICATION: ___ year old man with cirrhosis s/p NG placement // check tube
placement check tube placement
IMPRESSION:
The Dobhoff tube extends to the lower part of the second portion of the
duodenum. Mild adynamic ileus with residual contrast presumably in the
hepatic flexure of the colon.
Radiology Report
EXAMINATION: Portable chest radiographs
INDICATION: ___ year old man with acute liver failure from HBV, needing
Dobhoff for TF. Dobhoff replacement. // evaluate for Dobhoff placement
TECHNIQUE: Portable chest
COMPARISON: Portable chest radiograph dated ___
FINDINGS:
In comparison to the chest radiograph obtained approximately 1 week prior,
there has been replacement and advancement of a Dobhoff tube. Sequential
radiographs show the tip of the Dobhoff tube in the midesophagus and then
gastric fundus. Lungs are fully expanded and clear without consolidations or
suspicious pulmonary nodules. No pleural abnormalities. Heart size is
top-normal. Cardiomediastinal and hilar silhouettes are normal.
IMPRESSION:
A Dobhoff tube terminates in the gastric fundus.
Radiology Report
EXAMINATION: NASOINTESTINAL TUBE PLACEMENT
INDICATION: ___ year old man with existing Dobhoff (no longer has wire in
place), needs advancement to post pyloric.
TECHNIQUE: Post pyloric tube placement under fluoroscopy.
DOSE: Acc air kerma: 33 mGy; Accum DAP: 549 uGym2; Fluoro time: 3 minutes 48
seconds
COMPARISON: ___ intestinal tube placement ___.
FINDINGS:
Under intermittent fluoroscopic guidance, a Dobhoff feeding tube was advanced
post-pylorically using a guidewire.
20 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the type of the feeding tube in the
second portion of the duodenum.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Successful placement of a Dobhoff post-pyloric feeding tube into the second
portion of the duodenum. The tube is ready to use.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with acute on chronic liver failure from HBV
reactivation, no interval improvement in his liver function tests, concern for
possible infection. // evaluate for any interval development of pneumonia
evaluate for any interval development of pneumonia
IMPRESSION:
Comparison to ___. Minimal atelectasis at the left lung bases.
No pneumonia. No pulmonary edema, no pleural effusion. The course of the
feeding tube is unremarkable.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with acute on chronic liver failure from HBV
reactivation now with stable LFTs, no interval improvement. // please perform
with Doppler. Evaluate for any biliary pathology. Any evidence of portal
vein thrombus?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound, ___, CT abdomen and pelvis, ___
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is
smooth. There is no focal liver mass. The main portal vein is patent with
hepatopetal flow. There is mild ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: There is sludge without gallbladder wall thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 14.4 cm.
KIDNEYS: The visualized portion of the horseshoe kidney appear unremarkable
and are unchanged from prior exams.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Coarse liver without suspicious lesions. No evidence of portal vein
thrombosis.
2. Splenomegaly and mild ascites.
Radiology Report
EXAMINATION: ___ TUBE PLACEMENT (W/FLUORO)
INDICATION: ___ year old man with HBV needs Dobhoff for feeding please advance
Dobhoff to NJ position.
DOSE: Acc air kerma: 4 mGy; Accum DAP: 84.26 UGym2; Fluoro time: 00:31
COMPARISON: ___ ___ intestinal tube placement.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, a feeding tube was advanced post-pylorically using a
guidewire.
10 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the type of the feeding tube in the
third portion of the duodenum.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Successful placement of ___ feeding tube. The tube
is ready to use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dobhoff placement // evaluate dobhoff
placement
COMPARISON: ___
IMPRESSION:
The tip of the Dobhoff is in the distal esophagus and needs to be advanced at
least 15 cm. This was subsequently advanced under fluoroscopic guidance.
Radiology Report
EXAMINATION: ___ TUBE PLACEMENT (W/FLUORO)
INDICATION: ___ year old man with HBV acute liver failure post dobhoff
placement to stomach please advance dobhoff to small intestine
DOSE: Acc air kerma: 4 mGy; Accum DAP: 122.1 UGym2; Fluoro time: 00:43
COMPARISON: ___ is intestinal tube placement.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, a dobhoff feeding tube was advanced from the stomach
post-pylorically using a guidewire.
10 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the tip of the feeding tube in the
second portion of the duodenum.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Successful advancement of Dobhoff post-pyloric feeding tube. The tube is
ready to use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dobhoff placed // Dobhoff placed
IMPRESSION:
Since a recent radiograph of ___, a feeding tube is been replaced,
with tip terminating in the proximal stomach. Cardiomediastinal contours are
stable in appearance. Minimal blunting of left costophrenic sulcus may
reflect small pleural effusion or pleural thickening.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Abd pain, N/V, Jaundice
Diagnosed with Unspecified viral hepatitis B without hepatic coma
temperature: 97.2
heartrate: 65.0
resprate: 14.0
o2sat: 99.0
sbp: 114.0
dbp: 65.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ year old man with a history of chronic HBV who
presented with liver failure from reactivation HBV in the
setting of medication non-adherence. AST/ALT > 1000s and TBili
of 19 on presentation. The patient was restarted on tenofovir.
However, LFTs did not improve and TBili continued to uptrend, so
entecavir was added with subsequent decrease in HBV viral load.
He reported early satiety throughout admission. He was initiated
on tube feeds via Dobhoff to ensure adequate nutrition. He was
evaluated for liver transplant and listed on ___.
================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status, falls and weakness.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Note: Patient report of history limited by word-finding
deficits and cognition, key aspects of history confirmed with
wife via phone.
The patient is a ___ man, with known metastatic
melanoma, who presents after several days of increased falls,
lethargy and weakness, and concern from his wife, in the setting
of decreased dexamethasone dosing as an outpatient. Per the
patient and wife (spoken to via phone), the patient denies
fevers, chills, nausea, vomiting, diarrhea, or dysuria. They
note no new rashes or swelling. The patient and wife note he is
not taking his furosemide regularly, but has needed it at times
for leg swelling. He denies shortness of breath or cough. Pain
is controlled on current regimen, per wife and patient.
In the emergency department, patient received 10mg IV
dexamethasone dose, CT with increased interval edema, suggested
considering MRI. Blood glucose was not elevated. Patient was
admitted for further evaluation of change in mental status and
recent falls in setting of decreased dexamethasone dosing.
ROS: As noted above, patient also denies constipation. He
feels speech has been 'foggy' at times and he has trouble with
word finding which he feels is stable. Ten-system ROS is
otherwise negative.
Past Medical History:
PAST ONCOLOGIC HISTORY: (Taken from OMR notes)
-___, Mr. ___ underwent biopsy of a right cheek skin
lesion revealing lentigo maligna.
-He underwent a wide local excision with a focal positive margin
with no further resection at that time.
-In ___, he underwent abdominal US to evaluate
abdominal pain which revealed small gallstones. There were
liver nodules noted consistent with hemangiomas. He underwent a
liver MRI on ___, revealing a dominant liver nodule
concerning for possible metastatic disease.
-Torso CT revealed lung nodules
-On ___, he underwent a brain MRI revealing three brain
lesions.
-On ___, he underwent a CT-guided liver biopsy confirming
melanoma.
-He was subsequently referred to ___ to Dr.
___ for a Gamma knife evaluation. He underwent Gamma
knife treatment to three brain lesions on ___ with brain
MRI one month later revealing stability.
-He began off protocol ipilimumab on ___. F/U brain MRI in
early ___ showed several new small brain lesions without
associated edema. He had evidence of regression in SQ nodules at
this time so he was observed.
-F/U brain MRI revealed resolution of the largest CNS lesion
with growth in some smaller lesions felt to be ipilimumab
effect. Torso CT revealed continued improvement in systemic
disease. He underwent Gamma knife therapy to 5 lesions on
___ by Dr. ___. ___ CT was stable.
-He was admitted in ___ twice at ___ for
mental status changes responsive to steroids, presumably due to
edema surrounding known metastatic disease.
-___ office visit, decreased dose of dexamethasone from 4mg
tid to bid.
PAST MEDICAL HISTORY:
1. Status post traumatic neck injury in ___ after falling off a
ladder, status post C-spine fusion;
2. history of chronic dysphagia from nutcracker esophagus
syndrome;
3. history of a frozen shoulder status post physical therapy
with
improvement in mobility;
4. history of lentigo maligna of the right cheek;
5. Metastatic Melanoma as above.
Social History:
___
Family History:
There is no history of melanoma.
Physical Exam:
Physical Exam on Admission:
Vital Signs: Temperature 98.2 F, blood pressure 150/72, pulse
81, repsiration 19, and oxygen saturation 98% in room air.
Blood glucose was 154 on arrival to floor.
General: Patient with moon facies, comfortable in NAD
HEENT: No bruits or stridor on ausculatation of neck. Supple.
Cardiovascular: Regular, S1 S2, no murmurs or gallops
Lungs: No rales or rhonchi bilaterally, good air movement
Abdomen: Positive bowel sounds, soft, non-tender, no suprapubic
tenderness
Extremities: Trace pitting edema bilateral feet, no leg or
thigh edema. Warm extremities without rashes. Right hand with
some patches of flat, non-fluctuant bruises. IV in right dorsum
of forearm.
Gait: Not tested, given patient report of instability and
weakness.
Neuro: Patient alert, conversant, with moderately fluent
speech. Some prominent word finding difficulties, which patient
appears aware of. He moved all four extremities. Mild decrease
in coordination of right hand. There was no resting tremor.
Both physical and neurological examinations were unchanged on
discharge.
Pertinent Results:
___ 02:34PM GLUCOSE-64*
___ 02:19PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:56PM GLUCOSE-72 UREA N-15 CREAT-0.3* SODIUM-133
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-27 ANION GAP-12
___ 01:56PM WBC-9.1 RBC-3.72* HGB-12.2* HCT-35.7* MCV-96
MCH-32.7* MCHC-34.1 RDW-15.9*
___ 01:56PM NEUTS-86.2* LYMPHS-6.0* MONOS-7.6 EOS-0
BASOS-0.2
___ 01:56PM PLT COUNT-265
___ 01:56PM ___ PTT-27.8 ___
CT Head ___:
IMPRESSION: Metastatic disease with extensive vasogenic edema
within the left cerebral hemisphere, unchanged in degree from
prior MRI. If further characterization of metastatic disease is
needed, an MRI would be the study of choice.
MR head with and without contrast ___:
IMPRESSION: 1. Multiple large metastatic hemorrhagic lesions,
stable in size with stable. No midline shift. No acute infarct.
2. Stable left cerebellar rim-enhancing and left cerebellar
leptomeningeal enhancing lesions.
CTA chest ___:
CONCLUSION: Patient is known with metastatic melanoma to the
brain, lungs, and liver.
1. New bilateral pulmonary emboli are seen from the distal
right and left main pulmonary artery going into all pulmonary
lobar arteries continuing into segmental and subsegmental level.
The burden of clot is important. Main pulmonary artery and right
heart chambers have dilated since prior exam. New lower lobe
most predominant on the right opacities are consistent with
pulmonary infarct.
2. Multiple bilateral lung cavitary lesions have slightly
decreased in size since ___. It is presumed to be
atypical manifestation of pneumocystis infection proven by
bronchoscopy and under treatment.
3. The residual millimetric metastases to the lungs seen on
___ are hard to assess throughout the new lung opacities.
4. A 9-mm liver lesion at the junction of segment VIII and ___
is new.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver ___
via phone, due to patient's difficulty with word-finding and
cognition.
1. Dexamethasone 4 mg PO Q12H
2. Testosterone 4 mg Patch 1 PTCH TD Q24H Start: In am
3. Furosemide 20 mg PO DAILY (wife notes not taking regularly).
Per wife report, patient not taking regularly
4. LeVETiracetam 500 mg PO BID
5. Levothyroxine Sodium 88 mcg PO DAILY Start: In am
6. Glargine 30 Units Breakfast and Glargine 10 Units Dinner
7. Zolpidem Tartrate ___ mg PO HS
8. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
11. Omeprazole 20 mg PO DAILY Start: In am
12. Nystatin Oral Suspension 15 mL PO QID Start: In am
13. Morphine Sulfate ___ 15 mg PO Q12H Start: In am
14. Morphine Sulfate Contin: Patient takes extended release
15mg twice daily at home.
-Note: wife notes patient has not yet started ondansetron and
temzolomide, as not yet taking chemotherapy.
Discharge Medications:
1. LeVETiracetam 500 mg PO BID
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Nystatin Oral Suspension 15 mL PO QID
4. Omeprazole 20 mg PO DAILY
5. Senna 1 TAB PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Capsule Refills:*0
6. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine 15 mg 1 tablet(s) by mouth q12hrs Disp #*60 Tablet
Refills:*0
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Docusate Sodium 200 mg PO DAILY constipation
RX *docusate sodium 100 mg 2 capsule(s) by mouth daily Disp #*60
Capsule Refills:*0
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
11. Tamsulosin 0.4 mg PO HS
12. Testosterone 4 mg Patch 1 PTCH TD Q24H
13. Zolpidem Tartrate ___ mg PO HS
14. Enoxaparin Sodium 50 mg SC Q12H
RX *enoxaparin 100 mg/mL Inject 50mg of enoxaparin two times per
day. q12hrs Disp #*30 Syringe Refills:*0
15. Glargine 15 Units Breakfast and Glargine 10 Units Dinner
16. Insulin SC Sliding Scale using HUM Insulin
17. Dexamethasone 6 mg PO DAILY
RX *dexamethasone 6 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
- metastatic cutaneous melanoma
- pulmonary embolism
SECONDARY:
- acute confusional state
- diabetes
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Metastatic melanoma to the lungs, liver, brain with mental status
changes and right weakness.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: Chest CT ___. Chest radiograph ___.
FINDINGS:
Lung volumes are low. The heart size is normal. Re- demonstrated are
numerous calcified mediastinal and hilar lymph nodes. The mediastinal and
hilar contours otherwise are unchanged. Ill-defined nodular opacities are
scattered within the left lung and are better demonstrated on the prior CT,
not significantly changed in the interval. No pleural effusion or
pneumothorax is present. Subtle increase in interstitial markings within the
right lung base likely reflects lymphangitic spread of tumor, as demonstrated
on the prior CT. Previously seen compression deformity of the T11 vertebral
body as well sclerotic lesion within T12 is better assessed on the recent CT.
IMPRESSION:
No significant interval change compared to the prior CT. No new areas of
opacification within the lungs.
Radiology Report
INDICATION: ___ male with brain mets from melanoma with new right
weakness and mental status changes, evaluate for stroke or changes in mass.
COMPARISON: MRI of the head ___ and head CT ___.
TECHNIQUE: Continuous axial sections through the brain were obtained without
the administration of IV contrast. Coronal and sagittal reformations were
provided and reviewed.
FINDINGS: Multiple hyperdense masses are again seen throughout the left
frontal and temporal lobes, compatible with metastatic melanoma, increased in
size compared to the prior CT, but similar compared to the prior MRI. These
measure 1.7 x 1.2 cm in the left frontal lobe (2:16), 1.1 x 1.3 cm along the
parafalcine vertex (2:22) and 1.6 cm x 0.8 cm adjacent to the internal capsule
(2:15). There are significant confluent white matter hypodensities,
representative of vasogenic edema, which is unchanged in distribution compared
to prior MRI. There are no new foci of metastatic disease identified on this
non-enhanced CT. The right cerebral hemisphere is unremarkable. Known left
cerebellar metastases as noted on the prior MRI are not clearly delineated on
this exam. There is no acute hemorrhage or shift of the normally midline
structures. The basal cisterns are patent. There is no large acute
territorial vascular infarction seen. The mastoid air cells and imaged
paranasal sinuses are well aerated. There is no fracture.
IMPRESSION: Metastatic disease with extensive vasogenic edema within the left
cerebral hemisphere, unchanged in degree from prior MRI. If further
characterization of metastatic disease is needed, an MRI would be the study of
choice.
The above findings were communicated to Dr. ___ to reflect the change in
the wet reading at 1740 hours by telephone by Dr. ___.
Radiology Report
INDICATION: ___ male with brain mets from melanoma, now with
weakness.
COMPARISON: MRI of the C-spine, ___.
TECHNIQUE: MDCT-acquired axial images were obtained through the cervical
spine without administration of IV contrast. Coronal and sagittal
reformations were provided and reviewed.
FINDINGS: There is no fracture or malalignment. The normal cervical lordosis
has been maintained. The patient is status post right posterior fusion of
C6-7 and there is no evidence of hardware complications. There are mild
multilevel degenerative changes without critical central canal stenosis. The
thyroid and imaged left lung apex are unremarkable. There is no prevertebral
soft tissue swelling.
The intracranial contents are better evaluated on the concurrent head CT.
IMPRESSION: No fracture.
Radiology Report
INDICATION: ___ man with metastatic melanoma to the brain, with new
altered mental status and right-sided weakness, evaluate for new mets,
hemorrhage.
TECHNIQUE: Multiplanar, multisequence MRI of the brain was obtained before
and after the administration of 6 mL of Gadavist as per departmental protocol.
COMPARISON: MRI of ___ and CT head non-contrast of ___.
FINDINGS: When compared to the prior examination, there has been no
significant change. Again noted are multiple enhancing hemorrhagic masses,
not significantly changed in size when compared to the prior examination.
There is stable perilesional FLAIR signal abnormality.
Similar to before, there is persistent leptomeningeal enhancement along the
left mid cerebellar peduncle as well as a small rim-enhancing lesion within
the left cerebellum, both of which appear stable.
There is no evidence of midline shift. The basal cisterns remain patent. The
ventricles are normal in size. There is no evidence of acute infarct.
The flow voids are unremarkable.
There is mucosal thickening of the ethmoidal and maxillary sinuses. Fluid is
also noted within the mastoid air cells, left more than right.
IMPRESSION:
1. Multiple large metastatic hemorrhagic lesions, stable in size with stable.
No midline shift. No acute infarct.
2. Stable left cerebellar rim-enhancing and left cerebellar leptomeningeal
enhancing lesions.
Radiology Report
CHEST CT WITH CONTRAST
INDICATION: Patient with tachypnea, tachycardia, desaturation at rest; rule
out PE.
COMPARISON: Multiple chest CTs and CT torso from ___ to ___.
TECHNIQUE:
Axial helical MDCT images were obtained from the suprasternal notch to the
upper abdomen with injection of IV contrast following the CTA PE protocol.
Multiplanar reformatted images were generated.
FINDINGS:
HEART AND GREAT VESSELS:
Multiple pulmonary embolism are new, starting at the distal left and right
main pulmonary arteries going into all the lobar arteries and continuing in
segmental and subsegmental level.
Increase in size of main pulmonary artery and right heart chambers since
recent exam is accompanying the pulmonary embolism.
Bilateral lower lobe new ground-glass opacities, consolidation, and septal
thickening is consistent with infarct.
There is no acute aortic syndrome. The aorta is not dilated. There is no
pericardial effusion.
LUNGS AND AIRWAYS:
Multiple cavitary lung nodules that appeared between CT scan of ___ and
___ proven to be pneumocystis by bronchoscopy have slightly improved
since ___. For example, main dominant lesion in the left upper
lobe went from 2 x 3.2 cm to 1.8 x 2.9 cm.
Residual lung metastases shown on ___ CT are hard to assess throughout all
those lung abnormalities. One is in the left upper lobe, series 2, image 12,
measuring 5 mm.
MEDIASTINUM:
The thyroid is unremarkable. Multiple calcified lymph nodes are consistent
with prior granulomatous infection. Some borderline mediastinal lymph nodes
are unchanged; for example, 9 mm in right lower paratracheal station. Small
right pleural effusion is new.
UPPER ABDOMEN: This study is not tailored for assessment for intra-abdominal
organs. 8 mm hypodense liver lesion in segment VII is unchanged since ___
but improved since last year consistent with a metastasis. 5 mm hypodense
lesion at hepatic dome, series 2, image 85, is unchanged since the CT torso of
___. 6 mm hypodense lesion at the junction of segments ___ and ___ is
new.
OSSEOUS STRUCTURES: T11 compression fracture is unchanged. Small lytic
lesion on the lateral right six rib, series 2, image 69, is unchanged.
CONCLUSION:
Patient is known with metastatic melanoma to the brain, lungs, and liver.
1. New bilateral pulmonary emboli are seen from the distal right and left
main pulmonary artery going into all pulmonary lobar arteries continuing into
segmental and subsegmental level. The burden of clot is important. Main
pulmonary artery and right heart chambers have dilated since prior exam. New
lower lobe most predominant on the right opacities are consistent with
pulmonary infarct.
2. Multiple bilateral lung cavitary lesions have slightly decreased in size
since ___. It is presumed to be atypical manifestation of pneumocystis
infection proven by bronchoscopy and under treatment.
3. The residual millimetric metastases to the lungs seen on ___ are
hard to assess throughout the new lung opacities.
4. 9 mm liver lesion at the junction of segment ___ and ___ is new.
The results have been discussed with Dr. ___ at the time of the
exam.
Radiology Report
HISTORY: ___ man, with altered mental status. More confused than
usual today. Has new pulmonary embolism on CTA today.
COMPARISON: Multiple prior comparisons with the latest MR head with and
without contrast on ___.
TECHNIQUE: Multiplanar, multisequence T1- and T2-weighted images were
acquired through the brain before and after administration of IV gadolinium
contrast. Diffusion-weighted images and ADC map were also obtained.
FINDINGS: Again noted are large intraparenchymal lesions predominantly in the
left hemisphere, with the largest one measuring 2.2 cm in the temporal lobe
(901a:62) and 14 mm in the left temporal lobe (image 901a:88), unchanged in
size overall, and also intrinsic T1 hyperintensity within the lesion could
either represent the inherent T1-hyperintense melanin or blood. There is,
however, no evidence of interval intracranial hemorrhage. The 3-mm left
cerebellar lesion and the leptomeningeal enhancement along the left middle
cerebral peduncle are unchanged.
The ventricles and sulci remain grossly symmetric. The FLAIR signal
abnormality around the known lesions is overall slightly improved.
The DWI images demonstrate no acute infarction. Major vascular flow voids are
present. Small mucus retention cysts are again noted in the bilateral
maxillary sinuses, but the remaining paranasal sinuses are clear.
IMPRESSION: Similar large metastases with intralesional hemorrhage, in
keeping with the known melanoma metastases. No evidence of interval
hemorrhage since the last study on ___. Slightly improved
perilesional FLAIR signal abnormality. No acute infarction. No new lesions.
Dr. ___ has discussed the pertinent findings with the primary team, Dr.
___, at 8:00 a.m. on ___, shortly after the preliminary
interpretation of the study.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ALTERED MENTAL STATUS
Diagnosed with ALTERED MENTAL STATUS , OTHER MALAISE AND FATIGUE
temperature: 98.0
heartrate: 90.0
resprate: 16.0
o2sat: 99.0
sbp: 137.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ man with known metastatic
melanoma here with weakness, falls, and report of worsening
mental status at home. Significant aspects of his hospital
course by problem are documented below.
(1) Altered Mental Status and Weakness: Patient's altered
mentation remained stable throughout his admission. He remained
oriented to self and person, was able to name year and season
but not specific month or date. As confirmed with wife, he had
pre-admission right-sided strenght deficits on neurologic
examination; throughout his stay his RUE and RLE were motor
strength ___ while the remainder of his examination was ___.
His cognitive difficulties were attributed to his underlying
cerebral metastases. It was presumed his pre-admission taper to
BID dosing of dexamethasone from TID may have contributed to his
new confusion. He was re-started on TID dosing upon admission,
though this was scaled back to dexamethasone 6mg PO daily during
his stay with planned continuation on this therapy for the
forseeable future. He underwent MRI scanning on ___ which
revealed the following: "1. Multiple large metastatic
hemorrhagic lesions, stable in size with stable. No midline
shift. No acute infarct. 2. Stable left cerebellar rim
enhancing and left cerebellar leptomeningeal enhancing lesions."
Given the continuing course of his melanoma, he was started on
bevacizumab (Avastin) on ___. Prior to starting this
therapy, the risks of hemorrhage and subsequent neurologic
deterioration were discussed with both the patient and his
family. All were in agreement to proceed with this course.
Unfortunately, Mr. ___ suffered a pulmonary embolism during
his hospitalization. It was felt this complicationh was
secondary to the hypercoagulable state of his melanoma and also
due to bevacizumab toxicity. He required anti-coagulation for
this PE, as discussed below. An MRI performed prior to
initiating anti-coagulation identified stable cerebral
metastases (no new hemorrhage) as above. His mental status was
unaffected by anti-coagulation; he did not demonstrate evidence
of new cerebral hemorrhage. Upon discharge, he was alert to
place and person, but disoriented to time. He continued to have
mild word finding difficulties, but was generally appropriate
with his communication.
(2) Pulmonary Embolism: As mentioned above, Mr. ___ suffered
the unfortunate complication of a pulmonary embolism. This was
discovered on CTA after the patient desaturated while ambulating
and was found to be tachycardic. This complication was
attributed to his melanoma and bevacizumab therapy. Given the
significant size of the emboli coupled with his stable cerebral
disease (on MRI shortly after CTA), it was felt anti-coagulation
was necessary. He was started on a heparin drip without initial
bolus dosing and at a decreased PTT goal of 50-70 (therapeutic
considered to be 60-100). After 24 hours of stable neurologic
examination and mentation, this anti-coagulation was
transitioned to subcutaneous enoxaparin. Based on his weight,
the recommended dose for anti-coagulation was 60mg BID. Mr.
___ was started on 50mg BID, roughly 80% of suggested dose, in
an effort to both treat the pulmonary emboli and prevent new
cerebral hemorrhage. He did not exhibit signs of new bleeding
with either heparin or enoxaparin. He was discharged on
enoxaparin SQ 50mg BID.
(3) Metastatic Melanoma: Melanoma initially presented at right
cheek and now known to be metastatic to brain, liver, and lung.
Levetiracetam was continued while hospitalized for seizure
prophylaxis given his cerebral involvement. He was started
bevacizumab ___ as above. His next scheduled dose was
___, however, this was delayed given the development of
pulmonary embolism. He was discharged on ___ with
scheduled appointment as an outpatient on ___ to receive
his next dose of bevacizumab.
(4) Diabetes Mellitus: Recent admission to ___ for diabetic
ketoacidosis. Management c/b current steroid use. His serum
glucose levels were well-controlled while hospitalized with his
home dose of insulin and sliding scale adjustment. He was
discharged with a ___ appointment with the endocrinology
service for further evaluation and management.
(5) Pneumocystis Pneumonoia: This was diagnosed on ___ by
___. He was prescribed 3 week course of Bactrim DS TID
(completed on ___. Now, he is on 1 tab Bactrim DS daily
for PCP ___. He will need to continue this regimen
until one month after stopping steroids (likely to be on
dexamethasone for extended period of time).
(6) Hypothyroidism: He continued home dose of levothyroxine.
(7) Oral Thrush: This was documented on ___ during visit
to Dr. ___. Outpatient nystatin was continued
while hospitalized.
(8) Physical Therapy: Mr. ___ performed well on his physical
therapy assessments during his stay, ambulating well with the
assistance of ___ staff members.
========================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
levofloxacin
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
___ Left posterior cervical lymph node biopsy
___ Right Tunneled HD line placement
History of Present Illness:
___ w/ complex past medical history including hypertension,
___ disease, history of PE (previously on warfarin but
discontinued due to ___), sclerosing cholangitis, kidney
disease,
presenting with productive cough and fevers x 1 week. The pt was
admitted on ___ when diagnosed with CAP. CTAP with no PE,
showed LLL PNA with small opacifications in RUL. Also showed
splenic infarct. Treated with CTX, azithro for two days,
discharged on Cefuroxime (for full 7 days course) and Azithro
(for full 5 day course.) She felt well for one week following
discharge, and went on a trip to ___ from which she returned
on ___. That day, she again deceloped cough, SOB and fevers for
which she presented to her PCP and was given a dose of
ceftriaxone on ___, doxycycline on ___ and ___, and CTX again
on
___ and ___. Despite these abx, she developed a fever to 103 on
___ and presented to the ED on ___.
Over the past week throughout this time, she endorses shallow
breathing but denies any frank shortness of breath or chest
pain.
She endorses some increasing leg swelling today, but denies
feeling like this is similar to her previous PE. She endorses
one
episode of nausea and vomiting posttussive yesterday, but denies
any significant abdominal pain, diarrhea.
In the ED, initial vitals were: T99.0 HR113 BP154/75 RR18
O2:100%
RA
- Exam notable for:
Tachycardic, otherwise stable
Coughing, non-productive
1+ edema to knees
Benign otherwise - no headache, no meningismus, no neuro sx
- Labs notable for:
132 / 99 / 32
---------------< 116
4.3 / 16 / 1.9
Ca: 8.5 Mg: 1.8 P: 3.0
6.0 > 11.2 / 135 < 31.7
Lactate: 2.2
Trop-T: 0.01
proBNP: 702
ALT: 36 AP: 154 Tbili: 0.4 Alb: 3.1
AST: 86
Lip: 47
pH 7.40 pCO2 25 pO2 77 HCO3 16
FluAPCR: Negative
FluBPCR: Negative
___: 12.4 PTT: 22.3 INR: 1.1
- Imaging was notable for:
B/L Lenis: No evidence of deep venous thrombosis in the right or
left lower extremity veins.
CXR:
1. Mild opacification of the left lung base likely reflects
resolving
pneumonia.
2. No new focal consolidations.
- Patient was given:
___ 12:35 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 12:35 IH Ipratropium Bromide Neb 1 NE___
___ 13:52 IV Hydrocortisone Na Succ. 100 mg
___
Upon arrival to the floor, patient reports ####
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
- HTN
- HLD
- ___ vasculitis
- Chronic eosinophilia
- Autoimmune hepatitis (5mg prednisone)
- PSC
- Pancreatic cyst - most likely intraductal papillary mucinous
neoplasm, acellular specimen (___)
- Skin lymphoma on forehead, ___ yr ago resected
- CKD - III (focal segmental glomerulosclerosis)
- Hyperparathyroidism due to renal insufficiency
- Neuropathy - hyperesathes. ___
- osteoporosis
Social History:
___
Family History:
Father ___ - ___, stroke
Mother Alive - ___ Onset; Hypertension
Sister ___ - diabetes, hypertension, kidney failure on
dialysis
Daughter: multiple pregnancy loss; membranous glomerulonephritis
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
VITAL SIGNS: ___ Temp: 98.6 PO BP: 107/62 HR: 96 RR:
18
O2 sat: 97% O2 delivery: RA
GENERAL: Sitting comfortably edge of bed, no acute distress
HEENT: PEERLA, sclera non-icteric
NECK: No JVD
CARDIAC: RRR, no m/r/g
LUNGS: Faint crackles at LLL. Otherwise clear without wheezes.
ABDOMEN: Soft, non-tender, non-distended. No RUQ tenderness.
EXTREMITIES: Bilateral 2+ pitting edema to mid shin.
NEUROLOGIC: CN intact, strength and sensation intact. No focal
deficits.
SKIN: No rashes or lesions.
DISCHARGE PHYSICAL EXAM
=========================
24 HR Data (last updated ___ @ 532)
Temp: 98.4 (Tm 98.9), BP: 146/73 (136-160/63-73), HR: 97
(95-106), RR: 18, O2 sat: 99% (95-100), O2 delivery: Ra, Wt:
123.68 lb/56.1 kg
General: Tired. Lying in bed, NAD
ENT: MMM, no sores/lesions.
Neck: R tunneled CVL c/d/i.
CV: NR, RR. ___ systolic murmur
Lungs: CTAB
Abdomen: soft, nontender, nondistended
Ext: 1+ pitting edema bilateral ___
Neuro: AOx3
Skin: No rashes/lesions.
LABS: Reviewed in OMR.
MICRO: Reviewed in OMR.
IMAGING: Reviewed in OMR.
Pertinent Results:
ADMISSION LABS
===============
___ 11:30AM BLOOD WBC-6.0 RBC-3.53* Hgb-11.2 Hct-31.7*
MCV-90 MCH-31.7 MCHC-35.3 RDW-15.1 RDWSD-48.7* Plt ___
___ 11:30AM BLOOD Neuts-92* Bands-1 Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-2* Metas-1* Myelos-0 AbsNeut-5.58
AbsLymp-0.30* AbsMono-0.06* AbsEos-0.00* AbsBaso-0.00*
___ 11:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+*
Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL
Target-OCCASIONAL Schisto-OCCASIONAL Burr-1+* Envelop-OCCASIONAL
___ 08:35AM BLOOD ___ PTT-23.5* ___
___ 11:30AM BLOOD Glucose-116* UreaN-32* Creat-1.9* Na-132*
K-4.3 Cl-99 HCO3-16* AnGap-17
___ 11:30AM BLOOD ALT-36 AST-86* AlkPhos-154* TotBili-0.4
___ 08:35AM BLOOD ALT-33 AST-72* LD(LDH)-1379* AlkPhos-144*
TotBili-0.4
___ 11:30AM BLOOD cTropnT-0.01 proBNP-702*
___ 11:30AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.0 Mg-1.8
___ 11:36AM BLOOD Lactate-2.2*
DISCHARGE LABS
=====================
___ 12:00AM BLOOD WBC-30.2* RBC-2.41* Hgb-7.8* Hct-23.9*
MCV-99* MCH-32.4* MCHC-32.6 RDW-18.7* RDWSD-57.1* Plt Ct-74*
___ 12:00AM BLOOD Neuts-76* Bands-6* Lymphs-1* Monos-6
Eos-0 Baso-0 Atyps-1* Metas-5* Myelos-4* Promyel-1*
AbsNeut-24.76* AbsLymp-0.60* AbsMono-1.81* AbsEos-0.00*
AbsBaso-0.00*
___ 12:00AM BLOOD Plt Smr-VERY LOW* Plt Ct-74*
___ 12:00AM BLOOD Glucose-180* UreaN-30* Creat-2.7* Na-137
K-3.7 Cl-100 HCO3-21* AnGap-16
___ 12:00AM BLOOD ALT-42* AST-43* LD(___)-546* AlkPhos-273*
TotBili-0.6
___ 12:00AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.2 UricAcd-4.8
PERTINENT LABS
===================
___ 06:26AM BLOOD ALT-41* AST-104* LD(___)-1603*
AlkPhos-207* TotBili-0.5
___ 11:30AM BLOOD cTropnT-0.01 proBNP-702*
MICROBIOLOGY
===================
__________________________________________________________
___ 9:49 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
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.
__________________________________________________________
___ 8:11 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Inadequate specimen for respiratory viral culture.
PLEASE SUBMIT ANOTHER SPECIMEN.
Respiratory Viral Antigen Screen (Final ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Recommend new sample be submitted for confirmation..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Reported to and read back by ___ ___ ___ AT
14:40.
__________________________________________________________
___ 1:03 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 5:28 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
__________________________________________________________
___ 9:15 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:05 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:13 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 9:13 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
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.
__________________________________________________________
___ 4:16 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
__________________________________________________________
___ 2:11 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING
=======================
___ Imaging MRCP (MR ___ IMPRESSION:
Technically suboptimal study due to non breath hold technique
and motion
artifact.
1. New multifocal areas of restricted diffusion within bilateral
kidneys with new retroperitoneal adenopathy raises the suspicion
of lymphoma. The lymph nodes would be amenable to CT guided
biopsy.
2. 17 mm left lower lobe pulmonary lesion appears similar to
previous and may represent a true mass lesion versus an area of
consolidation. Mild
superimposed bibasal airspace disease is seen, increased in the
right lower lobe from before but suboptimally evaluated.
3. Stable appearance of the liver with moderate intrahepatic
biliary ductal dilatation and cirrhotic morphology in keeping
with known history of PSC. No MRI findings to suggest
cholangitis.
___ Cardiovascular TTE Report Good image quality. Normal
study. Normal biventricular cavity sizes, regional/global
systolic function. No valvular pathology or pathologic flow
identified. High normal estimated
pulmonary artery systolic pressure. Mild-moderate tricuspid
regurgitation. LVEF 68%.
___ Imaging CHEST (PA & LAT) IMPRESSION:
Left lower lobe pneumonia.
___ Imaging LUNG SCAN
IMPRESSION: Indeterminant scan with a triple match of perfusion,
ventilation and chest X-ray abnormalities within the left lower
lobe.
___ Imaging LIVER OR GALLBLADDER US IMPRESSION:
1. Minimal intrahepatic biliary ductal dilatation.
2. Multiple cysts throughout the pancreas, better evaluated on
prior MRCP.
3. Multiple prominent and enlarged perihepatic and
peripancreatic lymph nodes.
4. Cholelithiasis without cholecystitis.
___ Imaging BILAT LOWER EXT VEINS IMPRESSION:
No evidence of deep venous thrombosis from the femoral to the
popliteal veins. Limited evaluation of the calf veins.
___ Imaging CHEST (PA & LAT) IMPRESSION:
1. Mild opacification of the left lung base likely reflects
resolving
pneumonia.
2. No new focal consolidations.
FLOW CYTOMETRY REPORT ___
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambda,
and CD antigens 2, 3, 4, 5, 7, 8, 10, 11c, 19, 20, 23, CD25,
CD26, CD30, 34,38,45,CD52,C56,and CD279.
RESULTS:
10-color analysis with linear side scatter vs. CD45 gating is
used to evaluate for leukemia/lymphoma.
The viability of the analyzed non-debris events, done by 7-AAD
is 99%.
CD45-bright, low side-scatter gated lymphocytes comprise 3.7% of
total analyzed events.
B cells comprise 2% of lymphoid gated events.
A subset of B-cells(0.4% of lymphoid gated events) demonstrate
monoclonal lambda light chain restriction. They coexpress pan-B
cell markers CD19 and CD20 along with CD11c. They do not express
any other characteristic antigens including CD5, CD10, and CD23.
T cells comprise 79% of lymphoid gated events and express mature
lineage antigens (CD3, CD5, CD2, and CD7). A subset (50%) of
T-cellshowed dim/variable loss of CD7. CD3 positive T cells
express CD52 and only a subset express
CD56(67%),CD25(24%),CDCD279a(32.6%). They are negative for CD30.
T cells have a normal CD4:CD8 ratio of 0.83 (usual range and
blood 0.7-3.0). There is an increase population of double
positive (CD4 positive/CD8 positive) T-cells comprising 26% of
CD3 positive cells which show significant loss of CD7.
CD56 positive, CD3 negative natural killer cells represent 9% of
gated lymphocytes and are normal in number (usual range in blood
___. They coexpress CD2, CD7 and CD8 (subset).
INTERPRETATION
Immunophenotypic findings consistent with involvement by
patient's recently diagnosed B-cell lymphoma. In addition an
increased double positive T-cells with significant loss of CD7
was identified, comprising 26% of the total T cells. Increased
double positive T-cells can be seen in reactive settings such as
autoimmune disease and viral infection. However, Given the
patients remote history of cutaneous T cell lymphoma as well as
the significant loss of CD7 expression, an involvement by a
clonal T cell process cannot be entirely ruled out. Thus, TCR
gamma gene rearrangement PCR was ordered to test for clonality
and result will be issued separately. Correlation with clinical
(see separate pathology report ___ and other ancillary
findings is recommended. Flow cytometry immunophenotyping may
not detect all abnormal populations due to topography, sampling
or artifacts of sample preparation.
FDG TUMOR IMAGING (PET-CT) Study Date of ___
1. Widespread FDG avid disease. Specifically, there is diffuse
central and
peripheral FDG avid lymphadenopathy involving the neck, chest,
abdomen, and
pelvis. Additionally, there are multifocal lung parenchymal
abnormalities that
FDG avid, multiple FDG avid hepatic foci, FDG avid gastric wall
thickening,
diffuse FDG avidity of the spleen, and multiple bilateral foci
of FDG avidity
within the kidneys, in addition to widespread, multifocal axial
and appendicular
skeletal FDG avid foci. Findings are concerning for widespread
lymphoma.
2. Shrunken and nodular liver, suggestive of cirrhosis.
Correlate with LFT's.
3. Moderate volume ascites, primarily layering in the dependent
pelvis.
4. Trace bilateral layering nonhemorrhagic pleural effusions.
Trace pericardial
effusion. Other incidental findings, as above.
___
PATHOLOGIC DIAGNOSIS:
Lymph node, cervical, biopsy:
DIFFUSE LARGE B-CELL LYMPHOMA, NOT OTHERWISE SPECIFIED; SEE
NOTE.
Note: Sections show small fragments of adipose tissue and lymph
node with diffuse effacement of
the nodal architecture. There is an abnormal infiltrate of
medium and large lymphoid cells with round
to mildly irregular nuclear contours, small to medium amounts of
cytoplasm and one or more small
somewhat prominent nucleoli. Occasional apoptotic cells and
scattered mitotic figures are seen.
By immunohistochemistry, the neoplastic cells are immunoreactive
for CD20, PAX5, BCL2 and
MUM1. They are negative for CD10, BCL6, BCL1 and nTdT. CD3 and
CD5 highlight a very minor
population of small admixed T cells which are scattered singly.
The Ki-67 proliferation index is
approximately 70-80%.
Corresponding flow cytometry detected a population of lambda
restricted B cells which were CD5
and CD10 negative (see separate report ___ for full
results).
Cytogenetics work-up revealed no evidence of interphase cells
with IGH/BCL2 gene rearrangement
or rearrangements of the BCL6 and MYC genes (see separate report
___-___ for full results).
Taken together, the morphologic and immunophenotypic features in
conjunction with cytogenetics
results are in keeping with involvement by a diffuse large
B-cell lymphoma with a non-germinal
center phenotype ___ algorithm). Correlation with clinical,
radiologic, and prior outside pathology
is recommended for further characterization.
___
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambda,
and CD antigens 2,3,4,5,7,8,10,11c,19,20,23,34,38,45, and 56.
RESULTS:
10-color analysis with linear side scatter vs. CD45 gating is
used to evaluate for lymphoma.
Approximately 37% of total acquired events are evaluable
nondebris events.
The viability of the analyzed non-debris events, done by 7-AAD
is 96%.
CD45-bright, low side-scatter gated lymphocytes comprise 81% of
total analyzed events.
B cells comprise 54% of lymphoid gated events.
B cells demonstrate monoclonal lambda light chain restriction.
They coexpress pan-B cell markers CD19 and CD20 along with CD11c
(subset). They do not express any other characteristic antigens
including CD5, CD10, and CD23.
T cells comprise 34% of lymphoid gated events and express mature
lineage antigens (CD3, CD5, CD2, and CD7).
A subset (28%) of T cells shows dim/variable loss of CD7
(nonspecific finding).
T cells have a CD4:CD8 ratio of 0.7.
There is a population of double-negative (CD4 negative/CD8
negative) T-cells comprising 12% of CD3 positive cells.
Approximately 9% of CD3 positive T-cells coexpress CD56.
CD56 positive, CD3 negative natural killer cells represent 0.3%
of gated lymphocyte. They coexpress CD2, CD7 and CD8.
INTERPRETATION
Immunophenotypic findings consistent with involvement by lambda
restricted B-cell lymphoma. Correlation with clinical,
morphologic (see separate pathology report ___ and other
ancillary findings is recommended. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation.
___ Renal U/S
1. Minimal symmetric fullness of the bilateral renal collecting
systems
without frank hydronephrosis, likely secondary to prominent
bladder
distension. Correlate for urinary outlet obstruction.
2. Echogenic debris within the left renal collecting system and
trace debris
within the bladder. Infection cannot be excluded based on
ultrasound in the
appropriate clinical context.
3. Several bilateral renal cysts.
___ RUQUS
1. Redemonstration of cirrhotic liver with unchanged
intrahepatic biliary
dilatation.
2. Peripancreatic and periportal adenopathy, as on prior.
3. Small perihepatic ascites.
Soluble IL-2 ___ ___
CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Study Date of
___ 12:31 ___
1. Cirrhotic liver, with stable intrahepatic biliary duct
dilatation, in
keeping with known history of PSC.
2. Stable mesenteric and retroperitoneal adenopathy. Multiple
hypoattenuating
foci in the bilateral kidneys. While some of these represent
cysts, others
are too small to characterize.
3. Small volume ascites, increased since the previous MRI, with
small
bilateral pleural effusions. Anasarca.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. NIFEdipine (Extended Release) 60 mg PO DAILY
5. NIFEdipine (Extended Release) 30 mg PO DAILY
6. PredniSONE 5 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Atovaquone Suspension 1500 mg PO DAILY
4. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all
dressing changes
8. Nephrocaps 1 CAP PO DAILY
9. Ondansetron 4 mg IV Q8H:PRN nausea/vomitting
10. Simethicone 40-80 mg PO QID:PRN gas/bloating
11. Ursodiol 300 mg PO BID
12. PredniSONE 10 mg PO DAILY
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Fluticasone Propionate NASAL 1 SPRY NU BID
15. Omeprazole 40 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. HELD- Atorvastatin 20 mg PO QPM This medication was held.
Do not restart Atorvastatin until your PCP tells you to do so.
18. HELD- NIFEdipine (Extended Release) 60 mg PO DAILY This
medication was held. Do not restart NIFEdipine (Extended
Release) until your PCP instructs you to do so.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=========
Diffuse large B cell lymphoma
Acute renal failure
Febrile neutropenia
SECONDARY
===========
Hyperbilirubinemia
Transaminitis
Malnutrition
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: History: ___ with SOB// PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: CTA chest from ___. multiple prior outside reference
chest radiographs, most recent from ___.
FINDINGS:
Lung volumes are reduced. The cardiomediastinal and hilar contours are within
normal limits. Mild opacification at the left lung base likely reflects
resolving pneumonia. No new focal consolidations are seen. There is no
pulmonary edema or pleural abnormality.
IMPRESSION:
1. Mild opacification of the left lung base likely reflects resolving
pneumonia.
2. No new focal consolidations.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: History: ___ with hxDVT/PE now with cough, fevers// DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Bilateral lower extremity DVT study from ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Evaluation of the bilateral
posterior tibial and peroneal veins is partly limited, but no definite
thrombus is seen.
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 from the femoral to the popliteal veins.
Limited evaluation of the calf veins.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ w/ complex past medical history including hypertension,
___ disease, history of PE (previously on warfarin but discontinued
due to ___), sclerosing cholangitis, kidney disease, presenting with
productive cough and fevers x 1 week.// H/o PSC, uptrending LFTs
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound dated ___. MR dated ___. CT dated
___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. A rounded, isoechoic focus in the right lobe of the liver
most likely represents hypertrophy. There is no focal liver mass. The main
portal vein is patent with hepatopetal flow. There is small volume ascites.
BILE DUCTS: There is mild intrahepatic biliary dilation. The CHD measures 5
mm.
GALLBLADDER: There are tiny stones versus sludge in a nondistended
gallbladder.
PANCREAS: Multiple cysts are seen throughout the pancreas, better evaluated on
prior MRCP.There are multiple enlarged periportal and peripancreatic lymph
nodes, the largest of which measures 3.0 x 3.6 x 1.8 cm.
SPLEEN: Normal echogenicity, measuring 8.3 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Minimal intrahepatic biliary ductal dilatation.
2. Multiple cysts throughout the pancreas, better evaluated on prior MRCP.
3. Multiple prominent and enlarged perihepatic and peripancreatic lymph
nodes.
4. Cholelithiasis without cholecystitis.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with hx PSC and churg ___ w/ elevated LFTs,
diarrhea, and fever of unknown origin.// 1. assess for interval change in
pancreas cyst; 2. PSC with bile duct dilation- assess for interval change; 3?
subclinical cholangitis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 11 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: MRI of the abdomen dated ___. CT scan of the thorax
dated ___.
FINDINGS:
Lower Thorax: 17 mm nodule within the left lower lobe appears similar in size
in comparison to the prior CT examination. There is mild consolidation within
the dependent portions of bilateral lower lobes, increased in the right lower
lobe from before but suboptimally evaluated.
Liver: Morphologic features of cirrhosis. Moderate segmental intrahepatic
biliary ductal dilatation appears similar in comparison to the prior MRI
examination from ___. No significant hepatic steatosis. No
suspicious liver lesion. Portal vein, splenic vein, and SMV are patent.
Biliary: Segmental intrahepatic biliary ductal dilatation, similar to
previous. No abnormal biliary tree enhancement to suggest cholangitis. No
extrahepatic biliary ductal dilatation. The gallbladder is contracted.
Pancreas: Multiple pancreatic cystic lesions, largest measuring 22 mm in
pancreatic tail (coronal series 5, image 18), unchanged from previous.
Spleen: No splenomegaly.
Adrenal Glands: The adrenal glands are not well visualized.
Kidneys: There has been interval development of multifocal geographic
predominantly rounded areas of hypoenhancement and diffusion restriction
involving bilateral kidneys (axial series 16, images 12, 16, 18, 20; axial
series 9, images 53, 58, 16, 66). This appears to correspond to areas of
hypodensity, partially imaged on recent CT scan of the thorax from ___.
21 mm T1 hyperintense lesion arising from the upper pole of the right kidney
likely represents a hemorrhagic/proteinaceous cyst.
Gastrointestinal Tract: The stomach is unremarkable. The imaged small and
large bowel are unremarkable.
Lymph Nodes: There has been interval development of extensive periportal and
retroperitoneal adenopathy. For example:
1. Periportal (axial series 3, image 34), measuring 21 mm.
2. Para-aortic (axial series 3, image 33) measuring 18 mm.
3. Gastrohepatic (axial series 3, image 23) measuring 12 mm.
Vasculature: No abdominal aortic aneurysm.
Osseous and Soft Tissue Structures: Unremarkable.
IMPRESSION:
Technically suboptimal study due to non breath hold technique and motion
artifact.
1. New multifocal areas of restricted diffusion within bilateral kidneys with
new retroperitoneal adenopathy raises the suspicion of lymphoma. The lymph
nodes would be amenable to CT guided biopsy.
2. 17 mm left lower lobe pulmonary lesion appears similar to previous and may
represent a true mass lesion versus an area of consolidation. Mild
superimposed bibasal airspace disease is seen, increased in the right lower
lobe from before but suboptimally evaluated.
3. Stable appearance of the liver with moderate intrahepatic biliary ductal
dilatation and cirrhotic morphology in keeping with known history of PSC. No
MRI findings to suggest cholangitis.
RECOMMENDATION(S): CT-guided biopsy retroperitoneal lymph node. Consider
chest CT if persistent thoracic symptoms.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:48 pm, 10 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with fevers, productive cough.// ? atelectasis,
?pulmonary edema ?pleural effusion ? interval change
TECHNIQUE: AP and lateral chest radiographs
COMPARISON: ___
FINDINGS:
Increased left lower lobe opacities likely reflect pneumonia. No pleural
effusion or pneumothorax. Patchy opacities in the periphery of the right lung
are also present in unchanged when compared to prior. The size of the cardiac
silhouette is within normal limits.
IMPRESSION:
Left lower lobe pneumonia.
Radiology Report
INDICATION: ___ year old woman with new line// new right PICC 47 cm ___
___ Contact name: ___: ___
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Right-sided PICC line projects to the cavoatrial junction. Small bilateral
effusions have slightly increased in volume. Patchy parenchymal opacity in
the right lower lobe is unchanged. Nodular opacity in the retrocardiac left
lower lobe is better seen on recent CT scan. No new consolidations. No
pneumothorax is seen. There is no pleural effusion.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with ___, diffuse lymphadenopathy// Assess for
renal obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Abdominal ultrasound ___. Whole-body PET-CT ___.
FINDINGS:
The right kidney measures 7.7 cm. The left kidney measures 8.5 cm. There is
minimal fullness of the bilateral renal collecting systems, symmetric, without
frank hydronephrosis. This is likely due to the extremely full bladder.
There is, however some debris seen within the left renal collecting system.
There are several bilateral anechoic renal cysts measuring up to 5.2 cm in the
left interpolar kidney and 2.9 cm in the right upper pole kidney. There is no
frank hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
There is a tiny amount of debris within the bladder. The bladder is
prominently distended, though is otherwise grossly unremarkable in appearance.
IMPRESSION:
1. Minimal symmetric fullness of the bilateral renal collecting systems
without frank hydronephrosis, likely secondary to prominent bladder
distension. Correlate for urinary outlet obstruction.
2. Echogenic debris within the left renal collecting system and trace debris
within the bladder. Infection cannot be excluded based on ultrasound in the
appropriate clinical context.
3. Several bilateral renal cysts.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with O2 requirement// Assess for pulmonary
edema or interval change in PNA
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___.
IMPRESSION:
Right-sided PICC is unchanged. Cardiomediastinal silhouette is unchanged.
Mild interstitial edema appears similar to mildly increased compared the prior
examination, though there remain hazy superimposed densities in the bilateral
lung bases. There are tiny bilateral pleural effusions, unchanged. There is
no pneumothorax. There is no upper lung consolidation.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with R IJ HD line placed// evaluate R temp HD
line placement Contact name: ___: ___
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___.
IMPRESSION:
There has been placement of a right IJ central venous catheter terminating in
the low SVC, satisfactory. Right PICC is unchanged. Cardiomediastinal
silhouette and hilar contours are stable. Patchy right greater than left lung
base opacities are unchanged along with small bilateral effusions. No new
consolidation is seen. There is no pneumothorax.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with a history of remote cutaneous lymphoma (s/p resection,
cytoxan, vincristine, pred), eosinophilic granulomatosis with polyangitis,
autoimmune hepatitis/PSC c/b cirrhosis w/ varices, FSGS w/ CKD III, and
unprovoked PE (not on AC) admitted with LLL PNA currently on
cefepime/metronidazole with incidental finding of extensive RP/periportal LAD
on MRCP suggestive of lymphoma, course c/b ___ and hyperuricemia s/p
rasburicase, now with worsening RUQ pain.// Please assess gallbladder, biliary
tree for obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___ liver gallbladder ultrasound, ___ MRCP.
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is
nodular, consistent with cirrhosis. Limited evaluation for mass. The main
portal vein is patent with hepatopetal flow. There is small volume perihepatic
ascites.
Peripancreatic and periportal adenopathy measuring up to 2.6 cm is similar to
prior.
BILE DUCTS: The known mild intrahepatic biliary dilatation is again noted.
The CHD measures 4 mm.
GALLBLADDER: The gallbladder is unremarkable except for biliary sludge.
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
SPLEEN: Normal echogenicity, measuring 8.7 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
Right pleural effusion is incidentally noted.
IMPRESSION:
1. Redemonstration of cirrhotic liver with unchanged intrahepatic biliary
dilatation.
2. Peripancreatic and periportal adenopathy, as on prior.
3. Small perihepatic ascites.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with lymphoma, dob hoff placement// evaluate
placement of dobhoff tube
TECHNIQUE: Portable frontal views of the chest.
COMPARISON: ___.
IMPRESSION:
Second image demonstrates Dobhoff tube in the mid gastric body, satisfactory.
Heart size is borderline. There remains mild unfolding of the thoracic aorta.
Hilar contours are stable. Hazy opacities in the right lung base have
improved compared the prior study. Small to moderate bilateral pleural
effusions have slightly increased in volume. There is adjacent compressive
atelectasis in the lung bases. The upper lung fields are clear. There is no
pneumothorax. Right PICC and right IJ central venous catheter are unchanged.
Radiology Report
INDICATION: ___ with a history of remote cutaneous lymphoma (s/p resection,
cytoxan, vincristine, pred), eosinophilic granulomatosis with polyangitis,
autoimmune hepatitis/PSC c/b cirrhosis w/ varices, FSGS w/ CKD III, and
unprovoked PE (not on AC) admitted with LLL PNA currently on
cefepime/metronidazole with incidental finding of extensive RP/periportal LAD
on MRCP suggestive of lymphoma// interval changes in opacities, pleural
effusions
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The right-sided PICC line, right IJ line are unchanged. The NG tube has been
reposition and projects below the left hemidiaphragm and tip projects over the
stomach. Bilateral effusions have slightly increased in volume. There is
bibasilar atelectasis. No obvious pneumothorax is seen. Pulmonary edema has
mildly worsened
Radiology Report
INDICATION: ___ year old woman with lymphoma, on HD, with abdominal pain//
Evaluate for source of abdominal pain
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are notable for degenerative changes in the lumbar spine
and both hips. The tip of an enteric tube projects over the stomach.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern.
Radiology Report
INDICATION: ___ with a history of remote cutaneous lymphoma (s/p resection,
cytoxan, vincristine, pred), eosinophilic granulomatosis with polyangitis,
autoimmune hepatitis/PSC c/b cirrhosis w/ varices, FSGS w/ CKD III, and
unprovoked PE (not on AC) now with worsening abdominal pain.// Please assess
for obstruction,
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph from ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel with an overall
paucity of small bowel gas though air is visualized within the transverse and
sigmoid colon.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for degenerative changes of the lower lumbar
spine.
An enteric tube is re-demonstrated which terminates within the stomach. There
are no unexplained soft tissue calcifications or radiopaque foreign bodies.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern, as described above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with h/o pneumonia s/p treatment w/
cefepime/flagyl now with febrile neutropenia on CRRT for renal failure//
pneumonia pneumonia
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Moderate bilateral pleural effusions have improved since ___. Left lower
lobe is still severely atelectatic. Skin folds obscure the right upper
lateral costal pleural margins, but if there were pneumothorax, I would expect
a fluid level given the substantial, right pleural effusion. Heart size
normal.
Right PIC line ends close to the superior cavoatrial junction. Right jugular
line ends in the upper SVC. Feeding tube ends in the upper stomach.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with cirrhosis ___ PSC with worsening LFT and
hyperbilirubiemia and diffuse abdominal pain/distension.// evaluate for
cholestasis/ biliary dilation and ascites vs bladder distention
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The parenchyma is coarse with nodular contour, consistent with
cirrhotic liver morphology. There is no focal liver mass. The main portal
vein is patent with hepatopetal flow. There is small volume ascites.
BILE DUCTS: There is persistent intrahepatic biliary dilation, as seen on
prior MRCP. The CHD was not well visualized.
GALLBLADDER: not well visualized.
PANCREAS: Again demonstrated, are multiple pancreatic cysts, better assessed
on recent MRCP. The imaged portion of the pancreas demonstrates no pancreatic
ductal dilation, with portions of the pancreatic tail obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 7.5 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
LYMPH NODES: As seen on prior MRCP, there is a large the 3.0 cm porta hepatis
lymph node. Other lymphadenopathy is better assessed on recent MRCP.
IMPRESSION:
1. Cirrhotic liver morphology.
2. Partially imaged abdominal lymphadenopathy, better assessed on recent MRCP.
3. Persistent moderate intrahepatic biliary dilatation.
4. Small volume ascites.
Radiology Report
EXAMINATION: CT scan of the abdomen and pelvis with contrast
INDICATION: ___ year old woman with PSC c/b cirrhosis, new diffuse large b
cell lymphoma, now with rising LFTs/Tbili.// Please evaluate for strictures,
evidence of infiltrative lymphoma in liver, obstruction from lymphadenopathy?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.5 s, 35.4 cm; CTDIvol = 3.2 mGy (Body) DLP = 110.7
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 2.2 s, 0.2 cm; CTDIvol = 36.7 mGy (Body) DLP =
7.3 mGy-cm.
4) Spiral Acquisition 3.5 s, 22.6 cm; CTDIvol = 6.3 mGy (Body) DLP = 137.5
mGy-cm.
5) Spiral Acquisition 7.1 s, 46.0 cm; CTDIvol = 6.3 mGy (Body) DLP = 287.6
mGy-cm.
6) Spiral Acquisition 3.5 s, 22.9 cm; CTDIvol = 6.3 mGy (Body) DLP = 139.8
mGy-cm.
Total DLP (Body) = 685 mGy-cm.
COMPARISON: MRCP from ___
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions, with atelectatic
changes at both lung bases.
ABDOMEN:
HEPATOBILIARY: The liver is cirrhotic in morphology. There is moderate
intrahepatic biliary ductal dilatation, which appears stable in comparison to
the previous MRCP. No focal liver lesions identified. The gallbladder is
collapsed. There is a small volume of ascites, slightly increased since the
previous MRI.
PANCREAS: Re-demonstration of multiple cystic pancreatic lesions, the largest
in the pancreatic body measuring approximately 2.6 cm, stable. The pancreatic
duct is not dilated.
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 are bilateral cortical hypodensities, some of which are simple
and hemorrhagic cysts, the largest hemorrhagic cyst measuring up to 2.1 cm in
the upper pole of the right kidney. The largest simple appearing cyst is seen
in the upper-interpolar region of the left kidney measuring up to 4.1 cm.
Other smaller hypoattenuating cortical foci are too small to characterize.
The patchy areas of hypoenhancement and restricted diffusion on previous MRI
are difficult to visualize under CT. There is no hydronephrosis.
GASTROINTESTINAL: The stomach is unremarkable. Small and large bowel loops
are collapsed, limiting assessment. T the appendix is not seen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: Mesenteric and retroperitoneal lymphadenopathy is stable, the
largest being a 2.7 x 2.1 cm portacaval lymph node. 1.7 cm left para-aortic
lymph node.
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 anasarca.
IMPRESSION:
1. Cirrhotic liver, with stable intrahepatic biliary duct dilatation, in
keeping with known history of PSC.
2. Stable mesenteric and retroperitoneal adenopathy. Multiple hypoattenuating
foci in the bilateral kidneys. While some of these represent cysts, others
are too small to characterize.
3. Small volume ascites, increased since the previous MRI, with small
bilateral pleural effusions. Anasarca.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with lymphoma, ESRD on CRRT, pulm edema// eval
interval change in edema, e/o PNA
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices are
stable, as is the cardiomediastinal silhouette. The hazy opacification
bilaterally of less prominent. This could reflect improving pleural
effusions, though in some part could be a manifestation of a better
inspiration and more upright position of the patient.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with DLBCL and ___ edema// eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. There is superficial
edema in the bilateral lower extremities, worse on the right.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins. Superficial edema bilaterally.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with DLBCL c/b ESRD on HD, having dobhoff
placed// confirm dobhoff placement
TECHNIQUE: 3 portable frontal views of the chest.
COMPARISON: ___.
IMPRESSION:
The final image demonstrates the Dobhoff tube in the mid gastric body,
satisfactory. Right IJ central venous catheter is unchanged. There remains
mild cardiomegaly with central pulmonary vascular congestion and mild
interstitial edema, similar to the prior study. Tiny bilateral effusions
appear slightly decreased in volume with minimal residual bibasilar
atelectasis. Otherwise no new consolidation is seen. There is no
pneumothorax.
Radiology Report
INDICATION: ___ year old woman with DLBCL course complicated by renal failure
on HD. Needs tunneled HD line.// Place tunneled HD line.
COMPARISON: Chest radiograph from ___.
TECHNIQUE: OPERATORS: Dr. ___ resident and Dr. ___,
___ radiologist performed the procedure. Dr. ___ supervised
the trainee during the key components of the procedure and has reviewed and
agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 30 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl and midazolam
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2.9 min, 3 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right upper chest right neck were prepped
and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was partially compressible and accessed using a micropuncture needle.
Permanent ultrasound images were obtained before and after intravenous access,
which confirmed vein patency. Subsequently a Nitinol wire was passed into the
right atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 19 cm 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. The ___ wire was
exchanged over the dilator for an Amplatz wire. The pre-existing temporary HD
line was pulled. 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. Dermabond also used to
close the venotomy incision site, as well as the venotomy incision site from
the pre-existing temporary HD line. Final spot fluoroscopic image
demonstrating good alignment of the catheter and no kinking. The tip is in the
right atrium. The catheter was flushed and both lumens were capped. Sterile
dressings were applied. The patient tolerated the procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing 19 cm
tip to cuff tunneled dialysis catheter with tip terminating in the right
atrium.
IMPRESSION:
1. Successful placement of a 19 cm tip-to-cuff length tunneled dialysis
line. The tip of the catheter terminates in the right atrium. The catheter is
ready for use.
2. Removal of the pre-existing temporary HD line.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea, Productive cough
Diagnosed with Fever, unspecified
temperature: 99.0
heartrate: 113.0
resprate: 18.0
o2sat: 100.0
sbp: 154.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | ___ w/ history of remote cutaneous lymphoma, eosinophilic
granulomatosis with polyangiitis, autoimmune hepatitis/PSC, FSGS
with CKD III and unprovoked PE who originally presented with
constitutional symptoms and concern for pneumonia but was
incidentally found to have aggressive DLBCL that was complicated
by secondary HLH. She was transferred to ___ for worsening
respiratory status and metabolic acidosis due to acute renal
failure requiring urgent renal replacement therapy. The patient
was stabilized in the FICU and was able to be transitioned to
HD. She was transferred back to the ___ service for continuation
of chemotherapy.
# DLBCL
# Secondary HLH
# Pancytopenia
Incidental finding of lymphadenopathy on ___ MRCP was
concerning for lymphoma. Subsequent PET scan showed widespread
disease. Excisional lymph node biopsy confirmed diagnosis of
diffuse large B cell lymphoma. The patient was initially started
on Cytoxan monotherapy however did not tolerate with the
development of renal failure and ongoing cytopenias. Course also
complicated by secondary HLH. She received one treatment of
rituxan, dose reduced etoposide and steroids. With improvement
in cell counts and liver function, the patient was started on
miniCHOP on ___. She was supported with G-CSF with improvement
in cell counts.
# Acute renal failure
# FSGS
Progressive renal failure with acidemia and volume overload
requiring transfer to the FICU for initiation of HD. Renal
failure most likely result of lymphoma invasion of kidneys. HD
sessions c/b A fib with RVR, hypotension, and SVT which resolved
with cessation of HD. Required CRRT for several days and
eventually was transitioned back to intermittent HD which she
then tolerated well. Began making some urine but continued with
HD. Tunneled line placed and continued on HD at discharge.
# Severe Malnutrition
Poor appetite, not meeting caloric needs so DHT placed ___.
Slowly advanced diet but unable to take sufficient nutrition.
Discussed moving towards PEG but decision made to remove DHT and
trial po intake for several days which resulted in some
improvement in appetite, meeting lower-end of calorie needs.
# CAP vs post obstructive pneumonia
Patient treated for PNA with 10 day course of cefepime/flagyl.
# HSV Infection
Developed fevers and had lesions on inner thigh c/f HSV
infection. No c/f MRSA. Treated with course of Valtrex then
transitioned back to acyclovir prophylaxis while neutropenic.
# Afib with RVR, resolved
Developed rapid rates to 170's during HD initiation and
subsequent HD sessions. Resolved outside of HD. Started on amio
during acute event, however this was discontinued.
# Steroid-Induced Hyperglycemia
Started on lantus and sliding scale Humalog to cover blood
sugars.
# ___ edema
# Elevated Pro-BNP
Likely ___ hypoalbuminemia iso lymphoma. No e/o heart failure.
TTE w LVEF 68% with Normal biventricular cavity sizes,
regional/global systolic function. No valvular pathology or
pathologic flow identified. High normal estimated pulmonary
artery systolic pressure. Mild-moderate tricuspid regurgitation.
# PSC
# Transaminitis
Pt with history of PSC. Developed worsening transaminitis during
admission with elevated TBili limiting chemotherapy options.
Unclear etiology for elevation, possibly ___ HLH given
improvement with etoposide. Continued Ursodiol.
# Eosinophilic Granulomatosis with Polyangiitis
Continued 10mg Prednisone (increased home dose in setting of
continued fatigue), additional steroids for lymphoma treatment
as above.
CHRONIC/STABLE ISSUES
=====================
# HTN
Holding home nifedipine given hypotension.
# COPD
Continued home Flovent.
# HLD
Held home statin given LFT abnormalities.
TRANSITIONAL ISSUES
===================
[ ] Monitor fingerstick BG daily, can use sliding-scale insulin
if needed. Not requiring Lantus at time of discharge.
[ ] Continued nutrition assessment to determine if meeting
caloric needs. ___ require PEG if not taking sufficient po.
[ ] Prednisone dose increased from 5mg daily to 10mg daily prior
to admission. Discharged on 10mg after finishing steroids for
chemotherapy.
[ ] Consider BRCA testing (father w h/o breast cancer)
[ ] Held nifedipine given intermittent hypotension here. If BPs
stable, can restart.
[ ] Held atorvastatin given LFT abnormalities. Check LFTs at
least weekly. Can restart as outpatient if LFTs
stable/improving.
[ ] Will need to come back to ___ clinic for cycle 2 of miniCHOP
on ___.
[ ] ___ need port in the future.
# Code: Full, confirmed
# Communication: Husband/HCP ___ (___) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
___
Attending: ___.
Chief Complaint:
Increase in head drop seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with mild static
encephalopathy and ___ syndrome who presents with an
increased frequency of her typical events.
Per group home staff, she had head-drops to evenings ago, then
yesterday she had two with Ativan given, then six events today.
These have interfered with her participation in group activity.
There have been no tonic-clonic seizure - the carers from the
home have actually never seen these, and do not know the last
time this happened. Per staff, she will suddenly drop her head,
the VNS is typically then swiped, she will then mumble and this
typically makes no sense, her lips will sometimes become blue.
If she is having a seizure and they lay her down to change her
(she is always double incontinent with seizure), she will kick
out and struggle a little whether the seizure has stopped or
not. Her eyes are typically open and her eyes are back. She
injured
her chin when having a head-drop event while cleaning her teeth.
Her head fell down and she hit her chin, resulting in a bite to
the tip of her tongue.
She has had frequent headaches and back pain, for which Tylenol
only was given. There has been malodorous urine recently, but
the patient denies 'burning with urination'. There has been no
cough, fever, aspiration, diarrhea or evidence of other
infection. ___ states that she had a very bad headache 'a
couple of months ago'. But staff suggest that this might have
been on ___.
She has recently had some rectal bleeding. She refused
colonoscopy - her mother apparently agreed. It was thought that
she likely had colitis, per hospital staff during a ___
admission for this complaint and upon a second bleed in ___
for which she was also taken to an ED, but not admitted. She
followed-up subsequently with her gastroenterologist. There has
been no bleeding since.
Summarizing from the ___ notes and after discussion with Dr.
___: Seizures appear to have begun in ___ with a likely
nocturnal seizure then a tonic-clonic seizure en route to an
emergency department. She aspirated during this event and
required intubation. These events appear to have been
generalized at onset. Complex partial events appeared in ___,
based on documentation that Dr. ___ had on her first review in
___, but semiology was not clear. Her first epilepsy monitoring
unit admission was in ___ at ___. "During
that admission, she had drop seizures and frontal spikes ...
interictal spikes were usually on the right side." Later, Dr.
___ the patient had had staring spells since
childhood. Given generalized seizures, head drop spells,
drop-attacks and absence-like events, a diagnosis of
___ syndrome was made. This appears to be cryptogenic
and medial temporal sclerosis is interpreted as a consequence of
her seizure disorder.
Review of systems negative except as above.
Past Medical History:
-___ Syndrome: Per Dr. ___, seizures
include:
1. Drop seizures during which she has head drops and these
correlated with frontal spikes.
2. Staring spells and unresponsiveness.
3. Eyes rolling up.
4. Oral and hand automatism with unresponsiveness.
5. Focal facial twitching involving the right side.
-Mental retardation: No known underlying dx per sister. She was
delayed in her walking and her speech. She is thought to
function at the level of an eighth grader. Her
neuropsychological testing in the past showed a verbal IQ of 66,
performance IQ 73, and full scale IQ of 68. She attended several
___ education programs.
-COPD
-Scoliosis
-Ankle fracture s/p fixation
-Tubal ligation
-Osteoporosis
Social History:
___
Family History:
Per prior notes, little is known about the family history. There
is no information about her father. ___ is apparently one of
six children, three boys and three girls. There is a cousin with
learning disability and an uncle with behavioral problems.
According to prior notes, sister reports no family history of
seizures.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8 86 113/44 20 97%
___ Appearance: Comfortable, no apparent distress.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+.
Asterixis is noted - mild.
Neurologic:
Mental status:
Awake and alert, cooperative with exam, normal affect. She is
pleasant, oriented to self, day and year, and later choose ___
from a list of months (it is early ___.
Language: Normal fluency, comprehension, repetition, naming. No
paraphasic errors. She has mild dysarthria and her speech is
mildly slow. She only recalls recent events and upcoming plans
with prompting. She forgot a trip to the beach that was planned
for tomorrow and that she was clearly excited about after
reminded by her carer.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation. Normal
fundi.
III, IV, VI: Extraocular movements intact bilaterally with
bilateral fast sustained end-point nystagmus on lateral gaze.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetric.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Tone normal throughout. Normal bulk. She has postural tremor in
both outstretched arms with occasional brief negative myoclonus.
Power
D B T WE WF FF FAb | IP Q H AT G/S ___ TF
R ___ ___ 5 | ___ ___ 5
L ___ ___ 5 | ___ ___ 5
Reflexes: B T Br Pa Ac
Right ___ 2 1
Left ___ 2 1
Toes downgoing bilaterally
Sensation intact to light touch, vibration, joint position
bilaterally.
Mildly ataxic on finger nose and toe to finger. RAM's fast but
mildly inaccurate.
DISCHARGE PHYSICAL EXAM: unchanged.
Pertinent Results:
ADMISSION LABS:
- WBC-7.8 RBC-4.41 Hgb-14.5 Hct-44.9 MCV-102* MCH-33.0*
MCHC-32.4 RDW-13.2 Plt ___
- Neuts-50.8 ___ Monos-9.4 Eos-1.7 Baso-0.9
- ___ PTT-33.7 ___
- Glucose-84 UreaN-22* Creat-0.5 Na-139 K-5.2* Cl-101 HCO3-26
AnGap-17
- ALT-12 AST-23 AlkPhos-57 TotBili-0.2
- Albumin-3.7 Calcium-9.1 Phos-4.4 Mg-1.7
- Valproate: 91
- Serum tox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
- Urine tox: bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
- UA: Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG RBC-0 WBC-<1
Bacteri-NONE Yeast-NONE Epi-0
- BCx (___): NEGATIVE.
EEG (___): This is an abnormal continuous video EEG due to
the presence of bursts of generalized spike and wave or sharp
and slow wave discharges at ___ Hz primarily seen in sleep
without any clear clinical correlate. Independent focal
epileptiform discharges are also seen in the temporal regions
bilaterally. These findings indicate generalized and focal
cortical irritability. The waking background is moderately
slowing indicative of a mild encephalopathy. There are no clear
electrographic or clinical seizures.
EEG (___): This is an abnormal continuous video EEG due to
the presence of bursts of generalized spike and wave or sharp
and slow wave discharges at 1.5-2.5 Hz primarily seen in sleep
without any clear clinical correlate. Independent focal
epileptiform discharges are also seen in the temporal regions
bilaterally. These findings indicate generalized and focal
cortical irritability. The waking background is moderate slowing
indicative of a mild encephalopathy. There are two accidental
pushbutton activations. There are no clear electrographic or
clinical seizures.
EEG (___): This is an abnormal continuous video EEG due to
the presence of bursts of generalized spike and wave or sharp
and slow wave discharges at 1.5-2.5 Hz more noticeable in sleep
without any clear clinical correlate. Independent focal
epileptiform discharges are also seen in the temporal regions
bilaterally. These findings indicate generalized and focal
cortical irritability. There are no clear electrographic or
clinical seizures.
EEG (___): This is an abnormal continuous video EEG due to
the presence of bursts of generalized spike and wave or sharp
and slow wave discharges at 1.5-2.5 Hz, primarily seen in sleep,
without any clear clinical correlate. Independent focal
epileptiform discharges are also seen in the temporal regions
bilaterally indicative of generalized and focal cortical
irritability. There are no clear electrographic or clinical
seizures. The background activity is slightly slow suggesting
very mild encephalopathy.
EEG (___): This is an abnormal continuous video EEG due to
the presence of bursts of generalized spike and wave or sharp
and slow wave discharges at 1.5-2.5 Hz without any clear
clinical correlate. Independent focal epileptiform discharges
are also seen in the temporal regions bilaterally. These
findings indicate generalized and focal cortical irritability.
There are no clear electrographic or clinical seizures.
Medications on Admission:
Medications - Prescription
ALENDRONATE - alendronate 70 mg tablet. 1 Tablet(s) by mouth
once
a week - (Prescribed by Other Provider)
DIVALPROEX [DEPAKOTE ER] - Depakote ER 500 mg tablet,extended
release. 1 Tablet(s) by mouth twice daily
DIVALPROEX [DEPAKOTE ER] - Depakote ER 250 mg tablet,extended
release. 1 Tablet by mouth once in the evening, to be combined
with Depakote ER 500mg for a total evening dose of 750mg.
FELBAMATE [FELBATOL] - Felbatol 400 mg tablet. 3 Tablet(s) by
mouth three times per day
FLUTICASONE - fluticasone 50 mcg/actuation Nasal Spray, Susp. 2
sprays nasally once daily - (Prescribed by Other Provider)
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - Advair Diskus 500
mcg-50
mcg/dose for Inhalation. one puff twice daily - (Prescribed by
Other Provider)
IPRATROPIUM-ALBUTEROL [COMBIVENT] - Dosage uncertain -
(Prescribed by Other Provider: 2 puffs po bid)
LORAZEPAM - lorazepam 2 mg tablet. 1 Tablet by mouth for seizure
longer than 5 minutes, or 7 or more head drops in 2 hours; or a
generalized convulsive seizure or staring spell longer than 5
min
Max 4mg in 12 hours
MONTELUKAST [SINGULAIR] - Singulair 10 mg tablet. 1 Tablet(s) by
mouth once daily - (Prescribed by Other Provider)
OXCARBAZEPINE - oxcarbazepine 600 mg tablet. 1 Tablet(s) by
mouth
twice daily
PANTOPRAZOLE [PROTONIX] - Protonix 40 mg tablet,delayed release.
1 Tablet(s) by mouth every morning - (Prescribed by Other
Provider)
PREGABALIN [LYRICA] - Lyrica 150 mg capsule. 1 Capsule(s) by
mouth twice daily
PREGABALIN [LYRICA] - Lyrica 100 mg capsule. one Capsule(s) by
mouth once in the morning
RUFINAMIDE [BANZEL] - Banzel 400 mg tablet. 2 Tablets by mouth
twice a day
TRIPLE ANTIBIOTIC OINTMENT - Dosage uncertain - (Prescribed by
Other Provider: prn for cut or scrape)
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. 2 Tablet(s) by
mouth
twice a day for pain - (Prescribed by Other Provider)
CALCIUM CARBONATE - calcium carbonate 200 mg calcium (500 mg)
chewable tablet. 1 Tablet(s) by mouth twice a day - (Prescribed
by Other Provider)
CALCIUM CARBONATE [TUMS] - Dosage uncertain - (Prescribed by
Other Provider: 500 mg by mouth twice daily)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Dosage uncertain -
(Prescribed by Other Provider: 50,000IU by mouth once a month)
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vitamin B-12)
1,000 mcg tablet. 1 tablet(s) by mouth once daily - (Prescribed
by Other Provider)
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] - Milk of Magnesia 400
mg/5 mL Oral Susp. 30 ml by mouth q hs if no BM in 3 days -
(Prescribed by Other Provider)
POLYETHYLENE GLYCOL 3350 [MIRALAX] - Miralax 17 gram Oral Powder
Packet. 1 packet by mouth once daily - (Prescribed by Other
Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Calcium Carbonate 500 mg PO BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Divalproex (EXTended Release) 750 mg PO QHS
5. Divalproex (EXTended Release) 500 mg PO QAM
6. Felbatol *NF* (felbamate) 1200 mg ORAL TID Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Lorazepam 2 mg PO Q6H:PRN seizure >5 min or >7 head drops in
two hours, or generalized convulsive seizure or staring spell
longer than 5 min
Max 4mg in 12 hours
10. Montelukast Sodium 10 mg PO HS
11. Oxcarbazepine 600 mg PO BID
12. Pantoprazole 40 mg PO Q24H
13. Rufinamide 800 mg PO BID
14. Polyethylene Glycol 17 g PO DAILY
15. Milk of Magnesia 30 mL PO PRN if no BM in 3 days
16. Pregabalin 150 mg PO QAM
17. Pregabalin 250 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
1. ___ Gastaut epilepsy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam from ___.
CLINICAL HISTORY: Increasing seizures, question pneumonia.
FINDINGS: PA and lateral views of the chest were provided. A vagal
stimulator projects over the left chest wall with catheter extending into the
left neck. The lungs appear clear without focal consolidation, effusion, or
pneumothorax. Cardiomediastinal silhouette is normal. No bony abnormalities
are seen.
IMPRESSION: No acute findings in the chest.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ^ SZ ACTIVITY
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY
temperature: 97.8
heartrate: 86.0
resprate: 20.0
o2sat: 97.0
sbp: 113.0
dbp: 44.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ yo F with mild static encephalopathy and
___ syndrome who presented with increased frequency
of head drops (one of her typical seizure semiologies).
# NEURO: Patient was admitted to the Epilepsy service for
further workup and EEG long-term monitoring. She underwent
toxic-metabolic and infectious workup which was all negative.
Serum VPA level was therapeutic at 91. She was briefly placed on
a lorazepam "bridge" to treat her increased seizure frequency,
which was tapered and stopped after two days. She was monitored
on EEG LTM for 5 days which showed occasional bursts of
generalized spike and slow wave activity (usually during sleep)
which appeared baseline compared to her prior EEGs. Clinically,
she appeared well and at baseline throughout hospitalization,
with no clinical seizures observed. As she was clinically at her
baseline with no significant seizure activity on EEG, no
adjustments to Ms. ___ AED regimen were made during
hospitalization. She was discharged back to her group home on HD
#5, and will follow up as an outpatient with her epileptologist
Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Metformin / Penicillins
Attending: ___.
Chief Complaint:
Chest Pain and Dypnea
Major Surgical or Invasive Procedure:
right and left cardiac catheterization
History of Present Illness:
___ with DM, HTN, HLD, smoker, presents with worsening
intermittent chest pain over the past several months. Patient
reports her chest pain is always left-sided, and has no
association with activity (occurs at rest and when active), has
been occurring for approx the past several months, and has been
worsening. Last night, she had sudden onset of severe substernal
CP at 0300, anxiety, diaphoresis, and dyspnea lasting
approximately ___ minutes, which woke her from sleep. The pain
then went away without intervention and she went back to sleep.
At 1100, the pain recurred and was similar in character and
lasted approximately 20 minutes. BP per ___ nurse during
witnessed episode this morning 150/90 with HR in ___ accompanied
by significant diaphoresis. Patient reports that she has a
cervical disk bulging resulting in parasthesias/pain in her arms
bilaterally, therefore it is hard to assess if the pain radiates
to her arms. Pain lasting several minutes with pain scale ___.
Pain was non exertional. Patient denies CP, N/V/D, chills,
fevers, cough.
She has experienced similar pains for "years." Per recent
cardiology note, this pain was left sided and stabbing lasting
less than 3 seconrds in duration without radiation or
correlation wtih exertion. The pain resolves spontaneously.
These pains usually occur approximately monthly and are
unrelated to exertion but are not typically this severe.
Recently established care with Dr. ___ in early ___. She
was concerned about the severity of the patients aortic stenosis
and recommended that she undergo cardiac catheterization with
valvular assessment as well as right and left heart cath to
assess her pressures and any CAD in the event that AVR and
bypass required.
In the ED, initial vitals were 96.4 78 132/37 20 100% RA. ECG
showed NSR with ST depressions in V4-V6, STD, TWI in II.
Troponins were negative x1. ASA 325 was given by EMS. She was
also given atorva 80, metoprolol 50 mg, and started on a heparin
gtt. In addition she was given a percocet. Chest pain recurred
prior to transfer to floor, EKG no changes, vitals stable, nitro
and morphine.
Currently, she is feeling well with no further complaints. she
is chest pain free.
Past Medical History:
Diabetes mellitus type 2
Hyperlipidemia
Hypertension
H/o peptic ulcer disease
COPD
Peripheral neuropathy from DM2
Cervical radiculitis
Chronic low back pain
Social History:
___
Family History:
She was a ward of the ___ starting at age ___ and does not
know anything about her parental history. She has one sister,
one son, and two daughters. There is no family history notable
for stroke, hypertension, hyperlipidemia, diabetes, early
coronary artery disease, or sudden cardiac death.
Physical Exam:
ADMISSION:
VS: 98.4 133/63 65 20 96%RA
___ 239
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
CARDIAC: RR, normal S1, S2. systolic murmur heard best at RUS
border, No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
DISCHARGE:
VS: 98.5 105-126/38-52 59-65 20 96%RA BS 154-418
weight 84.7 ( admission weight 87.2)
I/O: po 1519/uop 2900
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. no JVD at 30
degrees.
CARDIAC: RRR, normal S1, S2. ___ systolic murmur heard best at
RUS border, No thrills, lifts. No S3 or S4.
LUNGS: Fine crackles in both lower lobes improved
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c. No pedal edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
Pertinent Results:
___ 09:18PM CK-MB-5 cTropnT-<0.01
___ 09:18PM PTT-45.0*
___ 12:49PM LACTATE-3.2*
___ 12:30PM GLUCOSE-255* UREA N-14 CREAT-0.9 SODIUM-141
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-23 ANION GAP-20
___ 12:30PM estGFR-Using this
___ 12:30PM cTropnT-<0.01
___ 12:30PM WBC-7.7 RBC-4.44 HGB-12.7 HCT-38.5 MCV-87
MCH-28.5 MCHC-32.9 RDW-15.3
___ 12:30PM NEUTS-52.1 ___ MONOS-6.8 EOS-2.5
BASOS-0.9
___ 12:30PM PLT COUNT-342
___ CXR
No acute cardiopulmonary process.
Cath ___
1. Selective coronary angiography of this right-dominant system
demonstrated single vessel CAD. The LMCA, LAD, and LCX had no
angiographically-apparent lesions. The dominant RCA was a large
caliber
vessel with 70% stenosis in the proximal segment.
2. Limited resting hemodynamics revealed severely elevated right
and
left-sided filling pressures with measured RVEDP 20mmHg and
LVEDP
33mmHg. There was severe pulmonary artery hypertension with a
measured
mean PAP 42mmHg. Transpulmonary gradient of 9 and PVR 111
dyne-sec/cm5
suggestive of secondary PHTN driven by elevation of left-sided
filling
pressures. Cardiac index was preserved at 3.5 L/min/m2. Systemic
arterial pressure was elevated with a measured central aortic
pressure
of 159/72/108.
3. Aortic valve study revealed moderate-severe AS with a
measured mean
gradient of 35mmHg. ___ was calculated at 1.1cm2.
4. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Single vessel CAD.
2. Elevated left and right-sided filling pressures.
3. Severe PHTN (due to elevation of left-sided filling
pressures).
4. Severe systemic arterial hypertension.
5. Moderate-severe AS (mean gradient 35mmHg).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
3. Gabapentin 300 mg PO BID
4. HydrOXYzine ___ mg PO QHS
5. Metoprolol Succinate XL 25 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Atorvastatin 40 mg PO DAILY
8. Glargine 25 Units Bedtime
9. Furosemide 20 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
12. Omeprazole 20 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Loratadine *NF* 20 mg Oral BID
15. glimepiride *NF* 2 mg Oral qhs
16. Amitriptyline 25 mg PO HS
17. Albuterol Inhaler 2 PUFF IH QID:PRN wheezing
18. Aspirin EC 325 mg PO DAILY
19. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Gabapentin 300 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Albuterol Inhaler 2 PUFF IH QID:PRN wheezing
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO AM ___
RX *metoprolol succinate [Toprol XL] 100 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
9. Loratadine *NF* 20 mg Oral BID
10. Amitriptyline 25 mg PO HS
11. HydrOXYzine ___ mg PO QHS
12. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
13. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Aspirin 81 mg PO DAILY
RX *aspirin [Aspirin Low Dose] 81 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
16. glimepiride *NF* 2 mg ORAL QHS
17. Outpatient Lab Work
please check chem 7(Na, K, Chl, Bicard, BUn, Cr) on ___ and
fax results to ___.
18. Glargine 30 Units Bedtime
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: coronary artery disease, diastolic heart
failure
Secondary diagnosis: hypertension, hyperlipidemia, diabetes
type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain.
COMPARISON: Multiple prior chest radiographs from ___ to ___.
FINDINGS: PA and lateral chest radiographs demonstrate no focal
consolidation, pleural effusion, or pneumothorax. Mild prominence of the
pulmonary vasculature and azygos is noted without evidence of interstitial
edema. The cardiomediastinal silhouette is normal.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with CHEST PAIN NOS
temperature: 96.4
heartrate: 78.0
resprate: 20.0
o2sat: 100.0
sbp: 132.0
dbp: 37.0
level of pain: 0
level of acuity: 2.0 | ___ with DM, HTN, HLD, smoker, presents with sudden onset of
severe substernal CP overnight with diaphoresis and dyspnea
which woke her from sleep, then recurring several times since,
radiating to left arm, non-exertional, ST depressions. Cardiac
cath showed 1 vessel disease with elevated end diastolic
pressures in both biventricularly consistent with diastolic
heart failure. Patient has been medically optimized during
admission and has been getting IV diuresis for fluid overload. |