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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / Food Extracts
Attending: ___
___ Complaint:
dyspnea, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o CAD s/p CABG s/p posterior MI with ischemic CM EF ___
with resultant VT with multiple syncopal episodes resulting in
ICD implantion in ___, asthma, OSA, hyperlipidemia presenting
for persistent cough for nearly 2 weeks and increasing dyspnea
over the last 2 days. He also experienced 3 episodes of distinct
lightheadedness over the previous 24hrs which he says felt
similar to prev episodes of VT. He denies any CP or feeling
palpitations at the time. Denies PND/ orthopnea, worsening DOE.
Denies NV, diaphoresis w/ these episodes.
Pt was recently admitted ___ after being admitted for an
asthma exacerbation complicated by several runs of VT. Prior to
admission, he had been using his albuterol inhaler up to ___
puffs 5 to 6 times within a few hours. During this time, he
experienced several episodes of lightheadedness (his sensation
of VT, doesn't get palpitations) and received a ICD shock. PPM
interrogation then confirmed episode of VT that broke with
single shock at that time. He had 2 other prior episodes of ___
seconds that broke spontaneously and pace terminated. He
received PO steroids, as well as antibiotics for mild
diverticulitis flair and was subsequently discharged ___. Pt
reports he has since completed antibiotic course for
diverticulitis, though d/s summary states that abx should be
through ___.
He returned to the ED again yesterday for lightheadedness and
concern for VT. In the ED, initial vs were: 97.7 72 128/76 32
95%. Interrogation in ED that time noted single episode of 15
beat VT, no ICD firing. He received solumedrol and Vanc/levaquin
for possible RLL infiltrate on CXR. He was admitted to medicine
initially for management of pneumonia, being transfered to
Cardiology for management of VT.
On the floor, pt reported feeling back to baseline since getting
lasix IV. He states this his cardiologist has been trying to get
him to increase his metoprolol dose for sometime now, but he has
been resistant as he feels it makes his breathing worse.
Past Medical History:
Cardiac Risk Factors: Dyslipidemia, HTN
.
Cardiac History:
- CAD s/p CABG in ___ with LIMA to LAD, SVG to OM2, SVG to OM1,
SVG to R Marg. Cath results from ___ showed LMCA 95% lesion
- reports MI in ___
- NSTEMI ___ cath at OSH(no interventions)
- h/o NSVT
- h/o ventricular tachycardia s/p ICD placement ___
- CHF - EF 30% ___
- h/o mitral regurgitation
.
Percutaneous coronary intervention, in ___ anatomy as
follows:
PCI with BMS of the proximal SVG-->OM lesion
Partially successful PTCA of the distal SVG-->OM lesion
Patient reports 7 vessel bipass, 4 stents, and 14 angioplasties
.
Pacemaker/ICD, in ___
Other Past History:
- OSA on CPAP
- Asthma
- Diverticulitis
- Esophagitis
Social History:
___
Family History:
Notable for two identical twin sons with CAD in their ___.
Dad-heart disease at ___ YO
Physical Exam:
ADMISSION EXAM:
Vitals: T:98.6 BP:123/73 P:73 R:20 O2:93% RA wt 137.7kg
General: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 7 cm, no LAD
Lungs: Scattered wheezing in all lung fields. No rales, ronchi.
CV: Distant heart sounds. Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, mildly tender to deep palpation LLQ,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Scar over medial aspect of R leg with surounding erythema.
Warm, well perfused, 2+ pulses, trace pedal edema
Skin: No rashes
Neuro: CN ___ grossly intact, ___ strength in all extremities,
gait deferred.
.
DISCHARGE EXAM:
Vitals: T:97.7 BP:97/65 P:59 R:18 O2:98% RA wt 135.4 from
137.7kg
I/O:24 hr 480/2150
tele: frequent PVC, no VT
General: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 7 cm, no LAD
Lungs: Scattered wheezing in all lung fields. No rales, ronchi.
CV: Distant heart sounds. Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, mildly tender to deep palpation LLQ,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Scar over medial aspect of R leg with surounding erythema.
Warm, well perfused, 2+ pulses, trace pedal edema
Pertinent Results:
ADMISSION LABS:
___ 12:45PM BLOOD WBC-12.3*# RBC-4.79 Hgb-15.0 Hct-44.9
MCV-94 MCH-31.2 MCHC-33.3 RDW-13.0 Plt ___
___ 12:45PM BLOOD ___ PTT-28.4 ___
___ 12:45PM BLOOD Glucose-162* UreaN-26* Creat-0.9 Na-140
K-4.1 Cl-103 HCO3-22 AnGap-19
___ 12:45PM BLOOD Calcium-9.2 Phos-3.4 Mg-2.1
___ 12:51PM BLOOD Lactate-1.9
.
DISCHARGE LABS:
___ 08:05AM BLOOD WBC-12.4* RBC-5.51 Hgb-17.7 Hct-52.4*
MCV-95 MCH-32.2* MCHC-33.8 RDW-13.4 Plt ___
___ 08:05AM BLOOD Glucose-106* UreaN-51* Creat-1.2 Na-135
K-3.6 Cl-99 HCO3-24 AnGap-16
___ 08:05AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.3
.
IMAGING:
# CXR:
FRONTAL CHEST RADIOGRAPH: An ICD generator overlies the left
chest wall. The single-lead is intact with the tip projecting
over the expected position of the right ventricle. Median
sternotomy wires appear intact on the single frontal view.
There is increased opacification of the medial right lung base,
which could reflect early developing pneumonia and/or focal
congestion. There is no overt interstitial edema. No
pneumothorax is identified.
IMPRESSION: Subtle opacity in the medial right lung base may be
due to early pneumonia and/or congestion.
# EKG: Sinus rhythm. Wandering baseline and baseline artifact.
Left bundle-branch block
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Montelukast Sodium 10 mg PO DAILY
6. Rosuvastatin Calcium 20 mg PO QHS
7. Valsartan 160 mg PO DAILY
8. Nabumetone 750 mg PO BID:PRN pain
9. Pulmicort Flexhaler *NF* (budesonide) 180 mcg/actuation
Inhalation BID
10. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Senna 1 TAB PO BID:PRN constipation
13. Tiotropium Bromide 1 CAP IH DAILY
14. PredniSONE 40 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Montelukast Sodium 10 mg PO DAILY
7. Nabumetone 750 mg PO BID:PRN pain
8. PredniSONE 40 mg PO daily Duration: 2 Days
RX *prednisone 20 mg ___ tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
9. PredniSONE 20 mg PO daily Duration: 2 Days Start: After 40
mg tapered dose.
10. PredniSONE 10 mg PO daily Duration: 2 Days Start: After 20
mg tapered dose.
11. Pulmicort Flexhaler *NF* (budesonide) 180 mcg/actuation
Inhalation BID
12. Rosuvastatin Calcium 20 mg PO QHS
13. Senna 1 TAB PO BID:PRN constipation
14. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
15. Levofloxacin 750 mg PO DAILY
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*2 Tablet Refills:*0
16. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth q 8 hr Disp #*4
Tablet Refills:*0
17. Xopenex Neb *NF* 0.63 mg/3 mL Inhalation q4hrs prn wheezing
Reason for Ordering: albuterol inducing vtach
RX *levalbuterol tartrate [Xopenex HFA] 45 mcg/actuation ___
puffs q4-6hr prn Disp #*1 Inhaler Refills:*0
18. Tiotropium Bromide 1 CAP IH DAILY
19. Valsartan 80 mg PO DAILY
RX *valsartan [Diovan] 80 mg 1 tablet(s) by mouth daily Disp
#*20 Tablet Refills:*0
20. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
pneumonia
systolic heart failure exacerbation
asthma exacerbation
Secondary:
ventricular tachycardia
diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with COPD presenting with cough and dyspnea.
COMPARISON: Chest radiograph from ___
FRONTAL CHEST RADIOGRAPH: An ICD generator overlies the left chest wall. The
single-lead is intact with the tip projecting over the expected position of
the right ventricle. Median sternotomy wires appear intact on the single
frontal view. There is increased opacification of the medial right lung base,
which could reflect early developing pneumonia and/or focal congestion. There
is no overt interstitial edema. No pneumothorax is identified.
IMPRESSION: Subtle opacity in the medial right lung base may be due to early
pneumonia and/or congestion.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: SHORTNESS OF BREATH
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.7
heartrate: 72.0
resprate: 32.0
o2sat: 95.0
sbp: 128.0
dbp: 76.0
level of pain: 0
level of acuity: 1.0 | ___ h/o CAD s/p CABG s/p posterior MI with ischemic CM EF ___
with resultant VT with multiple syncopal episodes resulting in
ICD implantion in ___, asthma, OSA, hyperlipidemia presenting
for persistent cough for nearly 2 weeks and increasing dyspnea
over the last 2 days despite treatment with steroids of asthma
flare, treated for pneumonia, volume overload, asthma
exacerbation
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain and fever
Major Surgical or Invasive Procedure:
1. Incision and drainage.
2. Removal of instrumentation.
3. Fusion exploration.
4. V.A.C. placement.
History of Present Illness:
___ woman with recent spinal surgery presenting
with upper back pain, fever, and abnormal laboratory tests x
24 hours. The patient has been inpatient at ___ after a Revision spinal surgery. She
noted a fever last night which was measured as high as
101.6, which did return despite Tylenol. Per the staff at her
rehabilitation hospital, there has been significantly more
swelling and erythema around the incision site. Her labs
were also notable for an elevated wbc and decreased hct.
Past Medical History:
Hyperlipidemia
Asthma
Hypertension
Scoliiosis s/p surgical correction
Mild CHF
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On examination the patient is well developed, well nourished,
A&O x3 in NAD. AVSS.
Range of motion of the thoracolumbar spine is somewhat limited
on flexion, extension and lateral bending due to pain.
Halo is in place.
Ambulating well with the assistance of a walker and ___, with
CTLSO brace for support.
Gross motor examination reveals good strength throughout the
bilateral lower extremities.
There is no clonus present.
Sensation is intact throughout all affected dermatomes.
The posterior thoracolumbar incision is clean, dry and intact
without erythema, edema or drainage.
The patient is voiding well without a foley catheter.
Pertinent Results:
___ 04:08AM BLOOD WBC-6.2 RBC-3.33* Hgb-9.9* Hct-28.8*
MCV-87 MCH-29.7 MCHC-34.3 RDW-14.5 Plt ___
Radiology Report
INDICATION: Recent spine surgery with fever. Evaluate for pneumonia.
TECHNIQUE: A single AP supine view of the chest was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Posterior spinal fusion hardware is suboptimally imaged on this limited
frontal radiograph. Please see the CT report for further description of the
hardware. A halo brace is present, limiting evaluation of the upper lobes.
Within the limitations, the lungs are clear without evidence of a
consolidation. There is no pulmonary edema, pleural effusion, or pneumothorax.
The cardiomediastinal silhouette is normal.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: DX THORACIC AND LUMBAR SPINES
INDICATION: Status post thoracic spine fusion with increased swelling and
fevers. Evaluate hardware.
TECHNIQUE: AP and cross-table lateral views of the thoracic and lumbar spine
were obtained with a total of 5 exposures.
COMPARISON: Thoracic spine radiographs from ___ and ___. Note, these radiographs are read in conjunction with a CT of the
thoracic spine which was obtained immediately after these radiographs.
FINDINGS:
The most superior aspect of the thoracic spine hardware appears to be
positioned more posteriorly than on the intraoperative radiographs from ___. This may represent hardware migration. The mid and distal
portions of the thoracic spinal hardware appear to be unchanged. These are
better evaluated on the recent CT. The lumbar spinal fusion appears stable
without evidence of a hardware complication. There is evidence of osseous
fusion of the lumbar vertebral bodies. There is no significant residual
scoliosis. No acute fracture is identified.
The imaged portions of the lungs are clear. The cardiac silhouette is normal
in size. The bowel gas pattern is nonobstructive. No free intraperitoneal air
is identified.
IMPRESSION:
The most superior aspect of the thoracic spinal fusion hardware appears to be
positioned more posteriorly than on in the intraoperative radiographs,
potentially due to hardware migration. Please see the thoracic CT report for
more details.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST
INDICATION: 6 ___ female with history of scoliosis status post op day
9 after thoracic spine instrumentation revision, now with increased swelling
to upper thoracic spine. Assess for new fracture, infection, or hardware
migration.
TECHNIQUE: Aaxial, helical, MDCT images were acquired through the lumbar
spine without the administration of intravenous contrast. Coronal, sagittal,
and bone algorithm thin section reformatted images were generated.
DOSE: CTDIvol: 48.76 mGy
DLP: ___ mGy-cm
COMPARISON: T-spine radiographs ___. CT thoracic spine ___.
FINDINGS:
Please note study is substantially limited due to patient positioning, beam
hardening artifact, and lack of intravenous contrast.
For the purposes of numbering, the highest rib-bearing vertebral body was
designate the T1 level. Please note that this method is inappropriate for
surgical planning and that prior to any intervention appropriate levels must
be established.
Patient is status post fusion of T1 through 11 with postoperative changes
involving the entire thoracic spine with bilateral posterior fixation rods and
hooks, posterior mid line staples, and bone graft material. There is mild
levoscoliosis with apex at T9. Multiple posterior laminectomies are again
noted most prominent at T1. Significant soft tissue swelling and stranding is
seen throughout the course of the posterior spinal fusion, most prominent
along the upper thoracic spine from T1 through T4. At T1 through T4 posterior
spinal rods and hooks are within bone graft material approximately 1.5-2cm cm
posterior to the level of the lamina.
Subcutaneous emphysema is seen throughout the surgical site most prominent at
C7 the T1. At the level of T1-T2 bony changes are post laminectomy given clean
margins and absence of cortical irregularity. No locules of air within the
central canal. Given absence of IV contrast and beam hardening artifact from
hardware limited evaluation for fluid collection.
The prevertebral and soft tissues are within normal limits. Evidence of
chronic healed fracture along posterior right twelfth rib. A small right
pleural effusion is stable. Again seen is probable mild left hydronephrosis,
only partially imaged. There is of an enlarged approximately 12 mm mesenteric
lymph node (see series 2 image 132). Allowing for difference in technique,
this structure is also noted on the ___ prior CT thoracic spine
study (series 2a image 107).
Partially visualized liver demonstrates an approximately 8 mm left hepatic
lobe hypoattenuating structure that is obscured by streak artifact (see series
3, image 130).
IMPRESSION:
1. Limited evaluation due to patient positioning, absence of IV contrast and
beam hardening artifact.
2. Subcutaneous emphysema at T1-2 is nonspecific, and may be postsurgical in
nature. However emphysematous changes secondary to infection cannot be
excluded on the basis of this examination. Recommend clinical correlation.
3. Within limits of examination, no definite CT evidence of osteomyelitis or
discitis identified in thoracic spine. If additional evaluation is warranted a
contrast enhanced study may be helpful, however this will be limited in
evaluation due to beam hardening artifact.
4. At T1 through T4 posterior spinal rods and hooks are suggested to being
within bone graft material approximately 1.5 -2 cm posterior to the lamina.
Recommend clinical correlation and correlation with surgical history for
evaluation of hardware orientation.
5. Probable mild left hydronephrosis, partially imaged.
6. Stable small right pleural effusion.
7. Approximately 12 mm mesenteric lymph node as described. Recommend clinical
correlation.
8. Limited evaluation of the liver suggests at least one 8 mm hypoattenuating
area that is nonspecific. Recommend clinical correlation. If clinically
indicated, further evaluation may be obtained via dedicated hepatic imaging.
NOTIFICATION: Findings and recommendation discussed by Dr. ___ with Dr.
___ at 17:45 on ___.
Radiology Report
INDICATION: Hardware removal.
TECHNIQUE: 2 intraoperative frontal projection of the thoracic spine were
obtained without the radiologist present.
COMPARISON: Radiographs of the thoracic spine ___.
FINDINGS:
There has been interval removal of paraspinal rods from the thoracic spine.
The paraspinal rods extending from the inferior thoracic spine into the lumbar
spine remain in place. A skin staple line projects over the mid thorax. The
distal tip of an endotracheal tube projects above the carina. Visualized
portions of the lungs are unremarkable.
IMPRESSION:
Status post thoracic spine hardware removal. Please see the operative report
for further details.
Radiology Report
EXAMINATION: SCOLIOSIS SERIES
INDICATION: ___ year old woman s/p removal of instrumentation thoracic spine
after loss of fixation and possible infection. // evaluation of kyphosis and
spinal alignment. Please have patient stand with CTLSO on.
TECHNIQUE: AP and lateral views of spine.
COMPARISON: ___.
FINDINGS:
Levoconvex scoliosis in the thoracic spine is noted. There is been removal of
thoracic spine posterior hardware since previous radiograph. Posterior fusion
hardware from lower thoracic spine through S1 remains in-situ. There is
multilevel mature osseous fusion of vertebral bodies in the lumbar spine
There are degenerative changes in the thoracic spine, with some mild loss of
vertical height anteriorly at several levels appearing similar to prior study.
There is degenerative change in the cervical spine, and there is grade 2
anterolisthesis of C4 with respect to C5. There is also grade 1
anterolisthesis of C5 with respect to C4. This was difficult to assess on the
most recent exam, excluded from the field of view, but appears similar to
previous radiograph on ___. MRI cervical spine has also been
previously performed on ___, with these alignment changes visible,
and there is also mild retrolisthesis of C2 with respect to C3 which appears
similar the current radiograph.
Heterogeneous density of the right iliac bone may reflect previous graft
harvest site. Mild bilateral hip joint degenerative change.
IMPRESSION:
Degenerative changes, scoliosis, alignment abnormalities as detailed above.
Interval removal of thoracic hardware. No evidence of complication of
remaining hardware.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new picc // 43cm left picc. ___ ___
Contact name: ___: ___ left picc. ___ ___
IMPRESSION:
In comparison with study of ___, there is an placement of a left
subclavian PICC line that extends to the mid to lower portion of the SVC. The
upper spinal fusion device has been removed. No evidence of acute focal
pneumonia or vascular congestion.
NOTIFICATION: ___, a venous access nurse.
Radiology Report
INDICATION: ___ year old woman s/p removal of thoracic instrumentation. //
for evaluation of spinal alignment. please obtain x-ray while in traction.
COMPARISON:
Compared to radiographs from ___
IMPRESSION:
There is a new left-sided central venous catheter with the distal lead tip in
the distal SVC. Visualized lung fields are grossly clear. There is moderate
thoracolumbar scoliosis with convexity to the left side centered at T7 and to
the right side centered at T12. There is minimal anterior wedging of several
mid to lower thoracic vertebral bodies causing thoracic kyphosis, unchanged.
There is again seen posterior fixation hardware from T11 down to S1 with
metallic disc prostheses at L4-L5 and L5-S1. Overall, these findings appear
unchanged from the previous.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Abnormal labs
Diagnosed with FEVER, UNSPECIFIED
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 2.0 | ___ presented to the ___ emergency department on
___ from her rehabilitation facility with fever, back pain
and leukocytosis and decreased hct. CT scan of her thoracic
spine revealed loss of fixation of the thoracic instrumentation
from prior revision fusion on ___. She was taken to the
operating room on ___ for emergency incision and drainage,
removal of instrumentation, and washout of posterior wound. A
wound vac was placed at the time of surgery. Refer to the
dictated operative note for further details. The surgery was
performed without complication, the patient tolerated the
procedure well, and was transferred to the PACU in a stable
condition. TEDs/pneumoboots were used for postoperative DVT
prophylaxis. Intravenous antibiotics were started in the
emergency department and continued postoperatively. Urine
culture was positive for pseudomonas. Intra-operative cultures
were negative. She was closely monitored for signs of infection
postoperatively. Initially, postoperative pain was controlled
with a PCA. Diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
___ remained in halo and traction to 20lbs. She was
also fitted for CTLSO brace for when out of bed. The wound vac
and hemovac were removed on post-operative day three. Infectious
disease was consulted and recommends continuing parenteral
antibiotics, specifically vancomycin and cefepime for about 6
weeks. PICC line placement was consented for and placed on ___.
Traction was discontinued on ___ and she was placed back in
halo vest. She will remain in halo vest for about 3 months. On
the day of discharge she was tolerating oral pain medication,
urinating without difficulty, and tolerating regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left lower extremity tissue defect overlying tib-fib fracture
Major Surgical or Invasive Procedure:
___
ORTHO
1. Washout and debridement open fracture down to and inclusive
of bone, left tibia.
2. Closed treatment left tibia-fibula fracture with
manipulation.
3. Application multiplanar external fixator, left leg.
4. Application VAC sponge less than 50 sq cm left leg.
.
___
ORTHO
1. Washout and debridement open fracture down to and inclusive
of bone left tibia.
2. Removal external fixator under anesthesia.
3. Open reduction and internal fixation left bimalleolar ankle
fracture with internal fixation.
4. Intramedullary (IM) nail left tibia.
5. Insertion of antibiotic cement delivery device.
.
___
PLASTICS
1. Debridement of open fracture.
2. Radial forearm free flap reconstruction.
3. Split thickness skin graft of left forearm donor site (10 x 6
cm).
History of Present Illness:
___ year old male admitted for polytrauma after motor cycle
collisionwith large soft tissue defect over left tib/fib
fracture. Patient reports he was driving at approximately 25mph
when he was cut off and had to lay down his motorcycle. Patient
was itially transported to ___ and subsequently transferred to
___. Upon arrival was seen by ACS for polytrauma and ortho for
management of open left tibial fracture. Taken to OR urgently
for washout, external fixation and wound vac placement of open
left tib/fib fracture.
Past Medical History:
Denies
Social History:
___
Family History:
Noncontributory.
Physical Exam:
Left upper extremity: neurovascularly intact distal to site of
injury with full range of motion of wrist and fingers.
approximately 6x3cm abrasion overlying hypothenar eminence and
3x3cm abrasion over thenar eminence. Both abrasions have well
granulated bases with small amount of devitalized skin at
periphery. two small blisters along ulnar aspect of palm and
multiple small abrasions across palm and fingers.
.
Left lower extremity: neurovascularly intact distal to injury,
pulses palpable. Distal tibia with triangular soft tissue defect
10x10cm. Wound vac in place.
Pertinent Results:
___ 04:49PM GLUCOSE-150* LACTATE-3.0* NA+-137 K+-4.0
CL--102 TCO2-26
___ 04:40PM UREA N-21* CREAT-1.0
___ 04:40PM estGFR-Using this
___ 04:40PM LIPASE-22
___ 04:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:40PM WBC-15.3* RBC-4.45* HGB-13.5* HCT-38.7*
MCV-87 MCH-30.3 MCHC-34.9 RDW-13.4
___ 04:40PM PLT COUNT-266
___ 04:40PM ___ PTT-25.7 ___
___ 04:40PM ___ 06:13AM BLOOD Hct-23.8*
___ 12:17PM BLOOD Glucose-105* UreaN-13 Creat-0.9 Na-137
K-4.1 Cl-104 HCO3-31 AnGap-6*
___ 12:17PM BLOOD Calcium-7.6* Phos-2.1* Mg-1.9
.
RADIOLOGY:
Radiology Report TRAUMA #3 (PORT CHEST ONLY) Study Date of
___ 4:03 ___
IMPRESSION: No acute findings on this trauma chest radiograph.
Please refer to outside hospital CT chest for further details.
.
Radiology Report TIB/FIB (AP & LAT) LEFT PORT Study Date of
___ 4:32 ___
FINDINGS: A single portable lateral view of the left tibia,
fibula/ankle was provided. There are acute fractures involving
both the distal tibia and fibula with associated significant
soft tissue injury. Soft tissue gas is noted compatible with
known compound fracture.
.
Radiology Report UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST
Study Date of ___ 6:27 ___
IMPRESSION: Intraoperative placement of external fixating
device across
distal tibia/fibula fracture as described. Please see surgical
note for
operative details.
.
Radiology Report CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND
RECONS Study Date of ___ 10:25 AM
IMPRESSION:
1. Minimal calcific atherosclerosis without evidence of
significant stenosis. Patent bilateral inflow and outflow
vessels with normal bilateral lower extremity runoffs.
2. Again seen is complicated and comminuted displaced open
fracture of the left distal fibula and tibia. The distal
fibular fracture appears to extend into the ankle mortise.
Partially visualized bones of the foot appear intact.
.
Radiology Report SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT
Study Date of ___ 11:36 AM
IMPRESSION:
1. Full shaft width superior displacement of the distal
clavicle relative to the intact acromion indicative for at least
Grade III acroclavicular injury with prominent associated soft
tissue swelling.
2. No acute fracture.
.
Radiology Report WRIST(3 + VIEWS) LEFT Study Date of ___
5:05 ___
Three views (four images) of the left wrist are normal. No
fracture or other osseous abnormalities and normal joints.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever/pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth Q6-8h Disp #*60
Tablet Refills:*2
2. Aspirin 121.5 mg PO DAILY
RX *aspirin 81 mg 1.5 tablet(s) by mouth once a day Disp #*45
Tablet Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*2
5. Enoxaparin Sodium 40 mg SC QD Duration: 14 Days
RX *enoxaparin 40 mg/0.4 mL 1 injection once a day Disp #*14
Syringe Refills:*0
6. Senna 1 TAB PO BID:PRN constipation
7. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*28 Tablet Refills:*0
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6h Disp #*100
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Left lower extremity tissue defect overlying tib-fib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires crutches
Followup Instructions:
___
Radiology Report
TRAUMA CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Outside hospital chest CT performed on same date.
FINDINGS: Supine portable AP view of the chest was provided with underlying
trauma board in place. Lungs are clear. Cardiomediastinal silhouette is
normal. No osseous injuries seen.
IMPRESSION: No acute findings on this trauma chest radiograph. Please refer
to outside hospital CT chest for further details.
Radiology Report
LEFT TIBIA AND FIBULA RADIOGRAPH PERFORMED ON ___
COMPARISON: Outside hospital radiograph from same date.
CLINICAL HISTORY: Open fracture of the left distal tibia and fibula.
FINDINGS: A single portable lateral view of the left tibia, fibula/ankle was
provided. There are acute fractures involving both the distal tibia and
fibula with associated significant soft tissue injury. Soft tissue gas is
noted compatible with known compound fracture.
Radiology Report
EXAM: Radiograph of the left tibia/fibula.
CLINICAL INDICATION: External fixation of distal tibia and fibula fractures.
COMPARISON: Radiographs from ___.
FINDINGS: Four spot intraoperative radiographs demonstrate comminuted
fractures involving the distal tibia and fibula, with an external fixating
device (with two screws) transfixing the mid tibial diaphysis. A second
external fixating screw device is seen across the calcaneus. Total radiation
dose of 20.57 rads/cm2 during radiation time of 20.7 seconds.
IMPRESSION: Intraoperative placement of external fixating device across
distal tibia/fibula fracture as described. Please see surgical note for
operative details.
Radiology Report
HISTORY: ___ -year-old man with left open tib-fib fracture, bilateral rib
fractures. Pain of the right shoulder.
TECHNIQUE: Four views of the right shoulder.
COMPARISON: Portable chest radiograph performed ___ at 1623
hours.
FINDINGS:
Distal clavicle is superiorly displaced relative to the intact acromion by a
full shaft width. 2.0 cm coracoclavicular interval. Prominent overlying soft
tissue swelling is present in this region. No evidence for clavicular
fracture however.
Proximal right humerus is intact. Right humerus demonstrates normal
articulation with the glenoid. Scapula is intact. Imaged portions of the
ribs are intact. Lung apices are clear. No pneumothorax. Imaged portions of
the left clavicle and shoulder are intact and normal in appearance.
IMPRESSION:
1. Full shaft width superior displacement of the distal clavicle relative to
the intact acromion indicative for at least Grade III acroclavicular injury
with prominent associated soft tissue swelling.
2. No acute fracture.
Radiology Report
CTA OF THE AORTIC BIFURCATION WITH BILATERAL ILIAC AND BILATERAL LOWER
EXTREMITY RUNOFF.
HISTORY: ___ man with open left distal fibular tib-fib fracture and
soft tissue defect, which will require a soft tissue flap. CTA of the left
lower extremity to assess vascular flow.
COMPARISON: Left tib-fib radiographs, ___.
TECHNIQUE: Standard departmental protocol CTA of the aortic bifurcation and
bilateral lower extremity runoff was performed with intravenous contrast
administration. Non-contrast, initial CT of the aortic bifurcation and lower
extremities was also performed. Coronal and sagittal reformats as well as 3D
reformats were obtained.
TOTAL EXAM DOSE LENGTH PRODUCT: 2960.78 mGy-cm.
FINDINGS: Visualized small and large bowel and appendix appear unremarkable.
Normal-appearing urinary bladder. Coarse prostatic calcifications. No
evidence of pelvic free fluid. No evidence of lymphadenopathy. Normal
appearance of the aortic bifurcation. Minimal calcific atherosclerosis with
normal caliber of the bilateral common iliac arteries.
LEFT: Normal course and caliber, left external iliac artery. Minimal
calcific plaque at the proximal portion of the left internal iliac artery,
without significant stenosis. Normal course and caliber, left common femoral
artery as well as the profunda femoris artery. Normal course and caliber,
left superficial femoral artery and popliteal artery. Minimal calcific plaque
at the popliteal artery at the level of the takeoff of the anterior tibial
artery, without significant stenosis. Minimal calcific plaque of the
tibioperoneal trunk bifurcation, without significant stenosis. Mild calcific
plaque at the proximal portions of the left posterior tibial artery with
perhaps mild stenosis. There is normal three-vessel runoff into the distal
left leg and left foot.
Again seen is a comminuted, mildly-displaced diagonal fracture of the left
distal tibia and fibula, with external fixators in place. The distal fibular
fracture line appears to extend into the ankle mortise. No evidence of ankle
mortise widening. The talar dome and remaining bones of the foot appear
intact. Significant subcutaneous soft tissue stranding is seen in the left
lower leg associated with the open fracture. A large soft tissue defect is
seen in the medial aspect of the left lower leg.
RIGHT: Normal course and caliber right common iliac and right external iliac
artery. Minimal calcific plaque at the origin of the right internal iliac
artery, without significant stenosis. Normal course and caliber right common
femoral artery and bifurcation. Normal course and caliber of right
superficial femoral artery and popliteal artery. Moderate calcific plaque at
the tibioperoneal trunk, causing mild stenosis. Otherwise, normal
three-vessel runoff of the right lower extremity into the distal right leg and
right foot.
IMPRESSION:
1. Minimal calcific atherosclerosis without evidence of significant stenosis.
Patent bilateral inflow and outflow vessels with normal bilateral lower
extremity runoffs.
2. Again seen is complicated and comminuted displaced open fracture of the
left distal fibula and tibia. The distal fibular fracture appears to extend
into the ankle mortise. Partially visualized bones of the foot appear intact.
Radiology Report
HISTORY: Pain in left wrist post-trauma.
Three views (four images) of the left wrist are normal. No fracture or other
osseous abnormalities and normal joints.
Radiology Report
HISTORY: Left tibial fracture ORIF.
Fluoroscopic assistance provided to surgeon in the OR without the radiologist
present. 280 or 281 images were obtained. Fluoro time not recorded on the
available requisition. Given the large number of images and RF technique,
detailed assessment is limited. Views demonstrate steps related to fixation
about a lower extremity fracture. Correlation with real-time findings and
when appropriate conventional radiographs is recommended for full assessment.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MOTORCYCLE ACCIDENT
Diagnosed with FX SHAFT TIBIA W FIB-OPN, FRACTURE ONE RIB-CLOSED, LUNG CONTUSION-CLOSED, MV TRAFF ACC NEC-MOCYCL
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient was admitted to ___ service after a motorcycle
crash where he sustained an open tib-fib fracture, bilateral
first rib fractures and pneumomediastinum. His left lower
extremity fracture was determined to be a grade 3 open left
tibia-fibula fracture and patient was taken to the OR on ___
by Orthopedic service for washout and debridement of open
fracture with application of multiplanar external fixator and
wound VAC to anterior left lower extremity wound defect.
Plastic surgery was consulted on ___ for flap coverage
planning to left lower extremity (LLE) wound defect. On
___, the patient returned to the OR with both Orthopedics
and Plastics services. Orthopedics began with washout and
debridement of LLE wound, removal of external fixator with open
reduction and internal fixation left bimalleolar ankle fracture
with internal fixation and Intramedullary (IM) nail left tibia
with insertion of antibiotic cement delivery device. Plastics
then did a radial forearm free flap reconstruction to LLE wound
defect and placed a split thickness skin graft to left forearm
donor site. Patient tolerated all of these procedures very
well. Patient was admitted to Plastic surgery service and placed
on bedrest for 5 days after the final surgery with close
monitoring of free flap to LLE. He received Toradol x 3 days
post-operatively and then transitioned to 121.5mg of ASA QD as
part of a free flap anticoagulation protocol. On POD#5, all
surgical dressings were removed and flap remained warm, pink and
viable. All LLE incisions remained patent and without signs of
infection. Patient's LLE was maintained in a pre-fabricated
posterior support splint for the remainder of his stay and he
was discharged home with same. Left forearm incision and skin
graft sites were patent and without signs of infection or
breakdown. Left thigh donor site remained open to air to dry.
Patient began a LLE dangle protocol three times a day on POD#5
with incremental increases in dangle times each day as part of
flap dependency training. The LLE free flap tolerated dangle
challenges well.
.
Neuro: Post-operatively, the patient's pain was managed with a
dilaudid PCA and/or IV pain medications with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient was given IV fluids during pre-op periods of
NPO and directly post-operatively until tolerating oral intake.
His diet was advanced when appropriate, which was tolerated
well. He was started on a bowel regimen to maintain bowel
movements. Patient was commenced on Flomax PO for urinary
retention post-operatively. Patient able to void freely and
without difficulty during the remainder of admission. Intake
and output were closely monitored.
.
ID: Post-operatively, the patient was given 3 doses of IV
cefazolin and then IV gentamicin was added on ___.
Gentamicin was discontinued on ___ and patient was
maintained on cefazolin (and then keflex) alone until ___.
The patient's temperature was closely watched for signs of
infection.
.
Prophylaxis: The patient received subcutaneous heparin during a
portion of this stay and was transitioned to Lovenox prior to
discharge for purposes of teaching self lovenox injections.
Patient was discharged home with 2 weeks of lovenox therapy.
.
At the time of discharge on HD#12, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating with crutches and non wt bearing on LLE, voiding
without assistance, and pain was well controlled. All incisions
were clean and intact without signs of infection or breakdown.
LLE flap site remained pink, warm and viable. LLE was
maintained in pre-fab posterior splint with ace wrap to just
below knee. Left forearm skin graft site was healthy and pink
with 100% take. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, vaginal spotting
Major Surgical or Invasive Procedure:
operative laproscopy, right salpingectomy, removal of ectopic
pregnancy
History of Present Illness:
Patient is a ___ yr old G2p1 presenting with RLQ pain, near
syncope and pain.She reported the acute sonnet of symptoms and
presented to the ER.
Past Medical History:
negative
OB HX; NVD x 1 at term. breastfeeding.
Social History:
NO tobacco, alcohol or drug use.
Lives with son and FOB>
Physical Exam:
Discharge physical exam
Vitals: stable and within normal limits
Gen: no acute distress; alert and oriented to person, place, and
date
CV: regular rate and rhythm; no murmurs, rubs, or gallops
Resp: no acute respiratory distress, clear to auscultation
bilaterally
Abd: soft, appropriately tender, no rebound/guarding; incisions
clean, dry, intact
Ext: no tenderness to palpation
Pertinent Results:
Labs on Admission:
___ 12:00PM BLOOD WBC-12.7* RBC-4.12 Hgb-12.0 Hct-36.8
MCV-89 MCH-29.1 MCHC-32.6 RDW-12.0 RDWSD-39.1 Plt ___
___ 12:00PM BLOOD Glucose-105* UreaN-11 Creat-0.7 Na-137
K-3.3* Cl-104 HCO3-19* AnGap-14
___ 12:00PM BLOOD Albumin-4.7
___ 12:00PM BLOOD HCG-8923
___ 12:33PM BLOOD Lactate-2.4*
Relevant Labs:
___ 06:02PM BLOOD WBC-13.9* RBC-4.12 Hgb-11.9 Hct-36.5
MCV-89 MCH-28.9 MCHC-32.6 RDW-13.1 RDWSD-42.5 Plt ___
___ 12:00PM BLOOD Neuts-81.9* Lymphs-10.8* Monos-6.0
Eos-0.6* Baso-0.2 Im ___ AbsNeut-10.38* AbsLymp-1.37
AbsMono-0.76 AbsEos-0.08 AbsBaso-0.03
___ 06:02PM BLOOD ___ PTT-26.4 ___
Medications on Admission:
denies
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*1
2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*1
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ruptured ectopic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: History: ___ with severe lower abd pain// torsion
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: None
FINDINGS:
Surrounding the uterus, there is a large amount of heterogeneous material that
lacks internal vascularity, most consistent with hematoma/hemoperitoneum.
Otherwise, the uterus is anteverted and measures 7.6 x 3.9 x 5.4 cm. The
endometrium is heterogenous and measures 19 mm. There is no evidence of a
gestational sac within the uterus.
The left ovary is normal. The right ovary is not identified, likely
surrounded by hematoma/complex fluid.
These findings, in combination with serum beta hCG level of greater than 8000,
are highly worrisome for ruptured ectopic pregnancy with associated
hemorrhage.
IMPRESSION:
Findings highly worrisome for ectopic pregnancy: Large amount of
hematoma/hemoperitoneum in the pelvis, which, along with an absence of
intrauterine gestational sac and elevated beta HCG, highly worrisome for
ruptured ectopic pregnancy.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:06 pm, 2 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Lower abdominal pain
Diagnosed with Unspecified ectopic pregnancy without intrauterine pregnancy
temperature: 97.1
heartrate: 100.0
resprate: 18.0
o2sat: 99.0
sbp: 127.0
dbp: 74.0
level of pain: 7
level of acuity: 3.0 | On ___, Ms. ___ presented to the emergency room with RLQ
pain, hypotension and vaginal posting. She had a positive
pregnancy test and ultrasound imaging concerning for
hemoperitoneum and ruptured ectopic pregnancy. An HG of 8900 was
noted and no intrauterine pregnancy.
She received IV resuscitation and 3 units of red cells and in
the ER and was taken urgently to the operating room. She
underwent an operative laproscopy, evacuation of hemoperitoneum,
and right salpingectomy for ruptured ectopic. Please see the
operative report for full details. Her pre-operative HCT was
36.8. Patient received 2 additional units of packed red blood
cells intra-operatively, for a total of 5 units. EBL was 4000cc.
PACU HCT was stable at 36.5. Her coagulation factors were
trended and were stable.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with IV toradol. Her diet was
advanced without difficulty, and she was transitioned to PO
oxycodone, ibuprofen, and Tylenol. On post-operative day 1, her
urine output was adequate, so her foley was removed, and she
voided spontaneously.
She expressed significant tearfulness regarding these events and
pregnancy loss. Patient was seen by Social Work during her
admission. She will have outpatient followup with this service.
She was discharged to home with outpatient followup in one week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
R-sided weakness, dysarthria, word-finding difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old right handed young lady, with past
history of Ebstein anomaly, ___ s/p unsuccesful ablation in
___,
intratrial communication, who presented to the ED with sudden
onset difficulty comprehending and producing speech and right
sided facial droop and arm weakness.
Patient was last well seen at 19:00, code stroke called at
19:30.
She was brought by EMS and per their report, she was talking
normally until suddenly she was unable to find words and had
some
difficulty comprehending speech, with a right facial droop, and
she became unable to hold her right arm up. She was immediatly
brought to our ED. It was also noted that she had one episode of
incontinence.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, lightheadedness, vertigo, tinnitus or hearing
difficulty. She reports feeling tired and sleepy.
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, but required oxygen on the field due
to saturation in the high 80's. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
-Ebstein anomaly (diagnosed at the age of ___ with reported
fatigue at baseline but no recorded hypoxia, followed by
cardiologist Dr. ___ in ___,
___
-ASD
-___ s/p unsuccessful ablation in ___
-Migraines with visual aura
Social History:
___
Family History:
Negative for strokes below age ___. No DVTs. Sister with
migraines. No history of seizures.
Physical Exam:
============================
ADMISSION PHYSICAL EXAM
============================
Vitals: T: 97.9 P:80 R:20 BP:122/77 SaO2:93% (on 5L O2)
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, SEM III/VI
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 EXAM
-Mental Status: Alert, has word finding difficulty and unable to
relate full history. Repetition is intact, naming is slightly
impaired for unfrequent objects.
Normal prosody. There were no paraphasic errors. Able to read
without difficulty but is dysarthric. Able to follow both
midline and appendicular commands. There was no evidence of
apraxia or neglect upon the last evaluation.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. slight pronation butno
drift on the right.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Motor:
Normal bulk and tone, no rigidity or bradykinesia.
Left:
Delt ___, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, Quad
___, Ham ___, TA ___, ___ ___, Gastroc ___
Right:
Delt ___, ___ 4+/5, Tri ___, Grip 4+/5, Spread ___, IP ___, Quad
___, Ham ___, TA ___, ___ ___, Gastroc ___
-Sensory: No deficits to light touch, pinprick. No extinction to
DSS.
Reflexes:
DTRs
Right: ___ 2+ Tri 2+ ___ 2+ Patellar 2+ Achilles 1+ Toes
upgoing
Left: ___ 2+ Tri 2+ ___ 2+ Patellar 2+ Achilles 1+ Toes
mute
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: not performed.
============================
DISCHARGE PHYSICAL EXAM
============================
Vitals: T: P: R: BP: SaO2:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without c/r/r
Cardiac: RRR, nl. S1S2, III/VI holosystolic murmur loudest at
the LLSB
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: WWP, 2+ pulses b/l, no edema
Skin: no rashes or lesions noted.
NEUROLOGIC EXAM
-Mental Status: Awake and alert, pleasant. Oriented to person,
and place. Oriented to date, but verbalizes it mixing ___
and ___. Able to speak in ___ word sentences in ___,
intact repetition and comprehension. Dysarthric speech. No
evidence of apraxia.
-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: Nasolabial flattening and slightly decreased excursion on
lower R side with improvement from admission examination
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. slight pronation but no
drift on the right.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Motor:
Normal bulk and tone, no rigidity or bradykinesia.
Left:
Delt ___, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, Quad
___, Ham ___, TA ___, ___ ___, Gastroc ___
Right:
Delt ___, ___ 4+/5, Tri ___, Grip 4+/5, Spread ___, IP ___, Quad
___, Ham ___, TA ___, ___ ___, Gastroc ___
-Sensory: No deficits to light touch, pinprick. No extinction to
DSS.
Reflexes:
DTRs
Right: ___ 2+ Tri 2+ ___ 2+ Patellar 2+ Achilles 1+ Toes
upgoing
Left: ___ 2+ Tri 2+ ___ 2+ Patellar 2+ Achilles 1+ Toes
mute
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: stable
Pertinent Results:
======================
LABORATORY
======================
___:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 07:44PM GLUCOSE-94 NA+-145 K+-4.4 CL--107 TCO2-21
___ 07:42PM CREAT-0.7
___ 07:30PM UREA N-9
___ 07:30PM ALT(SGPT)-40 AST(SGOT)-33 ALK PHOS-90 TOT
BILI-0.3
___ 07:30PM LIPASE-50
___ 07:30PM cTropnT-<0.01
___ 07:30PM ALBUMIN-4.9 CALCIUM-9.8 PHOSPHATE-3.2
MAGNESIUM-2.1
___ 07:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:30PM WBC-9.5 RBC-5.89* HGB-17.9* HCT-53.1* MCV-90
MCH-30.4 MCHC-33.7 RDW-13.2
___ 07:30PM NEUTS-61.6 ___ MONOS-4.8 EOS-3.5
BASOS-1.2
___ 07:30PM ___ PTT-26.3 ___
___ 07:30PM PLT COUNT-273
___ 07:30PM ___ PTT-26.3 ___
___ 07:30PM AT III-107 PROT C FN-94 PROT S FN-86
___ 07:30PM LUPUS-NEG
___ 05:45PM D-DIMER-681*
======================
IMAGING
======================
(___) CTA NECK W&W/OC & RECON/ CT BRAIN PERFUSION:
1. No acute intracranial abnormality, with no evidence of
infarct or
hemorrhage. No CT perfusion abnormality to suggest ischemia
or
infarct.
2. Unremarkable CTA of the head and neck.
3. Bilateral enlarged cervical lymph nodes, which may be
reactive.
(___) CXR: Prominent heart size, no acute process
(___) CT CHEST W/ CONTRAST: No evidence of PE
(___) BILAT LOWER EXT VEINS: No DVT bilaterally
(___) MR HEAD W/O CONTRAST: Acute L caudate/putamen infarct,
possible old R frontal infarct
(___) ECHO: Ebstein's anomaly, large RA, PFO/ASD
(___) CT HEAD: Hypodense area in the left lenticular nucleus
and head of the caudate nucleus is compatible with evolving left
MCA stroke. No areas of hemorrhage or hemorrhagic conversion
are identified.
======================
MICROBIOLOGY
======================
(___) Blood Culture: Pending/No growth
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ___ 28 *NF* (drospirenone-ethinyl estradiol) ___ mg
Oral daily
Discharge Medications:
1. Enoxaparin Sodium 60 mg SC BID
RX *enoxaparin 60 mg/0.6 mL 1 syringe subcutaneous twice a day
Disp #*14 Syringe Refills:*0
2. Warfarin 4 mg PO DAILY16
RX *warfarin 2 mg 2.5 tablet(s) by mouth daily Disp #*75 Tablet
Refills:*0
3. Outpatient Occupational Therapy
434.91 Acute Ischemic Stroke
Outpatient Occupational Therapy, please evaluate and treat
4. Outpatient Physical Therapy
434.91 Acute Ischemic Stroke
Outpatient Physical Therapy, please evaluate and treat
5. Outpatient Speech/Swallowing Therapy
434.91 Acute Ischemic Stroke
Outpatient Speech Therapy, please evaluate and treat
Discharge Disposition:
Home
Discharge Diagnosis:
-L caudate/putamen stroke
Discharge Condition:
Mental Status: Clear and coherent, slight dysarthria, slightly
halting speech
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with right-sided weakness. Question stroke.
COMPARISON: None.
TECHNIQUE: Images were obtained through the brain without contrast material.
An axial perfusion CT run was performed during infusion of Omnipaque
intravenous contrast. Subsequently, rapid imaging was performed from the
aortic arch to the brain during infusion of Omnipaque intravenous contrast
material. A total of 110 mL of Omnipaque were utilized. Images were
processed on a separate workstation with display of mean transit time,
relative cerebral blood volume, and cerebral blood flow maps for the CT
perfusion study and curved reformats, 3D volume rendered images, and maximum
intensity projection images for the CTA.
FINDINGS:
Head CT: the ventricles, sulci, subarachnoid spaces are normal in size and
configuration. There is no evidence of hemorrhage or acute vascular
territorial infarct. There is a prominent left occipital arachnoid
granulation involving the left transverse sinus. There is no mass lesion.
There is no shift of the midline structures. The orbits, paranasal sinuses,
and mastoids are unremarkable.
CT perfusion: There is no evidence of a perfusion defect. The mean transit
time, cerebral blood volume, and cerebral blood flow are within normal limits.
Head CTA: The vertebral and basilar arteries are normal in appearance with a
normal branching pattern. There is no evidence of significant stenosis,
occlusion, dissection, or aneurysm.
The intracranial internal carotid arteries and the anterior, middle, and
posterior cerebral arteries are normal in appearance without evidence of
significant stenosis, occlusion, dissection, or aneurysm.
There is no vascular malformation.
Neck CTA: The right common, internal, and external carotid arteries are normal
in appearance without evidence of a hemodynamically significant stenosis,
dissection, or occlusion. The distal right internal carotid artery measures
4.6 mm.
The left common, internal, and external carotid arteries are normal in
appearance without evidence of hemodynamically significant stenosis,
dissection, or occlusion. The distal left internal carotid artery measures
4.4 mm.
The bilateral vertebral arteries are normal in appearance without evidence of
dissection, stenosis, or occlusion. The left vertebral artery is dominant, a
normal variant.
The aortic arch and the origins of the great vessels are unremarkable.
There are scattered bilateral prominent cervical lymph nodes at all levels,
largest at levels 2 date bilaterally measuring up to 12 mm. These are likely
reactive. The thyroid is normal. The lung apices are clear. The thymus is
prominent, likely normal for age. There is no suspicious bony lesion or
significant osseous abnormality.
IMPRESSION:
1. No acute intracranial abnormality, with no evidence of infarct or
hemorrhage. No CT perfusion abnormality to suggest ischemia or infarct.
2. Unremarkable CTA of the head and neck.
3. Bilateral enlarged cervical lymph nodes, which may be reactive.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Hypoxia.
COMPARISONS: None.
TECHNIQUE: Chest, portable AP upright.
FINDINGS: Although perhaps exaggerated by AP portable technique, the heart is
relatively prominent in size for age with a globular appearance. The lungs
appear clear. There are no pleural effusions or pneumothorax.
IMPRESSION: Mildly prominent heart size for age although potentially
exaggerated by technique; follow-up standard PA and lateral radiographs may be
useful to reassess when feasible. No evidence of acute disease.
Radiology Report
INDICATION: Presentation concerning for stroke, neuro deficits.
COMPARISON: CTA ___.
TECHNIQUE: MRI of the brain without contrast.
FINDINGS: There is slow diffusion in the left caudate head and putamen. This
is in the distribution of the lenticulostriate arteries. This area also has
increased signal on T2 and FLAIR images. There is also a small area of T2 and
FLAIR hyperintensity in the right periventricular region (3, 16) that does not
demonstrate slow diffusion. No other areas of abnormal diffusion are
identified. There is no evidence of mass or mass effect. Flow voids are
grossly maintained. The orbits and globes are normal. Again seen are
enlarged lymph nodes in the left neck. Visualized paranasal sinuses and
mastoid air cells are well aerated.
IMPRESSION:
1. Acute to subacute infarction involving the left putamen and caudate head.
2. Likely old small area of infarction in the right periventricular region
adjacent to the lateral ventricle.
These findings were discussed with Dr. ___ by Dr. ___ at
2:15 p.m. on ___ by telephone.
Radiology Report
HISTORY: ___ year old woman with Ebstein's Anomaly with ASD, L MCA infarct of
possible embolic source and hypoxia
COMPARISON: None
Technique: MDCT axial images were acquired through the abdomen following oral
and intravenous contrast administration. Three minute delyed imaging through
the abdomen was also performed. Sagittal and coronal reformats were obtained.
FINDINGS:
The main pulmonary artery is normal in size. No filling defects are seen
within the pulmonary arteries to suggest pulmonary embolism. There is
cardiomegaly with atrialization of the right ventricle. There is also
rightward bowing of the intraventricular septum, compatible with the provided
history of ebstein's anomaly. The pericardial and pleural spaces are clear.
The aorta and great vessels are also patent.
There is residual thymic tissue within the anterior mediastinum. There is no
enlarged mediastinal, axillary or hilar lymphadenopathy. The central
tracheobronchial tree is clear. The lung apices are incompletely visualized.
There are no suspicious pulmonary nodules. Dependent atelectasis is seen at
the bases.
The visualized upper abdominal structures are unremarkable.
There are no ominous osseous abnormalities.
IMPRESSION: Changes of Ebstein anomaly as described above. Otherwise
unremarkable examination. In particular, there is no evidence of pulmonary
embolism.
Radiology Report
HISTORY: ___ year old woman with know ASD and left MCA infarct. Assess for
venous embolic source
TECHNIQUE: Grayscale, color Doppler, and spectral analysis of the venous
system of both lower extremities was performed.
COMPARISON: None available
FINDINGS:
There is normal compression and augmentation of the proximal, mid and distal
superficial femoral veins as well as the popliteal veins in both lower
extremities. The peroneal and posterior tibial veins were visualized and
demonstrate wall to wall flow in bot lower extremities. There is normal
phasicity of the common femoral veins bilaterally.
IMPRESSION:
No evidence of DVT in either the right or left lower extremity.
Radiology Report
INDICATION: ___ female with left MCA stroke, now with worsening word
finding difficulties, on heparin drip. Evaluate for evidence of intracranial
hemorrhage.
COMPARISON: Head CT from ___ and head MR from ___.
TECHNIQUE: Axial contiguous MDCT images were obtained through the head
without administration of IV contrast. Coronal, sagittal, and thin-slice bone
reformats were generated.
DLP: 1025.72 mGy-cm.
CTDI: 64.11 mGy.
FINDINGS: An area of hypodensity involving the left lenticular nucleus and
head of the caudate is compatible with developing infarct previously seen in
head MR. ___ is seen within the lesion to suggest hemorrhagic
conversion. There are ___ other foci of hypodensity. There is preservation of
gray-white matter differentiation in the non-affected parts of the brain. The
basal cisterns are patent. The ventricles and sulci are normal in size and
configuration.
___ fractures are identified. The visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear.
IMPRESSION: Hypodense area in the left lenticular nucleus and head of the
caudate nucleus is compatible with evolving left MCA stroke. ___ areas of
hemorrhage or hemorrhagic conversion are identified.
Gender: F
Race: HISPANIC/LATINO - MEXICAN
Arrive by AMBULANCE
Chief complaint: RIGHT SIDED WEAKNESS
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ y/o R-handed F with hx of Ebstein anomaly with ASD, WPW
syndrome s/p unsuccessful ablation in ___ presenting with acute
onset dysarthria, word-finding difficulty and R-sided weakness
with MRI notable for L caudate/putamen stroke. Cardiac workup
revealed arrhythmia with ASD/PFO due to known abnormalities,
likely cardioembolic source of clot. Started on anticoagulation
with heparin, now transitioned to coumadin with lovenox bridge.
#Neuro: Admission neurologic exam was notable for dysarthric
speech, word-finding difficulty, R-facial asymmetry and R-sided
weakness. MRI was notable for L caudate/putamen stroke, likely
of embolic etiology in the setting of recently started OCP. TTE
and ___ studies were done without clear source of embolism, and
coagulation panel was unremarkable. Patient was started on
heparin drip and transitioned to coumadin with lovenox bridge
upon discharge. Patient was also evaluated by cardiology as
below. ___ and speech and language consults were obtained,
which recommended outpatient follow-up. Symptoms were monitored
daily with improvement in ___ language fluency, dysarthria
and weakness throughout the course of admission. Upon discharge,
patient could speak in ___ word ___ sentences, had mild
persistent asymmetry of the lower R facial musculature and mild
dysarthria.
#CV: Patient underwent TTE for evaluation of possible
cardioembolic source and delineation of congenital anomaly.
Ebstein's anomaly with ASD was confirmed. EKG was consistent
with ___ syndrome. Patient was found to be
hypoxic to 89% on 6L O2, raising the concern for pulmonary
embolism. CTPA was negative for PE. Patient was evaluated by
both the cardiology service and the ___ Adult Congenital
Heart Disease service to evaluate chronic versus acute onset
hypoxemia. Both services felt that her hypoxemia was
physiologic given the extent of her shunting and that there was
likely no worsening of her defect, but that cardiac surgery
should be pursued in the near future. O2 supplementation was
stopped given physiologic shunting. Patient's O2 saturation
ranged between 82-93%/RA without any evidence of cyanosis,
tachypnea or dyspnea. Patient was started on heparin and
transitioned to coumadin with lovenox bridge.
#Resp: Patient was kept on continuous O2 monitoring. Had a desat
to the los ___ while in the shower with associated cyanosis,
which was thought to be vasovagal. No PE on CTPA. Her O2 sats
remained in the mid-high ___ on room air.
#FEN: Patient was maintained on cardiac healthy diet.
#HEME: Started on anticoagulation with heparin, now transitioned
to coumadin with lovenox bridge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with history of rheumatic fever,
paroxysmal atrial fibrillation, type 2 diabetes mellitus,
hypertension, and hyperlipidemia who presented with shortness of
breath and palpitations. She was found to be in an SVT by
paramedics and converted to sinus with adenosine.
The patient reports that she developed palpitations and
shortness of breath beginning around 0800 on day of admission.
The patient called ___. EMS found the patient was found to be in
SVT. Adenosine 6 mg was administered with subsequent conversion
to normal sinus rhythm (confirmed on EKG strips).
On arrival to the ED, the patient reported that she felt back to
normal and denied ongoing chest pain, palpitations, shortness of
breath, abdominal pain, nausea, vomiting, diarrhea, leg
swelling, orthopnea, paroxysmal nocturnal dyspnea. She lives at
home alone and has 6 hours a day of ___ services. She reports
that he had episodes of SVT in the past when she lived in
___. She also stated that she has had 8 falls in the last
year, but has not fallen since her recent discharge.
In the ED initial vitals were: T 97.8 HR 87 BP 150/72 RR 20 SaO2
98% on RA. Exam notable for regular rhythm, clear lungs, RUQ
tenderness to palpation. EKG showed NSR at 82 bpm, normal axis
and intervals, no ischemic changes. Labs/studies notable for
CBC, BMP, LFTs within normal limits. Mg 1.5. CXR showed no
definite radiographic evidence for pneumonia with mild bibasilar
atelectasis. RUQ US was unremarkable with a normal gallbladder
without gallstones or acute cholecystitis. Patient was given
Magnesium Sulfate 2 gm IV. Vitals on transfer: T 98.5 HR 82 BP
134/71 RR 19 SaO2 98% on RA.
After arrival to the cardiology ward, the patient reported that
she felt well. She had a mild headache. She denied any ongoing
palpitations, chest pain, shortness of breath, abdominal pain,
or other specific complaints.
Past Medical History:
1. CAD RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Rheumatic fever
- Atrial fibrillation
- Subdural hemorrhage
- Hyperthryoidism
- Anxiety
- RA
- OA
- Lumbar spinal stenosis (MRI ___
- Cervical degenerative disc disease with cervicalgia
- Cervical facet disease and myofascial pain syndrome
- Sacroiliac Joint Pain
- Lumbar radiculopathy
- Recurrence of shingles
Social History:
___
Family History:
- Mother: Heart Disease, ___, no strokes or seizures,
deceased
- Father: ___, deceased
- Brother: MI, ___ Bypass Surgery, deceased
- Son: Healthy
- Daughter: healthy
Physical ___:
On admission
GENERAL: Elderly white woman A&Ox3, in no acute distress
VITALS: T 98.0 BP 145/81 HR 78 RR 18 SaO2 92% on RA
HEENT: Blind. PERRL. Mucous membranes moist.
NECK: Supple with JVP of 5 cm.
CARDIAC: RRR; no murmurs, rubs or gallops.
LUNGS: CTAB--no wheezes, rales or rhonchi.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
EXTREMITIES: No peripheral edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
At discharge
GENERAL: AOx3, in no acute distress
Vitals: T 98.2 BP 177/83 HR 70 RR 20 SaO2 93% on RA
HEENT: Blind.
NECK: Supple with JVP of 5 cm.
CARDIAC: RRR; no murmurs, rubs or gallops.
LUNGS: CTAB--no wheezes, rales or rhonchi.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
EXTREMITIES: No peripheral edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
___ 11:07AM BLOOD WBC-5.4 RBC-4.51 Hgb-13.5 Hct-41.3 MCV-92
MCH-29.9 MCHC-32.7 RDW-12.9 RDWSD-42.9 Plt ___
___ 11:07AM BLOOD Neuts-63.4 ___ Monos-6.7 Eos-1.3
Baso-0.9 Im ___ AbsNeut-3.41 AbsLymp-1.48 AbsMono-0.36
AbsEos-0.07 AbsBaso-0.05
___ 11:07AM BLOOD Glucose-135* UreaN-13 Creat-0.7 Na-145
K-4.1 Cl-103 HCO3-24 AnGap-18
___ 11:07AM BLOOD ALT-13 AST-18 AlkPhos-48 TotBili-0.6
___ 11:07AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.7 Mg-1.5*
___ 11:07AM BLOOD TSH-0.22*
___ 06:20AM BLOOD T4-5.8 Free T4-1.0
___ 11:05AM BLOOD Lactate-1.9
___ 06:20AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:10PM BLOOD CK-MB-2 cTropnT-0.02*
___ 11:07AM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD Glucose-104* UreaN-12 Creat-0.6 Na-142
K-3.7 Cl-103 HCO3-28 AnGap-11
CXR ___
Heart size is top-normal. The aorta is tortuous with
atherosclerotic calcifications noted at the aortic arch and
descending thoracic aorta. Mediastinal and hilar contours are
otherwise unchanged. The pulmonary vasculature is not engorged.
Patchy atelectasis is noted in the lung bases without focal
consolidation. No pleural effusion or pneumothorax is present.
Mild degenerative changes are noted in the thoracic spine.
IMPRESSION: No definite radiographic evidence for pneumonia.
Mild bibasilar atelectasis.
RUQ US ___
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the liver is smooth. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is
no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD
measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The imaged portion of the pancreas appears within
normal limits, without masses or pancreatic ductal dilation,
with portions of the pancreatic tail obscured by overlying bowel
gas.
SPLEEN: Normal echogenicity, measuring 10.5 cm.
KIDNEYS: Limited views of the right kidney show no
hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal limits.
IMPRESSION: Unremarkable abdominal ultrasound. Normal
gallbladder without gallstones or acute cholecystitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Moderate
2. Calcium Carbonate 1200 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY:PRN constipation
5. Gabapentin 300 mg PO TID
6. Methimazole 2.5 mg PO DAILY
7. Senna 8.6 mg PO DAILY:PRN constipation
8. Simvastatin 20 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. biotin 5,000 mcg oral DAILY
11. meloxicam 15 mg oral DAILY:PRN
Discharge Medications:
1. Verapamil SR 120 mg PO Q24H
RX *verapamil 120 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Moderate
3. biotin 5,000 mcg oral DAILY
4. Calcium Carbonate 1200 mg PO DAILY
5. Citalopram 10 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Gabapentin 300 mg PO TID
8. meloxicam 15 mg oral DAILY:PRN pain
9. Methimazole 2.5 mg PO DAILY
10. Senna 8.6 mg PO DAILY:PRN constipation
11. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Supraventricular tachycardia
-Paroxysmal atrial fibrillation
-Hypertension
-Hyperlipidemia
-Type 2 diabetes mellitus
-Subdural hematoma
-Hyperthyroidism
-Osteoarthritis
-Rheumatoid arthritis
-Gait instability
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with RUQ abdominal pain// ?cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 10.5 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Unremarkable abdominal ultrasound. Normal gallbladder without gallstones or
acute cholecystitis.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with svt and shortness of breath// ? pneumonia
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is top-normal. The aorta is tortuous with atherosclerotic
calcifications noted at the aortic arch and descending thoracic aorta.
Mediastinal and hilar contours are otherwise unchanged. The pulmonary
vasculature is not engorged. Patchy atelectasis is noted in the lung bases
without focal consolidation. No pleural effusion or pneumothorax is present.
Mild degenerative changes are noted in the thoracic spine.
IMPRESSION:
No definite radiographic evidence for pneumonia. Mild bibasilar atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SVT
Diagnosed with Supraventricular tachycardia, Bradycardia, unspecified
temperature: 97.8
heartrate: 87.0
resprate: 20.0
o2sat: 98.0
sbp: 150.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ with history of rheumatic fever, paroxysmal atrial
fibrillation, type 2 diabetes mellitus, hypertension,
hyperlipidemia who presented with shortness of breath and
palpitations. She was found to be in an SVT by paramedics and
converted to sinus with adenosine. She was started on verapamil
as an inpatient and tolerated it well. She was discharged home
with continued services.
# Supraventricular tachycardia: Arrived to the hospital in NSR
following the adenosine. Unclear precipitant. EKG without
ischemic changes and serially negative troponin. No signs or
symptoms of infection. She appeared euvolemic on exam. She was
started on verapamil 120 mg daily with good effect, HRs in the
___ and no additional episodes of SVT. TSH was slightly low but
free T4 was normal. She was discharged with no antiocoagulation
for embolic prevention in the setting of underlying paroxysmal
atrial fibrillation given recent chronic subdural hematoma and
multiple recent falls; this risk-benefit trade-off was discussed
with daughter and patient.
# Hypertension: Antihypertensives discontinued during last
admission in setting of orthostasis and recent fall in favor of
verapamil.
# Recent subdural hematoma: Patient was recently admitted for
fall with headstrike, imaging showed chronic subdural hematoma.
Will follow-up with ___ clinic.
# Hyperthyroidism: Continued methimazole. TSH was low (0.22) but
free T4 was ultimately normal. Recommend rechecking with PCP at
followup.
# Gait instability: 8 falls in the last year. None since last
discharge. Has a walker, but per her daughter does not always
use. Very important to patient to remain independent. She was
discharged home with continued services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Wound dehiscence and infection
Major Surgical or Invasive Procedure:
Placement of irrigating wound vac (___) on ___
Wound irrigation and debridement on ___ with placement of
incisional vac
History of Present Illness:
From Admission HPI:
Mr. ___ is a ___ yo M well known to the neurosurgery team who
is s/p urgent L1-L3 laminectomies, and L2-3 diskectomy on ___
for cauda equina syndrome. He was discharged to ___
but presented on ___ with ongoing wound dehiscence and poor
healing. He was admitted for placement of a wound vac system and
initiation of IV antbiotics. He reports no fevers, chills or
sweats. He notes some improvements in ___ strength with ongoing
___.
Past Medical History:
Morbid obesity
Asthma
Psioriasis
Congenital spinal stenosis
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
O: T:98.5 HR: 89 BP:127/77 RR:18 Sat:100% RA
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
R 5 5 5 0 ___ 0
L 5 5 5 0 0 0
Sensation: decreased in the groin and buttock in the saddle
distribution
Incision:
Malodorous. No active drainage.
___ inch section of dehiscence with depth to the fascia, wound
edges are mildly erythematous. Visualized area of old hematoma
within the cavity.
Incision above and below the open area is well approximated
without erythema or edema.
On Discharge:
Vitals: ___
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
R 5 5 5 0 ___ 0
L 5 5 5 0 0 0
Sensation: decreased in the groin and buttock in the saddle
distribution
Incision: with serosanguinous drainage (serous > sanguinous).
replaced with new incision vac sponge.
Pertinent Results:
==============================================================
IMAGING
==============================================================
CT Lumbar Spine ___:
IMPRESSION:
1. Compared to ___, there has been interval
evacuation of the
previously seen large posterior subcutaneous hematoma. There is
subcutaneous gas in the region of the hematoma. Recommend
correlation with recent evacuation.
2. There is indistinctness of the posterior spinal musculature,
which could represent a persistent, though decreased, hematoma.
3. Linear lucency through the right L2 inferior facet may
represent a minimally displaced pars defect or artifact
Medications on Admission:
Colace 100 mg capsule
Constulose 10 gram/15 mL oral solution
Dakin's Solution 0.25 %damp gauze with Dakins and cover with
DSD
BID and PRN
Roxicodone 5 mg tablet three times
Sarna Anti-Itch 0.5 %-0.5 % lotion
acetaminophen 650mg every four hrs PRN pain
bisacodyl 5 mg tablet BID PRN
cephalexin 500 mg capsule four times a day
cyanocobalamin (vit B-12) 1,000 mcg tablet once a day
famotidine 20 mg twice a day
gabapentin 900mg TID,
sodium chloride 1 gram TID
zolpidem 5 mg at bedtime
iron -- Unknown Strength
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
Patient should take 1g every 24 hours (course complete on
___.
2. Vancomycin 1500 mg IV Q 8H
3. Bisacodyl 10 mg PO BID:PRN constipation
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 600 mg PO TID
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Mild
10. Sarna Lotion 1 Appl TP QID
11. Zolpidem Tartrate 5 mg PO QHS:PRN sleep
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Wound dehiscence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION:
___ year old man s/p L1-L4 laminectomy with L2-3 bilateral discectomy who
presents with increased drainage from wound site. Evaluate for hematoma
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 9.7 s, 37.8 cm; CTDIvol = 46.3 mGy (Body) DLP =
1,753.6 mGy-cm.
Total DLP (Body) = 1,754 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
As before, the patient is status post L2-L3 laminectomy and L2-L3 discectomy.
Compared to ___, there has been interval evacuation of a large
hematoma overlying the midline posterior subcutaneous tissues. There is
subcutaneous gas in the region of the hematoma. Please correlate with recent
evacuation. There is indistinctness of the posterior spinal musculature,
which could represent a persistent, though decreased, hematoma. Alignment is
normal.Linear lucency through the right L2 inferior facet may represent a
minimally displaced pars defect or artifact ___ B/35).
Incidentally noted IVC filter and Foley catheter.
IMPRESSION:
1. Compared to ___, there has been interval evacuation of the
previously seen large posterior subcutaneous hematoma. There is subcutaneous
gas in the region of the hematoma. Recommend correlation with recent
evacuation.
2. There is indistinctness of the posterior spinal musculature, which could
represent a persistent, though decreased, hematoma.
3. Linear lucency through the right L2 inferior facet may represent a
minimally displaced pars defect or artifact
Radiology Report
INDICATION: ___ year old man with picc // s/p left 47cm picc ___ ___
Contact name: ___: ___
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Left PICC line in situ with the tip projecting over the midline. Normal
cardiomediastinal shadow. No airspace consolidation. No pleural effusion.
No pneumothorax. No pulmonary edema.
IMPRESSION:
Left-sided PICC line in situ with the tip more medial than would be expected,
but in discussion with the referring NP I was assured that the PICC line is
not intra-arterial or extra-luminal.
The tip projects 2 cm inferior to the carina, then placing it in the low SVC.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Infection following a procedure, initial encounter, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 98.5
heartrate: 89.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 77.0
level of pain: 3
level of acuity: 3.0 | ___ was admitted to the ___ on ___ from
___ for concern of wound dehiscence and infection
from his prior urgent L1-L3
laminectomies, L2-3 diskectomy on ___ for cauda equina
syndrome.
On ___, he was started on IV cefazolin and received placement
of a ___ irrigating wound vacuum which he tolerated well. He
did not complain of any subjective fevers, chills, or sweats and
his WBC was within normal limits. He remained stable overnight.
On ___, he reported tolerating the wound vac well. He was eager
to return to rehab but per Dr. ___ was asked to remain
in house on antibiotics and with a vac change scheduled for ___
where he could also be examined by Dr. ___.
On ___, he continued to tolerate the wound vac and was
neurologically stable. He remained afebrile without any WBC.
On ___, the wound vac was changed and the patient
continued to do well.
On ___, in the early morning the team was notified that
WoundVac dressing was leaking. Upon inspection, the foam was
found to be intact, and the dressing wasreinforced.
On ___, the patient's neurological and motor exam remained
stable. The team changed the wound-vac dressing with Dr.
___ changed ___ irrigation fluid from saline
to Dakins ___.
On ___, the patient continued to do well and was without fever
or complaint. The WoundVac dressing maintained a good seal.
On ___ the patient remained neurologically stable. His
wound vac remained in place and he was preparing for surgery on
___.
On ___ the patient was taken to the operating room and
underwent a Lumbar Wound Revision. His case was uncomplicated
and he was extubated in the OR and recovered in the PACU. He was
transferred to the floor when stable. He was placed on
vancomycin, cefepime, and flagyl for antibiotic coverage pending
an ID consult.
On ___, the patient continued to be stable on the floor with a
stable neurological exam. He was seen by ID who recommended
vancomycin, ceftazidime, and flagyl while awaiting culture
speciation.
The patient continued to remain stable in house from on ___ and
___ where he continued on vancomycin, ceftazidime, and flagyl.
He did have a run of ventricular tachycardia on ___, lytes and
a formal EKG were obtained that were unremarkable.
The patient was discharged in stable condition on ___. He
was discharged on Vancomycin 1500 mg q8h and ertapenem 1g q24h
both until ___. The patient's incisional vac was changed on
the day of discharge. This vac will be changed by the Prevena
___ Wound Nurse ___ cell: ___ on ___.
Per the infectious disease team, there was no need for ID follow
up at this time. However, the infectious disease team at ___
will continue to monitor the final speciation of his wound
cultures and will notify the team at ___ should any
antibiotic changes be necessary.
This plan was discussed with the patient prior to discharge and
the patient expressed understanding. He will call to schedule a
two week follow up with Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
visual disturbances
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old male who is status post Stent assisted
coiling of a basilar aneurysm on ___ and reports ongoing
left visual field "gap" and poor visual acuity with fine print
for the past 4 days. . The patient reports that he was in his
yard lifting heavy bags of mulch for about 2.5 hours when his
legs buckled, he lost balance and tried to ambulate without
success. He reports feeling as if he was in a "drunken stupor".
This episode was associated with a global visual disturbance
which is difficult for the patient to explain. The patient
states that this episode lasted approximately ___ minutes at
which time he just sat on the ground to rest. A few days
earlier
he reports the sensation of loss of balance and the feeling of
his ears being "clogged"- at which time he believed this to be
related to seasonal allergies.
At this time he denies headache, numbness, tingling sensation,
weakness, nausea, or vomiting.
Past Medical History:
HTN
bailar aneurysm s/p ___ coiling of basilar aneurysm,
depression
Social History:
___
Family History:
___
Physical Exam:
O: T:99.8 BP:213 / 100 HR:97 R: 18 O2Sats: 98%
Gen: comfortable, NAD.
HEENT: Pupils: 4-3mm EOMs:intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
On Discharge:
stable
Pertinent Results:
___ MRI/MRA Brain
Bilateral occipital infarcts right greater than left side likely
subacute in nature. No evidence of hemorrhage. No mass effect or
hydrocephalus.
Medications on Admission:
LEVOTHYROXINE - levothyroxine 112 mcg tablet. 1 tablet(s) by
mouth once a day - (Prescribed by Other Provider)
METHYLPHENIDATE [RITALIN] - Ritalin 20 mg tablet. 6 tablet(s) by
mouth twice a day - (Prescribed by Other Provider)
NORTRIPTYLINE - nortriptyline 75 mg capsule. 2 capsule(s) by
mouth once a day - (Prescribed by Other Provider)
OLANZAPINE [ZYPREXA] - Zyprexa 10 mg tablet. 1 tablet(s) by
mouth
once a day - (Prescribed by Other Provider)
SIMVASTATIN - simvastatin 20 mg tablet. 1 tablet(s) by mouth at
bedtime - (Prescribed by Other Provider)
VENLAFAXINE - venlafaxine ER 150 mg capsule,extended release 24
hr. 3 capsule,extended release 24hr(s) by mouth once a day -
(Prescribed by Other Provider)
ASPIRIN - aspirin 325 mg tablet. 1 tablet(s) by mouth once a day
started on ___
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
3. Bisacodyl 10 mg PO/PR DAILY
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
5. Docusate Sodium 100 mg PO BID
6. Levothyroxine Sodium 112 mcg PO DAILY
7. MethylPHENIDATE (Ritalin) 60 mg PO BID
8. Nortriptyline 150 mg PO HS
9. OLANZapine 10 mg PO DAILY
10. Senna 8.6 mg PO BID
11. Simvastatin 20 mg PO DAILY
12. Venlafaxine XR 450 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Subacute stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN
INDICATION: ___ year old man with aneurysm, possible stroke // evaluate for
stroke, history of aneurysm coiling
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of cc 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. 3D time-of-flight MRA of the circle of ___ was obtained
before and after gadolinium. .
COMPARISON: Correlation was made with the cerebral angiography. No previous
MRI examinations.
FINDINGS:
There are patchy areas of increased signal in both occipital lobes on FLAIR
images. Diffusion images also demonstrate increased signal but on ADC there
are corresponding areas of high and isointense signal indicative of subacute
infarcts. There is no evidence of blood products. There is no evidence of
midline shift, mass effect or hydrocephalus.
The MRA of the circle of ___ demonstrates the cortex in the region of the
basilar artery tip. There is some residual filling of the base of the
aneurysm identified best visualized on the source images. No other vascular
occlusion or stenosis seen.
IMPRESSION:
Bilateral occipital infarcts right greater than left side likely subacute in
nature. No evidence of hemorrhage. No mass effect or hydrocephalus.
MRA shows flow signal in the base of the aneurysm .
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Unsteady gait, Weakness
Diagnosed with VISUAL DISTURBANCES NEC, HYPERTENSION NOS
temperature: 99.8
heartrate: 97.0
resprate: 18.0
o2sat: 98.0
sbp: 213.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | ___, Patient was admitted to the floor after being evaluated
in the emergency department. He was started on Plavix and
aspirin. Stroke neurology was consulted and recommended an
ophthalmology consult as well as an MRI/MRA to evaluate for
stroke.
On ___ Mr. ___ had visual field testing which demonstrated
the presence of a left homonymous hemianopsia. On ___ he
underwent MRI/MRA which showed subacute right temporal,
bilateral occipital infarcts right greater than left. It was
felt that the strokes were possibly a result of dehydration in
the setting of exertion.
On ___ he remained neurologically stable and at the time of
discharge he was tolerating a regular diet, ambulating without
difficulty, afebrile with stable vital signs. He will follow up
as an outpatient to complete his work up with a TTE and follow
up with Dr. ___ in ___ weeks in clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with PMH polycystic
kidney disease w/ polycystic liver, chronic abdominal pain who
presented with 1 day of abdominal pain and fever.
Per ED note she reports: Sudden onset of symptoms yesterday
evening. Periumbilical/R and L flank pain with periumbilical
pain
worst, currently ___. Describes it as sharp, stabbing,
nonradiating. Alleviated lying on left side with legs drawn up
to
chest. Says pain feels similar to prior cyst ruptures. Reports
some nausea no vomiting, home promethazine/compazine helping. On
30mg oxycontin BID prn neck pain from prior trauma though this
has not helped with current symptoms. No change in bowel or
bladder habits. No sick contacts or recent travel. No
cough/chest
pain/SOB.
In the ED:
- Initial vital signs were notable for: T102.7 HR120 BP146/83
RR16 O2Sat 98% RA.
- Exam notable for: tachycardia, Abd - soft, mild TTP
throughout,
+BS
CVAT R>L.
- Labs were notable for: normal RFTs and LFTs, WBC 10.6 with
77.4% PMNs.
- Studies performed include: CT A/P which showed no definite
evidence of acute abdominopelvic process which would correlate
with patient's symptoms and innumerable cysts in liver and
kidneys. Also showed persistent mild enlargement of the common
bile duct measuring up to 9 mm, unchanged compared to prior
studies.
- Patient was given: Tylenol, IV Dilaudid, IV Zofran, IVF 1L LR.
Vitals on transfer: 98.5 78 121/75 12 96% Nasal Cannula.
Upon arrival to the floor, she reports that her pain started
___ night. It is in the upper abdomen and right flank. This
is
similar to prior pain flares when she has cyst ruptures. She
also
gets fevers during her cyst flares in the past. Endorses
nausea/vomiting but feels able to drink water right now and
feels
thirsty. She denies diarrhea/constipation, cough, chest pain,
SOB, dysuria.
Past Medical History:
-polycystic kidney disease, polycystic liver disease
-asthma, GERD, migraine
-anxiety, depression
-tinnitus, insomnia
-Chronic pain
-neck fracture from MVA s/p C6-C7 plate fusion/graft
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
-Denies family h/o PKD, cancer, or diabetes.
-Mother was adopted
-Sister: headache, migraine
Physical Exam:
ADMISSION
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, somewhat distended, tender to palpation over
upper quadrants. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, somewhat distended, tender to palpation over
upper quadrants, R>L. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION
___ 07:09PM BLOOD WBC-10.6* RBC-4.37 Hgb-13.6 Hct-39.0
MCV-89 MCH-31.1 MCHC-34.9 RDW-12.3 RDWSD-41.1 Plt ___
___ 07:09PM BLOOD Neuts-77.4* Lymphs-12.9* Monos-9.2
Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.19* AbsLymp-1.37
AbsMono-0.97* AbsEos-0.01* AbsBaso-0.02
___ 07:09PM BLOOD ___ PTT-27.1 ___
___ 07:09PM BLOOD Glucose-155* UreaN-8 Creat-0.8 Na-139
K-4.0 Cl-103 HCO3-24 AnGap-12
___ 07:09PM BLOOD ALT-11 AST-15 AlkPhos-90 TotBili-0.6
___ 07:09PM BLOOD Albumin-4.2
___ 07:46PM BLOOD Lactate-1.6
DISCHARGE
___ 05:42AM BLOOD WBC-7.8 RBC-4.02 Hgb-12.5 Hct-37.2 MCV-93
MCH-31.1 MCHC-33.6 RDW-12.3 RDWSD-42.4 Plt ___
___ 05:42AM BLOOD Plt ___
___ 05:42AM BLOOD Glucose-91 UreaN-6 Creat-0.8 Na-142 K-4.4
Cl-105 HCO3-25 AnGap-12
___ 05:42AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.8
CT abd/pel w/ contrast ___
1. No acute abdominopelvic process correlating with the
patient's symptoms.
2. Numerous cysts throughout the liver and bilateral kidneys, in
keeping with history of polycystic kidney disease.
3. Persistent mild enlargement of the common bile duct measuring
up to 9 mm, unchanged compared to multiple prior studies and
stable since at least ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. DICYCLOMine 5 mg PO TID:PRN abdominal pain
2. Zolpidem Tartrate 5 mg PO QHS
3. LORazepam 0.5 mg PO Q6H:PRN anxiety
4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
6. Senna 8.6 mg PO DAILY
7. naloxegol 12.5 mg oral DAILY
8. Ranitidine 150 mg PO QHS
9. Multivitamins 1 TAB PO DAILY
10. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
11. Sucralfate 1 gm PO QID
12. Omeprazole 40 mg PO BID
13. Sumatriptan Succinate 50 mg PO PRN headache
14. Promethazine 12.5 mg PO BID:PRN nausea
15. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain
16. diclofenac sodium 1 % topical DAILY:PRN
17. Prochlorperazine 25 mg PR Q12H:PRN Nausea/Vomiting - Second
Line NOT relieved by Ondansetron
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 8 hours
Disp #*5 Tablet Refills:*0
2. diclofenac sodium 1 % topical DAILY:PRN
3. DICYCLOMine 5 mg PO TID:PRN abdominal pain
4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
5. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain
6. LORazepam 0.5 mg PO Q6H:PRN anxiety
7. Multivitamins 1 TAB PO DAILY
8. naloxegol 12.5 mg oral DAILY
9. Omeprazole 40 mg PO BID
10. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
12. Prochlorperazine 25 mg PR Q12H:PRN Nausea/Vomiting - Second
Line NOT relieved by Ondansetron
13. Promethazine 12.5 mg PO BID:PRN nausea
14. Ranitidine 150 mg PO QHS
15. Senna 8.6 mg PO DAILY
16. Sucralfate 1 gm PO QID
17. Sumatriptan Succinate 50 mg PO PRN headache
18. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Polycystic kidney disease complicated by cyst rupture
Polycystic liver
Chronic neck pain
Chronic abdominal pain
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: ___ with polycystic kidney/liver disease presenting with
periumbilical pain and fevers. Evaluation for free fluid, pancreatitis, free
air.
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 6.2 s, 49.1 cm; CTDIvol = 15.9 mGy (Body) DLP = 778.4
mGy-cm.
Total DLP (Body) = 787 mGy-cm.
COMPARISON: Comparison to MRI abdomen from ___ and CT
abdomen/pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is enlarged and contains innumerable cysts
throughout, overall similar in appearance to prior study. There is no
evidence of intrahepatic biliary dilatation. Mildly enlarged common bile duct
measures up to 9 mm (02:29), unchanged compared to multiple prior studies and
stable since at least ___. 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 enlarged and again demonstrate innumerable bilateral
cysts, with the largest in the left upper renal pole measuring 9.3 x 6.9 cm
(02:37), in the largest cyst in the right lower renal pole measuring 8.2 x 7.2
cm (02:41). Again seen is a hyperdense cyst at the left upper renal pole
measuring 1.5 x 1.2 cm (02:28) and an intermediate density cyst at the left
midpole measuring 1.0 x 0.9 cm (02:32), not significantly changed from prior
study and previously characterized as hemorrhagic cysts on MRI. There is no
evidence of hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized, however no
secondary signs of inflammation in the right lower quadrant.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Minimal atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute abdominopelvic process correlating with the patient's symptoms.
2. Numerous cysts throughout the liver and bilateral kidneys, in keeping with
history of polycystic kidney disease.
3. Persistent mild enlargement of the common bile duct measuring up to 9 mm,
unchanged compared to multiple prior studies and stable since at least ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Fever
Diagnosed with Epigastric abdominal tenderness
temperature: 102.7
heartrate: 120.0
resprate: 16.0
o2sat: 98.0
sbp: 146.0
dbp: 83.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ female with PMH polycystic kidney
disease w/ polycystic liver, chronic abdominal pain who
presented with 1 day of abdominal pain and fever.
#Abdominal pain/fever: Likely due to cyst rupture, as symptoms
are similar to prior flares of her polycystic kidney/liver
disease and she has no other signs or symptoms of infection.
Held off on antibiotics. Spoke to urology consult on the phone
who said that the patient has an appointment in 2 weeks and can
follow up as an outpatient for decortication; nothing to do in
the meantime to prepare for this clinic visit, and would not do
decortication while the patient is having a cyst rupture. Fever
downtrended by second day of admission. Continued home
oxycontin. Given IV dilaudid while vomiting, changed to PO by
second day of admission. Also gave Tylenol, though patient
reported that this had no effect. Patient reported being back to
her baseline chronic level of abdominal pain. Her home oxycontin
is for her neck pain. She requested dilaudid on discharge. I
discussed with her that she needs an overall pain management
plan with her outpatient providers and dilaudid is not a good
long term option, especially now that she is back to her
baseline level of pain. We agreed to a very short course to help
bridge her to her next PCP appointment, which has been scheduled
for early next week. Also continued home promethazine and
prochlorperazine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
1. Confusion
2. Incontinence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Primary Care Physician: ___
.
CHIEF COMPLAINT: failure to thrive, confusion
.
HISTORY OF PRESENT ILLNESS: Pt with pmhx of HTN, HLD, DM, etoh
abuse who presents with increased memory loss and failure to
thrive.
.
Pt was unable to make his cognitive neurology evaluation today
and refused to get his B12 injection. ___ NP advised his
daughter-in-law to bring pt to ED for further workup.
Pt denies any pain pain. New onset urinary incontinence and
possible fecal incontinence x2 days per daughter-in-law. No
known falls and no fevers. History otherwise limited as pt is
only oriented to person.
In the ED initial vitals were: 98.4, 66, 176/54, 16, 98%
- Labs were significant for hgb 13.9 (MCV 101) and relatively
unremarkable chem-7. Urine and serum tox screens negative.
- Patient was given nothing.
On the floor, an interview is conducted with the aid of a
___ interpreter. Pt is able to state his name. He is unsure
where he is or what the date is. He denies any pain, including
back and abdominal pain. He states he has not had any trouble
with his bladder however he is noted to be incontinent. He does
not know what medications he takes.
Review of Systems:
unable to obtain
Past Medical History:
B12 Deficiency
PVD
HTN
T2DM
CKD III
EtOH Abuse
Tobacco Use, HLD
CAD with fixed inferior defect
GIST s/p resection in ___
AAA s/p EVAR ___
Elevated PSA/microhematuria
Social History:
___
Family History:
No known family hx of DM, early coronary artery disease, clots
or MI.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals - 98.7, 117/47, 84, 18, 100% on RA
GENERAL: chronically ill appearing male in NAD
HEENT: AT/NC, anicteric sclera, MMM, poor dentition
NECK: supple
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: reducible ventral hernia, 2cm palpable mass superior to
umbilicus, otherwise nontender, nondistended, no fluid wave, no
CVAT
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, no spine TTP
NEURO: moving all extremities, AOx1, no asterixis, limited
participation in neuro exam
SKIN: warm and well perfused, multiple tattoos
DISCHARGE PHYSICAL EXAMINATION:
Vitals = 98.8, 59-66, 134-156/55-91, 18, 99% on RA, FSBG
114-200, Ins ___, Outs 2450
GENERAL: NAD, ___ only, tired
HEENNT: AT/NC, anicteric sclera, MMM, poor dentition, neck
supple
CARDIAC: RRR, no MRG
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Reducible ventral hernia, 2cm palpable mass superior to
umbilicus, otherwise nontender, nondistended, no fluid wave, no
CVAT
EXTREMITIES: No cyanosis, clubbing or edema, moving all 4
extremities with purpose, no spine TTP
NEURO: moving all extremities, A+Ox1, no asterixis, ___ UE
strength, limited participation
SKIN: warm and well perfused, multiple tattoos
Pertinent Results:
LABS:
___ 08:45PM BLOOD WBC-6.7 RBC-4.08* Hgb-13.9* Hct-41.1
MCV-101* MCH-34.1* MCHC-33.8 RDW-13.0 Plt ___
___ 05:40AM BLOOD WBC-9.7 RBC-4.12* Hgb-13.4* Hct-41.0
MCV-100* MCH-32.5* MCHC-32.7 RDW-12.9 Plt ___
___ 08:45PM BLOOD Neuts-54.4 ___ Monos-4.5 Eos-2.4
Baso-0.6
___ 08:45PM BLOOD ___ PTT-28.1 ___
___ 08:45PM BLOOD Glucose-208* UreaN-15 Creat-1.1 Na-138
K-4.6 Cl-101 HCO3-30 AnGap-12
___ 05:40AM BLOOD UreaN-23* Creat-1.3* Na-140 K-4.7 Cl-104
HCO3-24 AnGap-17
___ 08:45PM BLOOD ALT-13 AST-15 AlkPhos-95 TotBili-0.1
___ 05:09AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.7
___ 05:53AM BLOOD VitB12-262
___ 05:53AM BLOOD TSH-3.3
___ 08:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:00PM BLOOD Lactate-1.8
RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE
___ 08:45PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 08:45PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 02:51PM URINE Hours-RANDOM Creat-36 Na-168 K-33 Cl-143
TotProt-9 Prot/Cr-0.3*
___ 02:51PM URINE Osmolal-469
.
___ PA/LAT CXR
IMPRESSION:
No acute cardiopulmonary process.
.
___ CT HEAD
IMPRESSION:
No acute intracranial process.
.
___ MR HEAD
IMPRESSION:
No acute hemorrhage or acute infarction.
Generalized volume loss. T2/FLAIR signal hyperintensity in the
periventricular and subcortical white matter bilaterally
predominantly in the frontal lobes most likely secondary to
chronic small vessel ischemic change.
Right frontal lobe encephalomalacia
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Lisinopril 40 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Cyanocobalamin ___ mcg PO DAILY
7. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Cyanocobalamin ___ mcg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
7. FoLIC Acid 1 mg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Delirium
Vascular Dementia
SECONDARY:
Hypertension
Type II Diabetes Mellitus
Excessive Ethanol Use
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with dilirium // evidence of infection
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are well expanded and clear. There is no focal consolidation there
are effusion. Cardiomediastinal silhouette is stable. No acute osseous
abnormalities identified. Aortic graft is partially visualized in the abdomen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with AMS // evidence of bleed or infarct
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 1115 mGy-cm
COMPARISON: Head CT from ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or
acute vascular territorial infarct. Inferior right frontal encephalomalacia
is again seen. Predominantly bifrontal white matter hypodensities are
unchanged likely sequela of chronic small vessel disease. Prior left basal
ganglia and thalamic lacunar infarcts are again noted. Gray-white matter
differentiation is preserved. Ventricles are symmetric and unremarkable.
Included paranasal sinuses and mastoids are clear. Skull and extracranial soft
tissues are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with subacute memory deficits and new
incontinence, history of EtOH abuse + CAD/PVD/HTN + B12 deficiency //
?Potential Etiologies of subacute dementia/encephalopathy
TECHNIQUE: A MRI the brain was performed without intravenous contrast.
COMPARISON: No prior MRI available for comparison. Prior CT scan dated ___.
FINDINGS:
The ventricles and sulci are enlarged consistent with generalized volume loss.
There is no evidence of acute hemorrhage or extra-axial fluid collection.
There is no evidence of acute infarct. There is no evidence of mass effect or
shift of midline. There is increased T2/FLAIR signal hyperintensity in the
periventricular and subcortical white matter primarily in the frontal lobes
which is nonspecific but most likely secondary to chronic small vessel
ischemic change. There is also a region of encephalomalacia in the right
frontal lobe with T2/FLAIR signal abnormality.
Vascular flow voids are preserved. The visualized paranasal sinuses and
mastoid air cells are clear. Patient is status post bilateral lens
replacement.
IMPRESSION:
No acute hemorrhage or acute infarction.
Generalized volume loss. T2/FLAIR signal hyperintensity in the periventricular
and subcortical white matter bilaterally predominantly in the frontal lobes
most likely secondary to chronic small vessel ischemic change.
Right frontal lobe encephalomalacia
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Confusion, INCONT
Diagnosed with SEMICOMA/STUPOR
temperature: 98.4
heartrate: 66.0
resprate: 16.0
o2sat: 98.0
sbp: 176.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | ___ yo M PMHx atherosclerosis, DM, B12 deficiency, and EtOH abuse
presented with acute on chronic delirium. He had a full
delirium workup negative for reversible etiologies along with
MRI Brain showing chronic small vessel ischemia and he was
discharged to rehab
# Delirium / Dementia: Patient presents with relatively new
onset memory loss per family. Per report it seems it may be
waxing/waning so unclear if current status represents dementia
versus delirium, possibly combination of both. He was scheduled
to have a cognitive neurology appointment but was unable to make
as outpatient. Per family (___), patient had had a
question of mild memory impairment over the summer (and was thus
referred for neuropsychological evaluation, previously
relatively independent in ADLs, went to bank, took daily walks,
did own cooking, however ___ drinks/day). Only over the last 7
days has he had significant decompensation (urinary and bowel
incontinence, wandering hallways of his apartment complex
because he didnt remember where he lived, forgetful and not
himself, hygiene and upkeep poor, apartment unclean). History
and physical exam otherwise unremarkable except for somonolence
and disorientation.
Differential included electrolyte abnormalities or uremia (none
noted), infection (normal vitals and WBC), hepatic
encephalopathy (LFTs normal, no cirrhosis stigmata), UTI (clean
UA), intracranial process (CT/MRI show no acute process),
ethanol withdrawal or Wernicke's encephalopathy ___ drinks per
day, scoring minimally on CIWA, no improvement with
thiamine/folate/MVI), normal pressure hydrocephalus (no
characteristic gait, no evidence on imaging, variably continent
therefore likely functional), thyroid disease (normal TSH),
neurosyphilis (RPR negative, no other signs of tertiary
syphilis), and B12 deficiency (had been refusing shots as
outpatient but B12 within normal limits, no evidence of
neuropathy, on high dose oral cobalamin). MRI/CT Brain showed
chronic small vessel disease without acute disease process
making vascular dementia more likely. Epilepsy/post-ictal state
and meningeal process were considered but felt to be unlikely
given lack of clinical signs/symptoms and stable clinical and
mental status. Throughout his time, patient remained oriented
to person and hospital only and never knew date. He was given
thiamine/folate/B12 supplementation. Physical Therapy
recommended ___ rehab and he will see outpatient cognitive
neurology to continue workup of his delirium.
#Urinary Incontinence: Patient with reported new urinary
incontinence, likely relate to dementia/delirium process as
above. No signs of hydrocephalus concerning for normal pressure
hydrocephalus. No back pain or other focal neurological deficits
concerning for spinal cord pathology. No signs of UTI based on
UA. Patient was intermittently using toilet, so this was felt
to reflect functional pathology in the setting of dementia/AMS.
# Hypertension: Hypertensive on arrival to floor in setting of
missing home anti-hypertensives; continued on home lisinopril
and added HCTZ.
# Acute Kidney Injur: On ___, noted to have Cr 1.3 from
baseline 1. Patient has elevated BUN/Cr likely prerenal with
dehydration in setting of low PO intake. Patient was repleted
with IV fluids and his discharge Cr was 1.3.
# EtOH Use: Per HCP, patient drank at least ___ drinks per day.
As an inpatient, he was started on folate, thiamine, MVI for
nutrition support and concern for ___'s encephalopathy and
was monitored on CIWA scale for >48 hours; patient only scored
for confusion and the scale was discontinued.
# DMII: Poorly controlled and kept on insulin sliding scale as
inpatient as well as diabetic heart-healthy diet.
# B12 deficiency: Continue home dose ___ units B12 daily with
B12 level being WNL
# HLD: Chronic stable issue continued on home simvastatin.
# Code: Full Code confirmed with HCP
# Emergency Contact: HCP/daughter-in-law ___
___ or grandson ___ ___
# ___: ___
# Transitional Issues
- Continue dementia workup (consider LP/EEG); ___ cognitive
neurology
- Continue high-dose oral B12 therapy to minimize further
worsening of cognition
- Minimize access to ethanol
- Control vascular dementia risk factors (HTN, DM)
- Given CKD and baseline Cr 1.0-1.3, regularly evaluate
continuation of metformin for diabetes control given risk of
lactic acidosis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower Back Pain, Fever, Somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMH of RA, Nephrotic syndrome c/b renal vein
thrombosis on warfarin and hypertension who presented yesterday
to the ED with low back pain after being unable to get up. She
had several years of low back pain escalating over the past few
weeks (midline over left gluteal, worst with ambulation,
multiple recent falls, worsening difficulty standing) but has no
leg weakness or numbness (but legs give out several times over
past few weeks), has chronic urinary incontinence (unable to
reach bathroom in time for 1 month, nocturia multiple times per
night), but has no urinary retention or fecal
incontinence/retention, and she was febrile at triage.
___ evening after observation in the ED, she was found to be
unresponsive after spiking a temperature of 102.8. FSBG 157 and
pCO2 was 48 on VBG. CT Head negative for bleed. She was seen on
telemetry to have ST elevations, and this was confirmed on ECG
with diffuse ST elevations. She was unable to provide any
history to either me or the ED staff and was started on broad
spectrum antibiotics for concern for meningitis (no LP due to
elevated INR).
In ED she was given Alprazolam 0.5mg, Prednisone 60mg, many
albuterol-ipratropium nebs, ceftriaxone 2gm, vancomycin 1g,
acyclovir 450mg, and 1L NS as well as her home medications.
Lab workup in the ED significant for a CK of 214, MB 3, Trop
neg. Also pertinent were CRP of 78.3, creatinine 0.8->1.8, INR
2.9, lactate 1.7 and urine with 600 protein and no blood. CT
head - No acute intracranial process. MRI Spine showed large
C4-5 disc protrusion and moderate C3-4 disc protrusion with
moderate to severe spinal canal narrowing and contact on the
spinal cord; no evidence of epidural abscess but patient was
unable to tolerate exam.
ROS: As above, denies fever/chills despite readings, rash/LAD,
N/V/C/C, dyspnea, palpitations, chest pain (but ___ have upper
chest discomfort), snoring/CPAP use, urinary symptoms, or FNS.
Past Medical History:
# Rheumatoid arthritis with h/o R rheumatoid effusion
# Admission to Hand surgery in ___ for tenosynovitis
with I+D L thumb
# Nephrotic syndrome secondary to membranous nephropathy (biopsy
___, followed by Dr. ___ noncompliant with
tacro and prednisone, now prednisone/azathioprine, last dose
___
# Renal vein thrombosis on warfarin
# Asthma
# Hypertension
# Hypercholesterolemia
# dCHF and pulmonary hypertension on TTE ___, EF >55%
Social History:
___
Family History:
Significant for mother and aunt with RA, many family members
with HTN and DM. No other connective tissue diseases. No CAD or
cancer history.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
Vitals: Afebrile, 80, 18, 138/77
Gen: NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Poor
dentition.
NECK: Supple, No LAD. JVP low. Normal carotid upstroke without
bruits. No thyromegaly.
CV: PMI in ___ intercostal space, mid clavicular line. RRR.
normal S1,S2. No murmurs, rubs, clicks, or gallops
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: Obese. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits. Foley in place.
EXT: WWP, NO CCE. Full distal pulses bilaterally. No femoral
bruits.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Oriented x3, able to recite months of year backwards, CN
II-XII intact, ___ ___ strength, poor UE cerebellar exam, Gait
assessment deferred.
DISCHARGE PHYSICAL EXAM:
===========================
Temp: 98.3, BP 158/88, HR 72, RR 20, 93% 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, or
pericardial friction rubs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
Neuro: CN II-XII intact, ___ strength in upper and lower
extremities, gait not accessed.
Pertinent Results:
ADMISSION LABS:
=================
___ 06:00PM BLOOD WBC-7.7# RBC-3.65* Hgb-11.4* Hct-34.3*
MCV-94 MCH-31.1 MCHC-33.2 RDW-16.4* Plt ___
___ 06:00PM BLOOD Neuts-74.2* Lymphs-15.9* Monos-8.8
Eos-0.5 Baso-0.5
___ 06:00PM BLOOD Plt ___
___ 06:00PM BLOOD Glucose-86 UreaN-17 Creat-0.8 Na-137
K-4.5 Cl-102 HCO3-25 AnGap-15
___ 06:00PM BLOOD ALT-26 AST-37 AlkPhos-57 TotBili-0.5
___ 06:00PM BLOOD Albumin-3.0*
___ 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
================
___ 10:20AM BLOOD WBC-5.1 RBC-3.98* Hgb-12.7 Hct-39.8
MCV-100* MCH-31.9 MCHC-31.9 RDW-16.0* Plt ___
___ 10:20AM BLOOD Glucose-86 UreaN-20 Creat-0.6 Na-139
K-4.0 Cl-105 HCO3-23 AnGap-15
___ 10:20AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0
MICRO:
=======
___ Urine culture negative
___ Blood culture pending
STUDIES:
=========
ECG: Sinus 77, diffuse concave STE in I, II, aVL, V4-V6 with PR
elevation in aVR. Early R wave transition
TTE (Complete) Done ___ at 9:29:28 AM FINAL
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the ascending aorta measurement is normal. The other findings
are similar
___ MRI spine:
IMPRESSION:
MRI of the cervical spine, thoracic and lumbar spine without and
with IV
contrast: Study somewhat limited due to motion pulsation
artifacts and lack of axial postcontrast sequences through the
cervical and the upper thoracic spine.
1. C-spine: Multilevel, multifactorial degenerative changes,
moderate to
severe canal narrowing at C3-4, C4-5 and C5-6 levels with
deformity and some degree of compression on the cord.
T2 hyperintense foci in the posterior aspect of the cord at C4
and C5 levels, question related to myelomalacic changes or other
etiology.
Multilevel moderate to severe foraminal narrowing from C3-C7
levels with
deformity on the nerves.
2. Multilevel degenerative changes in the thoracic spine, with
mild canal and foraminal narrowing at T8-T9 and T9-T10 levels.
No compression on the thoracic spinal cord.
3. Multilevel, multifactorial degenerative changes in the
lumbar spine, most prominent at L3-4 level.
L1-2: Mild canal narrowing
L2- 3: Mild canal and foraminal narrowing
L3-4: Moderate to severe canal narrowing with compression on the
thecal sac and crowding of the nerves in the thecal sac
Bilateral moderate to severe foraminal and mild subarticular
zone narrowing with deformity on the L3 and L4 nerves.
Bilateral facet degenerative changes, with small to moderate
amount of fluid in the facet joints.
A small slightly T2 hyperintense focus in or adjacent to the
right ligamentum flavum indenting the thecal sac outline, ___
represent a cyst or a focus of ossification.
L4-5: Mild canal, mild to moderate foraminal narrowing
L5-S1: Mild foraminal narrowing.
Prominent epidural fat encasing the thecal sac at L4-5 and L5-S1
levels.
No fluid collection or abnormal enhancement is noted to suggest
epidural
abscess.
4. Enlarged slightly heterogeneous thyroid ; a 1.1cm focus in
spleen-?
Hemangioma/solid or cystic lesion; right kidney larger than
left; mildly
prominent aorta; bilateral adnexal cysts, larger one on the left
measures
2.8cm. Correlate with ultrasound
Correlate with ultrasound- thyroid, spleen, kidneys, aorta and
adnexa.
CT Head w/o contrast ___:
IMPRESSION:
No acute intracranial process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
2. Amlodipine 10 mg PO DAILY
3. Azathioprine 50 mg PO TID
4. Furosemide 80 mg PO BID
5. Losartan Potassium 100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. PredniSONE 5 mg PO DAILY
Tapered dose - DOWN
9. TraMADOL (Ultram) 50 mg PO TID:PRN Pain
10. Warfarin 6 mg PO DAILY16
11. Acetaminophen 325-650 mg PO Q6H:PRN Pain
12. arformoterol 15 mcg/2 mL Inhalation BID
13. Budesonide 0.25 mg/2 mL INHALATION BID
14. Pregabalin 50 mg PO QHS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain
2. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
3. Amlodipine 10 mg PO DAILY
4. Azathioprine 50 mg PO TID
5. Losartan Potassium 100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. PredniSONE 5 mg PO DAILY
Tapered dose - DOWN
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Pregabalin 50 mg PO QHS
10. TraMADOL (Ultram) 50 mg PO TID:PRN Pain
11. arformoterol 15 mcg/2 mL Inhalation BID
12. Budesonide 0.25 mg/2 mL INHALATION BID
13. Outpatient Lab Work
ICD-9 453.3 Renal Vein thrombosis
ICD-9 581.9 Nephrotic Syndrome
Please check INR and chem-7 on ___
14. Warfarin 4 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Lower back pain, weakness
Asymptomatic Pericarditis
Secondary:
Nephrotic syndrome ___ to membranous nephropathy
Renal Vein thrombosis on warfarin
Hypertension
Diastolic Heart Failure EF > 55%
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with low back pain, fever, no other localizing
symptoms, negative infectious workup otherwiseIV contrast to be given at
radiologist discretion as clinically needed // evaluate for epidural abscess,
cord or nerve compression, acuteeprocess
TECHNIQUE: MRI of the cervical, thoracic and the lumbar spine without and
with IV contrast with large field of view.
Only sagittal postcontrast through the cervical and upper thoracic and
sagittal and axial T1 postcontrast sequences through the lower thoracic and
the entire lumbar spine are available.
COMPARISON: CT of the abdomen ___
FINDINGS:
NUMBERING USED FOR THE PRESENT STUDY SHOWN ON SERIES 4, IMAGE 3 COUNTING FROM
C2 DOWNWARDS.
MRI OF THE CERVICAL SPINE:
Cervical vertebral bodies are normal in height and alignment.
Slightly heterogeneous marrow signal intensity, with scattered fat deposition.
Mild endplate irregularity noted at C4, C5 and C6 levels.
On the STIR sequence, no suspicious mass like lesions or foci of marrow edema
pattern noted.
Disc desiccation noted at all levels.
C2-C3: No disc herniation, no canal narrowing.
Mild diffuse disc bulge with uncovertebral changes, causing moderate bilateral
foraminal narrowing.
C3-4: Diffuse disc bulge, with small to moderate focal central disc extrusion
indenting the thecal sac outline and the cord, with moderate canal narrowing.
Bilateral severe foraminal narrowing by disc, uncovertebral and possible facet
changes.
C4-5 Diffuse disc bulge, with moderate to large sized focal central disc
extrusion causing severe canal narrowing with deformity on the cord with some
degree of compression.
Foci of increased T2 signal intensity within, may relate to the compression
and myelomalacic changes and better seen on the series 5, image 10 and se 11,
im 14.
Severe bilateral foraminal narrowing with deformity on the nerves by disc
uncovertebral and possible facet changes.
C5-6: Diffuse disc bulge, with focal central disc extrusion indenting the
thecal sac outline, with moderate canal narrowing.
Increased signal intensity in the posterior aspect of the cord on either side
of the midline question related to myelomalacic changes, other etiologies,
etc. Series 11, image 14.
Bilateral severe foraminal narrowing with deformity on the nerves.
C6-7: Diffuse disc bulge, with posterior osteophytes causing indentation on
the thecal sac outline.
Bilateral severe foraminal narrowing. Mild canal narrowing
C7-T1: Diffuse disc bulge indenting the thecal sac outline, with mild canal
narrowing. Bilateral foraminal narrowing.
No pre or paravertebral swelling noted.
The craniocervical junction region is unremarkable.
Prominent posterior fossa CSF spaces and partially empty sella noted,
inadequately assessed.
Enlarged and slightly heterogeneous thyroid on the STIR sequence, inadequately
assessed on the present study is not targeted.
MRI OF THE THORACIC SPINE:
Thoracic vertebral bodies are normal in height, signal intensity and
alignment.
Slightly heterogeneous marrow signal, with scattered fat deposition mixed with
cellular marrow.
No suspicious mass like lesions or marrow edema pattern noted on the STIR
sequence.
Disc desiccation noted at multiple levels.
Disc desiccation, mild disk bulge/small protrusion and facet degenerative
changes are noted at multiple levels.
T8-T9: Mild diffuse disc bulge, with a posterior component onto either side of
the midline, causing mild canal and foraminal narrowing.
T9-T10: Mild diffuse bulge, with a focal component extending into the left
foramen causing mild left foraminal narrowing.
The thoracic spinal cord is grossly normal in size and signal intensity
without obvious focal lesions.
No pre or paravertebral swelling noted.
Mildly prominent aorta, inadequately assessed.
A 1.1 x 1.0 cm T2 hyperintense focus in the spleen, which may represent a cyst
or hemangioma or a focal lesion.
This can be better assessed with ultrasound. This is not well seen on the
prior CT abdomen study, raising the possibility of a hemangioma or a solid
lesion. Series 12, image 34
MRI OF THE LUMBAR SPINE:
Lumbar vertebral bodies are normal in height, signal intensity and alignment.
Slightly heterogeneous marrow signal related to scattered fat deposition and
mixed with ___ changes.
Disc desiccation, facet degenerative changes and ligamentum flavum thickening
are noted at multiple levels.
L1-2: Mild disc bulge, with foraminal component and annular fissure, causing
mild foraminal narrowing.
Disc abuts the L1 nerves without significant deformity. No canal narrowing.
L2-3: Diffuse disc bulge, mild facet degenerative changes and ligamentum
flavum thickening.
Mild canal narrowing, facet degenerative changes and a congenital component.
Mild foraminal narrowing inferiorly.
L3-4: Diffuse disc bulge, bilateral facet degenerative changes, with
ligamentum flavum thickening.
Moderate amount of fluid noted in the facet joints on both sides.
Moderate to severe canal narrowing with crowding of the nerves of the thecal
sac.
In addition, there is a small focus of slightly hyperintense signal on the T2
weighted images, just towards the right side of the midline posteriorly,
adjacent to the ligamentum flavum series 14, image 20 indenting the thecal sac
outline contributing to the canal narrowing.
This can represent a cyst or a focus of ossification.
Bilateral moderate to severe foraminal narrowing, with some deformity on the
L3 nerves.
Mild subarticular zone narrowing with some deformity on the L4 nerves.
L4-5: Diffuse disc bulge, mild facet degenerative changes on both sides.
Mild to moderate foraminal narrowing on both sides.
Mild canal narrowing with prominent epidural fat, encasing the nerves and the
thecal sac.
L5-S1: No disc herniation, no canal or compression on the thecal sac.
Mild foraminal narrowing on both sides.
Prominent epidural fat encasing the thecal sac and the nerves.
Hypointense irregular focus at the lumbosacral junction series 14, image 31,
also seen on the prior inadequately assessed. CT as is slightly sclerotic
line.
Postcontrast sequences:
Limited due to motion and pulsation artifacts and lack of axial postcontrast
sequences through the cervical and the upper thoracic spine.
No abnormal enhancement is noted in the spine or in the spinal cord, or
epidural soft tissues.
No fluid collection or abscess.
The spinal cord ends at L1-
No pre or paravertebral swelling noted.
Right kidney larger than the left, better assessed on the prior CT abdomen
study.
Adnexal cyst noted on both sides on the localizing images series 3, image 6,
the larger 1 on the left measuring 2.2 x 2.9 cm.
IMPRESSION:
MRI of the cervical spine, thoracic and lumbar spine without and with IV
contrast: Study somewhat limited due to motion pulsation artifacts and lack
of axial postcontrast sequences through the cervical and the upper thoracic
spine.
1. C-spine: Multilevel, multifactorial degenerative changes, moderate to
severe canal narrowing at C3-4, C4-5 and C5-6 levels with deformity and some
degree of compression on the cord.
T2 hyperintense foci in the posterior aspect of the cord at C4 and C5 levels,
question related to myelomalacic changes or other etiology.
Multilevel moderate to severe foraminal narrowing from C3-C7 levels with
deformity on the nerves.
2. Multilevel degenerative changes in the thoracic spine, with mild canal and
foraminal narrowing at T8-T9 and T9-T10 levels. No compression on the thoracic
spinal cord.
3. Multilevel, multifactorial degenerative changes in the lumbar spine, most
prominent at L3-4 level.
L1-2: Mild canal narrowing
L2- 3: Mild canal and foraminal narrowing
L3-4: Moderate to severe canal narrowing with compression on the thecal sac
and crowding of the nerves in the thecal sac
Bilateral moderate to severe foraminal and mild subarticular zone narrowing
with deformity on the L3 and L4 nerves.
Bilateral facet degenerative changes, with small to moderate amount of fluid
in the facet joints.
A small slightly T2 hyperintense focus in or adjacent to the right ligamentum
flavum indenting the thecal sac outline, may represent a cyst or a focus of
ossification.
L4-5: Mild canal, mild to moderate foraminal narrowing
L5-S1: Mild foraminal narrowing.
Prominent epidural fat encasing the thecal sac at L4-5 and L5-S1 levels.
No fluid collection or abnormal enhancement is noted to suggest epidural
abscess.
4. Enlarged slightly heterogeneous thyroid ; a 1.1cm focus in spleen-?
Hemangioma/solid or cystic lesion; right kidney larger than left; mildly
prominent aorta; bilateral adnexal cysts, larger one on the left measures
2.8cm. Correlate with ultrasound
RECOMMENDATION(S): Consider spine/ neurosurgery consult to decide on further
management.
Correlate with ultrasound- thyroid, spleen, kidneys, aorta and adnexa.
Radiology Report
EXAMINATION:
CT head without contrast.
INDICATION: Altered mental status, fatigue and on Coumadin. Evaluate for
intracranial hemorrhage.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 1226.40 mGy-cm; CTDI: 165.55 mGy
COMPARISON: None.
FINDINGS:
There is no acute hemorrhage, edema or shift of the normally midline
structures. Slight prominence of the ventricles, out of proportion to the
sulci may relate to centrally predominant involutional changes. Scattered
periventricular white matter hypodensities, while nonspecific, are presumably
the sequela from chronic small vessel ischemic disease. Otherwise, the
gray-white matter differentiation is preserved and there is no evidence for a
large acute vascular territorial infarction. Vascular calcifications are seen
within the carotid siphons.
The included paranasal sinuses and mastoid air cells are well-aerated. There
is no fracture. The included lenses and globes are unremarkable.
IMPRESSION:
No acute intracranial process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Lower back pain, Fever
Diagnosed with FEVER, UNSPECIFIED, LUMBAGO, ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION
temperature: 102.6
heartrate: 82.0
resprate: 20.0
o2sat: 98.0
sbp: 118.0
dbp: 71.0
level of pain: 7
level of acuity: 3.0 | ___ with a PMH of RA, Nephrotic syndrome, hypertension and renal
vein thrombosis on coumdin who presented yesterday to the ED
with low back pain found to have fevers, EKG consistent with
pericarditis, and developed transient somnolence in ED and so
was transferred to MICU for concern of bacterial meningitis.
# Pericarditis: Patient presented with chest pain at home that
has now resolved. On arrival to ED patient was without chest
pain but did have diffuse ST segment elevation with mild PR
depressions. Etiology ___ be secondary to rheumatoid arthritis
vs. idiopathic vs. viral. Per rheumatology it is unlikely that
pericarditis is secondary to RA definitively. Also a possibility
that patient had a viral pericarditis though denies prodromal
viral symptoms prior to admission including fever, chills,
rhinorrhea, and cough. Echocardiogram was also reassuring
without evidence of pericardial effusion. She was not treated
with on NSAIDs/colchicine due to ___ and known membranous
nephropathy.
# Fever/Altered mental status:
Patient with RA/Nephrotic Syndrome on chronic corticosteroids
and azathioprine presented with back pain and difficulty with
ambulation and was found to have fevers. Differential includes
CNS/Spine source (ruled-out by MRI and exam, no meningeal signs,
no delirium or focal neurological deficits), cardiac
inflammatory source (can develop fever in setting of
pericarditis), pulmonary (no dyspnea/cough, normal CXR), urinary
source (incontinence but no dysuria and UA unremarkable), skin
source (no signs/symptoms). Infectious work-up was negative for
an acute process. There was concern that patient had meningitis
given encephalopathy and fevers, however given her rapid
improvement and resolution of fevers/AMS her antibiotics were
discontinued. Ultimately her fever ___ have been attributable to
her pericarditis though resolved this hospital course.
# Lower Back Pain with associated lower extremity subjective
weakness:
The ___ lower back pain and weakness that brought her to
the hospital was ultimately felt to be secondary to possible
dehydration and spinal stenosis symptoms. MRI imaging of her C,
T, and L-spine was completed. Patient was noted to have multiple
levels of foraminal narrowing and degenerative changes. Ortho
spine assessed patient and noted that the findings did not
warrant any surgical intervention. The ___ neurologic exam
also remained intact while in the hospital. Ultimately it was
determined that after ___ assessment patient could be discharged
home with continued physical therapy sessions and outpatient
spine clinic follow up.
# ___:
Patient came to hospital with normal renal function but
developed ___ during course of ED stay. Her losartan and
furosemide were held initially and she was given gentle IVF and
her Cr normalized. Chem-7 should be checked on ___ to assess
renal function.
# Membranous Nephropathy with renal vein thrombosis: Chronic
stable issue stable proteinuria and on prophylactic warfarin
post-renal vein thrombosis. She was maintained on prednisone
5mg and azathioprine 50mg TID as well as warfarin for post-renal
vein thrombosis prophylaxis and omeprazole for GIB ppx. INR
should be checked on ___ and warfarin dose adjusted
appropriately. INR was supratherapeutic on admission and
warfarin dose decreased to 4 mg from 6 mg. Goal INR of ___.
# HFpEF: Held furosemide in setting of ___. Patient remained
euvolemic on exam. It was felt that daily weights should be
monitored on discharge and if weight increased > 3 lbs then
furosemide should be restarted at 80 mg BID.
# HTN: Chronic stable issue continued on amlodipine. Losartan
was initially held secondary to ___ but restarted prior to
discharge.
# Asthma: Patient remained without wheezing or cough this
hospital course. Home inhaler regimen continued.
#Incidental Imaging Findings:
Right kidney larger than the left, better assessed on the prior
CT abdomen study. Adnexal cyst noted on both sides on the
localizing images series 3, image 6, the larger 1 on the left
measuring 2.2 x 2.9 cm. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Terrible triad elbow fracture dislocation
Major Surgical or Invasive Procedure:
closed reduction, hinged external fixator ___, Krod)
History of Present Illness:
___ ___ female with h/o HTN, HLD, GERD and
osteoarthritis who is not on anticoagulation presented to the ED
s/p fall. She was reportedly walking down stairs when she
tripped and fell down ___ steps. She landed on her right side
with +HS, -LOC. She was having epistaxis at the scene that
resolved prior to arrival. Upon arrival she was complaining of
right elbow pain and facial pain. She denies any numbness or
tingling in the arms or legs.
Past Medical History:
HTN, GERD, and hypercholesterolemia, s/p Appy, s/p tubal
ligation
Social History:
___
Family History:
n/c
Physical Exam:
General: Well-appearing, breathing comfortably
MSK:
Dressings with minimal staining
Arm and forearm compartments soft/compressible
Fires AIN/PIN/IO
SILT Ax/MRU
Hand WWP
Medications on Admission:
See OMR
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 25 mg by mouth q6hr prn Disp #*30 Tablet
Refills:*0
4. Atorvastatin 10 mg PO QPM
5. Calcium Carbonate 500 mg PO TID
6. Losartan Potassium 100 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Elbow fracture-dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with right L pain//eval for fx
COMPARISON: None
FINDINGS:
Two views of the right elbow were provided. There is posterior dislocation at
the right elbow. A small bony fragment is seen adjacent to the distal humerus
likely donor site is at the distal humerus.
IMPRESSION:
Dislocation of the right elbow with associated fracture at the distal humerus.
Discussed with Dr. ___.
Radiology Report
INDICATION: ___ with right wrist pain//eval for fx
COMPARISON: None
FINDINGS:
AP, lateral, oblique, and dedicated navicular views of the right wrist were
provided. The bones appear somewhat demineralized. The distal radius and
ulna are intact. The carpals appear to align normally. The scaphoid appears
intact on the views provided. No significant DJD. Soft tissues appear
normal.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with closed head inj, fall// eval for fx of c-spine, bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major infarction,hemorrhage,edema,or discrete
mass. Two foci of parenchymal calcification could be sequelae of prior
infection. The ventricles and sulci are normal in size and configuration.
There is a partially visualized Right nasal bone fracture. There is a mildly
displaced fracture of the nasal septum. 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.
2. Acute nasal septum and right nasal bone fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with closed head inj, fall// eval for fx of c-spine, bleed
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 499 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified.Multilevel degenerative
changes are seen, most extensive at C4-5 and C5-6 and notable for loss of
intervertebral disc height, subchondral cystic formation, osteophytosis, and
uncovertebral hypertrophy. There is mild spinal canal narrowing at C5-6.there
is no prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes of the cervical spine.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ with closed head inj, fall// eval for fx of c-spine, bleed
TECHNIQUE: Helical axial images were acquired through the facial bones. Bone
and soft tissue reconstructed images were generated. Coronal and sagittal
reformatted images were also obtained.
DOSE: DLP: 538.3 mGy-cm
COMPARISON: None.
FINDINGS:
An acute slightly impacted right nasal bone fracture with overlying soft
tissue swelling is seen. There is a acute fracture of the nasal septum (2;
55). Pterygoid plates are intact. There is no mandibular fracture and the
temporomandibular joints are anatomically aligned. The orbits are intact. The
globes and extra-ocular muscles are unremarkable. There is no orbital
hematoma.
There is mild mucosal thickening of the ethmoid air cells. The remaining
visualized paranasal sinuses are clear.
IMPRESSION:
Acute right nasal bone fracture and nasal septal fracture with overlying soft
tissue swelling.
Radiology Report
INDICATION: ___ with Elbow pain// post-reduction
COMPARISON: Prior performed 1 hour earlier
FINDINGS:
Four views of the right elbow were provided. Alignment is improved at the
right elbow though there is persistent subluxation.
IMPRESSION:
Persistent subluxation of the right elbow joint.
Radiology Report
EXAMINATION: ELBOW, AP AND LAT VIEWS IN O.R. RIGHT
IMPRESSION:
Images from the operating suite show steps in placement of a fixation device
about right elbow fracture. Further information can be gathered from the
operative report.
Radiology Report
EXAMINATION: CT UP EXT W/O C RIGHT Q51R
INDICATION: ___ year old woman with dislocated elbow, needs OR// Please
evaluate for OR planning
TECHNIQUE: Multiple contiguous 1.25 mm axial images were obtained through the
right elbow without the administration of intravenous contrast. Formatted
images were also obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.7 s, 26.6 cm; CTDIvol = 21.8 mGy (Body) DLP = 579.1
mGy-cm.
Total DLP (Body) = 579 mGy-cm.
COMPARISON: ___ is made to the prior radiographs from ___
FINDINGS:
The patient was scanned with the elbow at 90 degree flexion and adjacent to
the body which limits evaluation.
There remains dislocation at the ulnar trochlear articulation. The ulna is
dislocated posterior and laterally in relation to the trochlea. There is a
fracture of the coronoid process with the coronoid process fragments displaced
superiorly into the volar aspect of the elbow joint near the coronoid fossa,
best seen on series 306, image 60.
There is subluxation of the radial head posteriorly and widening of the
lateral radiocapitellar joint space, best seen on series 305, image 53.
Comminuted fracture of the lateral epicondyle is also seen, series 305, image
48. Evaluation for ligamentous injury is difficult; however, there is
prominent soft tissue swelling throughout the elbow.
IMPRESSION:
1. Fractures of the lateral epicondyle and coronoid process as described
above.
2. There is dislocation of the proximal ulna posteriorly and laterally in
relation to the trochlea.
3. Abnormal subluxation at the radiocapitellar articulation.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: R Elbow pain, s/p Fall
Diagnosed with Unsp fracture of lower end of right humerus, init, Fall same lev from slip/trip w/o strike against object, init
temperature: 98.3
heartrate: 75.0
resprate: 20.0
o2sat: 100.0
sbp: 154.0
dbp: 95.0
level of pain: 10
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 elbow fracture-dislocation and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for closed reduction and hinged external
fixation, 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 OT who determined that
discharge to home with family support 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
NWB in the operative extremity, and does not require DVT
prophylaxis on discharge. 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: NEUROSURGERY
Allergies:
sulfasalazine / Pyridium / heparin / codeine / tramadol
Attending: ___
Chief Complaint:
Worsening sensation changes in arms and legs. Pt states, "I
feel weird all over".
Major Surgical or Invasive Procedure:
___ C6 corpectomy, C4-C7 fusion
History of Present Illness:
Mrs. ___ is a ___ year-old female with a two year history of
peripheral neuralgia of her hands and feet. She has sought care
via her primary care physician and ___ neurologist for this
condition, among others as listed in her history (noted below).
The patient states that over the last month, she has begun to
experience worsening back pain ("my spine feels like it's on
fire"), as well as pain and numbness of her legs. She also
states that over the last two weeks, she suffered frequent
episodes of urinary and rectal incontinence.
Today, ___, Mrs. ___ saw her neurologist to review a MRI of
her spine. Due to concerns of spinal stenosis, the physician
advised the patient to seek care at the nearest emergency
department.
On exam, the patient explains that she has back pain from her
posterior neck down her entire spine, mainly mid-line.
Sensation
in her arms is symmetrical bilaterally. The patient states she
has pain in her anterior groin and thighs. Sensation is reduced
in both legs but symmetrical.
Past Medical History:
Asthma, IBS, Bipolar, ADD, PTSD, sciatica, neuropathy,
fibromyalgia
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
O: T 98 HR 98 BP 112/76 RR 18 O2 sat 100% on room air
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL, EOMs intact with observed bilateral lateral
nystagmus.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
Delt Bi Tri Grip Intrin IP Q Ham AT ___ ___
L 4 5 4- 5 3 ___ 5 4- 5
R 4 5 4- 5 3 ___ 4 4- 5
UE sensation symmetrical but slightly diminished.
___ sensation reduced but symmetrical.
No clonus, ___, saddle anesthesia. Rectal tone intact,
normal.
Reflexes:
Br Pa Ac
Right +2 +3 +2
Left +2 +3 +2
Rectal exam normal sphincter control.
On discharge:
AOx3, Full motor except bilateral grip, tricept, FI 4+/5.
Incision C/D/I
Medications on Admission:
Depakote 500mg BID, cymbalta 60mg daily, abilify 20mg daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/Wheeze
3. ARIPiprazole 20 mg PO DAILY
4. Diazepam 5 mg PO Q6H:PRN muscle spasm
RX *diazepam 5 mg 1 tab by mouth every six (6) hours Disp #*30
Tablet Refills:*0
5. Divalproex (DELayed Release) 500 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Duloxetine 60 mg PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Cervical fusion from C5-C7.
COMPARISON: Compared to outside hospital radiographs from ___
IMPRESSION:
Fluoroscopic images from the operating room demonstrate placement of a
corpectomy device within C6. There is anterior fusion from C5-C7. No hardware
related complications are seen. Please refer to the operative note for
additional details. The total intra service fluoroscopic time was 9.2 seconds.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Neck pain
Diagnosed with DISC DIS NEC/NOS-CERV
temperature: 98.0
heartrate: 98.0
resprate: 18.0
o2sat: 100.0
sbp: 112.0
dbp: 76.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ was admitted to the Neurosurgery service on ___ due
to concerns, as exhibited on MRI, of a spinal cord lesion at the
C5-C6 level. She was admitted to the inpatient ward and kept
NPO, given IV fluids overnight in preparation for an operative
intervention on her cervical spine. Surgical intervention was
discussed on ___. Dr ___ surgery's risks and
benefits and the patient consented to surgery. Surgery was moved
to ___ because of OR scheduling/ timing. The patient was kept
inpatient in preparation for surgery. On ___ Ms. ___ remains
neurologically intact with the exception of motor strength 4-
bilat tricep and 4+ right quad/hamstring. Ms. ___ was
consented for the OR and will be NPO for planned C6 corpectomy
and C5-C7 fusion on ___.
On ___, the patient was taken to the OR for her scheduled
procedure, which she tolerated well. Please see the operative
report for further details. Post-operatively, the patient was
recovered in the PACU and transferred to the inpatient ward for
further management and observation. Her pain was controlled with
narcotic and non-narcotic analgesics. On ___ her JP drain was
discontinued and her pain was controlled. She was ambulating
independently. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfur / clindamycin
Attending: ___.
Chief Complaint:
Fatigue, weakness, failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with a PMHx og pemphigus on steroids, HTN, recent PNA
treated as an outpatient p/w functional decline over the last 4
months.
Per patient report as well as available OMR records, 4 months
prior to her current admission the patient developed a dental
infection and subsequently had her chronic prednisone (had been
on for pemphigus) stopped by her PCP. The patient subsequently
developed weakness and fatigue. One month prior to this
admission, she was seen by her PCP who felt she may have adrenal
insufficiency and restarted her on prednisone/fludrocortisone.
Her symptoms initially improved and then worsened. The patient
subsequently developed severe hypokalemia and was started on
potassium supplementation. Five days prior to admission, the
patient was seen in ___ ED with the above complaints. She was
diagnosed with PNA and discharged home on levofloxacin. Per
report, the patient did not experience any improvement and
remained with poor PO intake and weakness.
The patient's nephew reports she has been urinating and stooling
in Tupperware and bags at home. She has not been eating and
sleeps very few hours per night. The family also reports a 25 lb
weight loss in the last month.
Per OMR documentation, she was referred to the ___ ED by a
medicine resident (who is currently caring for her husband who
is hospitalized with CLL complications).
In the ED, initial vs were: 98.4 74 148/72 14 99% 2L NC. Exam
was notable for frail female 4+/5 strength in extremities. Labs
were remarkable for WBC 9.5 with 81N, nl Hct, nl chem 7. CXR was
unremarkable. Patient was given 750mg levofloxacin and was
admitted to medicine for further management. Vitals on Transfer
97.8 73 147/66 15 99% RA.
On arrival to the floor, vitals were 97.9 111/53 74 16 98%RA
113lbs. Patient confirmed above story. Reported she has not
obtained her age-appropriate cancer screening (no colonoscopy
ever, no mammogram ever, cannot remember when her last pap smear
was). Son also noted, she has become increasingly "anxious"
during the above time, having difficulty with sleeping. He
reported that he has not noticed any confusion.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Pemphigus
- HTN
- GERD
- NIDDM
- Glaucoma
- h/o recent pneumonia
- h/o cataracts
- osteoporosis c/b vertebral fx
Social History:
___
Family History:
No family history of malignancy or cardiac disease.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.9 ___ 74 16 98%RA 113lbs
General: Elderly female, frail appearing, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, no LAD, no JVD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, ___ systolic murmur @ RUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no CVA tenderness
Ext: 2+ ___, no clubbing, cyanosis or edema
Skin: no blisters/bullae, rashes
Neuro: AOx3, ___ proximally over lower extremities, all else
___ and equal bilaterally, toes downgoing
DISCHARGE EXAM:
Vitals: 97.6 132/68 81 16 98% RA
General: Elderly female, anxious, frail appearing, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, no LAD, no JVD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, ___ systolic murmur @ RUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no CVA tenderness
Ext: 2+ ___, no CCE, lower extremity asymmetry L>R
Skin: no blisters/bullae, no rashes, overall very thin
Neuro: AOx3, ___ proximally over lower extremities, all else ___
and equal bilaterally, toes downgoing
Pertinent Results:
ADMISSION LABS:
___ 09:17AM BLOOD WBC-9.5 RBC-4.86 Hgb-14.7 Hct-44.5 MCV-92
MCH-30.3 MCHC-33.1 RDW-13.8 Plt ___
___ 09:17AM BLOOD Neuts-81.6* Lymphs-12.0* Monos-5.1
Eos-1.2 Baso-0.2
___ 09:17AM BLOOD Glucose-133* UreaN-17 Creat-0.8 Na-134
K-3.7 Cl-100 HCO3-23 AnGap-15
___ 09:17AM BLOOD ALT-20 AST-17 LD(LDH)-179 CK(CPK)-15*
AlkPhos-48 TotBili-0.6
___ 09:17AM BLOOD TotProt-5.8* Albumin-3.7 Globuln-2.1
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-7.7 RBC-4.44 Hgb-14.1 Hct-41.3 MCV-93
MCH-31.7 MCHC-34.1 RDW-13.9 Plt ___
___ 06:45AM BLOOD Glucose-117* UreaN-13 Creat-0.7 Na-139
K-3.4 Cl-103 HCO3-25 AnGap-14
___ 06:50AM BLOOD Glucose-138* UreaN-15 Creat-0.8 Na-143
K-4.5 Cl-105 HCO3-28 AnGap-15
___ 06:45AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0
PERTINENT LABS:
___ 06:39AM BLOOD ALT-14 AST-13 AlkPhos-41 TotBili-0.7
___ 09:17AM BLOOD ALT-20 AST-17 LD(LDH)-179 CK(CPK)-15*
AlkPhos-48 TotBili-0.6
___ 06:39AM BLOOD VitB12-217*
___ 09:17AM BLOOD %HbA1c-6.4* eAG-137*
___ 06:39AM BLOOD TSH-1.2
___ 06:39AM BLOOD Cortsol-15.1
CXR
FINDINGS:
The lungs are well expanded. A flask shaped opacity in the
right lower lobe is compatible with a large hiatal hernia.
There is no consolidation,
effusion, or pneumothorax. Cardiomegaly is mild. Aortic arch
calcifications are mild. Diffuse demineralization of the
osseous structures is noted with mild loss of height of multiple
thoracic vertebral bodies. Heterotopic ossifications vs. loose
bodies are noted in the left shoulder. IMPRESSION: 1. Large
hiatal hernia. 2. No acute cardiopulmonary abnormality.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 25 mg PO DAILY
2. Repaglinide 0.5 mg PO TIDAC
3. Omeprazole 40 mg PO BID
4. PredniSONE 5 mg PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
Discharge Medications:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
2. Omeprazole 40 mg PO BID
3. PredniSONE 2.5 mg PO DAILY
RX *prednisone 2.5 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
4. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
once daily Disp #*30 Tablet Refills:*0
5. Fludrocortisone Acetate 0.1 mg PO DAILY
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth once daily Disp
#*30 Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
7. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
RX *potassium chloride [Klor-Con] 20 mEq 1 tablet by mouth once
daily Disp #*30 Packet Refills:*0
8. Repaglinide 0.5 mg PO TIDAC
9. Outpatient Lab Work
Please draw CBC, Chem 10 on ___
Fax results to:
Name: ___.
Location: ___ PRIMARY CARE
Address: ___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___ syndrome
Mineralocorticoid deficiency
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: Poor oral intake and functional decline
COMPARISON: None at this institution
FINDINGS:
The lungs are well expanded. A flask shaped opacity in the right lower lobe
is compatible with a large hiatal hernia. There is no consolidation,
effusion, or pneumothorax. Cardiomegaly is mild. Aortic arch calcifications
are mild. Diffuse demineralization of the osseous structures is noted with
mild loss of height of multiple thoracic vertebral bodies. Heterotopic
ossifications vs. loose bodies are noted in the left shoulder.
IMPRESSION:
1. Large hiatal hernia.
2. No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: WEAKNESS
Diagnosed with OTHER MALAISE AND FATIGUE
temperature: 98.4
heartrate: 74.0
resprate: 14.0
o2sat: 99.0
sbp: 148.0
dbp: 72.0
level of pain: 0
level of acuity: 3.0 | ___ yo female with a past medical history of pemphigus, on long
term corticosteroids, with recent functional decline of
uncertain etiology.
# Functional decline: The patient and her family report a rapid
functional decline starting 4 months prior to the patient's
hospitalization. The patient was referred to the ___ emergency
department by a member of the housestaff who was caring for her
husband on the ___. The patient has a history of chronic
steroid use for pemphigus (prednisone 12.5 mg QOD x years, with
higher doses in the past), although the disease has been
inactive for many years. The patient's overall past medical
history is concerning for iatrogenic ___ syndrome
evidenced by cataracts, glaucoma, psychiatric disturbances,
proximal weakness/wasting (CK 15), glucose intolerance (A1C
6.4), recent infections (dental abscess, pneumonia),
osteoporosis c/b vertebral fractures and skin thinning. Her more
recent problems stem from treatment of a dental abscess. While
undergoing treatment for the abscess her corticosteroids were
stopped. She was re-evaluated by her PCP who diagnosed her with
adrenal insufficiency. She was started on cortisone acetate 5 mg
BID and fludrocortisone. She subsequently developed severe
hypokalemia and a more rapid physical decline including
substantial weight loss. Her major complaints include weakness,
decreased appetite and fatigue. She had no focal neurologic
findings. She was able to stand from a seated position. Her B12
was found to be low and she was started on supplementation. TSH
was normal (1.2) as was AM cortisol (15). The patient's albumin
was 3.7. MMSE score ___. She was found to be orthostatic. The
patient also admitted to depression given her current physical
state and her husband's illness. Overall her presentation was
consistent with iatrogenic ___ and mineralocorticoid
deficiency. She was discharged on prednisone 2.5 mg daily and
fludrocortisone 0.1 mg daily. Potassium supplementation was
provided as well. The patient should undergo diagnostic and age
appropriate cancer screening due to her significant weight loss.
Treatment for depression should be considered as well.
# GERD/ulcer prophylaxis: Stable. The patient was continued on
omeprazole while hospitalized. The need for a PPI should be
reassessed if the patient is fully tapered off of
corticosteroids.
# Glaucoma: Stable. The patient was continued on brimonidine eye
drops.
# Diabetes mellitus: The patient's diabetes was most likely
induced by her long term corticosteroid use. Her A1C was 6.4%.
She was given sliding scale insulin while hospitalized.
Rapaglinide was continued at discharge.
TRANSITIONAL ISSUES
*******************
1. PCP follow up
2. Taper prednisone and fludrocortisone as appropriate
3. Please check CBC, Chem 10 on ___
4. Diagnostic and age appropriate cancer screening recommended
5. Consider treatment for depression |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
tetracycline / codeine / BuSpar
Attending: ___.
Chief Complaint:
Back pain and fecal incontinence.
Major Surgical or Invasive Procedure:
None. You were offered surgery but declined and requested to
wait until after the holiday.
History of Present Illness:
___ y/o female with history of back surgery x2, posterior
instrumented fusion of L3-5, now with back pain for the last few
weeks. Presented to ___, an MRI was obtained and
showed multifactorial lumbar stenosis with complete effacement
of
CSF at L1-2, and retrolisthesis of L1 on L2. The patient
endorses
intermittent fecal incontinence the last few days with worsening
back pain. She endorses back pain that radiates to bilater
groins, and numbness to bilateral knees that extends down to
bilateral inner calves.
Past Medical History:
HTN, DM, HLD, MI s/p cardiac stent on Plavix, Depression,
gastric ulcer, Bilateral knee replacements about ___ yrs ago and
back surgeries x2 with posterior fusion 5 and ___ years ago.
Social History:
___
Family History:
NC
Physical Exam:
On the day of discharge:
Patient is awake and alert. TLSO at bedside.
Bilateral IP 4+/5
Left ___ ___
Left gastro ___
Paresthesia to R knee (baseline s/p B/L knee replacement)
Paresthesia from the lateral aspect of her L knee to L distal
great toe.
Poor effort with exam.
Pertinent Results:
CT L-SPINE W/O CONTRAST Study Date of ___ 10:10 ___
1. Status post laminectomy and posterior fusion of L3 through L5
without
definite evidence of hardware related complications. Note is
made of the left L5 pedicle screw which appears to extrude
beyond the vertebral body by 11mm.
2. Severe degenerative disc disease at L1/L2 causing severe
spinal canal
stenosis.
3. Bilateral punctate renal stones with mild fullness of the
right renal
collecting system.
L-SPINE FLEX AND EXT (2 VIEWS) Study Date of ___ 10:33 AM
IMPRESSION:
There has been posterior fusion extending from L3 to L5. No
definite hardware complications are seen on these radiographs;
however, the recent CT scan demonstrated extrusion of the left
L5 pedicle screw beyond the anterior margin of the vertebral
body. There are degenerative changes with loss of
intervertebral disc height at multiple levels. There is
retrolisthesis of L1 over L2 which measures 5 mm on flexion and
10 mm on extension. This constitutes abnormal motion. No
definite compression deformities are seen.
CXR ___
No previous images. Cardiac silhouette is within normal limits
and there is no vascular congestion, pleural effusion, or acute
focal pneumonia.
Of incidental note is evidence of a is lumbar fusion device.
Medications on Admission:
Metoprolol, Nitro SL prn, Aspirin, Plavix, Alprazolam, Lipitor,
Metformin Flexeril, Colace, Prozac Imdur, Tramadol, and
Protonix.
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN fever/pain
2. ALPRAZolam 0.5 mg PO TID:PRN anxiety
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl 10 mg PO/PR DAILY
5. Cyclobenzaprine 5 mg PO TID
6. Fluoxetine 20 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Metoprolol Tartrate 25 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
Q4 hours Disp #*30 Tablet Refills:*0
12. Pantoprazole 40 mg PO Q12H
13. TraMADOL (Ultram) 50 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Severe spinal stenosis L1-L2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: ___ with possible cauda equina on OSH MRI. Evaluate for spinal
hardware.
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 6.8 s, 26.6 cm; CTDIvol = 32.1 mGy (Body) DLP = 853.1
mGy-cm.
Total DLP (Body) = 853 mGy-cm.
COMPARISON: None.
FINDINGS:
There are 5 non rib bearing lumbar vertebral bodies. Note is made of partial
sacralization of the L5 vertebral body. Streak artifact from spinal fusion
hardware limits assessment of the lower lumbar spine. Given this limitation,
there is no acute fracture. Patient is status post laminectomies at L3
through L5 with posterior spinal fusion. Interbody spacers are seen from
L2-L3 through L4 -L5. Overall fusion hardware appears intact without definite
evidence of failure or loosening. Note is made of that the left L5 pedicle
screw appears to extrude beyond the vertebral body by approximately 11 mm
(2:70).
Severe degenerative changes are seen throughout the lumbar spine. There is
mild retrolisthesis of L1 on L2. There is a disc bulge at L1/L2 causing
severe spinal canal stenosis as well as moderate bilateral neural foraminal
narrowing. Remaining intrathecal detail is limited due to streak artifact
from the hardware.
Evaluation of the soft tissues is remarkable for moderate atherosclerotic
calcifications. Bilateral punctate renal stones are noted with mild fullness
of the right renal collecting system.
IMPRESSION:
1. Status post laminectomy and posterior fusion of L3 through L5 without
definite evidence of hardware related complications. Note is made of that the
left L5 pedicle screw which appears to extrude beyond the vertebral body by
11mm.
2. Severe degenerative disc disease at L1/L2 causing severe spinal canal
stenosis.
3. Bilateral punctate renal stones with mild fullness of the right renal
collecting system.
Radiology Report
INDICATION: ___ year old woman with retrolisthesis and stenosis. Please
evaluate stability. // ___ year old woman with retrolisthesis and stenosis.
Please evaluate stability.
COMPARISON: CT scan from ___
IMPRESSION:
There has been posterior fusion extending from L3 to L5. No definite hardware
complications are seen on these radiographs; however, the recent CT scan
demonstrated extrusion of the left L5 pedicle screw beyond the anterior margin
of the vertebral body. There are degenerative changes with loss of
intervertebral disc height at multiple levels. There is retrolisthesis of L1
over L2 which measures 5 mm on flexion and 10 mm on extension. This
constitutes abnormal motion. No definite compression deformities are seen.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ y/o with hx of back surgery x2, with fusion of L3-5, now with
back pain and fecal incontinence. // Pre-op testing Surg: ___
(Laminectomy) LOW BACK PAIN;CORD COMPRESSION
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits and there is
no vascular congestion, pleural effusion, or acute focal pneumonia.
Of incidental note is evidence of a is lumbar fusion device.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with Other intervertebral disc degeneration, lumbar region
temperature: 97.4
heartrate: 74.0
resprate: 18.0
o2sat: 98.0
sbp: 173.0
dbp: 70.0
level of pain: 0
level of acuity: 1.0 | On ___ the patient presented to an OSH for back pain and fecal
incontinence and was transferred to ___ for further evaluation
after an MRI was obtained and was consistent with lumbar
stenosis with complete effacement of CSF at L1-2, and
retrolisthesis of L1 on L2. The patient was admitted to the
Neurosurgery service and was admitted to the floor for further
care and evaluation.
On ___ the patient had flexion and extension films done which
demonstrated that the patient has extrusion of the left L5
pedicle screw beyond the anterior margin
of the vertebral body. There are degenerative changes with loss
of intervertebral disc height at multiple levels. There is
retrolisthesis of L1 over L2 which measures 5 mm on flexion and
10 mm on extension. This constitutes abnormal motion. She
remained neurologically intact with paresthesias to her right
knee although stated this has been stable since she had a knee
replacement ___ years ago, and also endorsed paresthesias from the
lateral aspect of her left knee to left distal great toe. Her
dexamethasone regimen was discontinued.
On ___ surgery was offered to patient who declined until after
___. TLSO brace ordered. ___ consult placed.
On ___ the patient's exam remained neurologically stable. Her
pain was well controlled. Surgery was again offered but was
declined by the patient as she requested to wait until after the
holiday. She was seen by ___ while wearing the TLSO brace and was
recommended for home ___. She was discharged in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
pericardial drain placement
History of Present Illness:
Mr. ___ is ___ ___ yo s/p
___ x1 on ___ whose post op course was complicated by acute
kidney injury requiring dialysis, post operative seizure with
negative head CT on dilantin followed by neurology, atrial
fibrillation on coumadin. He has been stable for the last week,
his weight has not changed, and over the last 3 days he has
noticed increased shortness of breath. He denies fever or
chills,
no productive sputum, denies chest pain or palpitations, no
increase in lower extremity edema. His shortness of breath has
worsened today with dyspnea on minimal exertion, but denies
problems lying flat. He went to ___ where he had an
echocardiogram which showed a moderate to large pericardial
effusion. He was transfered for further evaluation
Past Medical History:
Aortic stenosis
Hypertension
Hyperlipidemia
Mild COPD
Bladder cancer - BCG Irrigations to bladder
Transitional cell carcinoma s/p radical nephrectomy
Coronary artery disease s/p bare metal stent to RCA - ___
Ulcer
Diverticular disease
Cholelithiasis s/p cholecystectomy
Left hydrocele
? Sleep apnea (patient has not been evaluated)
BPH
Past Surgical History:
- Radical left nephrectomy ___ s/p 3.0 x 15mm Pomus drug eluting stent to mid RCA
- (B)total knee replacement ___ and ___
- bladder tumor resection ___
- open B carpal tunnel release ___
- TURP ___
Social History:
___
Family History:
Mother died of acute MI age ___, no prior known cardiac history.
Father died at ___, unknown cause, had Alzheimers. Sister had ___
for AS at age ___, doing well. No known history of cancers.
Physical Exam:
admission Physical examination:
Pulse:52 SB Resp:16 O2 sat:96% on 2L NC
B/P Right:164/57 Left:
Height: Weight:
General:well appearing in minimal distress
Skin: Dry [x] intact [x]
HEENT: PERRL [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs bilateral expiratory wheezes, bibasilar rales L>R,
forced exhillation with use of abdominal muscles
Heart: RRR [x] Irregular [] No Murmur [] grade ______
Abdomen: Soft [x] obese, non-distended [x] non-tender [x] bowel
sounds +[x]
Extremities: Warm [x], well-perfused [x] Edema [x] _2+____
Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
DP Right:1+ Left:1+
___ Right:1+ Left:1+
Radial Right:2+ Left:2+
Pertinent Results:
Pre-op TTE ___
FOCUSED STUDY/LIMITED VIEWS: Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
There is a large pericardial effusion. The effusion appears
circumferential. It is smallest in the subcostal views anterior
to the RV (0.5cm) and largest in the apical views (up to 3cm)
and posterior to the heart (2.6cm). No right ventricular
diastolic collapse is seen. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling.
Discharge TTE ___
labs
___ 04:37AM BLOOD WBC-7.4 RBC-2.74* Hgb-8.4* Hct-25.9*
MCV-95 MCH-30.7 MCHC-32.4 RDW-16.3* RDWSD-54.4* Plt ___
___ 02:17AM BLOOD WBC-7.1 RBC-2.53* Hgb-7.6* Hct-24.0*
MCV-95 MCH-30.0 MCHC-31.7* RDW-16.0* RDWSD-54.4* Plt ___
___ 04:37AM BLOOD ___ PTT-28.1 ___
___ 02:17AM BLOOD ___ PTT-27.6 ___
___ 08:10PM BLOOD ___ PTT-28.8 ___
___ 02:22AM BLOOD ___ PTT-31.0 ___
___ 04:37AM BLOOD Glucose-108* UreaN-40* Creat-3.1* Na-143
K-3.8 Cl-108 HCO3-20* AnGap-19
___ 02:17AM BLOOD Glucose-114* UreaN-42* Creat-3.2* Na-140
K-4.2 Cl-108 HCO3-20* AnGap-16
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Amiodarone 400 mg PO BID
7. Aspirin EC 81 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Metoprolol Tartrate 50 mg PO TID
10. Phenytoin Sodium Extended 130 mg PO TID
11. ___ MD to order daily dose PO DAILY16 afib
12. Multivitamins 1 TAB PO DAILY
13. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat)
100 mcg/0.5 mL injection 1X/WEEK
14. Acetaminophen 650 mg PO Q4H:PRN pain
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Metoprolol Tartrate 50 mg PO TID
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Phenytoin Sodium Extended 130 mg PO TID
10. Pravastatin 40 mg PO QPM
11. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat)
100 mcg/0.5 mL injection 1X/WEEK
12. Acetaminophen 650 mg PO Q4H:PRN pain
13. HydrALAzine 25 mg PO Q6H
RX *hydralazine 25 mg 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*0
14. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Capsule Refills:*0
15. Warfarin 1 mg PO DAILY16
dose to change daily per Dr. ___ goal INR ___, dx: AFib
RX *warfarin 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
16. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pericardial effusion with tamponade
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema - trace
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man post apical pericardiocentesis // r/o left lung
pneumothorax
COMPARISON: ___
IMPRESSION:
Pericardial drain is in situ. No evidence of pneumothorax or
pneumomediastinum. Otherwise unchanged radiograph.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with s/p pericardiocentesis // eval tamponade
Contact name: ___: ___
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the size of the cardiac silhouette has
not substantially changed. No pulmonary edema. No pleural effusions. No
pneumonia. Moderate retrocardiac atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p pericardial window // eval for pneumothorax
s/p pericardial drain removal eval for pneumothorax s/p pericardial drain
removal
COMPARISON: PRIOR CHEST RADIOGRAPHS ___.
IMPRESSION:
RETROCARDIAC OPACITY IS LARGELY LEFT LOWER LOBE ATELECTASIS AND SMALL
EFFUSION, NOT APPRECIABLY CHANGED RECENTLY. LUNGS OTHERWISE CLEAR. HEART
SIZE BORDERLINE ENLARGED. LEFTWARD TRACHEAL DEVIATION REFLECTS LARGE CHRONIC
THYROID MASS.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with ACUTE PERICARDITIS NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 97.6
heartrate: 54.0
resprate: 24.0
o2sat: 97.0
sbp: 164.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | Patient was admitted to the cardiac surgery service and was
taken urgently to the cath lab for drainage of pericardial
effusion that was causing tamponade physiology.
He tolearted the proceedure well. A pericardial drain was placed
for drianage of approximately 620cc of bloody drainage. He was
transferred to the CVICU for monitoring. During his stay in the
ICU he was hypertensive and medications were adjusted. He had
episodes of rapid afib and was bolused with amiodarone and
continued on amiodarone taper. He was resumed on coumadin
therapy. His pericardial drain was removed on POD#1. He remained
HD stable. TTE was obtained at discharge which was unchnaged
from previous per report.
He was cleared for discharge to home on POD# 2 All f/u
appointments arranged. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
SOB and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ ___ y/o M with a PMH of
paroxysmal a. flutter on eliquis, constrictive pericarditis,
ischemic cardiomyopathy (LVEF 40%), type 2 DM and HTN who
presents with SOB and fatigue and is diagnosed with atrial
flutter with RVR and acute on chronic sCHF.
Patient interrogated with grandson as interpreter. According to
the family the patient has had a progressive decline in his
health status during the past few months. He reports
palpitations that appear with minimal exertion, (walking around
room, getting dressed) as well as SOB.
He had been diagnosed with atrial flutter and was found to have
a RVR recently, with HR around 110. This was attributed to
missed doses of metoprolol, so the dose was increased (from 50mg
to 100mg Po QD) . The nurse who takes care of him has recently
remarked that the patient is weak, fatigued and anorexic.
Patient was brought to ED because nurse was concerned of
worsening status, found HR of 140. He also reports non-bloody
emesis yesterday.
In the ED intial vitals were: 97 ___ 16 985 RA
EKG: Atrial flutter with RVR of 114
Labs/studies notable for: Hb 11.5 glucose 153 HCO3 15 Anion gap
28 Urine WBC 180.
Patient was given: 250 cc NS
Vitals on transfer: 98.2 98 ___ 99%RA
On the floor 97.2 ___ 22 99% RA
ROS: Patient reports palpitations since a few months ago that
appears with mild activity. He presents SOB particularly when he
breathes in deeply.
The family has noticed persistent leg edema in the past 6 months
and believe he is constantly fatigued and weak.
Patient reports ortophnea.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension(+), dyslipidemia (+),
diabetes (+)
2. CARDIAC HISTORY:
- Constrictive pericarditis, diagnosed on ___. Etiology most
likely viral. Negative TB tests.
- Paroxysmal atrial flutter with RVR: on eliquis since ___
- Ischemic cardiomyopathy (LVEF 40%)
3. OTHER PAST MEDICAL HISTORY:
- PVD complicated with osteomyelitis R hallux (___).
Required debridement and antibiotics.
- Type II DM
- Hypertension
- Hx basal cell carcinoma
- Osteoarthritis
- GERD
- Depression
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
===============================
VS: 97.2 ___ 22 99% RA
Weight: 70.5kg
GENERAL: Cachexic gentleman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pale, no cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10-11 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Arrhythmic, 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. Crackles predominantely
in left base, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ edema in BLE. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric 2+
DISCHARGE PHYSICAL EXAMINATION
===============================
VS: 98 ___ 90-96%RA
Weight: 68kg
GENERAL: Cachexic gentleman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pale, no
cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with elevated JVP up to jaw.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Arrhythmic, 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: Trace/1+ edema in BLE. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric 2+
Pertinent Results:
ADMISSION LAB RESULTS
======================
___ 04:00PM BLOOD WBC-7.9 RBC-4.51* Hgb-11.5* Hct-37.4*
MCV-83 MCH-25.4* MCHC-30.7* RDW-17.6* Plt ___
___ 04:00PM BLOOD Neuts-70.3* ___ Monos-9.1 Eos-0.3
Baso-0.2
___ 04:00PM BLOOD ___ PTT-34.4 ___
___ 02:46PM BLOOD Glucose-151* UreaN-48* Creat-1.6* Na-129*
K-GREATER TH Cl-101 HCO3-16*
___ 04:19PM BLOOD K-5.0
PERTINENT LAB RESULTS
======================
___ 10:40AM BLOOD ___ PTT-35.6 ___
___ 10:40AM BLOOD Plt ___
___ 01:30PM BLOOD UreaN-59* Creat-1.8* Na-131* K-5.3* Cl-97
HCO3-18* AnGap-21*
___ 10:40AM BLOOD ALT-480* AST-469*
___ 07:05AM BLOOD Lactate-4.3*
DISCHARGE LAB RESULTS
======================
___ 05:45AM BLOOD WBC-6.3 RBC-4.52* Hgb-11.5* Hct-37.7*
MCV-84 MCH-25.6* MCHC-30.6* RDW-18.1* Plt ___
___ 05:45AM BLOOD ___ PTT-31.2 ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-193* UreaN-42* Creat-1.4* Na-144
K-3.8 Cl-103 HCO3-28 AnGap-17
___ 05:45AM BLOOD ALT-465* AST-367*
___ 05:45AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.7
___ 05:45AM BLOOD %HbA1c-8.0* eAG-183*
___ 06:45AM BLOOD ___ pO2-42* pCO2-51* pH-7.29*
calTCO2-26 Base XS--2 Comment-GREEN TOP
___ 06:45AM BLOOD Lactate-3.2*
OTHER RESULTS
==============
ECG (___)
Possible atrial fibrillation or atrial flutter with rapid
ventricular response. Decreased voltages in the limb leads.
Non-specific intraventricular conduction delay and extensive
ST-T wave changes which could be suggestive of myocardial
ischemia or cardiomyopathy. Clinical correlation is suggested.
Compared to the previous tracing of ___ the heart rate is
slightly faster, although the extensive abnormalities are still
present
CHEST (PA,LAT) ___
IMPRESSION:
Small left pleural effusion with left lower lobe opacity, which
may reflect
atelectasis, however pneumonia cannot be excluded.
Mild interstitial pulmonary edema
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Atorvastatin 20 mg PO QPM
3. Colchicine 0.6 mg PO EVERY OTHER DAY
4. Furosemide 20 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. MetFORMIN (Glucophage) 500 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Paroxetine 10 mg PO DAILY
10. Ketoconazole Shampoo 1 Appl TP DAILY
11. Fluocinonide 0.05% Ointment 1 Appl TP BID
12. Lactulose 30 mL PO BID:PRN constipation
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. Atorvastatin 20 mg PO QPM
3. Furosemide 20 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Paroxetine 10 mg PO DAILY
6. Digoxin 0.0625 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Colchicine 0.6 mg PO EVERY OTHER DAY
9. Cefpodoxime Proxetil 100 mg PO Q12H
10. Fluocinonide 0.05% Ointment 1 Appl TP BID
11. Ketoconazole Shampoo 1 Appl TP DAILY
12. Lactulose 30 mL PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Atrial flutter with rapid ventricular response
Acute on chronic systolic cardiac heart failure
Lactic acidosis due to metfromin overdose
Acute kidney injury
Acute liver failure
Urinary tract infection
SECONDARY DIAGNOSIS
Coronary artery disease
Type II diabetes mellitus
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with constrictive cardiomoypathy, increasing fatigue
// r/p pulm edema, pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs dated ___ through ___.
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate small left pleural
effusion with left lower lobe opacity, which may reflect atelectasis, however
pneumonia cannot be excluded. There is a small right pleural effusion and mild
interstitial pulmonary edema. Cardiomediastinal hilar contours are unchanged.
No pneumothorax.
IMPRESSION:
Small left pleural effusion with left lower lobe opacity, which may reflect
atelectasis, however pneumonia cannot be excluded.
Mild interstitial pulmonary edema.
NOTIFICATION: Updated read was discussed with Dr. ___ by Dr. ___
telephone at 16:52 on ___, approximate 30 min after discovery.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with ATRIAL FIBRILLATION, HEART FAILURE NOS, ATRIAL FIBRILLATION, HYPERTENSION NOS
temperature: 97.0
heartrate: 110.0
resprate: 16.0
o2sat: 98.0
sbp: 99.0
dbp: 50.0
level of pain: 0
level of acuity: 3.0 | ___ y/o M with a PMH of paroxysmal a. flutter on eliquis,
constrictive pericarditis, ischemic cardiomyopathy (LVEF 40%),
type 2 DM and HTN who presents with SOB and fatigue and is
diagnosed with atrial flutter with RVR, acute on chronic sCHF,
___, ALF and urinary tract infection.
ACTIVE ISSUES
# Atrial flutter: Patient with PMH of paroxysmal afib, is
admitted with atrial flutter with a RVR of 114. Patient was
given a loading dose of digoxin 0.125 mg PO/NG Q6H (2 Doses),
and was then mantained on digoxin 0.0625mg PO QD and metoprolol
tartrate 25mg PO Q6H. Patient's HR around ___ with
medication, asymptomatic. Will be kept on that dose of digoxin,
and will receive metoprolol succinate 100mg QD. Has indication
for anticoagulation, is receiving apixaban 2.5 mg PO/NG BID.
# Acute on chronic sCHF: Patient with PMH of ischemic
cardiomyopathy with an LVEF 40%. At admission the PE was
suggestive of mild fluid overload (JVP elevated to jaw,
billateral crackles and +1 edema in BLE). However, due to
constrictive pericarditis, diuresis was managed with caution. He
received lasix IV bolus of 20 mg and was then transitioned back
to home dose of furosemide 20mg PO QD. His discharge weight is
68kg (down from 70.5 at admission).
# Metabolic acidosis high anion gap/ Lactic acidosis: At
admission lactate was 4.3 and patient had a high anion gap that
peaked at 28. The lactic acidosis was attributed to
hypoperfusion and/or metformin overdose. The patient has shown
slow downtrend throughout hospitalization. Last lactate= 3.2.
# ___: Patient admitted with Cr: 1.6. (Baseline ___. Probably
secondary to hypoperfusion. Peaked at 1.8. At discharge 1.4.
# Acute liver failure: There was evidence of transaminitis since
admission, with ALT 374 AST 377. There was also an increase in
INR up to 2.9 and the patient was not oriented (possible grade I
hepatic encephalitis). The lab values downtrended slowly with
medications and patient's mental status improved.
# UTI: Urine culture was positive for PROTEUS MIRABILIS
>100,000 ORGANISMS/ML. The patient did not report any symptoms.
He received ceftriaxone 1g Q24H for 5 days and will be sent home
with cefpodoxime 100 mg Q12h for 2 days.
# Disposition: On ___, the patient reported to the team that
he adamantly wished to be discharged home. His providers had
been working on getting rehab placement, and occupational
therapy had recommended either home with 24-hour supervision or
rehab placement. Given the patient's insistence, the risks and
benefits of going home without adequately supervision were
explained to his daughter, ___. Risks included
potentially life threatening falls and his impaired ability to
call for help appropriately. Attempts were made to discuss the
patient's care with the patient, but his grandson, who was by
the bedside, was incredibly rude to the care team and
particularly to the ___ interpreter; he refused to step out
of the patient's room when asked.
CHRONIC ISSUES
# CAD: Evidence of CAD on past stress test. No current CP.
Patient was kept on Atorvastatin 20 mg PO/NG QPM
# Type II DM: had been receiving metformin at home. HPI
suggested metformin toxicity, so patient was kept on an insulin
sliding scale. Fingersticks in 150s-200s. Patient will be
discharged without metformin, shoulf F/U diabetes treatment with
PCP. A1C 8.0%
# Dyslipidemia: Will be kept on Atorvastatin 20 mg PO/NG QPM
# Depression: Will be kept on Paroxetine 10 mg PO/NG DAILY
# FEN: Heart-Healthy diet |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Reglan / IV Dye, Iodine Containing / Phenergan Plain
/ Vicodin / Percocet
Attending: ___.
Chief Complaint:
Acute on chronic Migraine
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH notable for chronic migraine and right total knee
replacement ___ and recent knee infection s/p washout and IV
antibiotics ___, presenting with one week of diarrhea and
severe ___ migraine headache.
Patient was discharged from ___ following her
knee washout about one month ago on IV ertapenem, then was
switched to IV clindamycin about one week ago. States that she
developed watery, non-bloody diarrhea around that time and was
tested for C diff which was negative. Clindamycin was stopped
three days ago and PICC line was discontinued. Endorses fever to
___ two days ago and has since been taking Tylenol around the
clock.
The patient reports a ___, throbbing headache primarily over
the R forehead but also w/ L-sided pain for the past 2-days, w/
10 episodes of associated emesis, nonbloody and non-bilious. No
photophobia or phonophobia. Per OMR and the patient, these
features are characteristic of her migraine headaches, for which
she is on prophylaxis with lamotrigine, and which she tries to
treat with zofran and ibuprofen. She has failed treatment with
calcium She believes that these severe headaches have been
becoming more frequent (used to occur every ___ months, now
every ___ months). She is managed for her migraines as an
outpatient w/ plan for botox injection.
With regards to her knee, she has noted some swelling of the
knee and states that the pain is about the same. She has been
able to ambulate on her knee with a crutch.
In the ED, initial vitals are as follows: 98.4 16 99/59 16
100%RA.
Exam was notable for abdomen soft, tender to palpation in LLQ
and hypogastrium with guarding. Right knee with +edema, no
erythema, able to range fully. Labs notable for non-gap
metabolic acidosis. The pt had non-con CT abdomen/pelvis which
was limited without IV contrast, No gross bowel pathology, No
large fluid collections or free air. In the ED, she received 3L
of NS. She also received 1mg Dilaudid IV x for abdominal
discomfort and migraine, 4mg IV Zofran x2. Vitals prior to
transfer 98.8F, 72, 16, 98/68, 98%RA.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- Chronic migraines with frequent hospitalizations/ED visits,
followed by neurology as an outpatient
- Asthma
PAST SURGICAL HISTORY
1) Diagnostic laparoscopy (lysis of adhesions, no endometriosis,
+small fibroid) - ___
2) Hysteroscopy/D&C - ___
3) Occipital muscle release - ___
4) Total knee replacement ___ - complicated by infection and
washout ___
5) Laparoscopic detorsion - ___
6) Septoplasty and turbinate resection on the right side
Social History:
___
Family History:
Mother and grandmother have migraine headaches.
Brother and mother have hypertension.
Father died of "liver cancer" ___.
Maternal uncle - colon cancer.
No breast or gynecologic cancers.
Physical Exam:
Initial physical exam:
Vitals - 98.0, 94/56, 58, 18, 99% RA
GENERAL: Well-appearing, NAD
HEENT: MMM, NCAT
CARDIAC: RRR, no M/R/G
LUNG: CTAB
ABDOMEN: Soft, nondistended, nontender
EXT: R knee with longitudinal incision from TKR. Full ROM of R
knee. Warmth of R knee is appreciated but no erythema. Small (1
cm ) pocket of swelling is appreciated in anterolateral knee.
Ext otherwise warm and well perfused.
NEURO: ___ R hip flexion, ___ L hip flexion, ___ R knee
extension/flexion, ___ L knee extension/flexion. ___
dorsiflexion and plantarflexion bilaterally. CN II-XII intact.
Good memory and concentration. No dysdiadokinesis. normal gait.
Discharge physical exam:
Vitals: 98.3 56-86, 94-104/56-74, 18, 97% on RA
Gen: Well-appearing, NAD
HEENT: MMM
Heart: RRR, no M/R/G
Lungs: CTAB
Abd: Bowel sounds intermittently audible without stethoscope.
Nondistended. Soft. Tender in midline of lower abdomen.
Ext: Right knee is warm and with 1 cm pocket of effusion,
similar to adission. 90 degrees ROM of R knee, ROM of R hip
flexion to 120 degrees.
Neuro: CNII-XII intact. Fluent speech, conversant. No
photophobia or phonophobia. Normal strength of upper
extremities.
Pertinent Results:
___ 01:00PM BLOOD CRP-0.2
___ 09:40AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.2
___ 12:00AM BLOOD Glucose-90 UreaN-25* Creat-0.8 Na-137
K-4.5 Cl-112* HCO3-17* AnGap-13
___ 01:00PM BLOOD ESR-6
___ 03:10AM BLOOD ___ PTT-33.7 ___
___ 09:40AM BLOOD ___ PTT-36.2 ___
___ 12:00AM BLOOD Neuts-43.7* Lymphs-47.3* Monos-4.1
Eos-3.4 Baso-1.5
___ 12:00AM BLOOD WBC-6.3 RBC-3.96* Hgb-12.4 Hct-38.6
MCV-97 MCH-31.4 MCHC-32.2 RDW-13.3 Plt ___ X ray knee:
FINDINGS: The knee prosthesis appears similar to prior with a
three-part
total knee prosthesis with cemented components and a single
horizontal screw
through the proximal tibia at the lower end of the cement.
There is no
fracture, bone destruction, or evidence of loosening.
___ CT A+P:
IMPRESSION: Limited exam, without evidence of acute bowel
pathology or large
fluid collections.
___ CXR:
IMPRESSION: Normal chest.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Ondansetron 8 mg PO Q8H:PRN migraines
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing/sob
3. LaMOTrigine 300 mg PO DAILY
4. Warfarin 4 mg PO DAILY Duration: 4 Days
5. Fluticasone Propionate 110mcg 4 PUFF IH BID
Discharge Medications:
1. Fluticasone Propionate 110mcg 4 PUFF IH BID
2. LaMOTrigine 300 mg PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing/sob
4. Ondansetron 8 mg PO Q8H:PRN migraines
5. Enoxaparin Sodium 30 mg SC Q12H Duration: 3 Doses
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic migraine
Diarrhea
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with fever.
COMPARISON: CT torso from ___.
CHEST, PA AND LATERAL: The lungs are clear. The cardiomediastinal and hilar
contours are normal. There are no pleural effusions or pneumothorax.
IMPRESSION: Normal chest.
Radiology Report
INDICATION: ___ female with right total knee arthroplasty and recent
infection, post-washout and IV antibiotics one month ago. Presents with
abdominal pain and diarrhea x1 week after being switched from ertapenem to
clindamycin, which was stopped two days ago. Evaluate for colitis or abscess.
___.
TECHNIQUE: Helical MDCT images were acquired from the lung bases through the
greater trochanters without intravenous contrast, due to the patient's
reported contrast allergy with anaphylaxis. Oral contrast was administered.
5-mm axial, coronal, and sagittal multiplanar reformats were generated.
FINDINGS: There is mild atelectasis at the lung bases. No pleural effusion
is present. Heart is normal in size, with trace physiologic pericardial
fluid. Relative hypoattenuation of the blood pool is compatible with anemia.
ABDOMEN: There are no large intra-abdominal fluid collections to suggest
abscess. No pneumatosis, pneumoperitoneum, or portal/mesenteric venous gas.
The liver, gallbladder, pancreas, and spleen are unremarkable on this
non-contrast examination. There is no intra- or extra-hepatic biliary ductal
dilation.
The adrenals are normal. Kidneys are symmetric, without stones or
hydronephrosis.
The stomach and small bowel are unremarkable.
PELVIS: The appendix is normal. There is moderate amount of retained fecal
material throughout the colon. Scattered descending colonic diverticula,
without acute inflammation. The bladder and distal ureters are normal. The
uterus and ovaries are unremarkable. There is no free intraperitoneal fluid
or air.
Interval development of degenerative changes at L3-L4, with moderate loss of
disc height, endplate sclerosis, and subchondral cysts. Persistent changes at
L4-L5.
IMPRESSION: Limited exam, without evidence of acute bowel pathology or large
fluid collections.
Radiology Report
KNEE FILMS ON ___
HISTORY: Swollen painful right knee joint status post TKA.
REFERENCE EXAM: ___.
FINDINGS: The knee prosthesis appears similar to prior with a three-part
total knee prosthesis with cemented components and a single horizontal screw
through the proximal tibia at the lower end of the cement. There is no
fracture, bone destruction, or evidence of loosening.
Gender: F
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: DIARRHEA
Diagnosed with DIARRHEA, NAUSEA
temperature: 98.4
heartrate: 16.0
resprate: 16.0
o2sat: 100.0
sbp: 99.0
dbp: 59.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with hx of right total knee
replacement, recently hospitalized at ___ for knee
infection s/p washout, s/p one month course of IV antibiotics,
admitted for one week of non-bloody diarrhea and migraine.
#Migraine: The patient's migraine improved with IV fluids, IV
zofran, and IV dilaudid 3 mg q2H prn pain. She briefly reported
nausa and emesis during this time, which resolved on its own.
The day prior to discharge, patient started to feel better.
#Diarrhea: This spontaneously improved upon admission such that
she had no bowel movements on HD1, one bowel movement on HD2,
and no bowel movements on HD 3. C diff repeated at ___ was
negative. All stool studies were negative: fecal culture,
campylobacter culture, ova and parasites, and fecal culture r/o
E coli. CT abd and pelvis was also reassuring.
#R knee: Noted to have mild effusion on exam, but patient had
full ROM and was able to ambulate. This was evaluated by ortho,
who in consultation with her home orthopedist decided not to tap
her knee. The patient was told by her orthopedist to take
warfarin for 6 weeks after the washout (to end ___, but it
was noted that her INR was subtherapeutic (1.1). Because it
would take her longer than this time to become therapeutic on
coumadin, in consultation with pharmacy, she was given enoxparin
30 mg BID SC for DVT ppx. She was discharged with 3 more doses
of enoxaparin.
#Asthma: stable and asymptomatic during hospitalization. We
continue home flovent and wrote for albuterol nebulizers PRN,
which she did not require. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man ___ C5-C6 quadriplegia, recent dx metastatic bladder
cancer now presents with lightheadedness, syncope yesterday.
Patient reports one day of continued lightheadness and one
episode of syncope yesterday. Has been experiencing
lightheadness, feeling like he was going to pass out, when
sitting in wheelchair. No sensation of lightheadness
Patient recently started chemotherapy last week (gemcitabine,
cisplatin)here at ___. No headache fever, dysuria, n/v/d. No
new weakness nor loss of sensation.
In the ED, EKG c/w bradycardia, 1st degree av-block, RBBB, s/p
CT
head to r/o metastatic disease (negative), CT a/p (unchanged),
and grossly positive U/A. Given 2L NS and Ceftriaxone. Lactate
2.6 upon admission, with BP in the 80's prior to 2L of IVF.
On arrival to the floor, patient comfortable, states dizziness
has abated (though has not tried to get up in wheelchair).
States
is on Bactrim ppx for UTI and has texas catheter.
REVIEW OF SYSTEMS: Per HPI, all systems reviewed and otherwise
negative
Past Medical History:
ONCOLOGIC HISTORY: A ___ male here for reason as stated
above.
--In ___, he noticed painless hematuria. Given his
history of prior UTIs, he was given Cipro treated for a course.
In about a month later, the hematuria recurred.
--He was then referred to urologist who ordered a CT urogram
sometime in early late ___ or early ___, which revealed a
right
bladder wall mass. He underwent a cystoscopy initially on ___ at ___, where he underwent TURBT; however, the
procedure was technically difficult due to the floppy nature of
the bladder as well as difficulty positioning the patient that
this was reported. The pathology at that time showed high-grade
transitional cell carcinoma, which was T1; however, there was no
muscle present in the pathologic specimen to confirm muscle
invasiveness.
--Therefore, he was referred to ___ where he
underwent a repeat TURBT and cystoscopy on ___.
Pathology from this specimen revealed an invasive high-grade
papillary urothelial carcinoma with squamous differentiation
extensively invading muscularis propria. He also did have an
initial CT scan back on ___ however, I do not have a
read from that at this time. There was a concern that he had a
lymph node that was enlarged at the time.
--repeat CT Torso showed metastatic disease in lungs, growth of
the bladder lesion, pelvic lymphadenopathy.
--___: Had mild hemoptysis. Sent to ED where IP evaluated
him and set him up for outpatient bronchoscopy.
--___: Bronchoscopy with scant blood in left lower lobe
superior segment. There was a distal pulmonary nodule that was
thought the probable cause but no endobronchial lesion. Biopsy
of lymph node taken
PAST MEDICAL HISTORY:
-spinal cord injury, C5-C6 in ___, he is paralyzed from the
neck
down, has some use of his upper extremities, but cannot grab
things and overall has difficulty using his hands.
-Neurogenic bladder, uses a condom catheter
-history of UTIs on chronic Bactrim double strength daily.
-He has a history of a silent MI seen on EKG
-cataracts
-prior DVT in ___.
PAST SURGICAL HISTORY: He has had a laminectomy in ___ ___s TURBTs as mentioned above.
Social History:
___
Family History:
Father with "bone cancer", mother with MI,
sister with MI. No other history of malignancies.
Physical Exam:
Admission physical exam:
General: NAD
VITAL SIGNS: BP 106/60 HR 56 O2 sat 100% RR 20
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper extremities;
Discharge Physical exam:
VS: 97.5 58->66 118/72 18 97%RA
General: Well appearing, lying in bed in NAD
Eyes: PERLL, EOMI, sclera anicteric
ENT: MMM, oropharynx clear without exudate or lesions
Respiratory: CTAB without crackles, wheeze, rhonchi.
Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or
gallops
Gastrointestinal: Soft, nontender, nondistended, +BS, no masses
or HSM
Extremities: Warm and well perfused, no peripheral edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert and oriented x3, paralyzed below chest.
Motor
and sensory exam above chest without focal deficits.
Pertinent Results:
ADMISSION LABS:
___ 06:37PM LACTATE-2.6*
___ 09:00PM LACTATE-0.8
___ 02:20PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 02:20PM URINE BLOOD-LG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG
___ 02:20PM URINE RBC-61* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-6
___ 02:20PM URINE WBCCLUMP-MOD MUCOUS-RARE
___ 01:24PM GLUCOSE-83 UREA N-14 CREAT-0.7 SODIUM-129*
POTASSIUM-5.2* CHLORIDE-91* TOTAL CO2-25 ANION GAP-18
___ 01:24PM ALT(SGPT)-13 AST(SGOT)-22 ALK PHOS-60 TOT
BILI-0.5
___ 01:24PM LIPASE-56
___ 01:24PM ALBUMIN-3.8 CALCIUM-8.4 PHOSPHATE-2.8
MAGNESIUM-2.4
___ 01:24PM WBC-4.5 RBC-4.21* HGB-11.6* HCT-35.6* MCV-85
MCH-27.6 MCHC-32.6 RDW-13.8 RDWSD-42.6
___ 01:24PM NEUTS-62.6 ___ MONOS-3.1* EOS-0.7*
BASOS-0.2 IM ___ AbsNeut-2.81# AbsLymp-1.48 AbsMono-0.14*
AbsEos-0.03* AbsBaso-0.01
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-4.3 RBC-4.03* Hgb-11.1* Hct-34.0*
MCV-84 MCH-27.5 MCHC-32.6 RDW-14.2 RDWSD-43.6 Plt ___
___ 01:25AM BLOOD Glucose-92 UreaN-11 Creat-0.6 Na-131*
K-3.9 Cl-96 HCO3-25 AnGap-14
___ 07:05AM BLOOD Glucose-83 UreaN-10 Creat-0.7 Na-134
K-4.0 Cl-100 HCO3-26 AnGap-12
___ 01:25AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.3
___ 07:05AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1
MICRO:
___ 2:20 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
MEROPENEM------------- 2 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
Bcx pending x2
IMAGING:
___ TTE
he estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF=55-60%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. The
descending thoracic aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Suboptimal image quality. Grossly normal left
ventricular systolic function. No aortic stenosis. No LVOT
gradient at rest (could not perform maneuvers). Right heart not
well visualized. Mildly dilated descending thoracic aorta.
___ CT Head
IMPRESSION:
No acute intracranial process. Please note that MRI is more
sensitive for the
detection of acute infarction and mass.
___ CXR
IMPRESSION:
No acute cardiopulmonary process. Known metastatic lesions not
clearly
delineated.
___ CT A/P w/ con
IMPRESSION:
1. No acute intra-abdominal process, no findings to explain
patient's
symptoms. Known biopsy-proven urothelial cell carcinoma
extending along the
right lateral lateral wall, possibly slightly decreased compared
to the prior
study.
2. Paracaval and right external iliac chain lymphadenopathy
appears grossly
unchanged compared with prior study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. Diazepam 5 mg PO QPM
4. Benzonatate 150 mg PO TID
5. Bethanechol 25 mg PO Q12H
6. Tamsulosin 0.4 mg PO QHS
7. FoLIC Acid 1 mg PO DAILY
8. Ascorbic Acid ___ mg PO BID
9. Fish Oil (Omega 3) 1000 mg PO BID
10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Benzonatate 150 mg PO TID
3. Bethanechol 25 mg PO Q12H
4. Diazepam 5 mg PO QPM
5. Fish Oil (Omega 3) 1000 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
10. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypovolemia, lightheadedness, hypotension
Secondary: Bacteruria, paraplegia, metastatic bladder cancer
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with metastatic bladder cancer p/w syncope, cont
light-headedness. // ?large met, infarct or bleed
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 18.0 s, 18.3 cm; CTDIvol = 49.5 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
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 normal in overall size and configuration.
Periventricular, deep and subcortical white matter hypodensities are
nonspecific, but likely reflect sequelae of chronic small vessel ischemic
disease.
There is mild mucosal thickening of the bilateral maxillary sinuses and
frontoethmoidal recesses. The remaining imaged paranasal sinuses are clear.
Mastoid air cells and middle ear cavities are well aerated. The bony calvarium
is intact. Surrounding soft tissue structures are within normal limits.
Globes appear unremarkable.
IMPRESSION:
No acute intracranial process. Please note that MRI is more sensitive for the
detection of acute infarction and mass.
Radiology Report
INDICATION: ___ with c5-c6 partial quadripelegia, now w/ SBP 80/50 // r/o
PNA
TECHNIQUE: 2 AP views of the chest.
COMPARISON: ___ chest x-ray and chest CT.
FINDINGS:
The lungs are clear besides streaky retrocardiac opacity compatible with
atelectasis. Known pulmonary metastases are not clearly delineated on this
x-ray The cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process. Known metastatic lesions not clearly
delineated.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ with quadriplegia, epigastric, pain, hypotension. // Eval
for acute intraabdominal pathology
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 982 mGy-cm.
COMPARISON: Chest CT and chest abdomen pelvis ___. .
FINDINGS:
LOWER CHEST: Pectus excavatum deformity is partially visualized. There is
atelectasis at the left lung base, unchanged compared to prior study. The
partially visualized heart is mildly enlarged. A small pericardial effusion
is seen. No pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains a punctate
density may represent a stone.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A subcentimeter hypodensity in the interpolar region of the left kidney is too
small to characterize, likely represents a simple cyst. There is no evidence
of focal suspicious renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: 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 bladder is markedly distended. Again seen is an enhancing mass
extending along the right lateral wall of the bladder measuring 7.9 x 1.9 cm,
slightly decreased in size compared to prior study. There is no free fluid in
the pelvis.
REPRODUCTIVE ORGANS: Calcifications are seen within the prostate.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy. A 1.4 cm right para-aortic lymph
node (03:38), is unchanged in size compared to the prior study. A 2.5 by 2.0
cm soft tissue lesion in the right periaortic region (03:41) is grossly
unchanged. Central low density likely at necrotic lymph node conglomerate
seen along the right pelvic sidewall measuring 3.9 x 4.3, previously 4.9 x
3.5. Slightly more posterior necrotic node measuring 1.2 x 1.9 cm which is
unchanged.
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: Coarse calcifications are seen in the subcutaneous tissues
overlying bilateral gluteus muscles.
IMPRESSION:
1. No acute intra-abdominal process, no findings to explain patient's
symptoms. Known biopsy-proven urothelial cell carcinoma extending along the
right lateral lateral wall, possibly slightly decreased compared to the prior
study.
2. Paracaval and right external iliac chain lymphadenopathy appears grossly
unchanged compared with prior study.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness
Diagnosed with Dizziness and giddiness
temperature: 97.6
heartrate: 53.0
resprate: 16.0
o2sat: 99.0
sbp: 164.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | ___ yo man PMH C5-C6 paraplegia, recent dx metastatic
bladdercancer now presents with lightheadedness, syncope and
bacteruria.
#Lightheadedness/hypotension: Likely ___ hypovolemia as lactate
and Na improved with IVF, with low volume potentially related to
recent chemo administration. On first day of admission, had
episode of lightheadedness with SBP 97, vitals and sx improved
in ___ with IVF. Unlikely vertigo or medication effect given no
symptoms nor signs of vestibular disturbance and per heme-onc
his chemo regimen unlikely to cause vestibular effect,
especially as sx occurred several days after treatment. CT head
to r/o metastatic disease was negative. Autonomic dysfunction is
also on the differential given paraplegia, however less likely
given hypovolemia as noted above. No evidence of active
infection at this time. Patient continued to have some
lightheadedness initially after sitting up, but this improved
over the course of his admission and he was able to sit in
wheelchair without difficulty at time of discharge.
#Bacteruria: Initial concern for UTI given sx and UA with >182
WBC and bacteria; however, 6 epis in UA and Ucx, while growing
>100K pseudomonas, also grew skin/genital flora making
contamination/colonization likely.Given paraplegia and urinary
stasis, uses condom catheter and is on tamsulosin with Bactrim
ppx as outpatient. Has had
prior tx for urinary retention and remote hx of UTI in past. No
culture data in our system but known colonization. Difficult to
fully assess sx given paraplegia, but no WBC elevation, no
fevers. Initially covered with CTX and then switched briefly to
cipro when pseudomonas speciation was released, but
sensitivities showed only intermediate sensitivity to Cipro and
patient improved even without adequate antibiotic coverage,
making colonization and not active infection even more likely.
Antibiotics stopped and patient restarted on home bactrim ppx on
discharge. ___ benefit from intermittent self-caths if retention
predisposing to UTI's (f/u with urology).
#Metastatic bladder CA: Received cisplatin/gemicitabine ___.
Followed closely by heme-onc.
#Paraplegia: No sensation or motor function below nipple line.
Cared for closely by wife who is ___.
>30 min spent on discharge coordination on day of discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Penicillins / Keflex / fentanyl / Lidoderm /
indomethacin / Haldol / Compazine / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Levofloxacin / Benadryl / Bactrim DS
Attending: ___.
Chief Complaint:
Right Long Finger Pain
Major Surgical or Invasive Procedure:
1. Irrigation of right long finger flexor tendon sheath.
2. Removal of multiple foreign bodies from surgical wound.
History of Present Illness:
___ yo female status post outpatient right long finger A1 pulley
release on ___. Returned to ___ on ___ with
complaint of increased throbbing pain and swelling with possible
infection of the operative site and the adjacent ring finger.
Denied fevers, chills, or signs of systemic infection. No
drainage from the wound. Claims she had been elevating the
extremity. Patient was admitted and placed on IV antibiotics
which were transitioned to PO Clindamycin. She was discharged
___ and returned today noting purulent drainage from her
wound and subjective fevers.
Past Medical History:
- Anorexia since age ___. Numerous stays in different programs.
Fears weight gain, has disturbed body image, amenorrhea since
___. No binging or purging; currently uses laxatives,
diuretics, intense exerciser, used emetics in past.
- Borderline personality disorder with self-mutilation
- PTSD ___ "a lot of things;" previous notes indicate witness to
robbery/murder, abuse by father
- ___
- L foot fracture ___ bike accident.
- Probable endometriosis, s/p lupron injection ___ months ago
Social History:
___
Family History:
Patient denies family history, specifically no eating disorders.
However, per records her mother had depression and recently
committed suicide.
Physical Exam:
Aferbile, VSS
A&O x 3
Calm and comfortable
Right Hand
Fingers held in flexion.
Erythema and edema. Purulent material expressed from surgical
wound. Pain over flexors long and ring,and palm. Pain with
passive extension. No wrist painl.
Arms and forearms are soft
Contralateral extremity examined with FROM at all joints, SILT,
motors intact
Pertinent Results:
___ 12:00AM WBC-6.3# RBC-4.24 HGB-11.2* HCT-34.9* MCV-82
MCH-26.4* MCHC-32.0 RDW-15.9*
___ 06:03AM WBC-4.7 RBC-4.01* HGB-10.7* HCT-33.4* MCV-83
MCH-26.6* MCHC-31.9 RDW-16.0*
Medications on Admission:
Multiple, see chart
Discharge Medications:
1. clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours) for 10 days.
Disp:*120 Capsule(s)* Refills:*0*
2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
every ___ hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right hand / long finger surgical wound infection with foreign
bodies
Discharge Condition:
stable
A&Ox3
independent ambulation
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with tendon release surgery one week ago,
complicated by cellulitis. Has increasing swelling and drainage concerning
for flexor tenosynovitis. Evaluate for retained foreign body.
Correlation to right wrist radiographs from ___.
RIGHT HAND, AP, OBLIQUE, AND LATERAL: Examination is limited by persistent
finger flexion. There is a 5-mm linear radiopaque foreign body in the volar
soft tissues of the long finger, overlying the base of the proximal phalanx.
Severe soft tissue swelling is present in this digit, without foci of soft
tissue gas. There is no evidence of fracture or osseous
fragmentation/erosion.
IMPRESSION: Retained foreign body in proximal volar long finger soft tissues,
with severe soft tissue swelling.
Findings were noted by Dr. ___ on ___.
Radiology Report
STUDY: Two intraoperative fluoroscopic images of the right fingers ___.
Note, images were provided for review on ___.
INDICATION: I&D right middle finger.
FINDINGS AND IMPRESSION: Status post I&D right long finger. Please see
operative report for further details.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R/O INFECTION
Diagnosed with OTHER POST-OP INFECTION, ACCIDENT NOS
temperature: 97.4
heartrate: 109.0
resprate: 16.0
o2sat: 100.0
sbp: 141.0
dbp: 101.0
level of pain: 9
level of acuity: 3.0 | The patient was admitted to the Orthopaedic Trauma Service for
I&D of wound infection on right hand. The patient was taken to
the OR and underwent an uncomplicated I&D and removal of foreign
bodies. The patient tolerated the procedure without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with PO pain meds. The patient
tolerated diet advancement without difficulty and made steady
progress with ___. Infectious diesease and psychiatry were
consulted
Weight bearing status: nwb rue, finger ROM as tolerated.
The patient received ___ antibiotics as well as
pneumoboots for DVT prophylaxis. The incision was clean. The
patient was discharged in stable condition with written
instructions concerning precautionary instructions and the
appropriate follow-up care. The patient will not require DVT
prophylaxis. All questions were answered prior to discharge and
the patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache, Fever
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
HPI: The pt is a ___ y/o LHF with a history of occasional
migraine
headaches who was transferred to ___ from ___ for concern
of encephalitis.
She had presented there after 4d of worsening right sided
headaches with photophobia, nausea and vomiting, and fever of
unclear duration. She had initially presented to her PCP, who
prescribed doxycycline on ___ and di lyme serology
(reportedly negative), and then went to ___ today for
wrosening of her symptoms. Her head CT showed right temporal
lobe
edema, which was confirmed on an MRI.
Her CSF showed 745 WBC, 76% lymphocytes and 23% monocytes, 20
RBC, glucose 43, protein 179, gram stain negative. Her labs were
notable for a normal WBC and a negative CrP, suggestive of a
viral infection. She was transferred here for further
management.
Clinically, there were no concerns for seizures.
No difficulties with producing or understanding speech.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, no sweats or recent weight loss or
gain. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- occasional migraines
Social History:
___
Family History:
No neurologic conditions
Physical Exam:
General: asleep
HEENT: NC/AT, MMM.
Neck: Supple, no carotid bruits appreciated. has nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: asleep, easily arousable, oriented x 3 (date
___. Able to relate history without difficulty, but speaks
in short sentences. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. There were no paraphasic errors. Pt. was able
to name ___ card items and read ___ card scentences. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall ___ at 5
minutes. Unable to claculate. There was no evidence of apraxia
or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No tremor, asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, vibratory sense,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally. ___ beat clonus on R
ankle.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: deferred
Pertinent Results:
___ 05:12AM BLOOD WBC-4.6 RBC-4.13* Hgb-12.7 Hct-38.8
MCV-94 MCH-30.9 MCHC-32.9 RDW-12.8 Plt ___
___ 05:12AM BLOOD Glucose-98 UreaN-13 Creat-0.8 Na-140
K-4.2 Cl-105 HCO3-30 AnGap-9
___ 05:35AM BLOOD ALT-9 AST-15 AlkPhos-39 TotBili-0.1
___ 05:10AM BLOOD Calcium-9.2 Phos-4.4# Mg-2.1
Medications on Admission:
NoneThe Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acyclovir 800 mg IV Q8H Duration: 14 Days
RX *acyclovir sodium 1,000 mg 0.8 cc IV every eight (8) hours
Disp #*42 Vial Refills:*0
2. LeVETiracetam 750 mg PO BID
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
3. Naproxen 500 mg PO Q8H:PRN headache
RX *naproxen [Naprosyn] 500 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
HSV ENCEPHALITIS
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 encephalitis // Progression of temporal
lobe swelling
TECHNIQUE: Multi sequence, multiplanar brain MRI was performed pre and post
intravenous administration of 8 cc of Gadavist. The following sequences were
utilized: Sagittal T1, axial T1 pre, axial GRE, axial FLAIR, axial T2, axial
T1 post, and sagittal MPRAGE post.
COMPARISON: Brain MRI dated ___.
FINDINGS:
The FLAIR hyperintensity within the anterior right temporal lobe and insula
has increased when compared to prior study. However, the patchy enhancement in
this region of signal abnormality has decreased from prior study. There is
unchanged mild adjacent dural thickening and enhancement. The mass effect on
the right lateral ventricle are unchanged.
There is no hemorrhage, or infarct. The principal intracranial flow voids are
present.
There is mild ethmoid mucosal thickening. The orbits, and visualized soft
tissues are unremarkable. There is minimal fluid in bilateral mastoid air
cells.
IMPRESSION:
Again noted are changes related to patient's known encephalitis. The FLAIR
signal abnormality/edema within the anterior right temporal lobe has increased
from prior study, but the patchy enhancement in this region has decreased.
There is unchanged mass effect on the right lateral ventricle.
There is no hemorrhage or infarct.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new picc // R picc 43cm sal ___ Contact
name: sal, ___: ___
TECHNIQUE: Portable AP view of the chest.
COMPARISON: None.
FINDINGS:
A right-sided PICC terminates just below the cavoatrial junction and could be
pulled back approximately 1 cm to reposition in the low SVC.
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen.
IMPRESSION:
Right -sided PICC terminates just below the cavoatrial junction and could be
pulled back approximately 1 cm to reposition in the low SVC.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ENCEPHALITIS
Diagnosed with VIRAL ENCEPHALITIS NEC, VIRAL MENINGITIS NEC
temperature: 101.4
heartrate: 68.0
resprate: 18.0
o2sat: 98.0
sbp: 112.0
dbp: 55.0
level of pain: 7
level of acuity: 2.0 | # Neurology: Mrs. ___ was admitted, started on acyclovir,
vancomycin, ceftriaxone, and ampicillin. She was connected to
vEEG. She stated that she had been having episodes of metallic
smells concerning for temporal lobe seizures. She was started on
keppra 750mg BID. Her EEG showed slowing in the right temporal
lobe but no epileptiform activity. It was discontinued after
24hrs. She was given toradol and tylenol #3 for pain control.
She had a normal neurological exam and was asymptomatic after
___ days of admission. She had a repeat MRI on ___ that showed
a stable right temporal lobe hyperintensity but did not have as
much contrast enhancement. She had a repeat LP done on ___ that
had an improved WBC count of 130. She was deemed stable for
discharge and to complete a 3wk course of acyclovir.
# ID: Her bacterial cultures from the initial lumbar puncture at
___ were negative. She came back HSV1 PCR positive. She was
taken off antibiotics after negative cultures and kept on
acyclovir. The rest of her viral testing was negative. The
repeat HSV is pending. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, weakness, poor apetite, tachycardia, hypotension
Major Surgical or Invasive Procedure:
___ HD
___ HD
History of Present Illness:
___ with PMHx ESRD secondary to chronic HTN and cardiorenal
syndrome on MWF HD, HFpEF, Afib on Coumadin, COPD on
intermittent home O2, presenting with SOB, weakness, poor
appetite, tachycardia, hypotension, and productive cough. Over
past week he has felt congested and has had a productive cough
with chills. On ___ at ___ he was sent home due to
tachycardia to 140s and told to take his metoprolol. No fluid
was removed. He returned to ___ on day of admission but HR was in
120s so was sent to ED for further evaluation, and did not take
metoprolol. At HD on ___, little fluid was removed as
well.
Over the past day he has been experiencing shortness of breath
on exertion without chest pain. He has also experienced poor
appetite and sleep over the past day. Notably, was seen 2 days
ago by his PCP for similar symptoms. He was felt to have acute
bronchitis, was recommended cough syrup, which helped his
symptoms.
His EDW is 65kg and his post-weight after treatment on ___ was
65.5kg.
In the ED, initial vitals: T 97.4, HR 117, BP 93/52, R 18, O2
100% RA
On exam: Right lower lungs decreased sounds, otherwise clear
with no rales or wheezing, heart alternated between regular and
irregular, abdomen soft nontender nondistended, BLE warm and no
edema.
Labs were significant for: K 6.8, then 7.3 on recheck. Cr 5.4
(b/l ___, Hgb 14.1 -> 11.7 (b/l ___, WBC 7.2, PLT 112 ->
87, Lactate 2.4, Trop 0.16 x2, CK-MB 3 x2, INR 3.3. Flu
negative. Stool guaiac negative.
Imaging was significant for: CXR: Decreased R side pleural
effusion with fluid in R minor fissure. No overt pulmonary edema
or focal consolidation.
EKG: no peaked T waves, sinus tachycardia, RBBB
Consults: Renal, Cardiology
In the ED, he received sodium bicarbonate 50mEq then 100mEq,
Calcium gluconate 2g x2, Insulin 10U then 10U (with Dextrose),
Albuterol nebulizer, Vancomycin 1g (1430), Cefepime 500mg
(1630), NS (unknown amount). Received HD.
On transfer, vitals were: T 97.9, HR 110, BP 89/63, R 18, O2 96%
RA
On arrival to the MICU, patient is alert, awake, well-appearing.
Complaining only of throat irritation. Has had intermittent
productive cough with green sputum but usually swallows it, does
not feel he could produce sputum sample. Has not used any home
O2 in the past week and does not currently feel short of breath.
Uses 2.5L at night occasionally. Measures BP at home, usually
around SBP 100. Was instructed to discontinue torsemide 200 mg
daily one week ago and hasn't noticed any change in symptoms.
Denies chest pain, palpitations, leg swelling, abdominal pain,
diarrhea, bloody stool. Was constipated but had well-formed
stool today.
Review of systems:
(+) Per HPI
Past Medical History:
- Heart failure with preserved ejection fraction (EF 60-65%)
- Paroxysmal atrial fibrillation s/p cardioversion on warfarin,
previously apixaban
- Stage 5 CKD (GFR 12), dialysis initiated ___ chronic
hypertension and cardio-renal etiologies, still makes some urine
- Past Hypertension
- Hyperlipidemia
- Peripheral neuropathy
- BPH
- Colon cancer s/p transverse colectomy and chemotherapy (___),
in remission
- Lung squamous cell carcinoma stage Ia (pT1aN0Mx) s/p VATS
Right lower Lobectomy ___ and lung adenocarcinoma stage Ia
(pT1aN0Mx) s/p VATS LLL wedge resection ___
- COPD 02, home oxygen when SOB, at night
- Umbilical melanoma
- Ocular myasthenia ___ (not active)
- Lumbar radiculopathy
- Gout
- Recurrent C. difficile infections
- Cataract surgery ___
- Tonsillectomy for OSA
Social History:
___
Family History:
Dad with CHF and breast cancer. Mom with DM and celiac sprue. He
has one sister without significant medical illness.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: T: 98.2 BP: 110/48 P: 133 R: 24 O2: 94% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL, s/p CEIOL, MMM, oropharynx clear
NECK: supple, JVP not elevated, scattered cervical LAD
LUNGS: Diffusely decreased breath sounds, scattered ronchi, no
overt crackles/wheeze
CV: Irregular rhythm, mildly tachycardic, distant S1 S2, no
murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace ___ edema, palpable thrill RUE, dressing over AVF c/d/i
SKIN: No lesions.
NEURO: A&O x3. Moving all extremities equally
ACCESS: PIVs
DISCHARGE PHYSICAL EXAM
=======================
Vitals: T 98.1 BP 94-108/55-63 HR 100-117 RR 20 95% RA
GENERAL: Alert, oriented, no acute distress elderly gentleman
laying in bed comfortably
HEENT: Sclera anicteric, PERRL, s/p CEIOL, MMM, oropharynx clear
NECK: Supple, no JVP elevation, scattered cervical LAD
LUNGS: CTAB fair inspiratory effort
CV: RRR, no murmurs, rubs, gallops
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, no
___ edema, palpable thrill RUE.
SKIN: No lesions.
NEURO: A&O x3. Moving all extremities equally and with purpose.
Pertinent Results:
ADMISSION LABS:
------------------
___ 12:28PM BLOOD WBC-7.2 RBC-4.14* Hgb-14.1# Hct-43.8#
MCV-106*# MCH-34.1*# MCHC-32.2 RDW-19.8* RDWSD-78.3* Plt ___
___ 12:28PM BLOOD Neuts-74.4* Lymphs-14.9* Monos-9.3
Eos-0.6* Baso-0.4 Im ___ AbsNeut-5.39 AbsLymp-1.08*
AbsMono-0.67 AbsEos-0.04 AbsBaso-0.03
___ 12:28PM BLOOD ___ PTT-39.3* ___
___ 12:28PM BLOOD Glucose-109* UreaN-85* Creat-5.4*# Na-134
K-6.8* Cl-92* HCO3-21* AnGap-28*
___ 01:59PM BLOOD CK(CPK)-70
___ 01:59PM BLOOD CK-MB-3
___ 01:59PM BLOOD cTropnT-0.16*
___ 12:43PM BLOOD Lactate-2.4* K-6.7*
___ 01:59PM BLOOD Lactate-1.3
DISHCARGE LABS
-------------------
___ 10:30AM BLOOD WBC-6.5 RBC-4.06* Hgb-13.9 Hct-43.6
MCV-107* MCH-34.2* MCHC-31.9* RDW-19.9* RDWSD-78.9* Plt ___
___ 10:30AM BLOOD ___ PTT-30.1 ___
___ 10:30AM BLOOD Glucose-125* UreaN-35* Creat-3.4*# Na-139
K-4.1 Cl-93* HCO3-27 AnGap-23*
___ 10:30AM BLOOD ALT-333* AST-207* AlkPhos-158*
TotBili-2.5*
___ 10:30AM BLOOD TotProt-7.1 Calcium-8.6 Phos-4.2 Mg-2.0
IMAGING:
---------------
___ CXR:
There is unchanged cardiomegaly. The right-sided pleural
effusion has decreased since previous and is now small in size.
There remains fluid within the right minor fissure. There is no
overt pulmonary edema or focal consolidation. There are no
pneumothoraces. Suture anchors are seen within the right
humeral head.
___ TTE:
Mild symmetric left ventricular hypertrophy with normal
biventricular cavity size and severe global biventricular
hypokinesis in a pattern most suggestive of a non-ischemic
cardiomyopathy (cannot exclude multivessel CAD if clinically
suggested). Mild aortic regurgitation. Mild mitral
regurgitation. \Very small circumferential pericardial effusion.
Compared with the prior study (images reviewed) of ___,
biventricular systolic function has significantly deteriorated.
___ RUQ Ultrasound:
Normal hepatic parenchyma. Trace perihepatic ascites.
Gallbladder polyps. Possible cholelithiasis with no evidence of
cholecystitis or bile duct dilation. Small left kidney with
cortical thinning.
___ TTE:
Restrictive cardiomyopathy (? amyloid).
Compared with the prior study (images reviewed) of ___,
the left ventricular ejection fraction is slightly increased;
other major abnormalities as described persist without major
change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nephrocaps 1 CAP PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Allopurinol ___ mg PO EVERY OTHER DAY
4. Ascorbic Acid ___ mg PO DAILY
5. Calcitriol 0.25 mcg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Nepro Carb Steady (nut.tx.impaired renal fxn,soy) Dose is
Unknown oral TID W/MEALS
8. Gabapentin 100 mg PO DAILY
9. Lidocaine-Prilocaine 1 Appl TP THREE TIMES A WEEK WITH HD
10. Methocarbamol 750 mg PO DAILY
11. Pravastatin 40 mg PO QPM
12. TraZODone 100 mg PO QHS
13. Vancomycin Oral Liquid ___ mg PO DAILY
14. Warfarin 2.5 mg PO 6X/WEEK (___)
15. Warfarin 5 mg PO 1X/WEEK (SA)
16. Metoprolol Succinate XL 150 mg PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO BID
BID until ___ then ONCE a day
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
puff inhaled twice a day Disp #*1 Disk Refills:*0
5. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Nepro Carb Steady (nut.tx.impaired renal fxn,soy) 1 can oral
TID W/MEALS
7. Warfarin 1.5 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 1.5 tablet(s) by mouth daily Disp
#*20 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
9. Allopurinol ___ mg PO EVERY OTHER DAY
10. Ascorbic Acid ___ mg PO DAILY
11. Calcitriol 0.25 mcg PO DAILY
12. Cyanocobalamin 1000 mcg PO DAILY
13. Gabapentin 100 mg PO DAILY
14. Lidocaine-Prilocaine 1 Appl TP THREE TIMES A WEEK WITH HD
15. Nephrocaps 1 CAP PO DAILY
16. TraZODone 100 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute Systolic Heart Failure
Atrial Fibrillation with Rapid Ventricular Rate
ESRD
SECONDARY DIAGNOSIS:
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with esrd on hd, with sob, tachycardia // evaluate
for pneumonia, pulm edema
COMPARISON: Radiographs from ___.
IMPRESSION:
There is unchanged cardiomegaly. The right-sided pleural effusion has
decreased since previous and is now small in size. There remains fluid within
the right minor fissure. There is no overt pulmonary edema or focal
consolidation. There are no pneumothoraces. Suture anchors are seen within
the right humeral head.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cough and CHF // ?cardiomegaly, pulm edema,
pna ?cardiomegaly, pulm edema, pna
IMPRESSION:
Comparison to ___. Minimal increase in extent of a pre-existing
right pleural effusion. Minimal increase in severity of the right basilar
atelectasis. Moderate cardiomegaly persists. No new parenchymal changes.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ ESRD ___ chronic HTN on ___ HD, HFpEF, Afib on Coumadin, COPD
on intermittent home O2, presenting with SOB, weakness, poor appetite,
tachycardia, hypotension, productive cough. On echo the patient found to have
severe global biventricular systolic dysfunction of unknown cause. // liver
parenchyma abncbd dilation?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Renal ultrasound ___. CT abdomen pelvis ___, CT chest ___.
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 trace perihepatic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 1.7
mm.
GALLBLADDER: There are several non mobile echogenic foci with no internal
vascularity and no posterior shadowing in the anterior gallbladder wall which
may represent gallbladder polyps. An echogenic foci adjacent to the
gallbladder wall on the dependent portion may be a polyp or a stone, measuring
0.6 x 0.3 x 0.6 cm. There is no evidence of larger stones or gallbladder wall
thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 11.5 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis. The right
kidney measures 9.5 cm. In the upper pole of the right kidney, there is a
simple cyst measuring 1.7 x 1.5 x 2.0 cm, previously measuring ___. The left
kidney measures 8.1 cm with cortical thinning.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Normal hepatic parenchyma. Trace perihepatic ascites. Gallbladder polyps.
Possible cholelithiasis with no evidence of cholecystitis or bile duct
dilation. Small left kidney with cortical thinning.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Tachycardia
Diagnosed with Hypokalemia
temperature: 97.4
heartrate: 117.0
resprate: 18.0
o2sat: 100.0
sbp: 93.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | ___ year old M with PMHx ESRD secondary to chronic HTN on ___ HD,
HFpEF (___), Afib on Coumadin, COPD on home O2, who
presented with dyspnea, generalized weakness, poor apetite,
tachycardia, hypotension and productive cough initially admitted
too the MICU for presumed volume overload after missing ESRD who
was subsequently transferred to the CCU for further management
after he was found to have severe global biventricular systolic
dysfunction on TTE:
# Acute Systolic Heart Failure Exacerbation
# NSTEMI
Patient presented with dyspnea, tachycardia, and hypotension
consistent with volume overload after missing his HD session on
___ prior to admission due to tachycardia. On day of
admission, patient sent from HD to emergency room for
tachycardia. Etiology of tachycardia and hypotension thought to
be secondary to atrial fibrillation with rapid ventricular
response and dyspnea and cough thought to be secondary to volume
overload after missing dialysis. TTE on admission revealed
severe global hypokinesis with newly depressed EF 25%. After
controlling his rate with metoprolol and volume removal, patient
had a subsequent TTE with severe LV diastolic dysfunction
suggestive of restrictive cardiomyopathy and EF 30%, likely
secondary to his ESRD and HTN with low suspicion of ischemic
etiology. Patient was discharged home on Metoprolol 100mg XL
daily, ASA 81mg daily, and atorvastatin 80mg daily with
appropriate primary care and cardiology outpatient follow up.
# Hyperkalemia
# ESRD on HD (___ schedule)
Patient presented with acute hyperkalemia likely secondary to
intravascular hypovolemia as suggested by elevated cell counts)
and missed HD sessions prior to admission. Urgent ultra
filtration was performed in the ED on admission and patient
received HD two sessions on ___ and ___.
# Paroxysmal atrial fibrillation
Patient has history of cardioversions and takes warfarin and
metoprolol. Given atrial fibrillation and rapid ventricular
rates with resultant hypotension, decision was made for
amiodarone load. Patient in sinus rhthym on discharge. Patient
discharged on amiodarone 400mg BID through ___ and then
daily, Metoprolol 100mg XL daily for rate control, and warfarin
with goal INR ___.
# Transaminitis
Patient had ALT/AST elevation to 300s, which were
downtrending/stable prior to discharge. Etiology unclear,
either secondary to hepatic congestion in setting of volume
overload versus medication side effect from empiric antibiotics
given on admission given his initial undifferentiated
hypotension, tachycardia, and cough. Amiodarone also possible.
RUQ u/s obtained and unremoarkable. TSH normal. Abdominal exam
benign. His outpatient primary care provider was contacted who
will follow up for resolution outpatient.
# COPD
# OSA
Patient continued on home O2 at night in hospital. Started
Advair as patient was not on home inhaler.
# Anemia
# Thrombocytopenia
Stable in patient, presumed secondary to ESRD. Patient is s/p
on Ferumoxytol ___.
# Hyperlipidemia: Atorvastatin replaced home pravastatin.
# Peripheral neuropathy: Continued gabapentin.
# Gout: Continued home allopurinol.
# History of Recurrent Cdiff: Patient takes oral vancomycin at
home for prophylaxis. Patient did not receive vancomycin in
house as did not have prior documentation for this for pharmacy
release of medication and in-house C.difficile negative.
# BPH: Home Doxazosin recently discontinued outpatient prior to
admission in setting of hypotension.
TRANSITIONAL ISSUES
===========================
- Patient discharged with transaminitis w/ possibility of
amiodarone effect, please assess for resolution on follow up.
- Patient's newly discovered restrictive cardiomyopathy was felt
to be related to his ESRD and history of HTN. Please evaluate
for alternative causes as clinically indicated, i.e amyloidosis.
- Amiodarone load for atrial fibrillation initiated on ___ and
patient discharged on amiodarone 400mg BID on ___. He will
start amiodarone daily on ___.
- The patient was found to be C.diff negative and therefore his
PO vancomycin was stopped.
- Patient was discharged with an INR of 1.8. His warfarin dose
was decreased to 1.5mg daily given his amiodarone. His INR
should be closely followed, and adjustments made as needed for
goal INR ___.
- The patient was not started on an ___ given low blood
pressures. Please consider outpatient initiation as tolerated
in the outpatient setting.
# Code: Full, confirmed
# Communication/HCP: ___ Wife/HCP ___ (H),
___ (c); Daughter ___ is ___ contact/co-HCP
___
# DRY WEIGHT: 65kg |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
___ Complaint:
Fever, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ female with a past medical history
significant for advanced Alzheimer's dementia with behavior
issues, depression, DVT on warfarin, rectovaginal fistula with
sigmoid colostomy, who is presenting from ___
___ with several days of low-grade fever and lethargy.
Patient is confused at baseline and is unable to provide an HPI.
HPI obtained from ___ notes as well as ED dashboard.
Per rehab notes, the patient was found to be twitching in the
a.m. on ___. She was given 0.5 mg of Ativan. This
allowed her to sleep for "some time-awaken for breakfast and
observed to continue with twitches." There was no history of
seizures. Labs were ordered by the NP, which showed a sodium of
152, creatinine 1.5 from a baseline of 1.3, BUN 24. Temperature
99.3. Tylenol
was given, and the patient was transferred to ___
___ emergency department.
Daughter reports patient has been twitching at baseline for the
past year.
In the emergency department, vitals were notable for temperature
99.3, heart rate 73, blood pressure 149/66, oxygen saturation
96% on room air.
Labs were notable for a white count of 12.8, sodium 153,
creatinine 1.5, lactate 1.6, UA with protein and trace ketones,
flu negative, alk phos 106, lipase 76.
EKG: NSR, RR, HR 63, prolonged PR interval, no STE/STD, Qtc 448
CT head was negative. Chest x-ray showed mild streaky basilar
opacities likely secondary to atelectasis/mild aspiration.
Patient was given 500 cc of normal saline, donepezil,
memantine,risperidone.
The patient's family declined a lumbar puncture in the emergency
department.
Geriatrics was consulted in the ED and recommended admission to
the geriatric team.
On arrival to the floor, the patient was not answering
questions. She reports that she was feeling fine. No further
history was obtained as the patient's family had left for the
evening.
REVIEW OF SYSTEMS:
Unable to obtain given patient's dementia
Past Medical History:
DVT on Coumadin
Rectovaginal fistula s/p colostomy
Alzheimer's dementia with behavioral disturbances
Hypertension
Depression
Insomnia
Vitamin D deficiency
Past Surgical History
Cholecystectomy
Hysterectomy
Tonsillectomy
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Pleasant, no acute distress, reports she's "in a place"
and not answering further questions.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation of the anterior lung fields
Abdomen: Soft, non-tender, non-distended, ostomy bag in place
Ext: 2+ pitting edema in the ankles bilaterally.
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, moving all extremities with purpose,
unable to fully complete neuro exam given patient's inability to
follow commands.
DISCHARGE PHYSICAL EXAM
General: Pleasant, no acute distress.
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs,gallops
Lungs: Clear to auscultation of the anterior lung fields
Abdomen: Soft, non-tender, non-distended, ostomy bag in place
Ext: trace pitting edema in the ankles bilaterally.
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, moving all extremities with purpose,
unable to fully complete neuro exam given patient's inability to
follow commands.
Pertinent Results:
ADMISSION LABS
===============
___ 08:40PM BLOOD Albumin-4.0 Calcium-9.8 Phos-2.7 Mg-2.4
___ 08:40PM BLOOD Lipase-76*
___ 08:40PM BLOOD ALT-26 AST-25 AlkPhos-106* TotBili-0.3
___ 08:40PM BLOOD Glucose-103* UreaN-40* Creat-1.5* Na-153*
K-4.3 Cl-111* HCO3-27 AnGap-14
___ 05:15AM BLOOD Glucose-110* UreaN-34* Creat-1.3* Na-152*
K-3.8 Cl-114* HCO3-28 AnGap-10
___ 12:50PM BLOOD Glucose-120* UreaN-28* Creat-1.3* Na-150*
K-4.0 Cl-113* HCO3-25 AnGap-12
___ 06:29AM BLOOD Glucose-90 UreaN-19 Creat-1.1 Na-148*
K-3.5 Cl-110* HCO3-27 AnGap-11
___ 08:40PM BLOOD WBC-12.8* RBC-4.00 Hgb-11.3 Hct-37.0
MCV-93 MCH-28.3 MCHC-30.5* RDW-13.5 RDWSD-46.0 Plt ___
DISCHARGE LABS
===============
___ 02:00AM BLOOD WBC-11.1* RBC-4.02 Hgb-11.3 Hct-35.4
MCV-88 MCH-28.1 MCHC-31.9* RDW-12.7 RDWSD-40.6 Plt ___
___ 02:00AM BLOOD ___
___ 02:00AM BLOOD Glucose-93 UreaN-15 Creat-1.0 Na-143
K-3.5 Cl-109* HCO3-24 AnGap-10
___ 02:00AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.8
OTHER RELEVANT LABS
===================
___ 08:59PM BLOOD Lactate-1.6
IMAGING/STUDIES
================
___ CXR
IMPRESSION:
Patient is rotated and kyphotic in position. The patient's chin
overlies the left lung apex, obscuring the view. Given the
above, there relatively low lung volumes. Right midlung
atelectasis seen. Re-demonstrated mild streaky basilar
opacities may be due to atelectasis/mild aspiration.
Gaseous distension of the stomach/bowel in the left upper
quadrant.
___ CTH
FINDINGS:
There is no evidence of acute, large territorial
infarction,hemorrhage,edema, or mass. There is prominence of
the ventricles and sulci suggestive of involutional changes.
Periventricular and subcortical white matter hypodensities are
nonspecific, likely sequela of chronic ischemic small vessel
disease.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with dementia, presents with fever and lethargy//
Infection, edema
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
FINDINGS:
Patient is rotated and kyphotic in position. Patient's chin overlies the left
lung apex, obscuring the view. Given this, there is right midlung
atelectasis. Re-demonstrated streaky bibasilar opacities which are relatively
mild. No large pleural effusion or pneumothorax is seen. Cardiac and
mediastinal silhouettes are stable. There is gaseous distension of the
stomach/bowel in the left upper quadrant.
IMPRESSION:
Patient is rotated and kyphotic in position. The patient's chin overlies the
left lung apex, obscuring the view. Given the above, there relatively low
lung volumes. Right midlung atelectasis seen. Re-demonstrated mild streaky
basilar opacities may be due to atelectasis/mild aspiration.
Gaseous distension of the stomach/bowel in the left upper quadrant.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with Alzheimer's disease presents with fever and
lethargy.// Mass, bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT ___.
FINDINGS:
There is no evidence of acute, large territorial infarction,hemorrhage,edema,
or mass. There is prominence of the ventricles and sulci suggestive of
involutional changes. Periventricular and subcortical white matter
hypodensities are nonspecific, likely sequela of chronic ischemic small vessel
disease.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever, Lethargy
Diagnosed with Weakness
temperature: 99.3
heartrate: 73.0
resprate: 18.0
o2sat: 96.0
sbp: 149.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | ___ female with a past medical history significant for
advanced Alzheimer's dementia with behavior disturbances,
depression, DVT on warfarin, rectovaginal fistula with sigmoid
colostomy, who is presenting from ___
with lethargy, found to have hypernatremia, leukocytosis, with
possible aspiration pneumonitis on CXR. Patient's hypernatremia
and Cr improved with hydration. Per ___ discussion with
daughter, family preferred to continue oral feeding with
soft/pureed foods despite aspiration risk at this time.
TRANSITIONAL ISSUES
====================
[] Patient is on a variety of medications. Given her age and
multiple comorbidities, she would benefit from deprescribing.
[] ___ should check INR on ___ and resume
Coumadin if in range
[] Encourage oral hydration as much as possible given patient's
risk of dehydration
[] Please follow up blood culture pending at discharge.
ACUTE ISSUES ADDRESSED
=======================
#Hypertnatremia
Patient presenting with a sodium of 153. Likely hypovolemic
hypernatremia in the setting of poor PO intake reported by
daughter. Patient was slowly repleted with NS followed by D5W
(received total of 2.5L). Na improved from 153 -> 143 on day of
discharge.
#Leukocytosis
Patient presented with white blood cell count of 12 with a
neutrophil predominance. No clear evidence of infection was
found. Chest x-ray was without consolidation but with possible
mild aspiration/atelectasis, UA without evidence of infection,
LFTs within normal limits. Flu PCR negative. UCx and BCx without
growth at time of discharge. Most likely cause of leukocytosis
is aspiration pneumonitis given aspiration risk described below.
Given lack of clear etiology, improvement in patient mental
status, and lack of fevers, no antibiotics were given.
Leukocytosis downtrended on day of discharge.
#Aspiration Risk
Speech & Swallow saw the patient and were concerned about
aspiration. Patient was initially maintained NPO. Per
conversation with daughter, patient had been doing well with 1:1
feeding and cueing at living facility. Given this, she expressed
a preference to continue feeding patient despite aspiration
risk. Patient was transitioned to pureed diet with thin liquids.
#GOC
Per last ___, pt is full code. The daughter confirmed that her
mother would want everything done to prolong her life.
___ on CKD
Per ___ records, the patient's baseline creatinine is ___.
Cr on admission was 1.5, likely in the setting of decreased PO
intake. Improved with IV fluids to 1.0.
#DVT on warfarin
Patient with DVT diagnosed in ___ on indefinite
anticoagulation. On admission, INR elevated at 3.5. Warfarin was
held with plan to recheck at ___ and restart if
within range. INR on day of discharge 3.1.
#Alzheimer's dementia
Continued home donepezil, memantine, risperidone. Held lorazepam
given concern for deliriogenic effects.
#Hypertension (Goal <150/80 given age/frailty)
Continued home atenolol
#Depression
Continued home trazodone QHS, citalopram
CORE MEASURES
#CODE: Full (confirmed w daughter, ___ in ___
#CONTACT: ___ (Daughter) Phone: ___ |
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:
Cardiac catheterization with no PCI.
History of Present Illness:
___ PMH significant for paraplegia s/p fall from roof (___),
multiple surgeries, chronic non-healing sacral decubitus ulcer,
recent bilateral psoas abscesses (___) s/p ___ drainage,
recurrent PE/DVT on Coumadin, no known cardiac history who
presented to the ED ___ with a chief complaint of "spike
like" substernal chest pain radiating to his back. He reports
having a similar episode 1 week ago that lasted for about one
hour. This time the CP started ___ at 5PM and lasted until ___
at 5AM. He was driving when the chest pain started and did not
notice any exacerbating or alleviating factors. The pain was so
severe that he was unable to sleep. It radiated down his L arm
and was associated with nausea.
On arrival to the ED his VS were 98.5 101 101/63 18 100% RA .
His
EKG showed showed NSR without STE/STD. Labs were obtained and
showed a trop of 0.21 so he was started on a hep gtt. There was
concern for NSTEMI vs PE so a CTA was obtained which showed no
evidence of PE so he was admitted to cardiology for NSTEMI
management. Prior to transfer he was given ASA 324mg, oxycodone
30mg PO once, and 500cc NS.
On arrival to the floor his VS were 98.2PO 103/57 77 18 99RA. He
was denying any chest pain, nausea, vomiting, diarrhea,
abdominal
pain, headaches. He was endorsing his baseline chronic pain and
a
mild cough.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- No known cardiac risk factors
2. CARDIAC HISTORY
- No known cardiac history
3. OTHER PAST MEDICAL HISTORY
- T12 paraplegic: ___ fall off roof while doing ___ in ___, had multiple spine surgeries immediately following
the accident
- s/p multiple ___ DVTs after above accident, on coumadin
- s/p IVC filter--placed in ___
- s/p motorcycle accident ___-- sustained "twisted R ankle"
- h/o R leg osteomyelitis following closed tibia fracture ___
- H/o MRSA from superficial right tibial ___
PSH:
- ___ - Osteotomies at L2, L3, Fusion T8-L4, Revision of
instrumentation T8-L4, Laminectomy at L2, L3, and L4.
- ___ - Anterior osteotomies L2-3 and L3-4, Fusion L2-4.
- ___ - Irrigation and debridement of skin, subcutaneous
tissue, fascia, and bone (measuring 15 x 15 cm). Pedicle of
anterolateral thigh flap reconstruction
- ___ - Debridement, irrigation, right hip with
disarticulation (girdlestone procedure)
- ___ - debridement of Right trochanteric pressure ulcer
with extension into the hip joint.
- ___ - Repeat debridement and surgical preparation of
right trochanteric pressure ulcer with placement of
vacuum-assisted closure dressing
- ___ - Debridement and surgical preparation of right
trochanteric pressure ulcer and placement of VAC dressing.
- ___ - Excision of ulcer, right third toe, Middle
phalangectomy, right third toe
- ___ - Right tibia removal of intramedullary rod, right
tibia irrigation and debridement
- ___ - Right tibia intermedullary rodding
- ___ - Multiple thoracic/lumbar laminotomies, total
laminectomy /transpedicular decompression T11, Open Treatment of
T11 fracture, Posterior spinal fusion from T8 to L2 for kyphosis
- ___ - Thoracic laminectomy, posterior fusion T9 to L2
with instrumentation.
- ___ - T11 vertebrectomy, T10-12 fusion for T11 burst
fracture and paraplegia.
- IVC filter placement (since ___
Social History:
___
Family History:
No known family history of cardiac disease. He thinks his father
may have had a "small heart attack".
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.2PO 103/57 77 18 99RA
GENERAL: AAOx3, NAD, appears stated age, well-nourished
HEENT: Normocephalic, atraumatic, EOMI, PERRL
CARDIAC: RRR, no murmurs, rubs, gallops
LUNGS: CTAB, no wheezes, ronchi, crackles
ABDOMEN: NABS, soft, NT, ND
EXTREMITIES: wwp, no peripheral edema appreciated
SKIN: ulcers on bilateral heels, non-healing ulcer on sacrum,
multiple wounds on legs that he says are from burns from his
motorcycle
NEURO: AAOx3, CN II-XII grossly intact, strength ___ bilateral
upper extremities, strength ___ bilateral lower extremities.
DISCHARGE PHYSICAL EXAM
VS: 98.4 104/63 81 18 97 Ra
Weight: not weighed today. (admit wt: 78.5 kg)
GENERAL: Sitting up in bed. Oriented x3. Mood, affect
appropriate. Paraplegic, wheelchair at bedside.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple, JVP flat.
CARDIAC: RRR, no murmurs, rubs, gallops
LUNGS: CTAB, no wheezes, ronchi, crackles
ABDOMEN: NABS, soft, NT, ND
EXTREMITIES: wwp, no peripheral edema appreciated
SKIN: ulcers on bilateral heels, non-healing ulcer on sacrum,
multiple wounds on legs that he says are from burns from his
motorcycle
NEURO: AAOx3, CN II-XII grossly intact, strength ___ bilateral
upper extremities, strength ___ bilateral lower extremities.
Pertinent Results:
ADMISSION LABS
======================
___ 02:30PM BLOOD WBC-9.4# RBC-3.86* Hgb-9.8* Hct-32.4*
MCV-84 MCH-25.4* MCHC-30.2* RDW-18.1* RDWSD-54.4* Plt ___
___ 02:30PM BLOOD Neuts-77.7* Lymphs-13.5* Monos-7.4
Eos-0.4* Baso-0.3 Im ___ AbsNeut-7.27* AbsLymp-1.26
AbsMono-0.69 AbsEos-0.04 AbsBaso-0.03
___ 02:30PM BLOOD Glucose-105* UreaN-12 Creat-0.6 Na-136
K-4.2 Cl-99 HCO3-24 AnGap-17
___ 02:30PM BLOOD proBNP-4949*
___ 02:30PM BLOOD cTropnT-0.21*
___ 08:30PM BLOOD cTropnT-0.22*
___ 03:25AM BLOOD cTropnT-0.19*
___ 08:00AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.1
DISCHARGE LABS
======================
___ 06:10AM BLOOD WBC-6.3 RBC-3.44* Hgb-8.8* Hct-29.6*
MCV-86 MCH-25.6* MCHC-29.7* RDW-18.0* RDWSD-56.5* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-100 UreaN-14 Creat-0.6 Na-137
K-4.7 Cl-99 HCO3-23 AnGap-20
___ 08:00AM BLOOD CK-MB-4 cTropnT-0.21*
___ 06:10AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.2
MICROBIOLOGY
======================
none
RADIOGRAPHIC STUDIES:
======================
CTA ___
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Right lower lobe bronchial wall thickening may be secondary
to inflammatory
or infectious airways disease.
3. Incidentally noted 4 mm left upper lobe nodule. Recommend
follow-up per
___ criteria below.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 5 mg PO BID
2. Warfarin 4 mg PO DAILY16
3. Docusate Sodium 100 mg PO BID
4. Doxycycline Hyclate 100 mg PO Q12H
5. Fluconazole 200 mg PO Q24H
6. metaxalone 800 mg oral DAILY
7. OxyCODONE (Immediate Release) 60 mg PO Q6H
8. OxyCODONE (Immediate Release) 15 mg PO Q3H:PRN BREAKTHROUGH
PAIN
9. Vesicare (solifenacin) 5 mg oral DAILY
10. Vitamin C With Rose Hips (ascorbic acid (vitamin
C);<br>ascorbic acid-ascorbate sodium) 500 mg oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Baclofen 5 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Doxycycline Hyclate 100 mg PO Q12H
7. Fluconazole 200 mg PO Q24H
8. metaxalone 800 mg oral DAILY
9. OxyCODONE (Immediate Release) 60 mg PO Q6H
10. OxyCODONE (Immediate Release) 15 mg PO Q3H:PRN BREAKTHROUGH
PAIN
11. Vesicare (solifenacin) 5 mg oral DAILY
12. Vitamin C With Rose Hips (ascorbic acid (vitamin
C);<br>ascorbic acid-ascorbate sodium) 500 mg oral BID
13. Warfarin 4 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI
Secondary Diagnosis:
History of DVT/PE
Paraplegia with chronic pain
Sacral and heel pressure ulcers
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ w/ midsternal chest pain, paralyzed; eval for pna.// ___ w/
midsternal chest pain, paralyzed; eval for pna.
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation. Lung volumes are slightly low, accentuating
bronchovascular markings. There is no pleural effusion or pneumothorax. Mild
cardiomegaly is stable. Hardware in the lower thoracic spine appear stable.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with recurrent PE/DVT presenting with chest pain and
subtherapeutic INR. Evaluate for pulmonary embolism. Trop and BNP elevation.
?submassive PE.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy (Body) DLP =
9.1 mGy-cm.
2) Spiral Acquisition 3.8 s, 30.1 cm; CTDIvol = 12.1 mGy (Body) DLP = 363.0
mGy-cm.
Total DLP (Body) = 372 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level. There is no evidence of pulmonary embolism. The thoracic
aorta is normal in caliber without evidence of dissection or intramural
hematoma. There are marked atherosclerotic calcifications of the coronary
arteries noted. The heart, pericardium, and great vessels are otherwise 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. Small pleural
calcifications are noted.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally. There is mild bronchial thickening in the right lower lobe.
There is a 4 mm nodule in the left upper lobe notedd (03:44).
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is poorly evaluated secondary
to streak artifact from spine hardware. Hyperenhancing focus within the left
lobe of the liver measuring approximately 16 mm (3:179) is unchanged from
previous CT of the abdomen pelvis from ___, compatible with a
hemangioma.
BONES: Posterior spinal hardware in the low thoracic spine is incompletely
imaged, though no complications are visualized. There is no acute fracture.
Chronic appearing right-sided rib deformities are noted.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Right lower lobe bronchial wall thickening may be secondary to inflammatory
or infectious airways disease.
3. Incidentally noted 4 mm left upper lobe nodule. Recommend follow-up per
___ criteria below.
RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommend in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:49 pm.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Nausea
Diagnosed with Precordial pain
temperature: 98.5
heartrate: 101.0
resprate: 18.0
o2sat: 100.0
sbp: 101.0
dbp: 63.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ ear old man with paraplegia secondary to
a fall in ___, chronic pain, recent bilateral psoas abscesses
who presents with acute onset chest pain and troponin elevation.
He was found to have troponin elevation but no STE on EKG. He
was taken the cath lab for coronoary angiography on ___,
___, which showed no significant blockage, moderate ___ LAD
disease, and nothing to stent. The plan is to optimize medical
management for his CAD by starting atorvastatin 80mg, metop
succinate 25 mg, and ASA ___oes not want to take
Plavix, so he will just be on dual therapy with warfarin +
aspirin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old woman with a history of factor V leiden
with prior DVT and PE as well as ?TIA and ?neurogenic bladder
(details of this are not clear at this point, since we do not
have any documentation how this diagnosis was made) who
presents with an episode of memory loss then right facial droop
and right arm and leg weakness this afternoon.
The patient remembers getting her family ready for school/work
this morning and then the next think she remembers is seeing her
husband when he got home from work. He returned around ___
and
found her on the floor, crying, not making sense (not completing
thoughts, no wrong words). At that time she had a right facial
droop and right arm > leg weakness so he drove her to the
hospital. She was able to walk and get into the car. She also
reports a posterior headache around the same time. Her right
cheek feels slight numb currently.
In ___ the patient had a similar episode where she got her
daughter ready for school and then has no memory until the
afternoon around 3pm when a house guest noted she was wondering
around, not making sense. She also had some right face and arm
weakness at that time. This was diagnosed as a TIA.
She report recent low grade fevers from recent UTIs. + nausea,
vomiting x2-3, and diarrhea the past few days.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies difficulty with gait.
On general review of systems, the pt 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:
Factor 5 leiden diagnosed afer DVT and PE last ___
?"TIA" in ___
?Neurogenic bladder
Right hydronephrosis
Frequent UTIs, ESBL
Obesity
Social History:
___
Family History:
No strokes, no seizures. Does not know mother.
Physical Exam:
ADMISSION:
Vitals: 97.0 112 ___ 100% RA
General: Awake, cooperative, NAD, obese
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA
Cardiac: RRR, nl. S1S2
Extremities: No C/C/E bilaterally
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt. was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Variable and volitional right facial droop. Absent when
unobserved. Distractible.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: giveway on SCM when turning RIGHT.
XII: Tongue protrudes in midline with normal strength
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally but right arm shakes as with effort.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 ___ 5
R 5 ___ ___ 5 5 ___ 5
Give way on the right arm and leg, full with encouragement and
in
first second.
-Sensory: reports intact pin throughout. Decreased JPS and
vibration at the right toe.
-DTRs:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride. Romberg
absent.
DISCHARGE:
General: Awake, cooperative, NAD, obese
HEENT: NC/AT, no scleral icterus, MMM
Neck: Supple
Pulmonary: Breathing comfortably
Extremities: No C/C/E bilaterally
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
comprehension. Normal prosody. There were no paraphasic errors.
Speech was not dysarthric. Able to
follow both midline and appendicular commands.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Variable and volitional right facial droop. Absent when
unobserved. Distractible.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: Giveway on SCM when turning RIGHT.
XII: Tongue protrudes in midline with normal strength
-Motor: Normal bulk, tone throughout. Drift without pronation on
right (most likely non-organic).
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 ___ 5
R 5 ___ ___ 5 5 ___ 5
Give way weakness on the right arm and leg, but full with
encouragement and in
first second.
-Sensory: Intact to light touch.
Pertinent Results:
___ 08:00PM GLUCOSE-82 UREA N-11 CREAT-1.0 SODIUM-137
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17
___ 08:00PM ALT(SGPT)-76* AST(SGOT)-46* ALK PHOS-71 TOT
BILI-0.6
___ 08:00PM cTropnT-<0.01
___ 08:00PM WBC-9.2 RBC-4.73 HGB-14.8 HCT-45.4 MCV-96
MCH-31.3 MCHC-32.6 RDW-12.9
___ 08:00PM NEUTS-68.2 ___ MONOS-4.1 EOS-2.5
BASOS-0.9
___ 08:00PM PLT COUNT-150
___ 08:00PM ___ PTT-30.9 ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
MR Brain:
IMPRESSION:
No significant abnormalities are seen on MRI of the brain
without gadolinium.
Medications on Admission:
Flexeril 10mg BID
Hiprex 1g BID
Ambien 10mg PRN
Tramadol 50mg ___ tabs QID
Zofran 4mg TID prn
Xarelto 20mg daily
Colchicine 0.6 mg BID
Discharge Medications:
1. Colchicine 0.6 mg PO BID
2. Cyclobenzaprine 10 mg PO BID
3. Hiprex (methenamine hippurate) 1 gram oral BID
4. Rivaroxaban 20 mg PO DAILY
5. Zolpidem Tartrate 10 mg PO HS:PRN Insomnia
6. TraMADOL (Ultram) 50-100 mg PO QID
7. Ondansetron 4 mg PO Q8H:PRN Nausea
8. Outpatient Physical Therapy
9. Outpatient Speech/Swallowing Therapy
10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
Please discuss this with the provider who manages your urinary
difficulties
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice daily Disp #*14 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right-sided weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with amnesia, right sided weakness // ? 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 ___.
FINDINGS:
There is no acute infarction, intracranial hemorrhage, extracerebral fluid
collection, midline shift or mass effect. Ventricles and extra-axial spaces
are normal in size. Flow voids are maintained. Suprasellar and craniocervical
regions are unremarkable.
IMPRESSION:
No significant abnormalities are seen on MRI of the brain without gadolinium.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Weakness
Diagnosed with OTHER MALAISE AND FATIGUE
temperature: 97.0
heartrate: 112.0
resprate: 16.0
o2sat: 100.0
sbp: 112.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | Ms ___ was admitted to the Stroke Service at ___
___ after presenting with right-sided
weakness. MRI of her brain was negative for evidence of stroke.
Her weakness was felt to be functional in origin considering the
drift without pronation and the clear signs of give-way
weakness, but full strength with encouragement. Her UA was
notable for 86 WBC, + nitrites, and large leukocyte esterase
with only 3 epithelial cells, concerning for UTI. She had
recently completed a 7 day course of Macrobid. She was restarted
on another 7 day course of Macrobid and instructed to discuss
this with the physician who manages her urinary difficulties. A
urine culture at ___ was done and was found to be positive for
E.coli, however, further incubation showed contamination with
mixed skin/genital flora. Clinical significance of isolate(s)
was thought to be uncertain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Flexeril
Attending: ___.
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ yo M w/ hx of COPD, PNA this
year, moderately severe dementia, afib, CKD, HTN who presents
with respiratory distress. Son reports pt was watching TV when
he started choking and gagging with gurgling sounds. The pt was
respondent during this time, engaging with his son. No LOC.
Family denies fall.
In the ED, initial vitals: T98.3 HR 105 BP 150/56 RR 25 100% on
BIPAP. He had a chest x-ray which showed "Patchy opacities in
the lung bases may reflect aspiration or infection. Mild
pulmonary vascular congestion", concerning for PNA. Given 4.5 g
zosyn, 1gm vanc, 125 methylpred, 1L NS. He was intubated using
20 mg etomidate and 100 mg succinylcholine. He was placed on
fentanyl and midalozam drips for sedation. After intubation, he
was given an additional 1L NS for hypotension ___, after
which his pressure improved to 103/62.
In At___ careweb, there is a note from today, in which his PCP
detailed ___ family meeting with pt's son ___ (caregiver),
daughter ___ (HCP), and grandson ___ (alternate HCP &
caregiver). The ultimate result was a signed MOLST and a
conclusion that he "...does not CPR, intubation and ventilation,
dialysis, artificial hydration, and artificial nutrition. He
would prefer to have all of his care at home or in outpatient
setting rather than go to hospital, unless required for
comfort." Despite this note, in ED, family was present and
expressed some misunderstandings regarding the DNR/DNI status.
They reportedly felt it was for chronic issues of progressing
dementia rather than acute issues and expressed desire for
intubation with valid HCP form present.
On transfer, vitals were: T99.6 HR67 BP 103/67 RR18, 100%
intubated
On arrival to the MICU, pt was comfortably sedated, and family
was available. Family verified that there was confusion
regarding the MOLST/DNR/DNI issues. They felt pt has a
satisfactory baseline function, being AAOx2, engaged, fairly
independent and they feel pt would want to be intubated if he
were to have a quick recovery. They state he would not want to
be intubated for a prolonged period.
Review of systems:
Unable to assess d/t intubated and sedated status.
Past Medical History:
Past Medical History
Diagnosis Date
Pneumonia x2
Abnormal renal function ___
Past Surgical History
Procedure Laterality Date
Anesth,elbow area surgery Age ___
Fracture, +metal rod
Cataract extracaps extract, complex w intraocular lens
___ lt
-BPH - started flomax in ___ in setting of urinary retention
brought on by Flexeril use; started on Flomax but unable to void
still so indwelling catheter placed ___. Multiple voiding
trials unsuccessful. C/b UTI x 2, the first requiring
hospitalization with hypotension in ___ at ___, the second in
___ dx'd in setting of delirium. Finasteride started
___.
-COPD
-History of atrial fibrillation
-Chronic Kidney Disease
-Hypertension
-Hx of Hematochezia (had positive FIT test in ___,
recommended for colonoscopy but declined)
-Multiple ophtho issues (Hx of central retinal vein occlusion,
Mature cataract, Pseudophakia, posterior vitreous detachment,
posterior capsular opacification)
-Environmental allergies, allergic rhinitis
-Onychomycosis
-Low back strain
-Incidental lung nodule, > 3mm and < 8mm
Social History:
___
Family History:
Diabetes - Type II Father
CAD/PVD Father
Stroke Neg HX
Cancer Neg HX
Kidney Disease Neg HX
Cancer - Prostate Neg HX
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: 98.2 124/57, 61, RR 19, 98% Spo2 intubated
HEENT: Sclera anicteric, MMM, oropharynx clear. PERRL.
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-distended. No grimacing to deep palpation. No
organomegaly.
EXT: No clubbing, cyanosis or edema. No ___ pulses b/l to
palpation but present on Doppler. Intact symmetric radial
pulses. Feet cool.
SKIN: No rash.
NEURO: PERRL. No posturing. Sedated.
DISCHARGE PHYSICAL EXAM
========================
S: Minimally conversational. No pain. No CP/SOB.
PHYSICAL EXAM
VS: 98.5 159/71 64 18 91RA (Typically in 96RA range)
GENERAL: unintelligible responses to questions/mumbling
HEENT: Sclera anicteric
NECK: unable to appreciate JVP
LUNGS: no crackles/wheezes anteriorly
CV: largely regular rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-distended. No grimacing to deep palpation. No
organomegaly.
EXT: No clubbing, cyanosis or edema.
SKIN: No rash.
NEURO: Interactive, severely dysarthric, appropriate behavior,
moves all extremities, non-conversational
LABS: Reviewed, as below
Pertinent Results:
==============
ADMISSION LABS
==============
___ 10:50PM ___ PTT-30.4 ___
___ 10:50PM NEUTS-87* BANDS-2 LYMPHS-6* MONOS-5 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-8.37* AbsLymp-0.56*
AbsMono-0.47 AbsEos-0.00* AbsBaso-0.00*
___ 10:50PM WBC-9.4 RBC-4.37* HGB-13.0* HCT-41.1 MCV-94
MCH-29.7 MCHC-31.6* RDW-14.2 RDWSD-49.1*
___ 10:50PM ALBUMIN-3.7 CALCIUM-9.4 PHOSPHATE-5.3*
MAGNESIUM-2.1
___ 10:50PM cTropnT-<0.01
___ 10:50PM proBNP-1408*
___ 10:50PM LIPASE-22
___ 10:50PM ALT(SGPT)-17 AST(SGOT)-22 ALK PHOS-307* TOT
BILI-0.5
___ 10:50PM GLUCOSE-190* UREA N-28* CREAT-1.2 SODIUM-139
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-24 ANION GAP-20
___ 10:59PM LACTATE-3.2*
==============
PERTINENT LABS
==============
=====
MICRO
=====
=======
STUDIES
=======
CT Head
1. Predominantly chronic 9 mm thick right frontoparietal
subdural hematoma
with scattered hyperdensity suggestive of acute on chronic
hemorrhage. No
significant mass effect or midline shift.
2. 9 mm thick left chronic subdural hematoma or subdural hygroma
versus
prominent subarachnoid space secondary to involutional changes.
CT Spine without Contrast
No acute fracture or traumatic malalignment of the cervical
spine.
CXR
No relevant change as compared to ___. In the
interval, the
patient has been extubated and the nasogastric tube was removed.
The size of the cardiac silhouette is slightly enlarged. There
are signs of bilateral mild basal apical blood flow
redistribution, suggesting mild pulmonary edema. In addition,
subpleural, peripheral and predominantly basal interstitial
opacities are noted. This could be caused by interstitial
pulmonary edema or an underlying interstitial lung disease.
These 2 entities could be differentiated using CT.
TTE
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is severely depressed (LVEF= ___ secondary
to severe global hypokinesis. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal with focal hypokinesis of the
apical free wall. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Severe global left ventricular systolic dysfunction
suggestive of diffuse process (toxic, metabolic, multivessel
CAD, etc). Regional right ventricular systolic dysfunction. No
significant valvular disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 10 mg PO QHS
2. docosahexanoic acid-epa unknown oral DAILY
3. Ascorbic Acid Dose is Unknown PO DAILY
4. Cyanocobalamin Dose is Unknown PO DAILY
5. melatonin unknown oral QHS
6. Finasteride 5 mg PO DAILY
7. Timolol Maleate 0.5% 1 DROP RIGHT EYE QHS
8. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
9. Aspirin 81 mg PO DAILY
10. Acetaminophen 650 mg PO BID:PRN pain
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Medical Equipment
One hospital bed for aspiration pneumonia.
ICD-10-CM J69.0
2. Aspirin 81 mg PO DAILY
3. Donepezil 10 mg PO QHS
4. Finasteride 5 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
6. Timolol Maleate 0.5% 1 DROP RIGHT EYE QHS
7. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*3
8. Acetaminophen 650 mg PO BID:PRN pain
9. Ascorbic Acid ___ mg PO DAILY
10. Cyanocobalamin 100 mcg PO DAILY
11. docosahexanoic acid-epa 1 g ORAL DAILY
12. melatonin 1 mg ORAL QHS
13. Multivitamins 1 TAB PO DAILY
14. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-hypoxia secondary to aspiration pneumonia
-possible COPD exacerbation
-global systolic dysfunction, unclear etiology
-acute on chronic subdural hemorrhage
SECONDARY:
-bulbar dysfunction
-dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ male with respiratory failure, found down, evaluate
for intracranial bleed.
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, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a right frontoparietal subdural collection measuring 9 mm in maximum
diameter from the inner table which is predominantly hypodense in attenuation
with scattered areas of hyperdensity. This likely represents a acute on
chronic subdural hematoma. There is a left frontal extra-axial collection
measuring up to 9 mm from the inner table. There is no significant shift of
midline structures or mass affect. There is no acute large territorial
infarction or edema. Prominent ventricles and sulci suggest age related
volume loss.
There is no evidence of fracture. Air-fluid level is seen within the sphenoid
sinuses as well as the right maxillary sinus. There is also mild mucosal
thickening in the ethmoid air cells. The remaining visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
Patient is status post bilateral lens replacements. The patient is intubated.
IMPRESSION:
1. Predominantly chronic 9 mm thick right frontoparietal subdural hematoma
with scattered hyperdensity suggestive of acute on chronic hemorrhage. No
significant mass effect or midline shift.
2. 9 mm thick left chronic subdural hematoma or subdural hygroma versus
prominent subarachnoid space secondary to involutional changes.
NOTIFICATION: Findings were discussed with Dr. ___ by ___ phone at
3:40am on ___, immediately following discovery.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ with respiratory failure, found down, evaluate for cervical
spine injury.
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.8 s, 22.6 cm; CTDIvol = 37.2 mGy (Body) DLP = 841.0
mGy-cm.
Total DLP (Body) = 841 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no acute fracture or traumatic malalignment. There is no
prevertebral soft tissue swelling. Multilevel, multifactorial degenerative
changes are noted with uncovertebral and facet hypertrophy causing mild right
neural foraminal narrowing at C3-C4 and mild to moderate bilateral neural
foraminal narrowing at C5-C6 and C6-C7. Degenerative fusion of the C2-C3
right facets is noted. No significant spinal canal stenosis is identified.
Severe emphysematous changes are noted in the included lung apices. There is
biapical scarring. An endotracheal tube and orogastric tube are both
visualized. The thyroid gland is unremarkable. There is no cervical
lymphadenopathy.
Chronic fracture deformity of the right first rib is identified. On scout
images, chronic fracture deformity and superior dislocation of the clavicle at
the acromioclavicular joint is indentified. Probable surgical clip in the
right parotid (series 3, image 14) is noted.
IMPRESSION:
No acute fracture or traumatic malalignment of the cervical spine.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pneumonia now with increased wheezing. //
Interval change? Interval change?
IMPRESSION:
No relevant change as compared to ___. In the interval, the
patient has been extubated and the nasogastric tube was removed. The size of
the cardiac silhouette is slightly enlarged. There are signs of bilateral
mild basal apical blood flow redistribution, suggesting mild pulmonary edema.
In addition, subpleural, peripheral and predominantly basal interstitial
opacities are noted. This could be caused by interstitial pulmonary edema or
an underlying interstitial lung disease. These 2 entities could be
differentiated using CT.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ afib, COPD, moderate-severe dementia p/w acute respiratory
failure w/ chest x-ray concerning for bilateral infiltrates, possibly due to
aspiration event, being covered on unasyn for aspiration PNA and pred
burst/azithro for presumed COPD flare. // eval for pulm edema, pneumonia
eval for pulm edema, pneumonia
COMPARISON: ___
IMPRESSION:
-Heart size and mediastinum are unchanged. There is interval substantial
progression of bibasal consolidations concerning for aspiration or progression
of multifocal infection.
-Stable appearance of subpleural, peripheral predominantly basal interstitial
opacities.
-Likely mild pulmonary vascular congestion.
-Possible new right small pleural effusion.
Radiology Report
EXAMINATION: Video oropharyngeal swallow
INDICATION: ___ year old man with dementia, recurrent aspiration. // recurrent
aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 4.7 min.
COMPARISON: None
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. Trace aspiration and penetration with thin liquids and nectar.
IMPRESSION:
Trace aspiration penetration with thin liquids and nectar.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RESP DISTRESS
Diagnosed with Pneumonitis due to inhalation of food and vomit
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ yo M w/ afib, COPD, moderate-severe dementia presenting with
acute respiratory failure and chest x-ray concerning for
bilateral infiltrates.
# altered mental status, progressive dementia: He was initially
intubated in ED for airway protection in the setting of altered
mental status with mixed picture of hypercarbic and hypoxic
respiratory failure. Patient's mental status continued to
improve after being called out of ICU, although he remained
altered. Per family, patient was at baseline. Dysarthric,
somewhat appropriate in responses, but not always intelligible.
Notably, pt with progressive dementia over past year.
Moderate-to-severe per FAST testing w/ PCP. Pt has HTN, smoking
hx, but normal lipid panel; possible component of vascular
dementia. Pt additionally found to have acute on chronic SDH
which could be responsible for, at least in part, his altered
state; no focal findings on neuro exam. Neurosurgery consulted;
did not feel SDHs were responsible for current presentation.
Patient was continued on home donepezil. Home melatonin was
held.
# aspiration PNA: concern given CXR opacities and acute
respiratory distress. Likely in setting of dementia. No
foreign body on CXR. Likely etiology of mixed hypercarbic and
hypoxic respiratory failure esp in setting of COPD. Could also
be CAP/aspiration given polymicrobial sputum specimen; S/S of
sputum unable to be performed given polymicrobial nature of
infxn. Legionella, MRSA, rapid viral panel negative. S/S
consulted in ICU who made patient strict NPO. Eventually was
reevaluated with video and patient was advanced to pureed/honey
diet. In reagrds to antibiotics, patient received Vanc/cefepime
(___), flagyl ___, then switched to monotherapy
with unasyn ___.
# hypoxia: The most likely cause for his respiratory failure was
an aspiration event given history of gargling and chocking in
the context of bilateral infiltrates and a history of
moderate-severe dementia. He was treated with
Vancomycin/Cefepime/Azithromycin. Emphysematous changes were
noted on CT C-spine and he was also treated with solumedrol for
a 5 day COPD exacerbation course. TTE was done which
demonstrated severe global left ventricular systolic dysfunction
(EF 20%) and regional RV systolic dysfunction. His respiratory
status improved and he was extubated on ___ prior to callout
to medicine floor.
# COPD: Wheezy on exam, hypercarbic, extensive smoking hx, CT
findings of possible interstitial lung dz suggestive of COPD. No
prior PFTs, no use of inhalers or O2 at home. Received
Albuterol/ipratropium nebs. Received a short course of azithro
(z-pak) and solumedrol (___) followed by a 4 day pred burst.
Consider PFTs/pulm f/u as outpatient.
# h/o subdural hemorrhage: For his moderate-severe dementia with
a suspected component of vascular dementia he underwent NCHCT on
admission which was negative for ICH or acute process, although
positive for likely chronic frontoparietal SDH. He did not have
a reported history of trauma or falls. Neurosurgery was
consulted and recommended no acute surgical intervention and
followed with repeat NCHCT in 6 weeks as an outpatient for
monitoring. His neurology exam was non focal. Home ASA was
continued and SQ heparin was started. He underwent speech and
swallow evaluation for aspiration.
# global systolic dysfunction: New, identified on echo.
Consider infiltrative vs toxic vs diffuse CAD. Started on 40
atorvastatin. He had no signs of volume overload. Given his
poor functional status and advanced dementia decision was made
not to pursue further work-up as an inpatient.
# HTN: Hypotensive in ED required 2L fluids with appropriate
response. Hypertensive up to SBP 170s in ICU post-extubation,
improved s/p IV hydral and labetalol. Patient's SBPs remained
150-160 while on medicine floor.
# CKD: Baseline creatinine ~1.2. Stable/better than baseline
during hospitalization.
# BPH: Foley placed in ED. Removed on xfer to floor ___.
Restarted home finasteride on medicine floor. Patient on condom
cath given urinary incontinence.
# Glaucoma: Blind in L eye. Continued home timolol, latanoprost
gtt.
#Primary prevention: continued ASA 81mg. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
- Chest tube placement
- Transjugular intrahepatic portosystemic shunt (TIPS)
- Right thoracentesis
History of Present Illness:
Ms ___ is a ___ female with past medical history
significant for insulin-dependent diabetes mellitus and NASH
___ B/C) c/b encephalopathy, esophageal varices
(s/p bleed several years ago), recurrent hepatic hydrothorax
requiring monthly taps, and HCC who was seen in transplant
clinic
today and referred to the ER for severe right sided chest pain
(pleurtic in nature) and shortness of breath.
She notes that she was at her baseline since her discharge on
___ and was feeling well up until ___ (2 days PTA) when
she began to experience shortness of breath and developed a dry
cough. She has not required a thoracentesis in ___ months. Her
chest pain began yesterday and she describes it as
non-radiating,
worse with deep breaths. She denies fevers or chills, dysuria,
abdominal pain. She has been eating small portions at home,
although denies eating salty foods. She has been compliant with
all medications since her last discharge. Of note, her
spironolactone was recently decreased on ___ from 100 mg
daily to 25 mg daily because of hyponatremia.
Past Medical History:
-Cirrhosis
-Hepatic Encephalopathy (1 prior hospitalization)
-Hepatic hydrothorax s/p multiple thoracenteses
-Esophageal varices (1 prior hospitalization for GIB in approx.
___ requiring banding. Last EGD about ___ year ago, no banding
necessary. Was scheduled for repeat EGD ___.
-Thrombocytopenia with baseline in ___
-T2DM (on lantus BID, no SSI or short acting)
-Umbilical hernia (uses abdominal binder at home)
-Bipolar disorder
-Schizophrenia: one hospitalization in ___, daughter states
pt's mood has been stable on medications
-Asthma
-Psoriasis
-Eczema
-Osteoporosis
Social History:
___
Family History:
One of her brother died of renal disease. She has five siblings
who are alive. There is no cancer or liver disease or liver
cancer or colon cancer in her . Her father died of upper GI
bleeding with unclear etiology. One of her
sisters died of chronic anemia. She has three kids, they are
all healthy.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 99.0 130/80 HR 113 RR 22 ___
GENERAL: Elderly appearing woman in mild distress, lying in
bed. Audible wheezes. A&Ox3
HEENT: NC/AT, EOMI, pinpoint pupils bilaterally, sclera
anicteric
NECK: Supple
CHEST: Multiple spider angiomata over anterior chest
CARDIAC: tachycardic, regular rhythm, normal S1/S2, no m/r/g
PULMONARY: Decreased breath sounds R side, no
crackles/wheezes/rales
ABDOMEN: Distended, abdominal binder in place, reducible
abdominal hernia, +BS, non-tender
EXTREMITIES: Multiple spider angiomata, diffuse ecchymoses, no
edema, no lesions, 2+ DP pulses bilaterally
NEUROLOGIC: Moving all extremities with purpose
PSYCHIATRIC: Normal mood and affect
DISCHARGE PHYSICAL EXAMINATION:
Vitals: 98.2 PO 106 / 62 85 16 96 Ra
General: ___ speaking woman, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Right IJ insertion site with surrounding ecchymosis,
stable.
Lungs: Pleurocentesis insertion site with dressing that is c/d/i
Decreased lung sounds at the right base with crackles and coarse
breath sounds over the remainder of the R lung field. L lung
field has coarse lung sounds as well, but are not decreased.
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Large abdominal hernia, reducible but NT to palpation.
Abdominal binder in place.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3 with some mild attention impairment; motor function
grossly normal; no Asterixis.
Pertinent Results:
Admission Labs:
===============
___ 12:05PM BLOOD WBC-2.1* RBC-3.34* Hgb-10.8* Hct-32.3*
MCV-97 MCH-32.3* MCHC-33.4 RDW-15.0 RDWSD-53.9* Plt Ct-22*
___ 12:05PM BLOOD Neuts-69.2 Lymphs-15.4* Monos-8.9 Eos-5.6
Baso-0.9 AbsNeut-1.48* AbsLymp-0.33* AbsMono-0.19* AbsEos-0.12
AbsBaso-0.02
___ 01:12PM BLOOD ___ PTT-34.1 ___
___ 12:05PM BLOOD Glucose-149* UreaN-18 Creat-1.0 Na-139
K-4.2 Cl-102 HCO3-23 AnGap-14
___ 12:05PM BLOOD ALT-37 AST-45* LD(LDH)-218 AlkPhos-170*
TotBili-2.4*
___ 12:05PM BLOOD cTropnT-<0.01
___ 12:05PM BLOOD TotProt-6.7 Albumin-3.3* Globuln-3.4
Cholest-122
___ 07:00AM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.8 Mg-2.0
___ 12:17PM BLOOD Lactate-1.6
___ 12:17PM BLOOD ___ pO2-29* pCO2-37 pH-7.45
calTCO2-27 Base XS-0
Microbiology:
===============
___ 12:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 11:02 pm PLEURAL FLUID PLEURAL FLUID.
**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..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
Close
___ 6:49 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 9:32 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
CXR ___
FINDINGS:
Right-sided pleural effusion which is large has increased since
prior exam. There is associated atelectasis as well. Left lung
remains clear without consolidation or effusion. Cardiac
silhouette is not well assessed.
IMPRESSION:
Large right pleural effusion which has increased since last
month's exam.
CXR ___
FINDINGS:
There has been interval placement of a right-sided pigtail
catheter which
projects over the right lung inferolaterally. Size of the
pleural effusion
appears slightly smaller. No obvious pneumothorax. Otherwise,
no change. IMPRESSION:
Interval placement of a right-sided chest tube.
Abdominal Ultrasound ___
IMPRESSION:
1. Cirrhotic liver with lesion in the left lobe better
characterized on
recent MR abdomen as suspicious for HCC.
2. Portal vein and its major branches are patent. No ascites.
3. Splenomegaly.
CXR ___
IMPRESSION:
In comparison with the study of ___, the right chest
tube remains in place and there is no evidence of pneumothorax.
There may be some increase in the degree of pleural effusion
with underlying compressive atelectasis. The low lung volumes
are substantially lower. Mild atelectatic changes and possible
small effusion on the left.
___ CHEST (PORTABLE AP)
IMPRESSION:
Right pigtail appears to be outside of the pleural space and
needs to be
repositioned or removed. Right pleural effusion appears to be
similar to
previous examination, moderate or potentially even minimally
decreased as
compared to ___ and substantially decreased as
compared to ___. No pneumothorax is seen. Vascular
congestion/minimal
interstitial edema are unchanged.
___ (PORTABLE AP)
IMPRESSION:
In comparison with study of ___, the right pigtail
catheter is been
removed and there is no evidence of pneumothorax. Continued
right pleural
effusion that may be slightly larger than on the previous study
with
underlying volume loss in the right lower lobe.
There are low lung volumes that accentuate the prominence of the
transverse
diameter of the heart. Mild indistinctness of pulmonary vessels
could reflect
mild elevation of pulmonary venous pressure. No evidence of
acute focal
pneumonia.
CXR ___:
Compared to chest radiographs ___ through ___.
Moderate right pleural effusion redistributed, probably
unchanged in volume. Pulmonary vascular congestion in the left
lung has worsened slightly. Mild cardiomegaly unchanged. No
pneumothorax.
___ (PORTABLE AP)
IMPRESSION:
Pulmonary venous congestion. Right pleural effusion. Mild
elevation of the
right hemidiaphragm.
___ CHEST W/O CONTRAST
IMPRESSION:
1. Large right pleural effusion and right lower lobe collapse,
not
significantly changed compared to the prior study.
2. Linear consolidation along the right middle lobe may
represent atelectasis
versus an infectious process.
3. Heterogeneous left thyroid nodule, increased in size since
the prior study.
Recommend further evaluation with thyroid ultrasound if not
previously worked
up.
___ (PORTABLE AP)
IMPRESSION:
1. Large right pleural effusion has increased substantially over
2 days,
responsible for worsened with right middle lobe and right lower
lobe
atelectasis.
2. Stable mild left pulmonary vascular congestion.
TIPS ___
PROCEDURE: 1. Right thoracentesis.
2. Right internal jugular venous access using ultrasound.
3. Pre-procedure right atrial pressure measurements.
4. CO2 portal venogram.
5. Contrast enhanced portal venogram.
6. Placement of a 10 mm x 6 cm x 2 cm Viatorr covered stent.
7. Post-stenting balloon angioplasty of the TIPS shunt with a 10
mm balloon.
8. Post-stenting portal venogram.
FINDINGS:
1. Pre-TIPS right atrial pressure of 12 mm Hg and portal venous
pressure
measurement of 36 mm Hg resulting in portosystemic gradient of
24 mmHg.
2. CO2 portal venogram showing portal venous anatomy with
favorable position
of a right portal vein branch for TIPS creation.
3. Contrast enhanced portal venogram showing a patent portal
vein.
4. Post-TIPS portal venogram showing good flow through the TIPS
and varices
arising off of the splenic vein.
5. Post-TIPS right atrial pressure of 28 mm Hg and portal
pressure of 34 mm Hg
resulting in portosystemic gradient of 6 mmHg.
6. Attempted access of varices arising off of the splenic vein
was
unsuccessful and abandoned as the indication for TIPS placement
was refractory
hepatic hydrothorax.
7. 4 liters of pleural fluid removed through right thoracentesis
drain with
blood-tinged fluid noted at the end of the procedure. A 1 hour
postprocedure
chest x-ray was ordered and in H&H was sent for analysis.
IMPRESSION:
Successful right internal jugular access with transjugular
intrahepatic
portosystemic shunt placement with decrease in porto-systemic
pressure
gradient. 4 liters of large pleural effusion were drained.
___ (PORTABLE AP)
IMPRESSION:
Compared to chest radiographs since ___, most recently
___.
Previous large right pleural effusion is now small. No
pneumothorax.
Pulmonary and mediastinal vasculature is now engorged and there
is new mild
pulmonary edema. Consolidation at the base of the right lung
could be
atelectasis surviving the previous large pleural effusion.
Cardiac silhouette
is mildly enlarged
___ (PA & LAT)
IMPRESSION:
Mild pulmonary edema and small right pleural effusion, stable.
Atelectatic
changes at the right lung base, developing pneumonia cannot be
excluded.
___ NECK, SOFT TISSUE
IMPRESSION:
A small, tubular tract of fluid is identified within the
superficial soft
tissues of the right neck, over the puncture site. This is
likely a small
amount of fluid following the tract of the catheter used for
recent TIPS
procedure. No organized hematoma is identified.
___ (PA & LAT)
IMPRESSION:
Right pleural effusion is increased in size from prior exam, now
small to
moderate. Mild bilateral pulmonary edema appears similar. No
pneumothorax.
Cardiac silhouette appears unchanged.
Discharge Labs:
=================
___ 05:55AM BLOOD WBC-3.7* RBC-2.62* Hgb-8.5* Hct-24.2*
MCV-92 MCH-32.4* MCHC-35.1 RDW-16.3* RDWSD-54.4* Plt Ct-37*
___ 05:55AM BLOOD Plt Ct-37*
___ 05:55AM BLOOD ___ PTT-40.8* ___
___ 05:55AM BLOOD Glucose-159* UreaN-14 Creat-0.8 Na-127*
K-4.8 Cl-93* HCO3-23 AnGap-11
___ 05:55AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Furosemide 20 mg PO DAILY
6. Lactulose 15 mL PO QID
7. Loratadine 10 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Ondansetron 4 mg PO Q4H:PRN nausea
11. Rifaximin 550 mg PO BID
12. Spironolactone 25 mg PO DAILY
13. Tolvaptan 30 mg PO DAILY
14. Ursodiol 300 mg PO TID
15. ammonium lactate ___ % PRN PRN
16. Ascorbic Acid ___ mg PO DAILY
17. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
18. Calcipotriene 0.005% Cream 1 Appl TP BID
19. PALIperidone Palmitate 410 mg IM Q10WEEKS
20. Vitamin B Complex 1 CAP PO DAILY
21. Glargine 15 Units Breakfast
Glargine 10 Units Bedtime
Discharge Medications:
1. Glucerna Shake (nut.tx.gluc.intol,lac-free,soy) 3 bottle
oral TID W/MEALS
RX *nut.tx.gluc.intol,lac-free,soy [Glucerna] ___ BOTTLE by
mouth TID with meals Disp ___ Milliliter Milliliter
Refills:*3
2. Glargine 10 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Lactulose 30 mL PO QID
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth four times a
day Disp #*180 Bolus Refills:*0
4. Spironolactone 50 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
7. BuPROPion (Sustained Release) 150 mg PO QAM
8. Calcipotriene 0.005% Cream 1 Appl TP BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Loratadine 10 mg PO DAILY
12. Montelukast 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Ondansetron 4 mg PO Q4H:PRN nausea
15. PALIperidone Palmitate 410 mg IM Q10WEEKS
16. Rifaximin 550 mg PO BID
17. Ursodiol 300 mg PO TID
18. Vitamin B Complex 1 CAP PO DAILY
19. HELD- ammonium lactate ___ % PRN PRN This medication was
held. Do not restart ammonium lactate until you see your primary
care provider
20. HELD- Ascorbic Acid ___ mg PO DAILY This medication was
held. Do not restart Ascorbic Acid until you see your primary
care provider
21. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until you see your primary care
provider
22. HELD- Tolvaptan 30 mg PO DAILY This medication was held. Do
not restart Tolvaptan until you see your primary care provider
23.Outpatient Lab Work
ICD-9: 571.2
provider: ___ MD ___ Address: ___ Phone: (___)
Test: LFT, albumin, coagulation profile, chem 10, CBC.
24.Radiology test
ICD-9: 571.2
provider: ___ MD ___ Address: ___ Phone: (___)
Test: chest x-ray
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-___ Cirrhosis ___ B/C)
-Hepatic hydrothorax
-Pancytopenia
-Coagulopathy
-Hepatocellular carcinoma
Secondary:
-Bipolar vs. schizophrenia disorder
-Asthma
-Umbilical hernia
-Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with sob// sob, pna vs effusion
TECHNIQUE: AP view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Right-sided pleural effusion which is large has increased since prior exam.
There is associated atelectasis as well. Left lung remains clear without
consolidation or effusion. Cardiac silhouette is not well assessed.
IMPRESSION:
Large right pleural effusion which has increased since last month's exam.
Radiology Report
INDICATION: ___ with hepatothorax s/p pig tail placement// Pigtail placement
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from earlier the same day.
FINDINGS:
There has been interval placement of a right-sided pigtail catheter which
projects over the right lung inferolaterally. Size of the pleural effusion
appears slightly smaller. No obvious pneumothorax. Otherwise, no change.
IMPRESSION:
Interval placement of a right-sided chest tube.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NASH cirrhosis, hepatic hydrothorax p/w
dyspnea s/p pigtail// eval for interval change, ptx
IMPRESSION:
In comparison with the study of ___, the right chest tube remains in
place and there is no evidence of pneumothorax. There may be some increase in
the degree of pleural effusion with underlying compressive atelectasis.
The low lung volumes are substantially lower. Mild atelectatic changes and
possible small effusion on the left.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with NASH cirrhosis, ___ presenting with
recurrence of hepatic hydrothorax, abdominal pain// Please observe for
abdominal ascites and portal venous thrombosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound ___
MRI abdomen ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is a 2.4 cm
hyper/hypoechoic lesion left lobe liver, better characterized on recent MR
abdomen. The main portal vein is patent with hepatopetal flow. There is no
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD is not well
visualized.
GALLBLADDER: The gallbladder is not well visualized, largely obscured by bowel
gas.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 19.9 cm.
KIDNEYS: Limited views the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with lesion in the left lobe better characterized on
recent MR abdomen as suspicious for HCC.
2. Portal vein and its major branches are patent. No ascites.
3. Splenomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NASH cirrhosis, recurrent hepatic
hydrothorax, and HCC who presents with evidence of hepatic hydrothorax.//
Comparison of pleural effusion to previous CXR after CT placement. Observe for
PTX. Comparison of pleural effusion to previous CXR after CT placement.
Observe for PTX.
IMPRESSION:
Right pigtail appears to be outside of the pleural space and needs to be
repositioned or removed. Right pleural effusion appears to be similar to
previous examination, moderate or potentially even minimally decreased as
compared to ___ and substantially decreased as compared to ___. No pneumothorax is seen. Vascular congestion/minimal
interstitial edema are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NASH cirrhosis recurrent hepatic
hydrothorax, and HCC who presents with shortness of breath, chest pain and
evidence of hepatic hydrothorax now with chest tube removed.// Eval after CT
removal
IMPRESSION:
In comparison with study of ___, the right pigtail catheter is been
removed and there is no evidence of pneumothorax. Continued right pleural
effusion that may be slightly larger than on the previous study with
underlying volume loss in the right lower lobe.
There are low lung volumes that accentuate the prominence of the transverse
diameter of the heart. Mild indistinctness of pulmonary vessels could reflect
mild elevation of pulmonary venous pressure. No evidence of acute focal
pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NASH cirrhosis, recurrent hepatic
hydrothorax, and HCC who presents with shortness of breath, chest pain and
evidence of hepatic hydrothorax. // Eval for hepatic hydrothorax. Compare
size to previous CXR Eval for hepatic hydrothorax. Compare size to previous
CXR
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate right pleural effusion redistributed, probably unchanged in volume.
Pulmonary vascular congestion in the left lung has worsened slightly. Mild
cardiomegaly unchanged. No pneumothorax.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old woman with NASH cirrhosis ___ B/C, MELD-Na 19
on admission) c/b encephalopathy, esophageal varices (s/p bleed several years
ago), recurrent hepatic hydrothorax, and HCC who presents with shortness of
breath, chest pain and evidence of hepatic hydrothorax. s/p pigtail catheter.
Now with worsening shortness of breath.// Eval for interval change.
TECHNIQUE: Portable chest x-ray
COMPARISON: Previous portable chest x-ray from ___
FINDINGS:
There is a moderate size right pleural effusion, not significantly changed.
There is loss of volume of the right lung with mild elevation of the right
hemidiaphragm. Pulmonary vascular congestion appears similar. There is mild
cardiomegaly, stable. The aorta is atherosclerotic and tortuous.
IMPRESSION:
Pulmonary venous congestion. Right pleural effusion. Mild elevation of the
right hemidiaphragm.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with NASH cirrhosis, HCC, and recurrent hepatic
hydrothorax who is p/w SOB c/f hepatic hydrothorax, s/p chest tube placement
and removal now having increasing dyspnea// Observe for pleural effusion,
consolidation/PNA
TECHNIQUE: Multidetector helical scanning of the chest was and reconstructed
as contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and
parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.0 s, 32.2 cm; CTDIvol = 13.5 mGy (Body) DLP = 433.6
mGy-cm.
Total DLP (Body) = 434 mGy-cm.
COMPARISON: CT chest ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid demonstrates a large
heterogeneous left thyroid nodule measuring approximately 2.8 cm.
Supraclavicular and axillary lymph nodes are not enlarged.
MEDIASTINUM: Mediastinal lymph nodes are not enlarged. Calcified mediastinal
lymph nodes compatible with history of granulomatous disease.
HILA: Hilar lymph nodes are not enlarged.
HEART: The heart is not enlarged and there is no coronary arterial
calcification. There is no pericardial effusion.
VESSELS: Vascular configuration is conventional. Aortic caliber is normal.
The main, right, and left pulmonary arteries are normal caliber.
PULMONARY PARENCHYMA: Right lower lobe collapse in the setting of large right
pleural effusion. Linear consolidation along the right middle lobe (602:55)
may represent atelectasis versus an infectious process.
AIRWAYS: The airways are patent to the subsegmental level bilaterally.
PLEURA: There is a large right pleural effusion, similar in size compared to
the prior study from ___.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion.
Multilevel degenerative changes are mild.
UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen.
Allowing for this, the partially visualized upper abdomen demonstrates
ascites, cholelithiasis, and cirrhotic liver.
IMPRESSION:
1. Large right pleural effusion and right lower lobe collapse, not
significantly changed compared to the prior study.
2. Linear consolidation along the right middle lobe may represent atelectasis
versus an infectious process.
3. Heterogeneous left thyroid nodule, increased in size since the prior study.
Recommend further evaluation with thyroid ultrasound if not previously worked
up.
RECOMMENDATION(S): Thyroid ultrasound.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NASH and hepatic hydrothorax s/p ___.
Evaluate shortness of breath and interval worsening.
TECHNIQUE: Frontal view of the chest.
COMPARISON: Chest x-ray ___ through ___. Chest CT ___.
FINDINGS:
The cardiomediastinal silhouette appears stable, although the right border is
obscured by fluid. Compared to the most recent prior radiograph, the right
pleural effusion has increased and is now large in size. Concurrent right
middle lobe and right lower lobe atelectasis. No mediastinal shift, left
pleural effusion, or pneumothorax. Stable mild left pulmonary vascular
congestion.
IMPRESSION:
1. Large right pleural effusion has increased substantially over 2 days,
responsible for worsened with right middle lobe and right lower lobe
atelectasis.
2. Stable mild left pulmonary vascular congestion.
Radiology Report
INDICATION: ___ year old woman with NASH cirrhosis c/b recurrent hepatic
hydrothorax, and ___ who presents with recurrence of hepatic hydrothorax.//
Eval for TIPS procedure given recurrent hepatic hydrothorax and prior to RFA
for HCC
COMPARISON: MR abdomen ___
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: General anesthesia
MEDICATIONS: None
CONTRAST: 130 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 41.2 min, 195 mGy
PROCEDURE: 1. Right thoracentesis.
2. Right internal jugular venous access using ultrasound.
3. Pre-procedure right atrial pressure measurements.
4. CO2 portal venogram.
5. Contrast enhanced portal venogram.
6. Placement of a 10 mm x 6 cm x 2 cm Viatorr covered stent.
7. Post-stenting balloon angioplasty of the TIPS shunt with a 10 mm balloon.
8. Post-stenting portal venogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The neck and abdomen were prepped and draped in the usual sterile
fashion.
Under continuous ultrasound guidance ___ needle/catheter was advanced into
the right pleural fluid. The ___ catheter was attached to a vacuum container
for drainage.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Images of
ultrasound access were stored on PACS. Subsequently a Nitinol wire was passed
into the right atrium using fluoroscopic guidance. A small incision was made
at the needle entry site. The needle was exchanged for a micropuncture sheath.
The Nitinol wire was removed and a ___ wire was advanced distally into
the IVC.
The micropuncture sheath was then removed and a 10 ___ sheath was advanced
over the wire into the right atrium. Right atrial pressure measurements were
then obtained measuring at 12 mm Hg. An Amplatz wire was advanced in the
sheath next to the ___ wire and passed into the IVC for stability. Using a
MPA catheter and a Glidewire, access was obtained in the right hepatic vein.
Appropriate position was confirmed with contrast injection and fluoroscopy in
AP and lateral views. Then an occlusion balloon was advanced over the wire
into the distal right hepatic vein. The wire was then removed and the balloon
was inflated. A CO2 portal venogram was performed in the AP projection.
Following procedural planning, the occlusion balloon was removed over an
Amplatz wire and the angled sheath was advanced through the 10 ___ sheath.
Once the sheath was placed in an appropriate position, the cannula device was
inserted over the Amplatz wire and the wire was exchanged for ___
needle. The angled sheath was turned anteriorly. The needle was then advanced
through liver parenchyma and the needle was withdrawn over its sheath. The
sheath was withdrawn while gentle suction was applied. Upon blood return, a
Glidewire was introduced into the catheter to pass into the portal vein. The
sheath was advanced into the main portal vein which was confirmed with a
contrast injection and a stiff Glidewire was advanced into the superior
mesenteric vein. The 10 ___ sheath was advanced over the inner cannula and
stiff Glidewire into the main portal vein. Next portal venous pressure
measurements were obtained.
An Amplatz wire was advanced through the sheath into the superior mesenteric
vein. A 5 ___ marker omni flush catheter was then advanced and a contrast
enhanced portal venogram was performed. The catheter was removed and a 10 mm
x 6 cm x 2 cm Viatorr covered stent was advanced into appropriate position and
deployed. Following stent deployment, the stent was dilated using a 10 mm
balloon.
The straight flush catheter was advanced over the wire into the splenic vein
and the wire was removed. Repeat right atrial and portal venous pressure
measurements were performed. Splenic venogram demonstrated varices arising
from the coronary vein and posterior gastric vein. While a glidewire was
successfully advanced into the coronary vein varix, multiple attempts to track
a catheter (MPA or Omni) were unsuccessful. Attempts to advance a stiffer
wire (Amplatz or stiff Glidewire) into the varix were unsuccessful
catheterization.
The sheath was then removed from the right internal jugular vein site and
pressure held for 10 minutes to achieve hemostasis. Sterile dressings were
applied.
4 L of fluid was drained from the right pleural space throughout the
procedure. Blood tinged fluid was noted at the end of the procedure.
The patient tolerated the procedure well. There were no immediate
post-procedure complications. The patient was transferred to the PACU in
stable condition.
FINDINGS:
1. Pre-TIPS right atrial pressure of 12 mm Hg and portal venous pressure
measurement of 36 mm Hg resulting in portosystemic gradient of 24 mmHg.
2. CO2 portal venogram showing patent portal venous anatomy with favorable
position of a right portal vein branch for TIPS creation.
3. Contrast enhanced portal venogram showing a patent portal vein.
4. Post-TIPS portal venogram showing brisk antegrade flow through the TIPS and
small varices arising off of the coronary and posterior gastric vein.
5. Post-TIPS right atrial pressure of 28 mm Hg and portal pressure of 34 mm Hg
resulting in portosystemic gradient of 6 mmHg.
6. Attempted catheterization of varices was unsuccessful and abandoned as the
indication for TIPS placement was refractory hepatic hydrothorax. Patient
will be assessed at clinical follow-up for need for further need for variceal
embolization/obliteration.
7. 4 liters of pleural fluid removed through right thoracentesis drain with
blood-tinged fluid noted at the end of the procedure. A 1 hour postprocedure
chest x-ray was ordered and in H&H was sent for analysis.
IMPRESSION:
Successful right internal jugular access with transjugular intrahepatic
portosystemic shunt placement with decrease in porto-systemic pressure
gradient. 4 liters of large pleural effusion were drained.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with right hepatic hydrothorax s/p
thoracentesis draining 4 L. Blood tinged fluid at end. // Monitor for
reaccumulation of right pleural fluid. Please obtain at 2330. Monitor for
reaccumulation of right pleural fluid. Please obtain at 2330.
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Previous large right pleural effusion is now small. No pneumothorax.
Pulmonary and mediastinal vasculature is now engorged and there is new mild
pulmonary edema. Consolidation at the base of the right lung could be
atelectasis surviving the previous large pleural effusion. Cardiac silhouette
is mildly enlarged.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ year old woman with new fever// eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Previous chest x-ray from ___, approximately 15 hours
prior
FINDINGS:
Low lung volumes compromise evaluation. There is a stable small right pleural
effusion. There is mild pulmonary edema, unchanged. Atelectatic changes are
seen at the right lung base, a developing pneumonia cannot be excluded. The
heart is mildly enlarged. The aorta is atherosclerotic and tortuous. The
trachea is midline.
IMPRESSION:
Mild pulmonary edema and small right pleural effusion, stable. Atelectatic
changes at the right lung base, developing pneumonia cannot be excluded.
Radiology Report
EXAMINATION: US NECK, SOFT TISSUE
INDICATION: Ms ___ is a ___ female with past medical history
significant for insulin-dependent diabetes mellitus and NASH cirrhosis
___ B/C, MELD-Na 19 on admission) c/b encephalopathy, esophageal
varices (s/p bleed several years ago), recurrent hepatic hydrothorax, and HCC
who presents with shortness of breath, chest pain and evidence of hepatic
hydrothorax, now s/p chest tube placement (removed ___ and TIPS
w/pleurocentesis ___// question of hematoma at Right IJ following TIPS
procedureplease examine right side of neck
TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the
superficial tissues of the right neck.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right neck. A small, tubular tract of fluid is identified within the
superficial soft tissues of the right neck, over the puncture site. This is
likely fluid following the tract of the catheter used for recent TIPS
procedure. No organized hematoma is identified.
IMPRESSION:
A small, tubular tract of fluid is identified within the superficial soft
tissues of the right neck, over the puncture site. This is likely a small
amount of fluid following the tract of the catheter used for recent TIPS
procedure. No organized hematoma is identified.
Radiology Report
INDICATION: ___ year old woman with hepatic hydrothorax// eval for progression
of hydrothorax
TECHNIQUE: Chest PA and lateral
IMPRESSION:
Right pleural effusion is increased in size from prior exam, now small to
moderate. Mild bilateral pulmonary edema appears similar. No pneumothorax.
Cardiac silhouette appears unchanged.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with cirrhosis and hydrothorax// Eval for
interval change of hydrothorax. Please perform CXR in early AM Eval for
interval change of hydrothorax. Please perform CXR in early AM
IMPRESSION:
Comparison to ___. Lung volumes have decreased. Stable mild to
moderate right pleural effusion. The pre-existing pulmonary edema is overall
moderate in severity. Moderate cardiomegaly persists. No new parenchymal
opacities.
Gender: F
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Pleural effusion, not elsewhere classified
temperature: 98.2
heartrate: 85.0
resprate: 16.0
o2sat: 98.0
sbp: 114.0
dbp: 51.0
level of pain: 8
level of acuity: 2.0 | Ms ___ is a ___ female with past medical history
significant for insulin-dependent diabetes mellitus and NASH
cirrhosis ___ B/C) complicated by a history of
encephalopathy, esophageal varices (status post bleed several
years ago), recurrent hepatic hydrothorax, and HCC who presents
with shortness of breath, chest pain and evidence of a right
hepatic hydrothorax.
#NASH cirrhosis ___ B/C)
#Hepatic hydrothorax
The patient has a history of NASH cirrhosis ___ B/C),
currently on the transplant list and followed by Dr. ___ as
an outpatient. Her cirrhosis has been complicated by
encephalopathy, esophageal varices (status post bleed several
years ago), recurrent hepatic hydrothorax, hyponatremia on
tolvaptan and HCC. For this admission, she presented with
shortness of breath, pleuritic chest pain, minimal ascites on
exam, found to have a large right pleural effusion on CXR,
concerning for hepatic hydrothorax. Her recurrent hydrothorax on
presentation occurred the setting of her spironolactone being
decreased from 100 mg daily to 25 mg daily secondary to
hyponatremia. While in the ED, the patient had a pigtail
placement with drainage of 1L of fluid with symptomatic
improvement. At this time her chest tube was clamped. On
admission, the patient had a MELD score of 14 and was without
any localizing signs of infection. The chest tube was removed on
___ and the patient remained stable with good O2 saturation on
room air. Her pleural fluid studies were consistent with a
pseudoexudate, most likely hepatic hydrothorax. Her home
diuretics were initially held due to creatinine increase to 1.3
from baseline of 1.0. She was given albumin 75g x2 and 25g x1.
As her creatinine returned to baseline levels, Lasix ___ IV
was started as diuretic therapy to treat her continuing
hydrothorax. An abdominal ultrasound was also obtained which
showed no lower abdominal ascites. The patient was evaluated by
interventional radiology for TIPS placement given her continued
recurrences of hydrothorax on diuretic therapy. The
interventional radiology team performed the TIPS procedure and a
right thoracentesis (draining 4 L) on ___. Following TIPS,
there was concern for ischemic hepatitis given significant
elevation in LFTs and up-trending INR, however these values
stabilized and downtrended after several days. She spiked a
fever to 100.7 F post TIPS with a mild leukocytosis, was
pan-cultured (blood cultures no growth, and no growth in urine
or sputum culture), but remained afebrile since with a normal
WBC. Following TIPS and thoracentesis, she also reported some
hemoptysis, thought to be due to epistaxis, though this
resolved. During her hospitalization, frequent CXRs were
obtained to monitor recurrence of her right hepatic hydrothorax.
Prior to discharge, the most recent CXR showed stable residual
hydrothorax. The patient was continued on rifaximin, ursodiol,
vitamin B12, and lactulose during hospitalization. On discharge
she was breathing well on RA and MELD score was 19.
# Pancytopenia
On admission, the patient had evidence of pancytopenia (WBC 2.2,
Hgb 10.8, plt 22) that was stable from prior admission. Her
pancytopenia has been persistent since her first labs recorded
in the ___ system on ___. She is followed by a
hematologist in ___, Dr. ___
(___). Per her hematologist, the patient's pancytopenia
is most likely due to her liver disease though she had at one
point considered an autoimmune process. A bone marrow biopsy was
preformed by her hematologist on ___, notable for erythroid
hyperplasia, normal number of megakaryocytes, suggesting
hypersplenism as main etiology of her cytopenia. There was no
evidence of lymphoma, MDS, or MPD (BM report from OSH placed in
chart). We trended her CBC, which showed improvement
#Coagulopathy
INR was 1.4 on admission, stable from prior admission. The
patient's coagulopathy was thought to be due to underlying liver
disease. INR remained stable around 1.4-1.7 until after the
TIPS, when it increased to 2.3 likely in the setting of lier
ischemia. However, the INR downtrended to 1.9 on discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Weakness, dysphagia, weight loss
Major Surgical or Invasive Procedure:
Electromyography (EMG) ___
History of Present Illness:
Ms. ___ is a ___ year-old woman with history of fatigue,
weakness, and hypophonia since ___ diagnosed with
"myasthenia-like syndrome" with multipe negative myasthenia
antibody profiles, POTS, gastroparesis, SIBO who presented to
the
ED with reports of progress weakness, dyphagia, and weight loss.
Her symptoms initially began in ___ with weakness,
and
hypophonia with periods where she is unable to speak at all, as
well as dysphagia with resultant weight loss. She has been
evaluated by neurology here and throughout ___ without a
neurologic etiology identified. She currently follows with Dr.
___ in ___ where she is treated for a "myasthenia-like
syndrome" most recently on monthly IVIG. She has also been
evaluated by several naturopathic doctors with various courses
of
antibiotics for chronic lyme disease, vitamins, and probiotics.
She reports that eventually the antibiotics seemed to be
worsening her symptoms and she has been off of them for a while.
She was also treated with courses of antibiotics for Bartonella.
She was evaluated by infectious disease in the Partner's system
who noted no concern for Lyme, Bartonella, anaplasma, Chagas,
HIV, or any infectious etiology of her symptoms. She also
underwent swallowing evaluation with a barium swallow in
___ with mild esophageal dysmotility but no strictures or
obstruction noted.
When she first saw Dr. ___ tried antibiotics, but all her
symptoms got worse with antibiotics. She then tried
pyridostigmine which she did not tolerate due to palpitations.
Decision was made to empirically trial IVIG which she had for 8
months but stopped 3 weeks prior to presentation due to her
progressive symptoms. She notes 4 months after starting IVIG
her
voice improved. She subsequently went to ___ ___ -
___ where she reports her symptoms have been the best
controlled
and she was about 40-50% of her previous baseline. Shortly
afterwards she noticed her symptoms began to recur with
worsening
fatigue, weakness, hypophonia, dysphagia, stiffness in her arms
and legs with minimal exertion. 6 weeks ago she reports she
could only lay in bed all day and was only able to communicate
with texting. 10 days ago she went to ___ stem cell
treatment ___ in ___ where she had a stem cell
injection. She was seen by her PCP ___ who recommended the
following laboratory workup which has not been completed:
-DHEA, estradiol, estrone, ferritin, FSH, hemoglobin A1c,
high-sensitivity CRP, LH, progesterone, prolactin, total
testosterone, TSH, free T3, free T4, vitamin B12, folic acid,
total vitamin D, a.m. cortisol, RBC zinc, methylmalonic acid,
SHBG, renin, and high GBM antibodies, CMV IgG and IgM, ___
a and B, ___ antibodies, EBV panel, echo virus antibodies,
enterococcus, hepatitis B surface antigen, herpes 1 IgG, herpes
2
IgG, HHV-6, mycoplasma culture
She states due to the dysphagia over the past week she has been
unable to eat for a few days and feels she is losing weight.
She
reports her most recent weight to be approximately ___ pounds.
While she was getting IVIG over the winter she states she was up
to 105 pounds. She also reports her hair is falling out in
clumps. Her skin is dry, and her arms and hands get cold with
exertion, and she has cold hands and cold feet. She has
occasional abdominal pains, several bowel movements daily, no
nausea, no vomiting, and no dysuria. He has been taking B
vitamins intermittently, magnesium, and a few days of mother
wart, ___, and licorice supplements to try to help her
symptoms
ED Course notable for:
-Afebrile, vital signs including orthostatics within normal
limits. -CBC, chemistry panel, LFTS, TSH, and UA all within
normal limits with a spec gr 1.007 on UA. Serum and urine tox
negative.
-ECG and CXR unremarkable.
-NIF -60 and VC 3.55, both normal.
-Neurology consulted and felt her picture was not consistent
with
CNS or neuromuscular junction pathology. Recommended no urgent
neuroimaging or testing other than EMG either inpatient or
outpatient.
-Received 2L IVF
-She reported inability to eat other than small amounts and
feeling unsafe at home and was admitted for further workup
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
-Gastroparesis (reportedly diagnosed on gastric emptying study
___
years ago at ___)
-POTS (reportedly diagnosed via tilt-table testing)
-SIBO
-Ovarian cysts
-Anxiety
-H. pylori infection
-Lyme infection
Social History:
___
Family History:
Depression and anxiety in multiple paternal family members
___ on mother's side
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: ___ 2349 Temp: 98.7 PO BP: 89/60 HR: 80 O2 sat: 97%
Weight 99.1 lbs. (stable from ___ year prior), last recorded
weight
___ in Partners records
GENERAL: Very pleasant, thin woman resting comforting in bed.
Speaks softly but able to be understood without difficulty.
Reported throat tightness several seconds into interview but
continued to talk without issue for 15 more minutes
HEENT: Anicteric sclera, MMM
NECK: supple
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial, DP pulses bilaterally
NEURO: CN II-XII intact. Alert, moving all 4 extremities with
purpose, face symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
___ ___ Temp: 98.9 PO BP: 100/68 HR: 102 RR: 18 O2 sat:
99%
O2 delivery: Ra
GENERAL: Thin woman, no acute distress
HEENT: NC/AT, MMM, anicteric sclera, EOMI
NECK: supple
CV: regular rate and rhythm, no murmurs appreciated
PULM: clear to auscultation bilaterally, no wheezes or crackles,
non-labored breathing
GI: abdomen soft, nondistended, nontender, bowel sounds normal
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses
NEURO: CN II-XII intact, no focal deficits
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 01:18AM BLOOD WBC-7.2 RBC-4.49 Hgb-11.2 Hct-35.5
MCV-79* MCH-24.9* MCHC-31.5* RDW-15.2 RDWSD-43.5 Plt ___
___ 01:18AM BLOOD Neuts-49.6 ___ Monos-13.4*
Eos-2.2 Baso-0.3 NRBC-0.3* Im ___ AbsNeut-3.59 AbsLymp-2.47
AbsMono-0.97* AbsEos-0.16 AbsBaso-0.02
___ 01:18AM BLOOD Glucose-108* UreaN-10 Creat-0.6 Na-140
K-3.7 Cl-103 HCO3-25 AnGap-12
___ 01:18AM BLOOD ALT-8 AST-15 AlkPhos-44
___ 01:18AM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.9 Mg-2.1
Iron-53
___ 01:18AM BLOOD calTIBC-324 VitB12-1304* Ferritn-30
TRF-249
___ 01:18AM BLOOD TSH-4.1
___ 01:18AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:15AM URINE Color-Straw Appear-Clear Sp ___
___ 01:15AM URINE Blood-TR* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 01:15AM URINE RBC-1 WBC-<1 Bacteri-FEW* Yeast-NONE
Epi-2
___ 01:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-6.3 RBC-4.16 Hgb-10.5* Hct-33.2*
MCV-80* MCH-25.2* MCHC-31.6* RDW-15.3 RDWSD-44.1 Plt ___
___ 06:15AM BLOOD ___ PTT-26.1 ___
___ 06:15AM BLOOD Glucose-92 UreaN-15 Creat-0.6 Na-139
K-4.0 Cl-100 HCO3-25 AnGap-14
___ 06:15AM BLOOD Calcium-9.5 Phos-4.4 Mg-2.1
___ 08:29AM BLOOD Albumin-4.5 Calcium-9.8 Phos-3.5 Mg-2.0
___ 04:45PM BLOOD Cortsol-26.7*
___ 03:55PM BLOOD Cortsol-12.0
MICRO:
___ 1:15 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING REPORTS:
___ EMG
IMPRESSION:
Normal study. There is no electrophysiologic evidence for a
polyneuropathy
involving large diameter sensory or motor fibers (including
AIDP). Based on
single fiber EMG and repetitive nerve stimulation studies, there
is no
electrophysiologic evidence for a disorder of neuromuscular
transmission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. B Complex 1 (vitamin B complex) oral ASDIR
2. Fludrocortisone Acetate 0.1 mg PO DAILY
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Fludrocortisone Acetate 0.1 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Generalized weakness NOS
Malaise NOS
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 dyspnea// evaluate for PNA
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: WHITE - BRAZILIAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Weakness
Diagnosed with Weakness, Dyspnea, unspecified
temperature: 98.1
heartrate: 90.0
resprate: 20.0
o2sat: 100.0
sbp: 113.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | BRIEF SUMMARY:
___ year-old woman with history of fatigue, weakness, and
hypophonia since ___ diagnosed with "myasthenia-like
syndrome" with negative myasthenia antibody profile, POTS,
gastroparesis, SIBO who presented to the ED with reports of
progress weakness, dyphagia, and weight loss. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
___ Right hemicolectomy with primary anastomosis
History of Present Illness:
___ year old male with hx of GERD, diverticulosis, and
multiple diverticular bleeds who is presenting with hematochezia
one day after discharge from hospital with similar presentation.
Admitted ___ with hematochezia which resolved. HCT 25.9 at
discharge after 3 units PRBC yesterday when he was having no
BMS.
EGD ___ -. Today 3:30 awoke with bloody bowel movement filled
the toilet bowl therefore to ED. No BM since that time. In the
ED, initial VS: T 96.6 BP 142/76 HR 83 RR 18. Transfused one
unit
at time I am seeing the patient in the ED. Reports very mild
left
lower quadrant discomfort, no nausea, vomiting, diarrhea, fever,
chills. Last colonoscopy Ocotber with diverticulosis of the
sigmoid colon, descending colon, and transverse colon but no
active bleed. After this last admission he was to follow up with
Dr. ___
___ Medical History:
- Diverticulosis
- Colonic polyps
- Chronic back pain with associated right lower extremity
tingling/numbness (has been evaluated by orthopedics, not
planning on surgical intervention)
- Hypertension
- ___
Social History:
___
Family History:
Patient is adopted and does not know anything about his father.
Knows that his mother had a fatal cancer, but does not know what
kind. His sister had a congenital "hole in her heart," and she
died at a young age. Does not have any known colon cancer.
Physical Exam:
On admission:
Temp: 96.6 HR: 83 BP: 142/76 Resp: 18
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Chest: Normal breathing
Normal
Abdominal: LLQ pain with palpation
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
On discharge:
Temp: 98.0 HR: 71 BP: 117/62 Resp: 18 94% RA
Constitutional: Comfortable
HEENT: atraumatic
Chest: CTA bilaterally
Abdominal: Abd soft, nondistended, appropriately tender at
incision site. Incision OTA with staples, minimal errythema, no
drainage. +BS
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
___ GI BLEEDING STUDY:
IMPRESSION: Acute bleeding within ___ minutes at the hepatic
flexure.
Path exam of right colon intraop spec:
DIAGNOSIS:
Terminal ileum and right colon, ileocolectomy:
1. Colonic segment with involvement by diverticular disease; no
abscesses or perforation are identified.
2. Small intestinal segment, appendix, and five regional lymph
nodes, within normal limits.
___ 01:05PM WBC-8.0 RBC-3.50* HGB-8.0* HCT-25.9* MCV-74*
MCH-23.0* MCHC-31.0 RDW-19.0*
___ 01:05PM PLT COUNT-225
___ 10:20AM ___ PTT-30.0 ___
___ 06:50AM GLUCOSE-94 UREA N-14 CREAT-1.1 SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-29 ANION GAP-10
___ 06:50AM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-2.4
___ 06:50AM WBC-7.6# RBC-3.50* HGB-8.2* HCT-25.8* MCV-74*
MCH-23.5* MCHC-31.8 RDW-18.8*
___ 06:50AM PLT COUNT-222
Medications on Admission:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q
24H (Every 24 Hours).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO four times a day as needed for pain.
7. Metamucil Powder Sig: One (1) PO once a day.
8. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day
as needed for constipation.
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or HA.
9. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right colon lower gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with history of diverticulosis, presenting with
bright red blood per rectum.
COMPARISON: None.
TECHNIQUE: MDCT data were acquired through the abdomen and pelvis before and
in arterial and venous phases after the administration of intravenous
contrast. Images were displayed in multiple planes. Arterial volume
rendering and maximum intensity projections were reconstructed on a dedicated
3D workstation.
FINDINGS: The visualized lung bases are free of nodules, consolidations, or
effusions. The liver enhances homogeneously, and no focal lesions are
identified. The gallbladder, pancreas and spleen are normal. The kidneys are
of normal contour and attenuation. Several cystic structures in the left
kidney are too small to characterize but most likely cysts. The kidneys
enhance symmetrically and excrete contrast promptly. Small periaortic
retroperitoneal nodes do not meet pathologic criteria for enlargement. There
is no mesenteric adenopathy. No ascites is present.
The stomach, small and large bowel are of normal caliber and appearance.
Diffuse diverticulosis is seen throughout the large bowel without evidence of
diverticulitis. No contrast extravasation is seen within the bowel. Fat
stranding surrounds a focus of fat adjacent to the sigmoid colon (4A:151)
which likely represents epiploic appendagitis of unknown chronicity.
PELVIS: Normal appendix is seen in the right lower quadrant. The bladder and
prostate are normal. There is no free pelvic fluid. There is no pelvic or
inguinal adenopathy.
CTA: The origins of the celiac, SMA, and single renal arteries are patent.
Hepatic arterial anatomy is conventional.
BONE WINDOWS: There are no concerning lytic or sclerotic lesions.
IMPRESSION:
1. No evidence of active gastrointestinal bleeding on this exam.
2. Diverticulosis without evidence of diverticulitis.
3. Stranding around sigmoid colon appendage, this may represent the sequelae
of prior epiploic appendagitis.
Radiology Report
MESENTERIC ANGIOGRAM
INDICATION: ___ man with lower GI bleeding.
OPERATORS: Drs. ___ (fellow) and ___ (attending
physician). Dr. ___ was present throughout the procedure.
SEDATION: Moderate sedation with divided doses of intravenous ___ mcg
fentanyl and 2 mg Versed over 2 hours and 35 minutes during which patient's
hemodynamic status was continuously monitored by a trained radiology nurse.
CONTRAST: Sterile 225 mL Omnipaque 320.
PROCEDURE AND FINDINGS: Consent was obtained from the patient after
explaining the benefits, risks, and alternatives. Patient was placed supine
on the imaging table in the interventional suite. Timeout was performed as
per ___ protocol.
Under aseptic conditions and palpatory guidance, a 19-gauge needle was placed
in the right common femoral artery at the level of mid-to-lower femoral head.
A 0.035 ___ wire was advanced through the needle and into the upper
abdominal aorta. The needle was exchanged for a 5 ___ ___ sheath.
After removing the inner cannula, the sidearm was aspirated, flushed and
connected to heparinized saline flush. A 5 ___ C2 glide cath was placed
over the wire and within the sheath, and advanced into the upper abdominal
aorta. After removing the wire, the catheter tip was placed in the SMA.
Multiple DSA runs were performed in AP and oblique projections to assess the
SMA territory, with special attention to the right colon. No contrast
extravasation, pseudoaneurysm or early draining vein was noted. Catheter was
removed. Right femoral arteriogram was performed to assess the access site.
A 6 ___ Angio-Seal was then deployed after removing the sheath. Firm
pressure was applied to the right groin for about 10 minutes to achieve
complete hemostasis. Site was appropriately dressed. Patient tolerated the
procedure well and no immediate post-procedure complications were seen.
IMPRESSION: Uncomplicated superior mesenteric arteriogram with no evidence
for extravasation, pseudoaneurysm or early draining vein.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RECTAL BLEEDING
Diagnosed with GASTROINTEST HEMORR NOS, HYPERTENSION NOS, RECTAL & ANAL HEMORRHAGE
temperature: 96.6
heartrate: 83.0
resprate: 18.0
o2sat: nan
sbp: 142.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ with HTN, GERD, diverticulosis, and multiple
diverticular bleeds who is presenting with BRBPR, with presumed
diverticular source.
.
# BRBPR: The patient has had multiple episodes of bright red
blood per rectum, likely ___ diverticular bleeds. He was most
recently admitted on ___, during which he was transfused
3U PRBCs, with a crit 25.9 at the time of discharge.
Colonoscopy from ___ with evidence of diverticulosis of the
sigmoid, descending, and transverse colon. An EGD done on
previous admission (___), was normal with no ulcers or
other potential sources for bleeding. The patient was
discharged then represented with another episode bright red
blood per rectum. The patient was initially doing well on the
floor, but had episode of BRBPR with feeling of dizziness and
shortness of breath; was given another unit of PRBC. CTA was
not able to localize the source; showed e/o diverticulosis.
.
While in the unit, the patient was transfused for goal crit of
30, receiving 4 units PRBC. He had a tagged RBC scan which did
not show bleeding source and the patient was not taken to ___ for
embolization. Surgery was also on board, and because no
specific bleeding vessel was found, the patient was taken to the
OR on ___ for R hemicolectomy.
.
# HTN: The patient's home atenolol was held in the setting of
his GI bleed. It was restarted postoperatively when
hemodynamically stable and the patient was tolerating PO's.
.
# Back pain: The patient's home percocet was continued
preoperatively. APS was consulted for postoperative pain
management and an epidural was placed. He was also started on a
PCA. On POD#3, the epidural was removed and he was transitioned
to oral pain medications. At discharge, he reported adequate
pain control with an oral regimen.
.
# GERD: On PPI at home, was held perioperatively and restarted
on POD#2 when tolerating PO's.
Postoperatively, the patient remained stable on the surgical
floor. His intake and output was monitored. On POD#3 after
removal of the epidural, his foley catheter was removed at which
time he voided without difficulty. His vital signs were
routinely monitored and he remained afebrile and hemodynamically
stable. His hematocrit remained stable. His WBC remained normal.
His electrolytes were monitored and repleted as needed. He was
encouraged to mobilize out of bed early as tolerated, which he
was able to do independently. He was also started on SC heparin
postoperatively for DVT prophylaxis.
Initially postoperatively, he was kept NPO and given IV fluids
for hydration. A NG tube was placed intraoperatively and removed
on POD#1. On POD#2 he reported passing flatus and he was started
on clear liquids, which were slowly advanced to a regular diet.
On POD#3, he was tolerating regular food without
nausea/vomiting. He was hemodynically stable and afebrile. His
pain was adequately controlled with oral pain medication and he
was out of bed ambulating independently. He was discharged to
home with follow up scheduled in ___ clinic ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iron Complex / Heparin,Porcine / Ibuprofen /
Gadolinium-Containing Agents / Morphine / Vancomycin / Dilaudid
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
___: right heart catheterization
History of Present Illness:
___ yo woman w/ a hx of HTN, HLD, ESRD on dialysis, multivessel
CAD, asthma and pHTN who presents with c/o shortness of breath.
Patient says she has been short of breath for 'months' and that
she has been in and out of the hospital and ___ has helped
her. She says ambulating even ___ feet requires significant
effort and the assistance of multiple helpers. She has a
history of pulmonary hypertension and multiple recent admission
for dyspnea. She endorses 6 pillow orthopnea that has been
stable for the past ___ months. For the last ___ weeks she
feels he shortness of breath is worse. She has also had mild
nausea without vomiting or diarrhea. Denies chest pain, chest
pressure. No fevers or chills. Denies dizziness or
lightheadedness. Patient tried albuterol at home with some
improvement but her symptoms persisted so she went to the ED.
Patient is due for dialysis today which she did not receive.
Patient denies any recent weight gain, in fact she says she has
been losing weight at dilaysis over the last several weeks. No
new dietary indescretions.
Of note, patient was admitted from ___ with c/o dyspnea,
underwent several rounds of dialysis with fluid removal. She
did develop episode of afib with RVR on ___ that responded to
her home dose metoprolol. Much of her symptoms were thought due
to progressive pulmHTN. Pulm was consulted and patient
apparently refused right heart ___ with vasodilator study.
Plan was for outpatient pulm followup.
In the ED, initial vitals: 97.6 65 130/42 20 96% RA. Labs were
notable for chem-7 that showed K 5.0 (4.0 on repeat), Cr 5.0,
trop 0.06 (baseline) with CKMB 2, proBNP of 54,000, unremarkable
CBC, and lactate 2.1. CXR showed mild pulmonary vascular
congestion and persistent severe cardiomegaly. EKG showed sinus
rhythmn with RBBB. Patient was given 81mg aspirin,
albuterol/ipratropium nebs and admitted for CHF exacerbation.
On review of systems, she denies fevers/chills, no
nausea/vomiting or dizziness. No sore throat or headaches. No
problems urinating. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
On arrival to the floor, patient says breathing is improved
after receiving albuterol nebulizer treatments. She currently
has no complaints but is anxious to become better.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia (atorvastatin
80mg), +Hypertension (losartan, isosorbide, metoprolol)
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-catheterization ___ with 70% D1, 60% D2
-catheterization ___ with 90% mid left circumflex, 80%
stenosis in a proximal small OM, occluded OM2. The RCA was
diffusely calcified with a proximal total occlusion that filled
with extensive left collaterals. Failed intervention to
circumflex due to inability to deliver balloons.
-Pericardial tamponade ___ s.p. pericardiocentesis
(etiology uremia vs. trauma).
-Severe pulmonary hypertension since ___, RHC on ___: PASP
65, PA mean 30, PCWP 12 mmHg. workup included V-Q scan which was
low probability, ECHO in ___ and RHC that showed normal PCWP.
Possible etiologies include renal disease, chronic fluid
overload
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
#End-stage renal disease from IgA nephropathy, hemodialysis
since ___, live donor transplant ___, failed ___, transplant
nephrectomy ___, Now on HD through right leg AV fistula
___
# Asthma
# Back pain requiring narcotics
# Gastroesophageal reflux disease
# Primary hyperparathyroidism s/p parathyroidectomy, has had
hypercalcemia in the past
# Non convulsive seizures
# History of abnormal ___ stim test and previously on
hydrocortisone but no longer felt to be adrenally insufficient
per endocrine (see OMR note, ___, ___
# Diverticulosis- s/p severe LGIB with colectomy ___
# History of a highly resistant abdominal wound infection with
carbepenamase producing Klebsiella.
# Hypothyroidism
# pre-eclampsia in her last pregnancy
# h/o ectopic pregnancy
# hypoglycemia of unclear etiology
PAST SURGICAL HISTORY:
# Status post appendectomy
# Status post Cesarean section
# Status post right colectomy ___ secondary to severe GIB
# Status post renal transplant graft nephrectomy ___
Social History:
___
Family History:
Mother died in her ___ of stroke. Sister with hypertension. No
history of cancer or DM in the family.
Physical Exam:
ADMISSION EXAM
VS: T97.6 BP 133/77 HR60 RR21 O2 sat 95%RA
GENERAL: awake, alert, appears anxious, in no apparent
respiratory distress, has significant kyphosis
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP to the mandible at 90 degress
CARDIAC: RRR, systolic murmur heard best LLSB, no rubs/gallops
LUNGS: good air movement, mild crackles in bases bilaterally, no
wheezing
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: mild (1+) PE to mid shins bilaterally, no cyanosis
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact, strength ___ in UE and ___ bilaterally
DISCHARGE EXAM
VS: T97.3 BP 137/63 HR76 (76-84) RR18 O2 sat 94%RA
GENERAL: awake, alert, in NAD, has significant kyphosis
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP to the mandible at 90 degress
CARDIAC: RRR, systolic murmur heard best LLSB, no rubs/gallops
LUNGS: good air movement, mild crackles in bases bilaterally, no
wheezing
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: mild (1+) PE to mid shins bilaterally, no cyanosis
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact, strength ___ in UE and ___ bilaterally
Pertinent Results:
ADMISSION LABS
___ 10:32AM LACTATE-2.1* K+-4.0
___ 10:25AM GLUCOSE-76 UREA N-17 CREAT-5.0* SODIUM-141
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-30 ANION GAP-18
___ 10:25AM cTropnT-0.06*
___ 10:25AM CK-MB-2 ___
___ 10:25AM WBC-3.6* RBC-4.36 HGB-12.3 HCT-40.7 MCV-93
MCH-28.2 MCHC-30.3* RDW-16.1*
___ 10:25AM NEUTS-49.2* ___ MONOS-8.5 EOS-2.5
BASOS-0.7
___ 10:25AM PLT COUNT-172
___ 10:25AM ___ PTT-34.4 ___
DISCHARGE LABS
___ 06:10AM BLOOD WBC-3.1* RBC-3.58* Hgb-10.1* Hct-33.3*
MCV-93 MCH-28.2 MCHC-30.3* RDW-16.0* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD UreaN-12 Creat-3.8* Na-138 K-4.4 Cl-100
HCO3-29 AnGap-13
___ 06:10AM BLOOD Calcium-10.0 Phos-4.2 Mg-2.4
MICRO
NONE
REPORTS
CHEST (PA & LAT)Study Date of ___ 11:33 AM
FINDINGS:
Severe enlargement of the cardiac silhouette and coronary
arterial
calcifications are again seen. The aorta remains tortuous and
diffusely calcified. Prominence of the hila bilaterally is
compatible with known pulmonary arterial hypertension. There is
mild pulmonary vascular congestion. Lungs are hyperinflated. No
focal consolidation, pleural effusion or pneumothorax is
identified. Degenerative changes of both glenohumeral joints
are re- again noted. Diffuse demineralization of the osseous
structures is present with a rugger jerset appearance compatible
with renal osteodystrophy.
IMPRESSION:
Mild pulmonary vascular congestion.
___ Cardiovascular C.CATH
COMMENTS:
1. Limited resting hemodynamics revealed the following values:
a. At baseline the PCW mean pressure was 20mmHg and the PA
pressure was
118/40 with a mean of 53mmHg. The PA sat was 77. The Cardiac
index was
3.6 L/Min/m2. When the patient's AV fistula was occluded the PA
saturation decreased to 69. The Cardiac index was then
calculated to be
2.67 L/min/m2. The pulmonary vascular resistence with AV fistula
occlusion was 592 dynes-sec/cm5 and without AV fistula occlusion
the
PVR was 427 dynes-sec/cm5.
b. With 100% Fi02 the mean PCW pressure was 13mmHg with a PA
pressure of
103/31 with a mean of 55mmHg. The PA sat was 87 and with
occlusion of
the AV fistula the PA sat was 80. The calculated cardiac index
was 4.14
L/min/m2 with AV fistula occlusion and 6.37L/min/m2 without
occlusion.
The pulmonary vascular resistence was 317 dynes-sec/cm5 without
AV
fistula occlusion and 486 dynes-sec/cm5 with occlusion.
c. With iNO the PCW pressure was 14mmHg and the PA pressure was
___
with a mean of 47. The PA sat was 87 without AV fistula
occlusion and 82
with occlusion. The calculated cardiac index with AV fistula
occlusion
was 4.6 L/min/m2 and without 6.4 L/min/m2. The pulmonary
vascular
resistence with AV fistula occlusion was 344dynes-sec/cm5 and
without
occlusion it was 249 dynes-sec/cm5.
FINAL DIAGNOSIS:
1. Severe primary pulmonary hypertension with limited response
to 100%
fiO2 and iNO.
___ Cardiovascular ECHO
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses and cavity size are
normal. Overall left ventricular systolic function is normal
(LVEF 55-60%). There is a minimal resting left ventricular
outflow tract obstruction. The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. 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. Physiologic mitral regurgitation
is seen (within normal limits). The tricuspid valve leaflets are
mildly thickened and do not fully coapt. Moderate to severe [3+]
tricuspid regurgitation (eccentric) is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mildly dilated right ventricle with moderate free
wall hypokinesis and abnormal septal motion consistent with
pressure/volume overload. Moderate to severe tricuspid
regurgitation. Severe pulmonary hypertension.
CTA CHEST W&W/O C&RECONS, NON-CORONARYStudy Date of ___
7:27
CT ABD & PELVIS WITH CO
IMPRESSION:
1. No evidence of pulmonary embolism. Mild interlobular septal
thickening
consistent with vascular engorgement /early pulmonary edema.
2. Small to moderate right-sided pleural effusion with adjacent
compressive
atelectasis and fluid within the minor fissure.
3. Abdominal ascites
4. Renal osteodystrophy with new compression fractures since
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q12H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Cinacalcet 60 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. LeVETiracetam 500 mg PO QHS
take additional tab after dialysis ___
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Lorazepam 0.5 mg PO Q6H:PRN anxiety
12. Losartan Potassium 50 mg PO DAILY
13. Metoprolol Tartrate 100 mg PO DAILY
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
15. Omeprazole 20 mg PO DAILY
16. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN pain
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q12H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Cinacalcet 60 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. LeVETiracetam 500 mg PO QHS
take additional tab after dialysis ___
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. Lorazepam 0.5 mg PO Q6H:PRN anxiety
11. Metoprolol Tartrate 100 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN pain
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 2.5 mg INH Q6H:PRN
Disp #*30 Vial Refills:*2
16. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
17. Losartan Potassium 50 mg PO DAILY
18. Nitroglycerin SL 0.4 mg SL PRN chest pain
19. Nebulizer machine
Nebulizer machine
20. LeVETiracetam 500 mg PO DAYS (___)
21. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
puff INH twice a day Disp #*3 Inhaler Refills:*0
22. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate [Imdur] 30 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: pulmonary hypertension
Secondary: ESRD on HD, systolic 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: Asthma, pulmonary hypertension, coronary artery disease, shortness
of breath.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Severe enlargement of the cardiac silhouette and coronary arterial
calcifications are again seen.
The aorta remains tortuous and diffusely calcified. Prominence of the hila
bilaterally is compatible with known pulmonary arterial hypertension. There is
mild pulmonary vascular congestion. Lungs are hyperinflated. No focal
consolidation, pleural effusion or pneumothorax is identified. Degenerative
changes of both glenohumeral joints are re- again noted. Diffuse
demineralization of the osseous structures is present with a rugger jerset
appearance compatible with renal osteodystrophy. IMPRESSION:
Mild pulmonary vascular congestion.
Radiology Report
HISTORY: ___ woman with hypertension and end-stage renal disease and
severe multi vessel coronary artery disease with acute on chronic dyspnea.
Question PE.
TECHNIQUE: CT of the chest was performed per department PE protocol. Coronal
sagittal oblique reformats were reviewed.
COMPARISON: None.
FINDINGS:
There is no mediastinal hilar or axillary lymphadenopathy by CT criteria. The
heart is severely enlarged, particularly the right side. Reflux is noted in
the hepatic vasculature. The thorax itself is enlarged in AP dimension. The
aorta has a tortuous route with minor calcifications but no evidence of
aneurysmal dilatation or acute aortic syndrome. There is no pericardial
effusion. The great vessels appear unremarkable.
The pulmonary arteries are patent to the segmental level.
There is a small to moderate right-sided pleural effusion with adjacent
compressive atelectasis. The trachea is patent to the subsegmental levels.
Diffuse mild interlobular septal thickening is likely due to a small amount of
early pulmonary edema.
Subdiaphragmatically a significant amount of ascites is noted in the imaged
portion of the abdomen.
Bones: Diffuse demineralization and rugger ___ appearance of the spine is
unchanged compatible with renal osteodystrophy. Height loss of multiple mid
thoracic vertebral bodies is new since ___.
IMPRESSION:
1. No evidence of pulmonary embolism. Mild interlobular septal thickening
consistent with vascular engorgement /early pulmonary edema.
2. Small to moderate right-sided pleural effusion with adjacent compressive
atelectasis and fluid within the minor fissure.
3. Abdominal ascites
4. Renal osteodystrophy with new compression fractures since ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: SHORTNESS OF BREATH
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 97.6
heartrate: 65.0
resprate: 20.0
o2sat: 96.0
sbp: 130.0
dbp: 42.0
level of pain: 0
level of acuity: 3.0 | ___ yo woman w/a hx of HTN, HLD, ESRD s/p failed transplant on
dialysis, severe multivessel CAD and pHTN who presents acute on
chronic dyspnea on exertion.
# Shortness of breath/pulmonary HTN: patient presented with
acute on chronic dyspnea on exertion in the setting of known
moderate to severe pulmonary hypertension. EKG was unchanged
and troponins were at baseline. Repeat ECHO here showed some
progression of pulmonary artery hypertension with elevated in PA
pressures and global RV dysfunction. Patient's symptoms were
likely due to worsening of her pulmonary hypertension in the
setting of slight volume overload. Patient underwent right
heart cath on ___ to assess pulmonary hypertension and
responsiveness to vasodilators, which she failed. Pulmonary
service was consulted who recommended keeping patient close to
dry weight as possible, starting advair BID, and having close
follow-up in ___ clinic for possible IV prostacyclin therapy.
CTA thorax was also done which showed no PE or evidence of ILD.
Patient symptomatically improved after dialysis treatments and
initiation of albuterol nebulizers. Patient was also started on
isosorbide mononitrate for potential responsiveness to nitrates.
She was discharged with a prescription for albuterol nebulizer
and advair and will follow-up in ___ clinic for her pulmonary
HTN.
# CAD: multivessel disease not amenable to intervention on
previous cath in ___. Patient did not c/o chest pain,
troponins remained at baseline, EKG was unconcerning. She was
continued on metoprolol, aspirin, atorvastatin 80.
# Asthma: patient reported symptomatic improvement with
nebulizer treatments. She was given a prescription for
albuterol nebs as well as adavair.
# ESRD on HD: nephrology was consulted, patient received
dialysis as per home schedule. Patient received dialysis as
needed, next due date is 2.19.
CHRONIC ISSUES
# HTN: stable, continued metoprolol, losartan
# HLD: continued atorvastatin 80mg
# GERD: continued omeprazole
# Chronic pain: pain controlled with tylenol
# Seizure Disorder: patient reports nonconvulsive seizures.
Continued keppra 500 mg QHS and QHD ___.
# Hypothyroidism: continued levothyroxine 75 mcg
# Anxiety: continued home lorazepam 0.5 mg tablet
TRANSITIONAL ISSUES
1. Patient has close followup to discuss further workup and
therapy for her severe pulmonary hypertension, which is likely
the cause of the progressive decline in her exertional capacity.
2. Patient remained full code. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
RLQ abdominal wound erythema and increased drainage
Major Surgical or Invasive Procedure:
___: Liver biopsy
History of Present Illness:
___ with history of RLQ abdominal wall abscess/infection of
unknown etiology s/p debridement by Dr. ___ in ___ presented
to the ED today with increased erythema and drainage from her
prior debridement site. Patient has been visiting ___ clinic
approxiamtely once per month for wound checks since her
debridement in ___ and has also been receiving daily wound
care by a visiting ___ nurse. Per prior notes, patient's RLQ
abdominal wound had been slowly improving over time and had most
recently been evaluated approximately 3 wks ago. Since that time
patient reports increased drainage from two "holes" in her
wound, as well as mildly increased erythema. She denies any
fevers or
increased pain. Due to the change in appearance of the wound and
the failure to improve since her last clinic visit, her ___
nurse urged her to come to the ED today. She has not had any
changes in her bowel movements and says she is eating a
"regular" amount. She has never had a colonoscopy.
Past Medical History:
Past Medical History:
mitral regurgitation, asthma, obesity, cholecystectomy, eczema,
depression, ?hepatitis B, multiple abdominal hernias, abdominal
wall cellulitis, anxiety, ?cognitive delay vs mood disorder
________________________________________________________________
Past Surgical History:
Debridement of right lower abdominal wall abscess
Bilateral tubal ligation
Ventral hernia repair
Subtotal lateral meniscectomy of right knee
Open chole w/ CBD exploration and choledochoduodenostomy
Multiple tooth extractions
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: T 97.6, HR 88, BP 124/60, RR 16, O2 sat 98%
GEN: Alert and oriented, no acute distress, conversant and
interactive, appears somewhat unkempt.
HEENT: Sclerae anicteric, mucous membranes moist.
CV: Regular rate and rhythm.
PULM/CHEST: Respirations are unlabored on room air.
ABD: Soft, nondistended, ...
Ext: Mild bilateral peripheral edema, distal extremities feel
warm.
Discharge Physical Exam:
General: A+Ox3, NAD
CV: RRR
Pulm: CTA b/l
Abd: soft, non-distended, non-tender
Extremities: warm, well-perfused.
Pertinent Results:
___ 10:38AM GLUCOSE-133* UREA N-7 CREAT-0.6 SODIUM-132*
POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-24 ANION GAP-15
___ 10:38AM CEA-3.5
___ 10:38AM WBC-4.7 RBC-3.26* HGB-8.5* HCT-27.8* MCV-85
MCH-26.1 MCHC-30.6* RDW-14.6 RDWSD-45.8
___ 10:38AM NEUTS-76* BANDS-4 LYMPHS-15* MONOS-3* EOS-0
BASOS-0 ___ METAS-1* MYELOS-0 PROMYELO-1* AbsNeut-3.76
AbsLymp-0.71* AbsMono-0.14* AbsEos-0.00* AbsBaso-0.00*
___ 10:38AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-2+
BURR-OCCASIONAL FRAGMENT-OCCASIONAL
___ 10:38AM PLT SMR-NORMAL PLT COUNT-253
IMAGING:
CT abdomen and pelvis ___, interval
enlargement of now 9.7 x 8.3 x 11.1 cm heterogeneously enhancing
mass likely arising from the cecum with at least two sinus
tracts
extending to the skin. There is interval increase in the size
and number of multiple hepatic lesions favoring metastases of
her
abscesses, interval growth of smaller lesions from ___,
lack of current infectious symptoms. Constellation of symptoms
and signs is consistent with metastatic colorectal cancer with
hepatic metastases, less likely infection. The sigmoid colon
abuts this mass and there is local invasion, cannot be excluded.
No bowel obstruction. Interval complete drainage of previously
seen right subcutaneous collection, no residual superficial
collection, complex small and large bowel containing ventral
hernia.
Liver US ___:
Multiple solid-appearing hypoechoic liver lesions corresponding
to abnormality seen on same-day abdominal CT. Findings are
highly concerning for metastases. These lesions are amenable to
ultrasound-guided biopsy.
Pathology: Liver biopsy. ___, adenocarcinoma, likely
of colonic origin, moderately differentiated, CK20 positive,
CDX2
positive, CK7 negative, TTF-1 negative, MSI and KRAS status are
pending.
Medications on Admission:
Acetaminophen 500, ProAir HFA 90, alendronate 35qwk, (vitamin
D3)
1,000U', omeprazole 20'
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
do NOT exceed 3gm in 24 hours
2. Vitamin D 1000 UNIT PO DAILY
3. ProAir HFA (albuterol sulfate) 1 PUFF INHALATION DAILY:PRN
SOB
4. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Colonic mass with liver metastasis
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: ___ woman with history of chronic right abdominal wall
cellulitis with necrotizing fasciatis drained in ___ presenting with
increased discharge and drainage, evaluate for deep wound infection.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technqiue.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: DLP: 736 mGy-cm (abdomen and pelvis).
IV Contrast: 130 mL Omnipaque.
COMPARISON: Comparison is made to abdominal and pelvic CT from ___ and ___.
FINDINGS:
LOWER CHEST: There is minimal dependent atelectasis and mild emphysematous
changes. The lung bases are otherwise clear. There is no pericardial or
pleural effusion.
ABDOMEN:
HEPATOBILIARY: There are multiple hypodense liver lesions which have overall
increased in number and size compared to ___. The largest lesions
measure 2.4 x 2.1 (transverse by AP), and 2.9 x 2.9 cm (transverse by AP)
(series 2, image 22, and 21) in segments III and V respectively. The lesion
in segment 5 has increased in size in previously measuring approximately 1.0 x
0.5 cm. The portal vein is patent. The gallbladder is surgically absent.
There is no intra or extrahepatic biliary duct dilation. Pneumobilia is
unchanged.
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 enhance and excrete contrast symmetrically. Multiple
subcentimeter renal hypodensities are unchanged from ___ and are too
small to characterize but statistically likely represent simple cysts. There
is no hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: There is a complex small- and large bowel-containing
ventral hernia, overall similar to prior. There is no evidence of bowel
obstruction. A heterogeneously enhancing irregular mass which measures
approximately 9.7 x 8.3 x 11.1 cm (transverse by AP by CC) appears to arise
from the cecum, and has significantly enlarged from ___ when it
measured approximately 6.0 x 4.7 x 6.2 cm. The sigmoid colon abuts this mass
(series 2, image 57) with new obscuration of the intervening fat; invasion is
not excluded. The mass appears adherent to the overlying fascia (series 2,
image 53). There appears to be at least two sinus tracts extending from the
mass to the skin surface, one lateral (series 2, image 63) and one more
medially (series 2, image 54). Additionally, there is a blind ending tract
seen just superiorly (series 2, image 44, series 601b, image 24). While there
is stranding within the superficial soft tissues and foci of air (series 2,
image 64) A previously-seen large superficial fluid collection is no longer
present, reflecting interim drainage. The appendix is not visualized. There
is diverticulosis of the sigmoid colon.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is mild calcification
within the abdominal aorta. The abdominal aorta and its major branches are
patent. Incidental note is made of a retroaortic left renal vein.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are within normal limits.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions.
There are mild degenerative changes of the lumbar spine. The abdominal and
pelvic wall is within normal limits.
IMPRESSION:
1. Interval enlargement of a now 9.7 x 8.3 x 11.1 cm heterogeneously enhancing
mass, likely arising from the cecum, with at least two sinus tracts extending
to the skin surface.
2. Interval increase in size and number of multiple hepatic lesions favor
metastases over abscesses given interval growth of smaller lesions from
___, and lack of current infectious symptoms. US pending for
further evaluation and for feasibility for biopsy.
3. The constellation of findings above are suspicious for colorectal carcinoma
with hepatic metastases, less likely infection.
4. The sigmoid colon abuts this mass and local invasion cannot be excluded. No
bowel obstruction.
5. Interval complete drainage of a previously seen large right subcutaneous
collection. No residual superficial fluid collection.
6. Complex small- and large-bowel containing ventral hernia, not significantly
changed from ___.
RECOMMENDATION(S): A liver ultrasound is recommended to further evaluate and
characterize liver lesions and assess for feasibility for US-guided biopsy.
NOTIFICATION: Findings were discussed in person with Dr. ___ Dr. ___
on ___ at 14:00, 5 minutes after they were made.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with newly discovered possible colon cancer and
liver metastasis, feasibility for biopsy.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the liver.
COMPARISON: CT abdomen and pelvis from same day.
FINDINGS:
There are multiple hypoechoic solid-appearing liver lesions with the largest
in the peripheral left lobe measuring 2.6 x 2.1 x 2.9 cm corresponding to
lesions seen on same-day CT scan.
IMPRESSION:
Multiple solid-appearing hypoechoic liver lesions corresponding to abnormality
seen on same-day abdominal CT. Findings are highly concerning for metastases.
These lesions are amenable to ultrasound-guided biopsy.
Radiology Report
EXAMINATION: Ultrasound-guided biopsy.
INDICATION: ___ year old woman with ? colonic mass and liver mets // ? liver
mets
COMPARISON: CT abdomen and pelvis and ultrasound ___.
PROCEDURE: Ultrasound-guided targeted liver biopsy.
OPERATORS: Dr. ___ radiology fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was
performed. The lesion for biopsy was identified in the right hepatic lobe. A
suitable approach for targeted liver biopsy was determined.
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.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 10 mL 1% lidocaine.
Under real-time ultrasound guidance, a single 18-gauge core biopsy sample was
obtained.
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 26
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated 18-gauge targeted right liver biopsy x 1.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with OTHER POST-OP INFECTION, CELLULITIS/ABSCESS OF TRUNK, ACCIDENT NOS
temperature: 97.6
heartrate: 88.0
resprate: 16.0
o2sat: 98.0
sbp: 124.0
dbp: 60.0
level of pain: 0
level of acuity: 3.0 | ___ year-old female with a history of RLQ abdominal wall
abscess/infection s/p debridement in ___, who now presented
to ___ on ___ with complaints of increased erythema and
drainage from her prior debridement site. On HD1, she had a CT
Abd/Pelvis and liver ultrasound which showed concern for
suspicious for colorectal carcinoma with hepatic metastases. She
was admitted to the Acute Care Surgery team.
On HD3, the patient underwent an ultrasound-guided targeted
liver biopsy. The finalized pathology report on ___
indicated metastatic adenocarcinoma, moderately-differentiated,
consistent with a colorectal primary. The patient was notified
of this finding, the Hematology/Oncology team was consulted and
outpatient follow-up appointments were made for the patient to
follow-up for outpatient care.
The patient was alert and oriented throughout hospitalization.
Pain was controlled with oral pain medication. The patient
remained stable from a cardiovascular standpoint; vital signs
were routinely monitored. The patient remained stable from a
pulmonary standpoint. Good pulmonary toilet, early ambulation
and incentive spirometry were encouraged throughout
hospitalization.
The patient tolerated a regular diet. The patient's intake and
output were closely monitored. The patient's fever curves were
closely watched for signs of infection.
The patient's blood counts were closely watched for signs of
bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L knee periprosthetic joint infection
Major Surgical or Invasive Procedure:
L TKA I+D and liner exchange with Dr. ___ ___
History of Present Illness:
___ male history of rheumatoid arthritis and prostate cancer
concern for left knee periprosthetic joint infection. Had a
total knee arthroplasty done around ___ with Dr. ___ in
___, decubitus and to become part of the ___. States 1 day ago he noted acute onset of mild left knee
pain. Knee was previously asymptomatic no issues. By the
morning the pain had worsened and he presented for evaluation.
Denies any fevers or chills. Denies any trauma. Denies any
twisting movements. Denies any headache nausea vomiting changes
in appetite sick contacts. Denies any numbness or paresthesias.
Of note patient has a history of prostate cancer status post
prostatectomy ___ years ago. Postoperatively he required
radiation
treatment for disease recurrence. Recently he was noted to have
a rising PSA.
Past Medical History:
rheumatoid arthritis
prostate cancer
Social History:
___
Family History:
Father with heart disease
Physical Exam:
On Discharge:
98.2 138/78 100 21 95% RA (HRs fluctuate from 80-120s in Afib)
GEN: elderly male in NAD
HEENT: MMM
CV: irreg/irreg
RESP CTAB no w/r appreciated
ABD: soft, NT, ND, NABS
GU: no foley
EXTR: RLE without any edema, LLE with 1+ edema, post-operative
changes from left knee hardware explant
NEURO: alert, appropriate, mentating at baseline
Pertinent Results:
Pertinent results include:
BCx (___): MSSA
BCx (___): MSSA ___
BCx (___): MSSA ___
BCx (___): Negative for growth
BCx (___): No growth to date
Joint fluid and tissue culture (___): MSSA
___ 3:58 pm Foreign Body - Sonication Culture
LEFT KNEE EXPLANTED HARDWARE.
Gram stain / culture not called - prior positive.
Sonication culture, prosthetic joint (Final ___:
STAPH AUREUS COAG +. <16 CFU /10ML.
________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
TTE: IMPRESSION: Mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global biventricular
systolic function. Echocardiographic evidence for diastolic
dysfunction with
elevated PCWP. Mild to moderate mitral and tricuspid
regurgitation. Mild pulmonary hypertension.
___:
IMPRESSION:
There has been interval removal of the left knee prosthesis and
placement of an antibiotic spacer. There is no evidence of an
acute fracture.
CXR Portable ___
The cardiomediastinal silhouette is unchanged since prior study,
the heart is enlarged but stable in size. There is no pulmonary
edema, no effusions, no pneumothorax or focal consolidation.
There has been interval placement of a left-sided PICC line with
its tip in the distal SVC.
IMPRESSION: Left PICC line is seen with its tip in the distal
SVC.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 40 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Hydroxychloroquine Sulfate 400 mg PO DAILY
4. AzaTHIOprine 150 mg PO DAILY
5. Sildenafil 100 mg PO PRN sexual activity
6. adalimumab 40 mg/0.8 mL subcutaneous every 10 days
7. Acetaminophen Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
3. CeFAZolin 2 g IV Q8H bacteremia/septic arthritis
Last day of therapy is ___
4. Diazepam 5 mg PO Q8H:PRN Spasm
RX *diazepam 5 mg one tablet by mouth every 8hrs as needed Disp
#*15 Tablet Refills:*0
5. Digoxin 0.25 mg PO DAILY
6. Diltiazem Extended-Release 480 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 200 mg PO TID
9. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate Duration: 10
Days
Reason for PRN duplicate override: Alternating agents for
similar severity
10. Metoprolol Succinate XL 300 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3hrs as needed
Disp #*30 Tablet Refills:*0
14. Ranitidine 150 mg PO DAILY
15. Senna 8.6 mg PO BID
16. Acetaminophen 1000 mg PO Q8H
17. HELD- adalimumab 40 mg/0.8 mL subcutaneous every 10 days
This medication was held. Do not restart adalimumab until you
are seen by rheumatology and the infection has cleared
18. HELD- AzaTHIOprine 150 mg PO DAILY This medication was
held. Do not restart AzaTHIOprine until until you are seen by
rheumatology and the infection has cleared
19. HELD- Hydroxychloroquine Sulfate 400 mg PO DAILY This
medication was held. Do not restart Hydroxychloroquine Sulfate
until until you are seen by rheumatology and the infection has
cleared
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L prosthetic joint infection, MSSA
Sepsis from ___ blood stream infection
Atrial fib with RVR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (2 VIEWS) LEFT
INDICATION: ___ year old man s/p left knee hardware removal/placement abx
spacer// eval
TECHNIQUE: AP and lateral portable views of the left knee were obtained
COMPARISON: ___
IMPRESSION:
There has been interval removal of the left knee prosthesis and placement of
an antibiotic spacer. There is no evidence of an acute fracture.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new 47 SL PICC left side// picc tip location
Contact name: ___: ___
TECHNIQUE: Portable frontal chest radiograph.
COMPARISON: Multiple plain film radiographs of the chest, most recent dated
___.
FINDINGS:
The cardiomediastinal silhouette is unchanged since prior study, the heart is
enlarged but stable in size. There is no pulmonary edema, no effusions, no
pneumothorax or focal consolidation. There has been interval placement of a
left-sided PICC line with its tip in the distal SVC.
IMPRESSION:
Left PICC line is seen with its tip in the distal SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with sepsis and new O2 requirement iso IVF
resuscitation. Also likely undiagnosed COPD, OSA// pulmonary edema/congestion,
PNA?
IMPRESSION:
No previous images. There is enlargement of the cardiac silhouette without
vascular congestion, pleural effusion, or acute focal pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new R IJ CVL placement// ___ year old man
with new R IJ CVL placement, please confirm line placement
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There is a right internal jugular central venous catheter, which terminates in
the lower superior vena cava. There are low lung volumes. There is no focal
consolidation, pleural effusion or pneumothorax. The cardiomediastinal
silhouette is stable in appearance. No acute osseous abnormalities are
identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with L knee septic arthritis and AFib with RVR,
recently admitted to TSICU now on the floor.// Consolidation or focal
abnormalities- decreased lung sounds on left with bilateral crackles
TECHNIQUE: Chest AP film
COMPARISON: ___
FINDINGS:
In comparison to the study completed on ___, improved pulmonary
edema. The right IJ catheter has also been removed. Cardiomegaly . Lungs are
well expanded. Bilateral pleural effusion, left greater than right with
compressive atelectasis. No evidence of focal consolidation or pneumothorax.
IMPRESSION:
1. Improved pulmonary edema.
2. Bilateral pleural effusions, left greater than right, with bibasilar
atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Knee pain, Transfer
Diagnosed with Infect/inflm reaction due to internal left knee prosth, init
temperature: 98.6
heartrate: 102.0
resprate: 18.0
o2sat: 92.0
sbp: 113.0
dbp: 71.0
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 L periprosthetic joint infection and was admitted to
the medicine service. The patient was taken to the operating
room on ___ for L TKA I+D with liner exchange by Dr. ___,
___ the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the TSICU with a hemovac
drain in place to the L knee. In the TSICU patient was
extubated, arterial line was discontinued, pressor support
weaned as appropriate. Patient developed Afib with RVR
refractory to diltiazem drip, transitioned to metoprolol and
heparin gtt with appropriate improvement in symptoms. Patient
was started on IV antibiotics of vancomycin and ceftriaxone
empirically, transitioned to ancef per culture sensitivities of
MSSA bacteremia/PJI. Pt was transferred to the medicine floor: |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
EtOH Withdrawl
Major Surgical or Invasive Procedure:
Lumbar puncture with sedation (___)
MRI with general anesthesia
History of Present Illness:
Mr. ___ is a ___ year old male with a PMH significant for
chronic alcohol use disorder who was recently seen in the
emergency department for withdrawal and subsequently placed in
detox. He is now presenting with hallucinations and tremors. The
patient reported that after his discharge from detox, he began
heavy daily consumption of EtOH. His last drink was on the day
of
admission. He reports feeling unwell since that drink. He
reports
having hallucinations of people and colors for the past ___
days.
In the ED, his exam was significant for tremulousness, Saccades
in all directions, tachycardia, AO x2/3 (person and place,
believes it is ___, and slightly ataxic gait. His labs
were
remarkable for a lactate of 2.1, but were otherwise within
normal
limits. He was given a normal saline bolus and then started on
maintence IVF. He was given thiamine and folate. He
phenobarbital
loaded and then admitted to medicine for further management and
ultimate placement in ___ facility. Patient will be loaded on
phenobarbital and monitored appropriately.
On arrival to the floor, patient reports that he is feeling well
with the exception of mild tremors and hallucinations
intermittently. Reports that his last drink was last night,
~24hours ago. He denies chest pain, palpitations, shortness of
breath, nausea, or vomiting. He denies any history of withdrawal
seizures.
Past Medical History:
- EtOH Use Disorder
- Hyperlipidemia
- HTN
- Depression
Social History:
___
Family History:
No family history of GI issues. Father is ___ with HTN and MI at
the age of ___. Mother died at ___ for unclear neurological
reasons. He has no siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T-97.3, BP- 156 / 98, HR- 79, RR- 16, O2- 97 Ra
GENERAL: Tremulous. No acute distress.
HEENT: Anicteric sclera, +nystagmus. MMM.
NECK: supple, no LAD, JVP not elevated.
CV: RRR, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Tremulous. No cyanosis, clubbing, or edema.
PULSES: 2+ radial pulses bilaterally
NEURO: A&O x3. Slow finger to nose. CN II_XII intact. Gait
ataxic.
DERM: warm and well perfused, no rashes
Discharge physical exam:
GENERAL: Thin ___ gentleman, pleasant, in no acute distress.
Walking around room back and forth
HEENT: Anicteric sclera, MMM.
CV: RRR, no murmurs, gallops, or rubs
PULM: Clear to auscultation bilaterally.
GI: abdomen soft, nondistended, nontender, no rebound/guarding
EXTREMITIES: No cyanosis, clubbing, or edema.
NEURO: Moves all four extremities with purpose.
DERM: warm and well perfused, no rashes
Pertinent Results:
ADMISSION LABS:
___ 06:00PM LACTATE-2.1*
___ 05:53PM URINE HOURS-RANDOM
___ 05:53PM URINE bnzodzpn-POS* barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 05:53PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 05:53PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-<1
___ 05:53PM URINE HYALINE-1*
___ 05:53PM URINE MUCOUS-FEW*
___ 05:50PM GLUCOSE-79 UREA N-16 CREAT-1.0 SODIUM-142
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-19*
___ 05:50PM estGFR-Using this
___ 05:50PM ALT(SGPT)-39 AST(SGOT)-40 ALK PHOS-79 TOT
BILI-0.6
___ 05:50PM LIPASE-28
___ 05:50PM ALBUMIN-4.7 CALCIUM-9.7 PHOSPHATE-3.8
MAGNESIUM-1.9
___ 05:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 05:50PM WBC-8.0 RBC-4.52* HGB-14.3 HCT-43.9 MCV-97
MCH-31.6 MCHC-32.6 RDW-13.9 RDWSD-50.0*
___ 05:50PM NEUTS-68.4 ___ MONOS-9.5 EOS-0.5*
BASOS-0.6 IM ___ AbsNeut-5.48 AbsLymp-1.67 AbsMono-0.76
AbsEos-0.04 AbsBaso-0.05
___ 05:50PM PLT COUNT-226
PERTINENT RADIOLOGY:
CXR PA AND LATERAL (___):
1. Mild pulmonary vascular congestion.
TRANSTHORACIC ECHOCARDIOGRAM (___):
Normal biventricular cavity sizes, regional/global systolic
function (LVEF 56%). No valvular pathology or pathologic flow
identified.
MRI/MRA brain (___):
1. Incomplete brain MRI with diffusion weighted and T1 weighted
images only. No acute infarction.
2. Motion limited brain MRA. No occlusion or high-grade stenosis
is seen
3. Flow in the cavernous and supraclinoid right internal carotid
artery appears minimally diminished compared to the left, which
may be due to asymmetric atherosclerosis.
4. M1 segment of the right MCA appears smaller in caliber than
the left, unclear whether secondary to diminished flow or
technical factors.
5. Flow is poorly seen in the intracranial left vertebral
artery, likely due to its small size, as it was shown to be
diminutive on the prior MRI. Flow suboptimally visualized in the
proximal right intracranial vertebral artery, likely due to
technical factors, with good flow seen in its mid and distal
portion."
EEG ___
This continuous ICU monitoring study was abnormal due to:
Generalized background slowing suggestive of a mild
encephalopathy, non-
specific in etiology. There were no push button events. There
were no focal
findings, electrographic seizures, or epileptiform discharges.
Compared to the
prior day's recording, there was slight improvement in the
background. Of
note, several portions of the study were obscured by electrode
artifact.
MR HEAD W & W/O CONTRAST Study Date of ___ 11:55 AM
There is diffuse pachymeningeal thickening and enhancement.
Additionally,
there is diffuse enhancing and FLAIR hyperintense sulcal linear
foci which
likely represent engorged cerebral cortical veins.
There is a FLAIR hyperintense 2.5 x 2.0 x 0.8 cm (SI by TV by
AP) (7:6 and
1000:83) enhancing signal abnormality along the posterior clivus
which is
favored to represent venous plexus engorgement (7:6, 4:6, 9:6),
less likely
retroclival hematoma given enhancement.
There is no evidence of abnormal mamillary body signal or
enhancement, or
abnormal signal within the medial thalamus or periaqueductal
gray matter to
suggest alcoholic/Wernicke encephalopathy.
There is no acute infarction, hemorrhage, edema, mass, or mass
effect. The
ventricles and sulci are prominent, compatible with global
parenchymal volume
loss.
There is mild right maxillary sinus mucosal thickening. The
remaining
visualized paranasal sinuses and mastoids appear clear. Major
intracranial
vascular flow voids are preserved. Globes and orbits are
unremarkable. Major
dural venous sinuses are patent and appear larger in
caliber/engorged compared
with prior MRI. Additionally, note is made of a more superiorly
convex margin
of the pituitary on the current study compared to prior
(1000:84).
IMPRESSION:
1. Diffuse mild pachymeningeal FLAIR hyperintensity and
enhancement.
Additionally, there is engorgement of the cerebral cortical
veins and the
dural venous sinuses and a more superiorly convex pituitary
gland which has
increased in height since prior MRI of ___
constellation of
findings most consistent with some component of new intracranial
hypotension,
possibly secondary to recent lumbar puncture.
2. 2.5 cm extra-axial midline enhancing signal abnormality along
the posterior
clivus is favored to represent engorged venous plexus. Although
retroclival
hematoma is considered less likely given the degree of
enhancement observed,
since this is new from prior study of ___, short-term
(3 days)
follow-up is recommended.
3. No additional acute intracranial abnormality identified. No
evidence of
alcoholic/Wernicke encephalopathy.
4. Chronic global parenchymal volume loss, stable.
CT HEAD W/O CONTRAST Study Date of ___ 4:24 ___
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no
evidence of acute large territory infarct or intracranial
hemorrhage.
2. Previously seen enhancing retroclival lesion is not
visualized. No
evidence of retroclival hematoma.
DISCHARGE LABS:
___ 07:42AM BLOOD WBC-6.0 RBC-4.61 Hgb-14.9 Hct-43.4 MCV-94
MCH-32.3* MCHC-34.3 RDW-13.0 RDWSD-45.0 Plt ___
___ 07:42AM BLOOD Glucose-106* UreaN-10 Creat-1.1 Na-145
K-4.4 Cl-103 HCO3-25 AnGap-17
___ 07:42AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.3
PLEASE SEE OMR FOR REMAINING LP STUDIES AND PATHOLOGY REPORTS
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. Escitalopram Oxalate 10 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
4. Escitalopram Oxalate 10 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Hallucinations
Likely underlying dementia
SECONDARY DIAGNOSES:
History of 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: CR chest PA lateral
INDICATION: ___ year old man with cough and bilateral lower extremity
crackles.// Please evaluate for pneumonia, pulmonary edema.
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
There is mild pulmonary vascular congestion in the lung bases. The
cardiomediastinal silhouette is unremarkable. There is no pleural edema.
There is no pneumothorax.
IMPRESSION:
1. Mild pulmonary vascular congestion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with altered mental status and agitation
overnight./Please evaluate for intracranial lesion, bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass effect, or acute major
vascular territorial infarction. Unchanged global parenchymal volume loss
with prominent ventricles and sulci.
There is chronic rightward deviation of the nasal septum, unchanged from
prior. No evidence for suspicious bone lesion. Mild mucosal thickening in the
ethmoid air cells.
IMPRESSION:
No evidence for an acute intracranial abnormality.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old man with chronic EtOH disorder who was recently seen
in the ED for hallucinations, concern for withdrawal vs. delirium. Any acute
intracranial findings or evidence of stroke? Neuro recommends MRI to further
workup delirium with abnormal physical exam findings.
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Three dimensional maximum intensity projection and segmented images were
generated.
Sagittal T1 weighted and axial diffusion weighted images of the brain were
obtained. The patient was not able to cooperate with additional imaging due
to mental status. FLAIR, T2 weighted, and gradient echo images were not
obtained.
This report is based on interpretation of all of the above images.
COMPARISON: Head CT from ___
Brain MRI with and without contrast from ___
FINDINGS:
MR BRAIN:
Diffusion-weighted images demonstrate no evidence for an acute infarction.
Mild global parenchymal volume loss is again seen with mildly prominent
ventricles and sulci. Diffusely heterogenous bone marrow signal is again
noted. There is mild mucosal thickening and small mucous retention cysts in
the maxillary sinuses.
MRA BRAIN:
Motion artifact limits evaluation. Flow is poorly seen in the intracranial
left vertebral artery, likely due to its small size, as it was shown to be
diminutive on the prior MRI. Flow suboptimally visualized in the proximal
right intracranial vertebral artery, likely due to technical factors, with
good flow seen in its mid and distal portion. Flow in the cavernous and
supraclinoid right internal carotid artery appears minimally diminished
compared to the left, which may be due to asymmetric atherosclerosis. M1
segment of the right MCA appears smaller in caliber than the left, unclear
whether secondary to diminished flow or technical factors. No occlusion or
high-grade stenosis is seen. No large aneurysm is seen; evaluation for small
aneurysm is limited by motion artifact.
IMPRESSION:
1. Incomplete brain MRI with diffusion weighted and T1 weighted images only.
No acute infarction.
2. Motion limited brain MRA. No occlusion or high-grade stenosis is seen
3. Flow in the cavernous and supraclinoid right internal carotid artery
appears minimally diminished compared to the left, which may be due to
asymmetric atherosclerosis.
4. M1 segment of the right MCA appears smaller in caliber than the left,
unclear whether secondary to diminished flow or technical factors.
5. Flow is poorly seen in the intracranial left vertebral artery, likely due
to its small size, as it was shown to be diminutive on the prior MRI. Flow
suboptimally visualized in the proximal right intracranial vertebral artery,
likely due to technical factors, with good flow seen in its mid and distal
portion.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with h/o EtOH abuse, Parkinsonism on exam,
subacute encephalopathy. ___ syndrome on differential// eval
for enhancement of the mammillary bodies, or any other acute finidngs which
may explain subacute encephalopathy
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:
1. MRI/MRA brain ___.
2. Unenhanced head CT ___.
FINDINGS:
There is diffuse pachymeningeal thickening and enhancement. Additionally,
there is diffuse enhancing and FLAIR hyperintense sulcal linear foci which
likely represent engorged cerebral cortical veins.
There is a FLAIR hyperintense 2.5 x 2.0 x 0.8 cm (SI by TV by AP) (7:6 and
1000:83) enhancing signal abnormality along the posterior clivus which is
favored to represent venous plexus engorgement (7:6, 4:6, 9:6), less likely
retroclival hematoma given enhancement.
There is no evidence of abnormal mamillary body signal or enhancement, or
abnormal signal within the medial thalamus or periaqueductal gray matter to
suggest alcoholic/Wernicke encephalopathy.
There is no acute infarction, hemorrhage, edema, mass, or mass effect. The
ventricles and sulci are prominent, compatible with global parenchymal volume
loss.
There is mild right maxillary sinus mucosal thickening. The remaining
visualized paranasal sinuses and mastoids appear clear. Major intracranial
vascular flow voids are preserved. Globes and orbits are unremarkable. Major
dural venous sinuses are patent and appear larger in caliber/engorged compared
with prior MRI. Additionally, note is made of a more superiorly convex margin
of the pituitary on the current study compared to prior (1000:84).
IMPRESSION:
1. Diffuse mild pachymeningeal FLAIR hyperintensity and enhancement.
Additionally, there is engorgement of the cerebral cortical veins and the
dural venous sinuses and a more superiorly convex pituitary gland which has
increased in height since prior MRI of ___ constellation of
findings most consistent with some component of new intracranial hypotension,
possibly secondary to recent lumbar puncture.
2. 2.5 cm extra-axial midline enhancing signal abnormality along the posterior
clivus is favored to represent engorged venous plexus. Although retroclival
hematoma is considered less likely given the degree of enhancement observed,
since this is new from prior study of ___, short-term (3 days)
follow-up is recommended.
3. No additional acute intracranial abnormality identified. No evidence of
alcoholic/Wernicke encephalopathy.
4. Chronic global parenchymal volume loss, stable.
RECOMMENDATION(S): Short-term (3 days) follow-up head imaging with CT or MRI,
as above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with subacute encephalopathy vs. dementia//
Follow up study for MRI findings "2.5 cm extra-axial midline enhancing signal
abnormality along the posterior clivus is favored to represent engorged venous
plexus. Although retroclival hematoma is considered less likely given the
degree of enhancement observed, since this is new from prior study of ___, short-term (3 days) follow-up is recommended."Please protocol
with contrast if needed to follow up this finding
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total exam DLP: 756.68 mGy cm
COMPARISON: MR brain ___, CT head ___.
FINDINGS:
There is no evidence of acute territorial infarctionhemorrhage,edema,or mass
effect. Stable global parenchymal volume loss with prominence of the
ventricle and sulci. Enhancing retrocaval lesion seen on previous MR from ___ is not visualized on the present exam. The basal cisterns are
patent.
There is no evidence of fracture. Stable rightward deviation of the nasal
septum, unchanged compared to prior studies. 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 abnormality on noncontrast head CT. Specifically no
evidence of acute large territory infarct or intracranial hemorrhage.
2. Previously seen enhancing retroclival lesion is not visualized. No
evidence of retroclival hematoma.
Gender: M
Race: OTHER
Arrive by OTHER
Chief complaint: EtOH detox
Diagnosed with Alcohol dependence with withdrawal, unspecified, Tremor, unspecified, Chest pain, unspecified, Visual hallucinations
temperature: 99.0
heartrate: 96.0
resprate: 18.0
o2sat: 99.0
sbp: 152.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | ___ year old male with a PMH significant for chronic alcohol use
disorder presented with hallucinations c/f withdrawal vs.
delirium. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
facial pain
Major Surgical or Invasive Procedure:
ORIF right PS fracture, CRMMF Left subcondylar fracture
History of Present Illness:
This patient is a ___ year old male who complains of
MANDIBLE FX. Patient transferred from OSH with open mandible
fx. Mixed martial fighter got hit in the face. Got morphine
at OSH. Complains of jaw pain, headache. Denies neck pain.
Denies chest pain or shortness of breath. Denies abdominal
pain. Given ampicillin at OSH.
Timing: Sudden Onset
Past Medical History:
mandible fx
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION
Temp: 98.4 HR: 56 BP: 144/67 Resp: 16 O(2)Sat: 98 Normal
Constitutional: Appears uncomfortable
HEENT: Malocclusion of jaw, tender palpation over the
medial mandible, Pupils equal, round and reactive to light,
Extraocular muscles intact
No C-spine tenderness
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Skin: Warm and dry
Neuro: Strength equal upper and lower extremities
Supplements
Physical examination upon discharge: ___:
vital signs: 97.6, HR=63, BP=136/82, RR=18, 97% room air
General: Sitting comfortably in bed, NAD
HEENT: Jaw wired
CV: ns1, s2, -s3, -s4, no murmurs
LUNGS: clear, no adventitious
ABDOMEN: soft, non-tender, no masses
EXT: no calf tenderness bil. no pedal edema bil.
NEURO: alert and oriented x 3, speech mumbled related to jaw
wiring
Pertinent Results:
___ 06:50AM BLOOD WBC-12.2* RBC-4.65 Hgb-14.8 Hct-43.1
MCV-93 MCH-31.9 MCHC-34.4 RDW-11.7 Plt ___
___:50AM BLOOD Neuts-80.9* Lymphs-11.2* Monos-7.2
Eos-0.3 Baso-0.5
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD ___ PTT-25.3 ___
___ 06:50AM BLOOD Glucose-101* UreaN-16 Creat-1.4* Na-136
K-4.0 Cl-103 HCO3-24 AnGap-13
___: cat scan of the head:
IMPRESSION:
1. No acute intracranial injury.
2. No acute fracture or traumatic malalignment of the cervical
spine.
3. Non-displaced fracture at the left ramus of the mandible is
fully assessed
on the CT facial bones performed earlier the same day.
___: cat scan of the c-spine:
IMPRESSION:
1. No acute intracranial injury.
2. No acute fracture or traumatic malalignment of the cervical
spine.
3. Non-displaced fracture at the left ramus of the mandible is
fully assessed
on the CT facial bones performed earlier the same day
___: cat scan of the head:
IMPRESSION:
1. No acute intracranial injury.
2. No acute fracture or traumatic malalignment of the cervical
spine.
3. Non-displaced fracture at the left ramus of the mandible is
fully assessed on the CT facial bones performed earlier the same
day.
___: Sinus films:
IMPRESSION:
1. Mildly displaced obliquely oriented fracture through the
right mental
tubercle of the mandible extending between the right central and
lateral
incisors with 5-mm anterior displacement and 3-mm overriding of
the right
fracture fragment.
2. Non-displaced fracture through the left ramus of the
mandible extending to the coronoid process.
3. No additional facial bone fractures.
Medications on Admission:
none
Discharge Medications:
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate [Peridex] 0.12 % Swish and spit 15mL
Twice a day Disp #*500 Milliliter Refills:*0
RX *chlorhexidine gluconate [Peridex] 0.12 % Mouth rinse twice a
day Disp #*1 Bottle Refills:*0
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 250 mg/5 mL 10 mL by mouth Four times a day Disp
#*300 Milliliter Refills:*0
RX *cephalexin 250 mg/5 mL 280 Suspension for Reconstitution(s)
by mouth every six (6) hours Disp #*1 Bottle Refills:*0
3. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL ___ cc
by mouth every four (4) hours Disp #*400 Milliliter Refills:*0
4. Docusate Sodium (Liquid) 100 mg PO BID
hold for loose stool
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Mandible Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with known mandibular fracture status post boxing
fight and blow to head.
COMPARISON: Outside CT scan of the facial bones performed earlier the same
day at ___.
FINDINGS:
Multiple Panorex views of the mandible as well as a PA view provided for
interpretation. Please note this is not a complete exam as the lateral and
oblique views were not performed. There is a vertically oriented
parasymphyseal fracture identified through the mandible. It involves the
roots ___ tooth numbers 25 and 26. Fracture through the ramus of the
mandible on the left is better seen on prior CT scan.
Radiology Report
INDICATION: Head and neck pain status post boxing injury, here to evaluate
for acute intracranial or cervical spine injury.
COMPARISON: Same day non-contrast CT of the facial bones.
TECHNIQUE: Outside CT of the head and cervical spine without contrast
performed at ___ at 01:13 a.m. on ___ was
uploaded for second opinion read. Coronal and sagittal reformatted images of
the cervical spine and coronal reformatted images of the head were uploaded
and reviewed.
FINDINGS:
CT HEAD: There is no evidence of acute intracranial hemorrhage, edema, mass
effect or shift of normally midline structures. The gray-white matter
interface is preserved without evidence of acute major vascular territorial
infarct. The ventricles and sulci are normal in size and configuration for
the patient's age. The orbits and globes are unremarkable. Mucus retention
cysts are noted in the left maxillary sinus. The remainder of the visualized
paranasal sinuses, middle ear cavities and mastoid air cells are clear
bilaterally. The bony calvaria appear intact.
CT C-SPINE: There is no evidence of acute fracture or traumatic malalignment
of the cervical spine. No prevertebral or paraspinal soft tissue swelling or
large hematoma is detected. The vertebral body heights and alignment are
preserved. The atlanto-occipital and atlantoaxial articulations are
maintained. Ossified densities anterior to the C4-5 and C5-6 intervertebral
levels appear chronic. Mild degenerative changes are most pronounced at the
C4-5 and C5-6 levels.
The imaged portion of the thyroid gland is unremarkable. The visualized lung
apices are clear. The mastoid air cells are clear bilaterally.
IMPRESSION:
1. No acute intracranial injury.
2. No acute fracture or traumatic malalignment of the cervical spine.
3. Non-displaced fracture at the left ramus of the mandible is fully assessed
on the CT facial bones performed earlier the same day.
Radiology Report
INDICATION: Jaw pain status post boxing injury, here to evaluate for
fracture.
COMPARISON: Same day non-contrast head CT and CT of the C-spine.
TECHNIQUE: Outside CT of the facial bones and the mandible performed at
___ at 01:30 a.m. on ___ uploaded for second
opinion read. Coronal reformats are also uploaded and reviewed.
FINDINGS: There is a non-displaced fracture through the left mandibular ramus
extending into the left coronoid process. A mildly displaced obliquely
oriented fracture through the right mental tuberole is also present with 5-mm
anterior displacement and 3-mm overriding at the right fracture fragment. The
fracture line extends superiorly from the right mental tuberole towards the
midline between the right central and lateral incisors. No associated tooth
fracture is detected. The zygomatic arches are intact. The paranasal sinuses
are clear with exception of mucus retention cysts in the left maxillary sinus.
The nasal septum is midline. The cribriform plate, lamina papyracea, orbital
roof and orbital floors are intact. Limited assessment of the nasopharyngeal
and oropharyngeal soft tissues is unremarkable. The visualized brain is
unremarkable. The bilateral mastoid air cells are clear.
IMPRESSION:
1. Mildly displaced obliquely oriented fracture through the right mental
tubercle of the mandible extending between the right central and lateral
incisors with 5-mm anterior displacement and 3-mm overriding of the right
fracture fragment.
2. Non-displaced fracture through the left ramus of the mandible extending to
the coronoid process.
3. No additional facial bone fractures.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: MANDIBLE FX
Diagnosed with MANDIBLE FX NOS-CLOSED, STRUCK BY OBJECT OR PERSON WITH OR WITHOUT FALL
temperature: 98.4
heartrate: 56.0
resprate: 16.0
o2sat: 98.0
sbp: 144.0
dbp: 67.0
level of pain: 8
level of acuity: 3.0 | ___ year old gentleman admitted to the hospital after being
punched in the face. He was reported to have sustained an
isolated mandible fracture. He was transferred here for further
management. Upon admission, he was made NPO, given intravenous
fluids, and underwent additional imaging. On cat scan imaging
of the head he was reported to have no acute intra-cranial
injury. C-spine imaging showed no mal-alignment of the spine.
Because of his injury, he was evaluated by the Oral Maxillary
service who recommended surgery. The patient was taken to the
operating room on HD #2 where he underwent an open reduction
internal fixation of right parasymphysis fracture and a closed
reduction maximum mandibular fixation of the left subcondylar
fracture. The operative course was stable with a 50cc blood
loss ( please see operative note). The patient was extubated
after the procedure and monitored in the recovery. His
post-operative course has been stable. He has been afebrile and
his pain has been controlled with oral analgesia. He has resumed
a full liquid diet withiout any difficulty in swallowing. He
has been instructed to continue antiobiotic coverage for 1 week
and peridex rinses for 2 weeks. He will follow- up with ___
surgeons in ___. A copy of the discharge summary and
operative note were given to the patient at discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Wellbutrin
Attending: ___.
Chief Complaint:
EtOH withdrawal, requesting detox
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: ___
Location: ___
Address: ___
Phone: ___
Fax: ___
HPI: ___ with Hx seizure disorder, multiple traumatic injuries,
EtOH abuse, recent admission at ___ for EtOH withdrawl (d/c
___, presents for detox.
The patient has a distant history of drug and alcohol abuse,
quit in ___. He was sober for ___ years, and in fact became a
drug and alcohol counselor with the ___ system. Last ___,
he had a seizure and was hospitalized. Shortly thereafter he
stopped his volunteer work at the ___ and started drinking.
His intake was not signficant until ___, when his best
friend died. Since ___ he has been drinking up to a fifth of
vodka a day. He has had sober periods, but cannot sustain
sobriety. He has also restarted smoking since ___. He sought
help earlier in ___ at ___, where he was admitted
for detox, discharged ___. Since discharge he has been
drinking a fifth of vodka a day, last drink this morning at 9am.
He lives alone, but this morning after a night of drinking went
next door and asked his neighbor to call ___.
In the last week he has had several falls, although he cannot
recall the details due to intoxication. He injured his left
knuckles and his back, at one point needed help getting back to
his apartment, but cannot recall a head strike. He does have a
small lump on his scalp that he can't remember getting.
He has never had a seizure triggered by EtOH withdrawl, and his
seizure disorder was discovered when he was sober.
In the ED, initial vitals ___ 110 170/98 18 96% RA. He
complained of chronic back pain from an old injury, but was
noted to be able to ambulate with a steady gait. He received
folic acid, thiamine, and MVI, as well as 1L NS. He received
diazepam 10mg at 1300 for withdrawl prevention. He also
received an ipratropium nebulizer treatment. CIWA = 4 at time
of transfer.
On the floor, he is complaining of mild back pain and is
slightly tremulous. He also notes pain at his right hand IV
site and requests replacement.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denies
shortness of breath, cough, dyspnea or wheezing. Denies chest
pain, chest pressure, palpitations. Denies constipation,
abdominal pain, diarrhea, dark or bloody stools. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
seizure disorder Dx ___ ___
chronic back pain
EtOH abuse
s/p liver resection ___ GSW
left knee ACL tear
h/o left lung trauma
h/o right wrist injury
left biceps tendon rupture
Social History:
___
Family History:
Brother with ___ syndrome, ICD placed.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 163/85 106 18 97% RA
GENERAL: NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, MMM
NECK: nontender and supple, no LAD, no JVD, no thyromegaly
BACK: mild midline tenderness over coccyx, no CVA tenderness
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal, pain over coccyx with SLR on
initiation of movement only, not with passive movement. L
biceps torn tendon with Popeye bulge, pain with L shoulder
movement. DTRs 2+ at biceps, brachioradialis, patella,
achilles.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5, 98.0, 129/78 (110-140/70-90), 92, 17, 100RA
-has not scored on CIWA
GENERAL: NAD, awake and alert, lying in bed comfortably and
relaxed appearing
HEENT: EOMI, PEERLA, no oropharyngeal lesions
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema.
SKIN: multiple tattoos on the arms bilaterally, IV in place in
the left forearm
Pertinent Results:
ADMISSION LABS:
___ 12:20PM BLOOD WBC-4.2 RBC-3.83* Hgb-13.5* Hct-40.7
MCV-106* MCH-35.3* MCHC-33.2 RDW-13.9 Plt ___
___ 12:20PM BLOOD Neuts-34.2* Lymphs-54.7* Monos-5.3
Eos-3.0 Baso-2.7*
___ 12:20PM BLOOD Glucose-141* UreaN-13 Creat-0.9 Na-143
K-4.1 Cl-99 HCO3-21* AnGap-27*
___ 12:20PM BLOOD ALT-36 AST-52* AlkPhos-86 TotBili-0.3
___ 12:20PM BLOOD Lipase-45
___ 12:20PM BLOOD cTropnT-<0.01
___ 12:20PM BLOOD Albumin-4.9 Calcium-9.0 Phos-3.5 Mg-1.8
Iron-153
___ 12:20PM BLOOD calTIBC-337 VitB12-607 Folate-17.0
Ferritn-481* TRF-259
___ 12:20PM BLOOD TSH-0.91
___ 12:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 02:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 02:30PM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
___ 02:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS:
___ 07:12AM BLOOD WBC-4.9 RBC-3.55* Hgb-12.8* Hct-38.3*
MCV-108* MCH-36.2* MCHC-33.5 RDW-13.3 Plt ___
___ 07:12AM BLOOD Glucose-90 UreaN-18 Creat-0.8 Na-137
K-4.1 Cl-99 HCO3-26 AnGap-16
___ 07:12AM BLOOD Calcium-9.8 Phos-5.0* Mg-1.6
MICROBIOLOGY: NONE
IMAGING:
CXR ___:
FINDINGS: There is no focal consolidation, pulmonary edema, or
pneumothorax seen. There is minimal blunting of the posterior
costophrenic angles, similar to ___. The heart and
mediastinal contours are normal.
IMPRESSION: No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation
1. FoLIC Acid 1 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
3. methylphenidate 50 mg oral daily
4. Multivitamins 1 TAB PO DAILY
5. Propranolol 20 mg PO BID
6. Sildenafil 100 mg PO PRN sexual activity
7. Thiamine 100 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Nicotine Lozenge Dose is Unknown PO Frequency is Unknown
The patient is not sure of his entire medication list. He uses
the ___ Pharmacy.
He was on Paxil, but stopped taking it about a week ago.
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. LeVETiracetam 500 mg PO BID
4. Nicotine Lozenge 4 mg PO Q1H:PRN withdrawl
5. Propranolol 20 mg PO BID
6. Thiamine 100 mg PO DAILY
7. methylphenidate 50 mg oral daily
8. Multivitamins 1 TAB PO DAILY
9. Sildenafil 100 mg PO PRN sexual activity
Discharge Disposition:
Home
Discharge Diagnosis:
primary: EtOH dependence
secondary: h/o seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Patient with hypoxia, evaluate for pneumonia.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS: There is no focal consolidation, pulmonary edema, or pneumothorax
seen. There is minimal blunting of the posterior costophrenic angles, similar
to ___. The heart and mediastinal contours are normal.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: SUBSTANCE USE/REQUESTING DETOX
Diagnosed with ALCOHOL WITHDRAWAL, ALCOH DEP NEC/NOS-CONTIN
temperature: 98.1
heartrate: 110.0
resprate: 18.0
o2sat: 96.0
sbp: 170.0
dbp: 98.0
level of pain: 8
level of acuity: 3.0 | ___ with Hx seizure disorder, multiple traumatic injuries, EtOH
abuse, recent admission at ___ for EtOH withdrawl (d/c ___,
presents for detox.
# EtOH withdrawal: Patient requested medical detox, will plan
to seek longer-term assistance via the ___ system. He has a
social worker, psychiatrist, and psychologist that he works with
in the ___ system. Refused our social work/case management
support. He has no history of withdrawal-related seizures. Only
scored on CIWA once, the night of ___. Continued thiamine,
folic acid, and MVI.
# h/o seizure disorder: No history of EtOH withdrawl seizure.
Continued Keppra
# Back pain: Likely ___ injury from a fall. No evidence of
neurological deficit. Only mild midline tenderness. Provided
ibuprofen PRN.
# ADHD: held methylphenidate, continue propranolol
# Tobacco abuse: nicotine lozenges
# Med rec: ideally we could get his medication list from the
___, however given the holiday this was not possible
# Code: FULL |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / thimerosal / Penicillins /
tape / latex
Attending: ___
Chief Complaint:
HA, lightheadedness, episodes of slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of DCIS (Dx ___ who only took tamoxifen for a
couple of years then stopped taking it because of side effects.
Two weeks ago, she was at dinner with a friend and had a couple
sips of wine (adamantly denies being drunk). She had a minute of
word finding issues as well as word slurring. ___ friend ___
notice but it was a loud bar. She dismissed it as nothing and
didn't seek any medical attention. On ___ she developed a
bi-temporal ___ constant pressure headache with the sensation
of pressure behind ___ right eye. She has been under a lot of
stress with the recent hospitalization of ___ mother for a
vertebral dissection. She is unsure if stress contributed to ___
headache and feels that she is hypersensitive to ___ own
symptoms because of ___ mother's symptoms. She does not
typically have headaches. She developed some occipital pain and
neck stiffness so she went to a masseuse on ___ and ___
and had several deep neck manipulations during the massages.
After these massages, she had intermittent feelings of
lightheadedness (not room spinning vertigo), left sided numbness
(especially ___ face). She was worried that these episodes may
represent strokes so she took aspirin ___ yesterday and today.
This morning, she made an appointment with the PCP to evaluate
___ headache. After making the appointment, while at the bank,
she had an episode where it was very difficult for ___ to sign
___ name on ___ check. She became very concerned. This resolved in
a minute. When she told this to ___ PCP, he sent ___ to the ED
for evaluation. While in the ED she complains of intermittent
episodes of mental slowing. Neurology was consulted for
recommendations on workup and management of these episodes.
On neuro ROS, (+) episode of slurred speech and work finding
difficulty two weeks ago, ___ constant pressure headache
for four days with pressure behind the right eye, (+)
lightheadedness with head movement, (+) left sided numbness. The
pt denies diplopia, dysarthria, dysphagia, vertigo, tinnitus or
hearing difficulty. 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:
LATEX ALLERGY- RASH
L4-5 DISC HERNIATION- PERSISTS FROM ___
DCIS - ___ AD ___- STOPPED TAMOXIFEN ON ___ OWN
COLONIC ADENOMA
ALLERGIC RHINITIS
ASTHMA
VITAMIN D INSUFFICIENCY
OSTEOPENIA
LT ARM PAIN - ___
PARTIAL MASTECTOMY FOR DCIS- ___
OOPHORECTOMY -RT ___ DUE TO TORSION
CYST REMOVAL - ___
LEFT KNEE LATERAL ___
Social History:
Country of Origin: usa
Marital status: Single
Children: No
Work: ___
Multiple partners: ___
___ activity: Past
Sexual orientation: Male
Sexual Abuse: Denies
Domestic violence: Denies
Contraception: Condoms - Male
Tobacco use: Never smoker
drinks per week: 1
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Family History:
Mother DIABETES MELLITUS
HYPERTENSION
Father DIABETES MELLITUS
HYPERTENSION
Sister ___ BREAST CANCER Maternal aunt in
___ ___
Comments: No early CAD, Alzheimer's disease or osteoporosis.
Physical Exam:
ADMISSION EXAM:
GENERAL EXAM:
- Vitals: 98.5 67 146/93 R16 100%RA
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple. No nuchal rigidity
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, 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. Able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Able to register
3 objects and recall ___ at 5 minutes.
- Cranial Nerves:
In a darkened room, right pupil 3.5mm->2mm, left pupil 5mm->2mm,
both briskly reactive. VFF to confrontation. EOMI without
nystagmus. 90% sensation to LT and PP in the right V1,V2,V3.
Asymmetric smile; both sides activate quickly. Right lid
slightly lower over ___ than left. Hearing intact to finger-rub
bilaterally. Palate elevates symmetrically. ___ strength in
trapezii and SCM bilaterally. Tongue protrudes in midline.
- Motor: Normal bulk and tone throughout. No pronator drift
bilaterally.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___- 5 5 5 5 5
- Sensory: intact to light touch. No extinction 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 or dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. No past pointing.
- Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
positive.
===============================================
DISCHARGE EXAM:
Notable for Right pupil 2-> 1.5, Left pupil 2.5 -> 2; no ptosis;
decreased LT to 95% on Right face, 90% on Right upper extremity.
Otherwise nonfocal, Motor ___, Coordination (FNF, HKS intact),
Gait normal.
Pertinent Results:
IMAGING:
CTA Head and Neck (___):
1. Findings suggestive of nonocclusive right carotid bulb focal
dissection.
Recommend clinical correlation. If clinically indicated,
consider carotid
ultrasound further evaluation.
2. No evidence of acute intracranial hemorrhage.
3. Ectasia of the ascending aorta measuring up to 4.4 cm.
Recommend clinical
correlation.
4. Mild heterogeneity of bilateral thyroid glands with 2 mm
right thyroid
gland nodule. Recommend clinical correlation. If clinically
indicated,
consider dedicated thyroid ultrasound.
5. Please note MRI of the brain is more sensitive for the
detection of acute
infarct.
6. Partially visualized lungs demonstrates 4 mm right upper lobe
pulmonary
nodule. Recommend clinical correlation and correlation with
dedicated chest
imaging.
RECOMMENDATION(S):
1. Findings suggestive of nonocclusive right carotid bulb focal
dissection.
Recommend clinical correlation. If clinically indicated,
consider carotid
ultrasound further evaluation.
2. Ectasia of the ascending aorta measuring up to 4.4 cm.
Recommend clinical
correlation.
3. Mild heterogeneity of bilateral thyroid glands with 2 mm
right thyroid
gland nodule. Recommend clinical correlation. If clinically
indicated,
consider dedicated thyroid ultrasound.
4. Partially visualized lungs demonstrates 4 mm right upper lobe
pulmonary
nodule. Recommend clinical correlation and correlation with
dedicated chest
imaging.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of Breath
2. Cyclobenzaprine 10 mg PO TID:PRN Back Spasm
3. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of Breath
3. Cyclobenzaprine 10 mg PO TID:PRN Back Spasm
4. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
Sensory Changes of Unknown Etiology, likely cervical muscle
tension vs. cervical radiculopathy.
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: ___ year old female with right sided numbness, headache, right
sided blurry vision. Evaluate for dissection, aneurysm, AVM, venous sinus
thrombosis or steno-occlusive disease.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
4) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
5) Spiral Acquisition 5.3 s, 41.4 cm; CTDIvol = 32.1 mGy (Head) DLP =
1,330.0 mGy-cm.
Total DLP (Head) = 2,252 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are 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. The dural
venous sinuses are patent.
CTA NECK:
There is a linear filling defect in the right internal carotid artery just
distal to the bifurcation (see 5:144-146). The remaining carotid and
vertebral arteries and their major branches appear normal with no evidence of
stenosis or occlusion. There is no evidence of internal carotid stenosis by
NASCET criteria.
OTHER:
There is a 4 mm nodule in the right upper lobe on image 5:47. The remaining
visualized portions of the lung are clear. There is ectasia of the ascending
aorta measuring up to 4.4 cm on image 5:1. Question mild heterogeneity of
bilateral thyroid glands with an approximately 2mm right thyroid gland nodule
(see 5:101). Scattered subcentimeter nonspecific lymph nodes are noted
throughout the neck bilaterally. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Findings suggestive of nonocclusive right carotid bulb focal dissection.
Recommend clinical correlation. If clinically indicated, consider carotid
ultrasound further evaluation.
2. No evidence of acute intracranial hemorrhage.
3. Ectasia of the ascending aorta measuring up to 4.4 cm. Recommend clinical
correlation.
4. Mild heterogeneity of bilateral thyroid glands with 2 mm right thyroid
gland nodule. Recommend clinical correlation. If clinically indicated,
consider dedicated thyroid ultrasound.
5. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
6. Partially visualized lungs demonstrates 4 mm right upper lobe pulmonary
nodule. Recommend clinical correlation and correlation with dedicated chest
imaging.
RECOMMENDATION(S):
1. Findings suggestive of nonocclusive right carotid bulb focal dissection.
Recommend clinical correlation. If clinically indicated, consider carotid
ultrasound further evaluation.
2. Ectasia of the ascending aorta measuring up to 4.4 cm. Recommend clinical
correlation.
3. Mild heterogeneity of bilateral thyroid glands with 2 mm right thyroid
gland nodule. Recommend clinical correlation. If clinically indicated,
consider dedicated thyroid ultrasound.
4. Partially visualized lungs demonstrates 4 mm right upper lobe pulmonary
nodule. Recommend clinical correlation and correlation with dedicated chest
imaging.
NOTIFICATION: Final reading was communicated to ED QA nurses for clinician
and patient followup.
Radiology Report
INDICATION: ___ year old woman with headache, lightheadedness, and episodes
concerning for TIA. Abnormality in right carotid bulb suspicious for
dissection on preceding CTA with right Horner syndrome on exam. Please
perform with FAT SAT sequences.
TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo,
and diffusion-weighted images of the brain were obtained. 3D time-of-flight
MRA of the brain was obtained with multiplanar maximum intensity projection
angiographic reformatted images. 2D time-of-flight MRA of the neck was
obtained. Axial T1 weighted images of the neck were obtained with fat
suppression. Fat-suppressed axial IDEAL images of the neck were also
obtained. 3D coronal T1 weighted gradient echo imaging of the neck was
obtained before, during, and after intravenous gadolinium administration with
multiplanar maximum intensity projection angiographic reformatted images.
COMPARISON: Head and neck CTA ___ at 01:57.
FINDINGS:
BRAIN MRI: There is no acute infarction, edema, evidence for blood products,
or pathologic contrast enhancement. Scattered small foci of high T2 signal in
the subcortical, deep, and periventricular white matter of the cerebral
hemispheres are nonspecific but likely sequela of mild chronic small vessel
ischemic disease in this age group. Ventricles and sulci are normal in size
for age. Major dural venous sinuses are patent on postcontrast MP RAGE
images.
NECK MRA: Fat-suppressed axial T1 weighted and IDEAL images are limited by
motion artifacts. Evaluation of the small dissection flap in the right
carotid bulb, seen on the preceding CTA, is further limited by the relatively
high slice thickness of these images. High signal in the posterior right
carotid bulb on image ___ correspond to the small focal dissection.
Gadolinium enhanced MRA demonstrates a 3 vessel aortic arch. Common carotid,
cervical internal carotid, and vertebral arteries appear patent without
evidence for flow-limiting stenosis.
BRAIN MRA: The intracranial internal carotid and vertebral arteries, and
their major branches, appear patent without evidence for flow-limiting
stenosis or aneurysm.
IMPRESSION:
1. No acute infarction and no evidence for other acute intracranial
abnormalities.
2. Fat-suppressed axial images are limited by motion artifact. There may be
high signal in the posterior right carotid bulb corresponding to the small
focal dissection seen on the preceding CTA. CTA images are concerning for the
presence of the small focal dissection in the right carotid bulb.
3. Unremarkable appearance of the major intracranial arteries.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old woman with right blurry vision, right sided numbness.
Any masses? Acute cardiopulmonary process?
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
The lungs are well-expanded and clear. No pleural effusion or pneumothorax.
Heart size, mediastinal contour, and hila are unremarkable. The aorta is
mildly tortuous.
IMPRESSION:
No acute cardiopulmonary process. Specifically no large intrathoracic mass.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Dizziness, Headache
Diagnosed with Anesthesia of skin, Other visual disturbances
temperature: 98.5
heartrate: 67.0
resprate: 16.0
o2sat: 100.0
sbp: 146.0
dbp: 93.0
level of pain: 3
level of acuity: 3.0 | She was admitted for concern of carotid artery dissection.
However history is not consistent (consists of 1 min of
difficultly gathering thoughts; lightheadedness; and
intermittent decreased LT on left side) with dissection and ___
clinical Exam was nonfocal except for physiological anisocoria
(R 2->1.5, L 2.5 to 2) and 90% decreased Lt on RUE and R face.
MRI showed no acute stroke, MRA images were reviewed on rounds
and appeared to be inconclusive. Imaging seems more consistent
with artifact than with dissections, but patient was started on
aspirin 81 mg daily and Patient should have repeat CTA in ___s follow up with neurology. In terms of stroke
workup A1c 5.8, LDL pending at time of discharge.
Transitional Issues:
- Repeat CTA in ___ weeks
- outpatient PCP and neurology followup |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
___ Cardiac Catheterization
History of Present Illness:
Mr. ___ is a ___ year old male with a PMHx of HTN and HLD who
presents from his PCP office with nausea, L arm pain, and EKG
changes.
His symptoms began on ___ (3 days prior to admission) when
he was at home. He became hot, dizzy, and sweaty and went to sit
down on the couch. He then felt nauseated and had pain in his L
arm that improved if he lifted the arm over his head. These
symptoms persisted through ___ and he rested most of the day.
By late morning on ___ he was feeling better, but his stomach
still bothered him. On day of admission, he went to his PCP
office for evaluation and was found to have EKG changes for
which he was sent to our ED. He received a full dose of aspirin
in the ambulance. The last time he felt nauseated was the
morning of ___.
In the ED initial vitals were: 98.2 108 134/84 16 99% RA
Labs/studies notable for: Trop-T 2.84, K 3.1
EKG with STD in V2-V6; Q waves in II, III, aVF; QWI in aVL and
V1
Patient was given:
___ 17:05 IVF 1000 mL NS 1000 mL
___ 17:43 IV Heparin 4000 UNIT
___ 17:43 IV Heparin Started 950 units/hr
Patient's EKG on admission, shows patient to be in complete
heart block with junctional escape in ___. Patient at the time
was placed on beta-blocker per ACS protocol and this AM,
patient's junctional rhythm slowed to the ___. Patient was also
very nauseous at the time. Patient was taken to the cath lab
and was found to have thrombus completely occluding the RCa.
Two thrombectomy passes were attempted at removing RCa clot.
Patient received x1 DES to to ___ RCa and x 1 DES to PDA.
Patient was Plavix loaded and started on integrillin drip.
Patient's junctional rate improved to the ___. EP were
consulted who felt patient's HRs and HB should improve with
removal of clot burden. No temp wire was placed and patient was
transferred to CCU for further monitoring.
REVIEW OF SYSTEMS:
(+) per HPI
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. Denies recent fevers, chills or rigors. Denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Past Medical History:
Hypertension
Hyperlipidemia
Recent L biceps tendon tear s/p surgery in ___
Social History:
___
Family History:
Grandfather with MI at ___. Father died of ALS.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VS: T 98.1 BP 132/77 HR 69 RR18 O2 sat 96 RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa
NECK: No JVD noted at 45 degrees
CARDIAC: RRR, normal S1, S2. No m/r/g.
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.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis. No hematoma at R radial site.
PULSES: Right: 2+ DP 2+ Left: 2+ DP 2+
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 98.6 BP 100-116/58-65 HR 56-58 RR 18 96RA
I/O: ___ (8h), 1000/2125 (24h)
Tele: Sinus with 1st degree AV block, PACs, rare PVCs
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 foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
=================
___ 04:20PM ___ PTT-26.3 ___
___ 04:20PM PLT COUNT-237
___ 04:20PM NEUTS-66.5 ___ MONOS-11.6 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-10.12* AbsLymp-3.17 AbsMono-1.76*
AbsEos-0.02* AbsBaso-0.06
___ 04:20PM WBC-15.2* RBC-4.43* HGB-13.9 HCT-40.1 MCV-91
MCH-31.4 MCHC-34.7 RDW-12.8 RDWSD-42.1
___ 04:20PM CK-MB-9
___ 04:20PM cTropnT-2.84*
___ 04:20PM CK(CPK)-336*
___ 04:20PM estGFR-Using this
___ 04:20PM GLUCOSE-99 UREA N-15 CREAT-0.8 SODIUM-137
POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-29 ANION GAP-13
___ 10:23PM PTT-41.2*
___ 10:23PM CK-MB-8 cTropnT-2.64*
TROPONIN TREND:
___ 04:20PM BLOOD cTropnT-2.84*
___ 10:23PM BLOOD CK-MB-8 cTropnT-2.64*
___ 07:15AM BLOOD CK-MB-6 cTropnT-2.71*
___ 02:08AM BLOOD CK-MB-6 cTropnT-2.91*
___ 06:00AM BLOOD cTropnT-2.23*
RELEVANT RESULTS:
===================
___ 07:15AM BLOOD %HbA1c-5.8 eAG-120
___ 07:15AM BLOOD Triglyc-80 HDL-55 CHOL/HD-2.7 LDLcalc-80
DISCHARGE LABS:
==============
___ 07:10AM BLOOD WBC-10.0 RBC-3.85* Hgb-11.9* Hct-36.3*
MCV-94 MCH-30.9 MCHC-32.8 RDW-13.0 RDWSD-44.3 Plt ___
___ 07:10AM BLOOD Glucose-86 UreaN-12 Creat-0.8 Na-141
K-4.3 Cl-105 HCO3-25 AnGap-15
___ 07:10AM BLOOD Calcium-9.8 Phos-3.2 Mg-2.2
IMAGING and OTHER STUDIES:
=========================
___ EKG: Probable complete heart block. Inferior wall
myocardial infarction with possible posterior involvement,
probably recent/acute. Lateral downsloping ST segments also
suggest myocardial ischemia. Compared to tracing #4 complete
heart block is probably present.
___ ECHO:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Mild focal basal inferior
hypokinesis is suggested. Overall left ventricular systolic
function is preserved (LVEF>55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
no clear change
___ Cardiac Catheterization
AO 109/60
Coronary Anatomy: Left Main with 20% stenosis, LAD with 70%
proximal, LCx with 60-70% mid, RCA occluded proximally with
thrombus
RCA occluded treated with 1 ___ stenosis treated with 1 DES
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Lisinopril 2.5 mg PO QHS
RX *lisinopril 2.5 mg 1 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*0
3. Rosuvastatin Calcium 20 mg PO QPM
RX *rosuvastatin [Crestor] 20 mg 1 tablet(s) by mouth at bedtime
Disp #*60 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually as needed if
chest pain Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-Acute Myocardial Infarction (NSTEMI) s/p 2 DES to RCA/PDA
-Hypertension
Secondary Diagnosis:
-Hyperlipidemia
-Asymptomatic Leukocytosis
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 EKG changes
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Lightheaded, Abnormal EKG
Diagnosed with Abnormal electrocardiogram [ECG] [EKG], Dizziness and giddiness
temperature: 98.2
heartrate: 108.0
resprate: 16.0
o2sat: 99.0
sbp: 134.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | ASSESSMENT AND PLAN:
Patient is a ___ with PMHx of HTN and HLD who presents with
nausea, L arm pain, and EKG changes found to have an NSTEMI,
concern for inferior wall ischemia with EKG changes c/b
bradycardia and 3rd degree block.
# CORONARIES: RCa disease now s/p x2 DES ___ RCa and PDA)
# PUMP: EF of 55%
# RHYTHM: Sinus but CHB with junctional escape, post perfusion
sinus rhythm with 1st degree AV block
#THIRD DEGREE HB/BRADYCARDIA: In the ED, his initial EKG showed
complete heart block with triggered fascicular idioventricular
rhythm versus a relatively rapid His-fascicular escape in the
___. At the time he was placed on beta-blocker per ACS protocol
and junctional rhythm slowed to the ___. He went to the cath
lab, and underwent junctional rate improved to the ___ after
thrombectomy and stenting of RCA. His heart block was thus most
likely ___ AV nodal infarct in setting of RCA occlusion. EP was
consulted and no temporary pacing wire was placed with the
expectation that block would likely resolve w/reperfusion of the
AV node. Beta blockers were held, would likely benefit beta
blocker initiation as an outpatient. Patient was also asked to
follow up with outpatient Holter monitoring with Cardiology
followup. Patient was asymptomatic on discharge, ambulating
comfortably in sinus rhythm with first degree AV block and HRs
of 65-80.
# NSTEMI: On presentation had ST depressions in V2-V6 with
Trop-T 2.84. Atypical symptoms of nausea, L arm pain had
resolved prior to arrival in our ED. He was taken to the cath
lab where he was found to have RCA completely occluded. He
underwent thrombectomy and DES to ___ RCa and PDA. He
underwent Plavix and integrillin loading in ___ cath lab and was
continued on Plavix. He was started on statin, ASA, ACE. As
above metoprolol was held. Troponins were trended to peak.
# HTN: Patient switched from amlodipine to lisinopril 2.5 mg
daily.
# HLD: Rosuvastatin 20 mg daily continued
#Leukocytosis: WBC overall down from admission (15.2->10) with
no signs of infection. This was likely due to stress reaction
from NSTEMI, and resolved during the course of hospitalization. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Atenolol / Lisinopril
Attending: ___.
Chief Complaint:
headache, high blood pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with past medical
history most notable for hyponatremia and resistant hypertension
who presents with headache and hypertension noted in clinic. His
other medical issues are notable for GERD, obstructive sleep
apnea on CPAP, and type II diabetes.
The patient's hyponatremia dates back to at least ___. He
has been as low as 116. Initially this was attributed to
diuretic-induced hyponatremia in the setting of HCTZ (___),
which initially improved with discontinuation of HCTZ and fluid
repletion. He has had multiple subsequent admissions (once in
___ where hyponatremia was thought related to polydipsia
with low solute intake; in ___ hyponatremia suspected related
to be SIADH; and then most recently in ___, etiology of
hyponatremia was unclear and urine studies not consistent with
SIADH, however, Na improved with fluid restriction).
Review of recent work up reveals TSH 1.1 ___, AM cortisol
14.1 ___ but 2.1 in ___. Most recent set of urine lytes
from ___ with Na 34 and Uosm 395. It appears that the patient
has been instructed to adhere to fluid restriction of 1.5L. He
has been evaluated by renal, who thought that diuretic holiday
would be the ultimate way to make the diagnosis, but that in the
setting of hypertension, this is not advocated.
With regard to patient's hypertension: this is again
longstanding, with extensive workup in past not revealing for
clear secondary cause of hypertension. Specifically, RAS,
pheochromocytoma and hyperaldosteronism were ruled out.
There have been multiple recent medication changes. Most
recently, his eplerenone was increased from 25 to 50 mg
(___), and he was started on indapamide 1.25 mg
(___). He notes that he started taking indapamide on
___ (which was a switch from torsemide) and started
experiencing dizziness upon changing positions. After 3 days of
the new medication, he decided to switch back to torsemide.
He notes that his BPs have been fluctuating recently, often with
SBP 140 when he goes to bed, then 150s when he wakes up.
However, on ___, he noticed that his BP was elevated to
197/88. In this setting, he developed gradual worsening
posterior headache, which he described as constant, ___, not
associated with nausea, vomiting, or sensitivity to light/sound.
He rested a bit, laid down in a dark area, and BP improved to
175/75, with slight improvement of headache. He took Tylenol
___ mg, which helped his headache as well. No weakness,
numbness, tingling present.
He subsequently presented to ___ clinic. In clinic, SBP noted to
be 160-180, with nonfocal neurological exam. He was subsequently
referred to ED for further management and workup of his
hypertension and headache.
Past Medical History:
- Hypertension
- Chronic Hyponatremia
- Alcohol use disorder (in remission for ___ years)
- Prostate cancer s/p XRT in ___
- GERD
- Achalasia
- Erectile dysfunction
- Obstructive sleep apnea on CPAP
- Type II diabetes mellitus
Social History:
___
Family History:
States his mother had hypertension and some type of cardiac
disease, unknown. Denies any family history of diabetes mellitus
or cancer.
Physical Exam:
ADMISSION EXAM:
ED vitals: Temp 98.1, HR 82, BP 216/88, RR 22, 100% 4L NC
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
24 HR Data (last updated ___ @ ___
Temp: 97.4 (Tm 98.0), BP: 180/70 (138-183/58-77), HR: 64
(50-73), RR: 18, O2 sat: 100% (97-100), O2 delivery: RA, Wt:
168.65 lb/76.5 kg
GENERAL: Lying comfortably in bed, easily arousable
HEENT: No scleral icterus or conjunctival pallor. MMM.
Oropharynx clear.
NECK: Supple, no LAD, no elevated JVP.
CV: Normal S1 S2. No additional heart sounds. Faint holosystolic
murmur, grade I/VI heard best in the RUSB.
PULM: CTAB. No wheezes, rales, rhonchi.
GI: Soft, NT, ND. No rebound tenderness or guarding. No
abdominal bruits.
EXTREMITIES: No cyanosis, clubbing, or edema. Warm, well
perfused.
PULSES: 2+ radial pulses bilaterally.
NEURO: Cranial nerves II-XII intact. Moving all extremities with
purpose.
Pertinent Results:
ADMISSION LABS:
___ 05:55PM BLOOD WBC-5.8 RBC-4.66 Hgb-14.0 Hct-39.2*
MCV-84 MCH-30.0 MCHC-35.7 RDW-12.4 RDWSD-37.7 Plt ___
___ 05:55PM BLOOD Neuts-72.0* ___ Monos-7.6
Eos-0.7* Baso-0.3 Im ___ AbsNeut-4.15 AbsLymp-1.11*
AbsMono-0.44 AbsEos-0.04 AbsBaso-0.02
___ 05:55PM BLOOD Glucose-172* UreaN-13 Creat-1.0 Na-123*
K-4.1 Cl-81* HCO3-28 AnGap-14
___ 11:26PM BLOOD Osmolal-258*
___ 01:51AM URINE Osmolal-309
___ 01:51AM URINE Hours-RANDOM UreaN-411 Creat-74 Na-48
PERTINENT REPORTS:
Barium swallow ___:
There is a short segment of mild smooth narrowing noted in the
distal esophagus near the GE junction. At this region, there
was holdup of the 13 mm barium tablet the was administered.
Patient was observed for greater than 10 minutes; however, the
tablet did not pass. Thyroid is delayed esophageal transit with
tertiary contractions noted, consistent with mild esophageal
dysmotility. There is no esophageal dilation or mass and the
mucosa appeared normal. There is no inducible gastroesophageal
reflux or hiatal hernia. No overt abnormality in the stomach or
duodenum on limited evaluation. There is no obstruction a the
gastroduodenal junction.
DISCHARGE LABS:
___ 12:56PM URINE Hours-RANDOM Na-<20
___ 06:50AM BLOOD WBC-3.4* RBC-3.52* Hgb-10.9* Hct-30.7*
MCV-87 MCH-31.0 MCHC-35.5 RDW-13.1 RDWSD-41.4 Plt ___
___ 06:50AM BLOOD Glucose-131* UreaN-32* Creat-1.2 Na-131*
K-5.4 Cl-90* HCO3-27 AnGap-14
___ 06:50AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ y/o M with a history of resistant HTN, T2DM, OSA on
CPAP,chronic hyponatremia, who presented with 2 days of headaches and elevated
blood pressure, found to have worsening hyponatremia, admitted for further
workup. Patient reports difficulty swallowing pills over the last several
weeks. Known esophagitis and lower esophageal stricture in the past.// Please
evaluate for swallowing defect
TECHNIQUE: Double contrast barium esophagram.
DOSE: Acc air kerma: 49 mGy; Accum DAP: 1048.9 uGym2; Fluoro time: 2 minutes
and 28 seconds
COMPARISON: Multiple prior esophagram scan most recent dated ___.
FINDINGS:
There is a short segment of mild smooth narrowing noted in the distal
esophagus near the GE junction. At this region, there was holdup of the 13 mm
barium tablet the was administered. Patient was observed for greater than 10
minutes; however, the tablet did not pass. Thyroid is delayed esophageal
transit with tertiary contractions noted, consistent with mild esophageal
dysmotility. There is no esophageal dilation or mass and the mucosa appeared
normal. There is no inducible gastroesophageal reflux or hiatal hernia. No
overt abnormality in the stomach or duodenum on limited evaluation. There is
no obstruction a the gastroduodenal junction.
IMPRESSION:
1. Mild smooth narrowing in the distal esophagus near the gastroesophageal
junction. There was hold up of the 13 mm barium tablet there for greater than
10 minutes.
2. Mild esophageal dysmotility.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Headache
Diagnosed with Hypertensive urgency
temperature: 98.1
heartrate: 82.0
resprate: 22.0
o2sat: 100.0
sbp: 216.0
dbp: 88.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ is a ___ year old male with a history of resistant
hypertension, type II diabetes mellitus, obstructive sleep apnea
on continuous positive airway pressure, and chronic hyponatremia
who presented with two days of headache and elevated blood
pressure and found to have worsening hyponatremia, admitted for
further workup. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Trazodone
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: ___ percutaneous cholecystostomy drainage
History of Present Illness:
___ with recent history of ERCP for gallstone pancreatitis who
now presents with recurrent RUQ pain/vomiting. She underwent
ERCP/Sphincterotomy on ___. She was followed by the ACS
service but did not wish surgery at that time; a follow up
appointment was scheduled for ___, and she was discharged to
rehabilitation at ___. Her hospital course was also
notable for some
fluid retention that resulted in persistent hypoxia that was
treated with diuresis with furosemide and her inhaled COPD
medications. Today she presents from rehab after developing RUQ
pain and emesis, reportedly bilious, since last evening. She
has reportedly vomited ___ times. No recorded fevers.
Past Medical History:
HTN
Arthritis
Glaucoma,
Extirpated L orbit with prosthesis and
L ptosis, dysarthria without diagnosed cause, COPD,
schizoaffective, HL
Social History:
___
Family History:
T2DM
Physical Exam:
Discharge Physical Exam:
VS: 98.4, 76, 99/42, 18, 94%2Lnc,
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+/-) BS x 4 quadrants, soft, mildly tender to
palpation over PCT drain site, non-distended. Drain site: clean,
dry and intact, draining amber bile.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema.
Pertinent Results:
___ 12:05PM PLT COUNT-287#
___ 12:05PM NEUTS-84.8* LYMPHS-10.7* MONOS-3.0 EOS-1.4
BASOS-0.2
___ 12:05PM WBC-11.4*# RBC-4.31 HGB-13.5 HCT-41.6 MCV-97
MCH-31.4 MCHC-32.5 RDW-13.9
___ 12:05PM ALBUMIN-4.0
___ 12:05PM LIPASE-46
___ 12:05PM ALT(SGPT)-14 AST(SGOT)-20 ALK PHOS-173* TOT
BILI-0.4
___ 12:05PM estGFR-Using this
___ 12:05PM GLUCOSE-103* UREA N-13 CREAT-1.0 SODIUM-137
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-31 ANION GAP-14
___ 12:24PM LACTATE-1.1
___ 12:24PM ___ COMMENTS-GREEN TOP
___:
US:
1. Cholelithiasis without evidence of cholecystitis.
2. No intrahepatic biliary duct dilatation. The common duct is
dilated
measuring 1 cm. This is a stable finding relative to prior
ultrasound dated ___. Correlation with lab values,
however, is advised for possible cholangitis.
___:
CT:
1. Distended gallbladder with a large gallstone and
pericholecystic fluid concerning for acute cholecystitis.
2. Resolving pancreatitis with improvement in pancreatic edema,
peripancreatic stranding and resolution of intra-abdominal
fluid.
3. Diverticulosis without diverticulitis.
Medications on Admission:
albuterol, aripiprazole 10', benzonatate 200''', diclofenac
topical gel, fluoxetine 20', fluticasone spray, furosemide 20',
gabapentin 300'', vicodin, hydrocortisone cream, lisinopril 40',
methazolamide 25'', omeprazole 20', pilocarpine eye drops,
simvastatin 40', timolol eye drops, tiotropium, docusate 100',
salmeterol
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/sob
3. ARIPiprazole 10 mg PO DAILY
4. Benzonatate 200 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. Fluoxetine 20 mg PO DAILY
7. Gabapentin 300 mg PO BID
8. Heparin 5000 UNIT SC TID
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
10. Pantoprazole 40 mg PO Q24H
11. Pilocarpine 4% 1 DROP RIGHT EYE QID
12. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
13. Simvastatin 40 mg PO QPM
14. Timolol Maleate 0.5% 1 DROP RIGHT EYE BID
15. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
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: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ female with right upper quadrant pain.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound dated ___ as well as CT 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. As demonstrated on
prior ultrasound dated ___, the common bile duct remains prominent
measuring 1.0 cm.
GALLBLADDER: A large stone within the gallbladder lumen is present which
measures 4 cm in size with echogenic debris within the gallbladder lumen
consistent with sludge. There is no gallbladder wall thickening or edema
suggestive of acute cholecystitis.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: The spleen is poorly visualized secondary to overlying bowel gas and
poor penetration.
KIDNEYS: Limited views of the right kidney demonstrate no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. No intrahepatic biliary duct dilatation. The common duct is dilated
measuring 1 cm. This is a stable finding relative to prior ultrasound dated
___. Correlation with lab values, however, is advised for possible
cholangitis.
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Schizoaffective disorder and recent history of gallstone
pancreatitis status post ERCP presenting with right upper quadrant pain and
bilious emesis.
TECHNIQUE: Chest, AP upright and lateral.
COMPARISON: Chest radiographs from ___.
FINDINGS:
The cardiac, mediastinal and hilar contours appear unchanged. There is mild
perihilar pulmonary edema. Opacity at the left lung base, which was
pre-existing, has increased with volume loss suggesting waxing and waning
atelectasis. There is no pleural effusion or pneumothorax.
IMPRESSION:
Findings suggesting mild pulmonary edema, which has increased. Increased
opacity at left base, probably atelectasis although not specific.
Radiology Report
INDICATION: +PO contrast; History: ___ with hx gallstone pancreatitis p/w abd
pain and vomiting+PO contrast // eval for gallstone pancreatitis,
obstruction, gallstone ileus
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: 824.3 mGy-cm (abdomen and pelvis.
IV Contrast: 130 mL Omnipaque
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST:
There is bibasilar atelectasis. The visualized heart and pericardium are
unremarkable.
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 main portal vein is patent. The
gallbladder is distended containing a 3.2 x 2.4 cm calcified gallstone. There
is a small amount of pericholecystic fluid and perhaps mild wall edema.
PANCREAS: The pancreas appears less edematous than on previous exams and
peripancreatic stranding has improved compatible with resolving pancreatitis.
A small residual component is seen inferior to the pancreatic tail.
Intra-abdominal free fluid has resolved since the prior study.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. A rounded 6 mm calcification in the region of the
splenic hilum may represent a small calcified splenic artery aneurysm.
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 or hydronephrosis. A tiny hypodensity within
the interpolar region of the left kidney is too small to characterize. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: There is a small axial hiatal hernia. Small bowel loops
demonstrate normal caliber, wall thickness and enhancement throughout. Colon
and rectum are within normal limits except for diverticulosis throughout the
colon without diverticulitis. Appendix contains air, has normal caliber
without evidence of fat stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and adnexae are unremarkable.
BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Again seen
are old fractures of the left superior and inferior pubic rami. Multilevel
degenerate changes are present within the thoracolumbar spine.
IMPRESSION:
1. Distended gallbladder with a large gallstone and pericholecystic fluid
concerning for acute cholecystitis.
2. Resolving pancreatitis with improvement in pancreatic edema,
peripancreatic stranding and resolution of intra-abdominal fluid.
3. Diverticulosis without diverticulitis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
___ at 9:22 ___, 10 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with schozoaffective disorder and recent history of gallstone
panc s/p ERCP/SPhincterotomy presenting from rehab with RUQ pain and bilious
emesis // s/p emesis ? aspiration
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___ obtained at 20:32
IMPRESSION:
Cardiomediastinal silhouette is stable. Interval increase in vascular
congestion is demonstrated. Left hilar enlargement is noted and should be
further assessed to exclude the possibility of a left hilar lesion. Bibasal
opacities have progressed and might be potentially concerning for aspiration.
Radiology Report
EXAMINATION: Percutaneous cholecystostomy tube placement under ultrasound
guidance.
INDICATION: ___ year old woman with cholecystitis, not operative candidate //
Needs percutaneous cholecystostomy tube
COMPARISON: CT abdomen pelvis dating ___
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine/left decubitus 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 ___ Exodus drainage catheter
was advanced via trocar technique into the gallbladder. A sample of fluid was
aspirated, confirming catheter position within the collection. The plastic
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 45 cc of cloudy bile 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: Patient received 25 mcg fentanyl and 4 mg Zofran throughout the
total intra-service time of 30 minutes during which patient's hemodynamic
parameters were continuously monitored by an independent trained radiology
nurse.
FINDINGS:
The gallbladder was the a moderately distended with wall thickening and edema.
There is cholelithiasis. Findings are compatible with acute cholecystitis.
IMPRESSION:
Successful ultrasound-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with history of pulmonary edema, now with cough
// please evaluate for interval change. please obtain ___ am.
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Bibasal opacities are present, concerning for infectious process. Slight
interval decrease in the hilar size bilaterally might be consistent with
improvement of vascular enlargement. No overt pulmonary edema is seen. No
pneumothorax is demonstrated. Small pleural effusion is most likely present.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Abd pain
Diagnosed with CHOLELITHIASIS NOS
temperature: 98.7
heartrate: 98.0
resprate: 18.0
o2sat: 97.0
sbp: 122.0
dbp: 78.0
level of pain: 9
level of acuity: 2.0 | The patient presented to ___ Emergency Department on ___.
Pt was evaluated by
the acute care surgery team. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Pharmacologic stress test
Cardiac Catheterization
History of Present Illness:
___ w/ cough x1 month, dyspnea at rest, worse on exertion for
several days. Cough productive of yellow sputum. No fevers or
chills. No chest pain, tightness, or discomfort. Dyspnea seems
positional, worse when lying down.
.
He was seen by his primrary care doctor on ___, and was
thought at the time to have bronchitis, and given duration, was
treated with a Z-Pak.
.
In the ED, an EKG showed sinus tach at 116, normal intervals,
normal axis, possible old anterior infarct, inferior nonspecific
ST changes, no priors. A bedside ECHO showed no effusion, but
LVEF was commented that it might be slightly slow. CTA showed no
dissection, no PE to the subsegmental levels, moderate sized
bilateral pleural effusions with central pulmonary vascular
congestion and mild interstitial edema, as well as mild
cardiomegaly with top normal size of the left ventricle. CXR was
read as moderate cardiomegaly, mild-to-moderate pulmonary edema,
focal infrahilar opacity.
.
In the ED, initial VS: 96.1 ___ 22 97%
.
Labs were notable for a D-Dimer 680*, CO2 21, BUN 25, BNP 1701*.
.
He was given 40 mg IV Lasix in the ED, to which he put out 1680
cc. He was, however, given 1 L NS for taachycardia.
.
Prior labs are ntoable for an A1c of 10.6 ___, trending down
to 6.1 ___. Most recent lipid panel is Chol 276, HDL 43,
LDL 201 ___.
.
Currently, he says that he has had high intake of salty foods
over ___, and had ___ food yesterday evening for
dinner, and this AM as well. He has had night swats fo rthe past
few days which cause him to soak his shirt. His shortness of
breath has come on gradually over the past ___ days. It is made
worse with exertion, and he can only climb 1.5 gliths of stairs.
Laying down makes it worse, and he has awoken from his sleep and
needed tos it up to catch his breath. He denies using any extra
pillows. He has also been having congestion. he ___ any new
weight loss or gain. His cough has been prsent for about a
month, and occasionally is productive with yellow/green sputum.
he has some lower abodminal pain which he attributes to
constipation. He had an episode of vomiting 3 days ago, but has
sbuseqnetly resovled. he is constipation.
.
REVIEW OF SYSTEMS:
Denies fever, chills, headache, vision changes, rhinorrhea, sore
throat, chest pain, diarrhea, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
DIABETES TYPE II
HYPERLIPIDEMIA
HYPERTENSION
MIGRAINE HEADACHES
SLEEP APNEA
STRESS
Social History:
___
Family History:
No family history of early CAD. Mother with hypertension,
grandmother with CHF, heart disease, and breast cancer; died in
___. The patient has not been in contact with his
father in ___ years.
Physical Exam:
On Admission:
VS - 99 BP 133/90 HR 115 RR 24 98% RA
GENERAL - well-appearing in NAD, anxious
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK - supple, difficult to appreciate JVD ___ habitus,
acanthosis nigricans
LUNGS - Crackles at the bilateral bases
HEART - Tachycardic, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
NEURO - awake, A&Ox3
Prior to discharge:
Physical Exam:
Vitals: ___ (max 98.4F), 90-94, 95-104/51-63, ___, 100% RA
Weight 105.2KG, I/O net out 1 liter over 24 hours yesterday
HEENT: NCAT, MMM, anicteric sclerae
NECK: JVP not appreciable
CV: RRR, no murmurs or rubs
Lungs: CTAB, no wheezes rales or rhonchi
Abdomen: soft, NTTP, ND, no masses, no rebound or guarding,
sounds present throughout
Extremities: warm, well perfused, pulses 2+ b/l
Pertinent Results:
On admission:
==============
___ 06:50PM BLOOD WBC-10.7 RBC-5.04 Hgb-14.5 Hct-43.1
MCV-86 MCH-28.8 MCHC-33.7 RDW-13.7 Plt ___
___ 06:50PM BLOOD Neuts-76.3* ___ Monos-2.9 Eos-0.9
Baso-0.3
___ 06:50PM BLOOD Glucose-126* UreaN-25* Creat-0.8 Na-138
K-3.9 Cl-105 HCO3-21* AnGap-16
___ 11:50PM BLOOD ALT-108* AST-63* CK(CPK)-97 AlkPhos-46
TotBili-0.7
___ 06:50PM BLOOD CK-MB-2 proBNP-1701*
___ 06:50PM BLOOD cTropnT-<0.01
___ 06:50AM BLOOD Albumin-4.0 Calcium-9.5 Phos-3.5 Mg-2.1
___ 11:50PM BLOOD Iron-44*
___ 06:50PM BLOOD D-Dimer-680*
___ 11:50PM BLOOD calTIBC-378 Ferritn-288 TRF-291
___ 11:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:50PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
___ 11:50PM BLOOD HIV Ab-NEGATIVE
.
Cardiac Persantine Perfusion Test
RADIOPHARMACEUTICAL DATA:
11.0 mCi Tc-99m Sestamibi Rest ___
30.5 mCi Tc-99m Sestamibi Stress ___
HISTORY: ___ year old male with history of DM, HTN, HLD, who
presents with
new-onset cardiomyopathy with EF 15%
SUMMARY FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
mg/kg/min.
No symptoms or significant ECG changes during dipyridamole
infusion or
recovery.
IMAGING METHOD:
Resting perfusion images were obtained with Tc-99m sestamibi.
Tracer was
injected approximately 45 minutes prior to obtaining the resting
images.
Following resting images and two minutes following intravenous
dipyridamole,
approximately three times the resting dose of Tc-99m sestamibi
was administered
intravenously. Stress images were obtained approximately 30
minutes following
tracer injection.
Imaging protocol: Gated SPECT.
INTERPRETATION:
The image quality is limited by soft tissue attenuation.
Left ventricular cavity size is 299 ml.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal severe global hypokinesis.
The calculated left ventricular ejection fraction is 16%.
IMPRESSION: 1. No focal myocardial perfusion abnormality. 2.
LVEF of 16% with a
markedly dilated left ventricle.
.
Stress test:
EKG: NORMAL SINUS RHYTHM, LVH, ISOLATED VPB
HEART RATE: 110 BLOOD PRESSURE: 110/80
PROTOCOL /
STAGE TIME SPEED ELEVATION WATTS HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
___/ KG/MIN ___ ___
TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 58
SYMPTOMS: NONE
ST DEPRESSION: NONE
INTERPRETATION: This is a ___ year old male with history of DM,
HTN,
HLD, who presents with new-onset cardiomyopathy with EF 15%. He
was
infused with 0.142mg/kg/min of dipyridamole over 4 minutes. He
had no
chest, arm, or back discomfort for the duration of the study.
The ECG
was normal sinus rhythm with LVH and isolated APBs. There was a
6 beat
run of PSVT during early recovery. There were no ST segment
changes.
Hemodynamic response during infusion and recovery was
apporpriate.
IMPRESSION: No symptoms or significant ECG changes during
dipyridamole
infusion or recovery. Nuclear report sent seperately.
SIGNED: ___.
.
TTE: Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. The left ventricular cavity is severely
dilated. Overall left ventricular systolic function is severely
depressed with akinesis/scarring of the anteroseptum and diffuse
hypokinesis of all other segments (LVEF= 15 %). A left
ventricular mass/thrombus cannot be excluded. The right
ventricular cavity is dilated 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. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild to moderate (___) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. The end-diastolic pulmonic regurgitation velocity
is increased suggesting pulmonary artery diastolic hypertension.
There is no pericardial effusion.
IMPRESSION: Severely dilated left ventricle with severely
depressed global left ventricular systolic function.
Akinesis/scarring of the anteroseptal segments and diffuse
hypokinesis of all other left ventricular walls. Mild to
moderate mitral regurgitation. Mild pulmonary artery systolic
and diastolic hypertension.
.
Repeat TTE:
There is severe global left ventricular hypokinesis. No masses
or thrombi are seen in the left ventricle. There is no
pericardial effusion
.
EKG: Sinus tachycardia. Prominent voltage of unknown
significance. Q wave in
leads V1-V2 which could be due to lead placement. However,
cannot exclude an
old anterior wall myocardial infarction. However, with the
patient's age,
clinical correlation is highly suggested. No previous tracing
available for
comparison.
Read by: ___.
EKG Intervals Axes
Rate PR QRS QT/QTc P QRS T
116 176 86 ___ 14 -5 -4
.
Cardiac CAth
FINAL DIAGNOSIS:
1. No angiographically-apparent flow-limiting CAD.
2. Severe left ventricular diastolic heart failure.
3. Mild-moderate pulmonary arterial hypertension.
4. Low normal systemic arterial pressure exacerbated by a
vasovagal
response. Femoral arterial and venous access with ultrasound
guidance,
but low threshold for imaging to exclude RP bleeding if SBP does
not
improve overnight.
5. Reinforce secondary preventative measures against systolic
and
diastolic heart failure and primary preventative measures
against CAD.
.
.
On Discharge:
___ 03:08AM BLOOD WBC-10.0 RBC-5.09 Hgb-14.7 Hct-44.3
MCV-87 MCH-28.8 MCHC-33.1 RDW-13.9 Plt ___
___ 03:08AM BLOOD ___ PTT-67.4* ___
___ 06:15PM BLOOD Glucose-245* UreaN-21* Creat-1.1 Na-140
K-4.2 Cl-104 HCO3-25 AnGap-15
___ 03:08AM BLOOD ALT-95* AST-41* LD(LDH)-181 AlkPhos-39*
TotBili-1.2
___ 06:15PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
___ 06:50AM BLOOD CK-MB-2 cTropnT-<0.01
Medications on Admission:
Lisinopril 10 mg Daily
lorazepam 0.5 mg BID-TID prn anxiety
metformin 500 mg Tablet Extended Release Daily
venlafaxine 150 mg ER Daily
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID-TID as
needed for anxiety.
2. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
3. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
Disp:*7 7* Refills:*0*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
New severe systolic congestive heart failure
Secondary:
Hypertension
Diabetes Mellitus Type 2
Hyperlipidemia
Obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Tachycardia, cough and dyspnea on exertion.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: There is a substantial moderate cardiomegaly with a globular
configuration, which appears increased since the prior examination.
Indistinct prominent perihilar opacities suggest mild-to-moderate pulmonary
edema. There is no definite pleural effusion or pneumothorax. In addition to
other opacities, there is an infrahilar opacity on the lateral view that
appears more prominent and may correspond to obscuring of the right
cardiophrenic sulcus on this examination. Incidental note is again made of an
azygos fissure, which is consistent with a normal variant. The osseous
structures are unremarkable.
IMPRESSION:
1. Moderate cardiomegaly including substantial increase. Clinical
correlation is suggested. True cardiac enlargement is a consideration, but
the possibility of a pericardial effusion could also be considered clinically.
2. Mild-to-moderate pulmonary edema.
3. Focal infrahilar opacity, of uncertain significance. It may reflect focal
edema, but a separate process such as developing focal opacity such as
pneumonia or atelectasis is an additional consideration. Short-term follow-up
radiographs are suggested to evaluate further.
Radiology Report
INDICATION: ___ male with dyspnea.
No comparison studies available.
TECHNIQUE: MDCT-acquired 1.25-mm axial images of the chest were obtained
following the uneventful administration of contrast. Coronal and sagittal
reformations were performed at 5-mm slice thickness. Additional right and
left oblique reconstructions were obtained for further evaluation of the
pulmonary vasculature.
FINDINGS: The heart is mildly enlarged. The left ventricle in particular
appears dilated. No pericardial effusion is present. The main pulmonary
arteries are patent and normal in caliber. No pulmonary embolus is detected
to the subsegmental levels. Thoracic aorta is normal in caliber and patent,
with no evidence of dissection.
Moderate-sized pleural effusions are present, greater on the right, with
tracking along the major and minor fissues, as well as an azygos fissure
(2:23). The central pulmonary vessels are engorged, particularly at the
bases, and surrounded by patchy ground-glass opacity, most compatible with
interstitial edema. Mild bronchial thickening is present within central
regions (2:64).
There is no axillary or mediastinal lymphadenopathy. Included views of the
thyroid are normal.
OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or
lytic lesions are identified.
IMPRESSION:
1. Moderate-sized right greater than left pleural effusions, with central
pulmonary vascular congestion and mild interstitial edema, and mild
cardiomegaly with left ventricular prominence, concerning for cardiac
decompensation.
2. No aortic dissection. No pulmonary embolus detected to the subsegmental
levels.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: SOB
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 96.1
heartrate: 120.0
resprate: 22.0
o2sat: 97.0
sbp: 149.0
dbp: 101.0
level of pain: 0
level of acuity: 2.0 | Primary Reason for Hospitalization:
===================================
Mr. ___ is a ___ with no known cardiac history but many CAD
risk factors including T2DM, HTN, HLD, Obesity, smoking, who
presented with 1 month of progressive dyspnea, orthopnea due to
new onset CHF.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y.o. female referred to ___ ED after
a brain MRI today showed a new left frontal brain mass. The
patient had reported a seizure 2 nights ago which was witnessed
by her young daughter. It was described with + LOC and all
extremities were shaking. Unclear length of time. Patient had
no memory of event (Postictal) and afterwards she was found with
a chipped tooth, laceration of her tongue and urinary
incontinence. She denies any other episodes since then. She saw
her PCP and an MRI was obtained today was showing a brain
lesion
and was subsequently referred to us for further management.
She has had no prior history of seizures, recent infections,
fevers. She denies any headache blurry vision numbness or
weakness in arms or legs speech or swallowing difficulties. She
denies gait ataxia. She does note intermittent nausea for the
past several days. All other systems are essentially negative
or
non-contributory.
Past Medical History:
Depression
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
O: T: 98.3 68 125/72 20 100
Gen: WD/WN, comfortable, NAD, mildy anxious and tearry eyed
HEENT: normocephalic, eyes: clear Pupils: PERRL EOMs - full
Neck: Supple, trachea midline
Lungs: resonant to percussion
Cardiac: RRR. S1/S2.
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
No clonus, No ___
Handedness Left
ON DISCHARGE:
alert and oriented x 3
PERRL
Face symmetric
No pronator drift
MAE ___ strength
sensation grossly intact
Pertinent Results:
___ CTA head
1. This report is generated without 3D reformats. If additional
information is
obtained, an addendum to this report will be issued.
2. Hemorrhage and developmental venous anomaly in the left
frontal region
without an identifiable nidus, most consistent with underlying
cavernous
malformation or less likely AVM. If clinically indicated, this
could be
confirmed with conventional angiogram.
3. Otherwise, no acute findings.
___ CT Torso with contrast
negative for malignancy, final read pending at time of discharge
___ CT abdomen/pelvis
No findings to suggest malignancy in the abdomen or pelvis.
Medications on Admission:
Sertraline 150mg daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN headache
2. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Sertraline 150 mg PO DAILY AM
Discharge Disposition:
Home
Discharge Diagnosis:
Left frontal brain lesion
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 AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ year old woman with left frontal mass // rule out primary
lesions
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis before
and following intravenous administration of 130cc of Omnipaque. Coronal and
sagittal reformations were performed. Oral contrast was administered.
DOSE: DLP: 895 mGy-cm.
COMPARISON: None.
FINDINGS:
ABDOMEN:
Lung Bases: The chest portion of this report will be dictated separately.
Hepatobiliary: The liver demonstrates homoenous 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,
without stones or gallbladder wall thickening.
Pancreas: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation.
Spleen: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
Adrenals: The adrenals glands are unremarkable bilaterally.
Kidneys: There is a sub 5 mm hypodensity in the right lower pole which is too
small to characterize but likely represents a cyst. The kidneys are otherwise
normal in appearance.
Bowel: The bowel loops and mesentery are normal in appearance. There is no
evidence of obstruction of abnormal wall thickening.
Retroperitoneum: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
Vascular: The abdominal vasculature appears patent.
PELVIS:
The visualized pelvic organs are normal. There is no significant pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions.
IMPRESSION:
No findings to suggest malignancy in the abdomen or pelvis.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ year old woman with left frontal mass unusual presentation on
MRI // eval for vascular anomaly
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed through the
brain during infusion of Omnipaque intravenous contrast material. Images were
processed on a separate workstation with display 3D volume redendered images,
and maximum intensity projection images.
DOSE: DLP: 1648.61 mGy-cm; CTDI: 128.44 mGy
COMPARISON: Comparison is made MR ___ from ___.
FINDINGS:
Head CT: There is hemorrhage and a developmental venous anomaly in the left
frontal region that drains into the deep venous system. A small amount of
edema is seen surrounding the lesion no large mass effect or midline shift is
seen. No nidus is identified and no enlarged draining vein is seen. Findings
are suggestive of a vascular anomaly, with underlying cavernous malformation
as the most likely etiology, and AVM being less likely given there is no
nidus. The ventricles and sulci are normal in caliber and configuration. No
fractures are identified.
Head an CTA: There is no evidence of aneurysm formation. There is patency of
the anterior and posterior circulation. No venous sinus thrombosis is seen.
IMPRESSION:
1. This report is generated without 3D reformats. If additional information is
obtained, an addendum to this report will be issued.
2. Hemorrhage and developmental venous anomaly in the left frontal region
without an identifiable nidus, most consistent with underlying cavernous
malformation or less likely AVM. If clinically indicated, this could be
confirmed with conventional angiogram.
3. Otherwise, no acute findings.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with frontal mass.
Assessment for the presence of primary lesion.
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen after administration of IV contrast. Axial images were reviewed in
conjunction with coronal and sagittal reformats.
FINDINGS:
Assessment of the mediastinum demonstrates normal aorta and pulmonary
arteries. Anterior triangular thymic tissue is present. Left axillary lymph
nodes are larger than right axillary lymph nodes and although
non-pathologically enlarged on both sides, are still prominent. Extensive
glandular tissue is noted in the breasts bilaterally with relative paucity of
the fat tissue. Imaged portion of the upper abdomen will be reviewed
separately as part of the CT abdomen and the corresponding report will be
issued.
Aorta and pulmonary arteries are unremarkable. Heart size is normal. There
is no pericardial or pleural effusion.
Airways are patent till the subsegmental level bilaterally.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
Lungs are clear. There is no evidence of interstitial lung abnormality.
IMPRESSION:
No evidence of intrathoracic malignancy demonstrated Of note are multiple
bilateral axillary lymph nodes, left more than right, nonspecific and
potentially may be reactive. Also extensive presence of glandular tissue
within the breast might be consistent with recent history of nursing or
pregnancy, please correlate clinically.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Seizure, NEW BRAIN MASS
Diagnosed with OTHER CONVULSIONS, SWELLING IN HEAD & NECK
temperature: 98.3
heartrate: 68.0
resprate: 20.0
o2sat: 100.0
sbp: 125.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Mrs. ___ was admitted to the Neurosurgery service for
further work-up of her left frontal lesion. The patient was
started on Keppra for seizure prophylaxis (and likely seizure at
home prior to her presentation). Frequent neurologic checks
were ordered. Further imaging was required to assess the
intracranial lesion further. A CTA of the head and CT of the
torso were ordered. CTA revealed Hemorrhage and developmental
venous anomaly in the left frontal region
without an identifiable nidus, most consistent with underlying
cavernous
malformation or less likely AVM. CT chest/abdomen/pelvis was
negative for malignancy
On ___ Patient did not have any seizures overnight. She
remained neurologically stable. Patient will be scheduled for
the OR with Dr. ___ week. She will be contacted with the
information once the OR has been booked. She was discharged home
in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Slurred speech
Major Surgical or Invasive Procedure:
Cerebral angiogram (___)
History of Present Illness:
Mr. ___ is an ___ yo M well known to the Neurosurgical
service s/p ___ Left CEA, s/p ___ wound exploration
hematoma evacuation. He presented today to ___ after episode of
dysarthria. Patient's daughter reports today at 12pm she was
driving the patient and noted slurred speech and L facial droop.
She reports "it lasted for longer than his other episodes" but
is
unable to say how long it last. She also reports a similar, but
shorter episode also happened on ___ but they did not seek
medical attention at that time. At ___ a CT head and CTA head
and
neck were done which were concerning for possible L carotid
dissection. He was given aspirin 325mg and started on a hep gtt
@
1400u/hr and transferred to ___ for Neurosurgical evaluation.
Past Medical History:
R ICA stenosis s/p CEA
History of TIA
History of CVA
Known L carotid stenosis
GI bleed
Hypertension
Social History:
___
Family History:
Non-contributory
Physical Exam:
===================================
ADMISSION PHYSICAL EXAM
===================================
O: T:98.0 BP: 137/84 HR:62 R 18 O2Sats 99%
Gen: WD/WN, comfortable, NAD. Elderly male lying on stretcher.
___ speaking only
HEENT: Pupils: PERRL EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: unable to assess secondary to language barrier
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
===================================
DISCHARGE PHYSICAL EXAM
===================================
SBP 130s-180s.
Orthostatics SBP 150s laying and 128 standing. After 1L IVF,
General and neurologic exam normal and non-focal.
Pertinent Results:
========
LABS
========
___ 07:00AM BLOOD ___ PTT-30.5 ___
___ 07:00AM BLOOD WBC-4.3 RBC-3.27* Hgb-8.6* Hct-28.0*
MCV-86 MCH-26.3 MCHC-30.7* RDW-15.6* RDWSD-49.0* Plt ___
___ 07:00AM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-142
K-3.7 Cl-109* HCO3-24 AnGap-13
___ 03:36PM BLOOD ALT-52* AST-44*
___ 07:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.0 Iron-PND
___ 06:38PM BLOOD cTropnT-<0.01
___ 12:43PM BLOOD cTropnT-<0.01
========
IMAGING
========
CEREBRAL ANGIOGRAM (___):
Left supraclinoid internal carotid artery occlusion. Filling of
the left
hemisphere via pial collaterals from the left anterior cerebral
artery.
MRI BRAIN WITHOUT CONTRAST (___):
1. There are few left periatrial and temporal lobe deep white
matter subacute infarcts.
2. There are stable chronic infarcts, and stable significantly
diminished left ICA, MCA flow voids, better evaluated on CTA
head and neck ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. Pantoprazole 40 mg PO Q24H
7. Clopidogrel 75 mg PO DAILY
8. dextran 70-hypromellose 0.1-0.3 % ophthalmic BID
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. dextran 70-hypromellose 0.1-0.3 % ophthalmic BID
7. Docusate Sodium 100 mg PO BID
8. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
TIA
Secondary diagnosis:
Left supraclinoid internal carotid artery occlusion. Filling of
the left hemisphere via pial collaterals from the left anterior
cerebral artery.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY ___ year old man with carotid dissection or occlusion.
EXAMINATION: Right common carotid artery angiogram of the right anterior
intracranial circulation.
Left common carotid artery angiogram of the left carotid bifurcation and left
anterior intracranial circulation.
Right common femoral artery angiogram.
ANESTHESIA: ANESTHESIA: Moderate sedation was provided by administrating
divided doses of 1 mcg of fentanyl and 30 mg of midazolam throughout the total
intra-service time of 30 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.
TECHNIQUE: OPERATORS: Dr. ___, Neurosurgery Vascular
Fellow and Dr. ___, attending physician performed the procedure. Dr.
___ personally supervised the trainee during the key components of
the procedure and has reviewed and agrees with the trainee's findings.
The patient was brought to the angio suite and positioned on the angio table.
Conscious sedation was administered. The patient was prepped and draped in
usual sterile fashion and a time-out was performed. The right common femoral
artery was localized using anatomic landmarks and a 6 ___ long sheath was
placed using Seldinger technique over ___ wire and micro puncture kit. A
___ 2 diagnostic catheter was used to select the right common carotid
artery. Aforementioned views were obtained. Next, the left common carotid
artery was selected. Aforementioned views were obtained. At the end of
procedure diagnostic catheter was removed and the arteriotomy site was closed
with Angio-Seal.
PROCEDURE: Two-vessel cerebral angiogram.
FINDINGS:
Right common carotid artery: The right carotid bifurcation shows some signs
of arteriosclerotic disease without significant stenosis. The right anterior
intracranial circulation is unremarkable. There is significant cross-filling
of the left hemisphere via pial collaterals from the left anterior cerebral
artery. There is no filling of the left middle cerebral artery.
Left common carotid artery: The carotid bifurcation on the left is free of
arteriosclerotic disease or stenosis. The left internal carotid artery shows
occlusion at the level of the supraclinoid internal carotid artery just past
the ophthalmic artery origin.
IMPRESSION:
Left supraclinoid internal carotid artery occlusion. Filling of the left
hemisphere via pial collaterals from the left anterior cerebral artery.
RECOMMENDATION(S): Medical management.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with L ICA occlusion, now with left sided
symptoms // new changes on MRI, ? TIA/stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON MRI brain ___
FINDINGS:
There are few non contiguous foci of mildly increased signal on diffusion
weighted images involving the left periatrial white matter, extending into the
deep white matter of the lateral left temporal lobe, with mildly decreased or
normalized ADC values, favoring subacute infarcts. There are no right-sided
acute or subacute infarcts. There is no evidence of hemorrhage, edema,
masses, mass effect, midline shift.
There Is generalized parenchymal atrophy. There is no hydrocephalus.
Partially empty sella is again seen. There are stable chronic infarcts
involving bilateral caudate nuclei, right putamen. There is chronic cortical
infarct involving right middle frontal gyrus, stable. Probable tiny chronic
cortical infarct involving medial right postcentral gyrus. Significantly
diminished flow void in the high left cervical ICA, extending to the ICA
terminus, similar. Diminutive caliber left MCA branches, similar. There is
preserved right ICA, vertebrobasilar and dural venous sinus flow voids. There
is mild mucosal thickening of the paranasal sinuses, similar. Mastoid air
cells and middle ear cavities are patent.
IMPRESSION:
1. There are few left periatrial and temporal lobe deep white matter subacute
infarcts.
2. There are stable chronic infarcts, and stable significantly diminished left
ICA, MCA flow voids, better evaluated on CTA head and neck ___. .
Gender: M
Race: ASIAN - CHINESE
Arrive by UNKNOWN
Chief complaint: Aphasia, Confusion
Diagnosed with Aphasia
temperature: 98.0
heartrate: 60.0
resprate: 14.0
o2sat: 99.0
sbp: 162.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ presented with transient right facial drop (upper motor
neuron pattern) and aphasia; symptoms resolved and MRI was
negative for new infarct. CTA and cerebral angiogram showed left
supraclinoid internal carotid artery occlusion (with filling of
the left hemisphere via pial collaterals from the left anterior
cerebral artery). Continued on aspirin, Plavix and Atorvastatin
for secondary stroke prevention. Counseled family on permissive
hypertension (goal SBP 110-140, may run up to 180) to prevent
stroke as pt is collateral dependent. Pt advised to maintain
adequate hydration and eat a normal amount of salt with his
diet.
Of note, on the day prior to discharge, pt was found to be
mildly orthostatic. He was asymptomatic with SBP 150s sitting to
130s standing. He was given IVF and then developed left armpit
pain and SBP 200s. This resolved. EKG and troponins x3 were
unremarkable. He was discharged home in stable condition (SBPs
130s-170s on day of discharge); physical therapy cleared pt for
home prior to discharge.
============================
TRANSITIONS OF CARE
============================
-Pt should have long term permissive hypertension (goal SBP
110-140, may run up to 180) to prevent stroke as pt is
collateral dependent. Pt advised to maintain adequate hydration
and eat a normal amount of salt with his diet.
-Iron studies pending at discharge for normocytic anemia. PCP to
___.
=
=
=
=
=
=
=
=
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
=
=
=
=
=
=
=
=
================================================================
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? () Yes (LDL = ) - (X) No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ s/p appendectomy ___ years ago in ___ presents with
L-sided ABD pain, nausea, and vomiting.
The patient woke up on ___ night with stomach pain, but then
was able to get back to sleep. This happened again on ___
night but worse pain. During the day on ___ her abdominal
pain got worse and it hurt to walk. It started as a band across
her upper abdomen and then moved towards the left side. She had
nausea and vomiting x2, worse after food. Tried omeprazole and
zantac which have not helped. Presented to urgent care and was
sent to the ED. Here she was discharged with ?gastritis. She
subsequently represented for evaluation for persistent symptoms.
Denies fever, chills, chest pain, SOB, cough.
In the ED, initial VS were 98.4 96 139/96 16 100% RA.
Exam notable for LUQ abdominal pain.
Labs were significant for a lipase of 61.
Imaging showed normal abd/pelvis CT with adrenal nodule.
Received:
PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
PO Donnatal 10 mL
PO Lidocaine Viscous 2% 10 mL
IVF NS 1 mL
PO/NG Sucralfate 1 gm
PO Omeprazole 20 mg
PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
PO Donnatal 10 mL
PO/NG Famotidine 40 mg
IV Morphine Sulfate 2 mg
IV Sodium Chloride 0.9% Flush 3 mL
IV Morphine Sulfate 2 mg
PO Ondansetron ODT 4 mg
PO/NG Sucralfate 1 gm
PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
PO Donnatal 10 mL
PO Lidocaine Viscous 2% 10 mL
PO Omeprazole 40 mg
PO/NG Famotidine 40 mg
IV Morphine Sulfate 2 mg
PO Ondansetron ODT 4 mg
IV Acetaminophen IV 1000 mg
Transfer VS were 100.2 135/74 132 18 99 RA
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports she is feeling much
better. She said she initially felt terrible and was vomiting in
the ED after morphine, but now no nausea and no ABD pain. LMP
___, but periods infrequent since starting current OCP in ___.
Past Medical History:
Appendectomy ___ years ago ___
Social History:
___
Family History:
Significant for IBS vs. colitis in maternal grandmother
Physical ___:
ADMISSION:
VS: 100.2 135/74 132 18 99 RA
GENERAL: NAD
HEENT: EOMI, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD,
HEART: Tachycardic, RR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild tenderness in the LUQ and LLQ
without rebound or guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
GENERAL: NAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild tenderness in the LUQ and LLQ
without rebound or guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION:
___ 07:55PM BLOOD WBC-6.9 RBC-4.72 Hgb-13.9 Hct-40.9 MCV-87
MCH-29.4 MCHC-34.0 RDW-12.1 RDWSD-38.4 Plt ___
___ 07:55PM BLOOD Neuts-67.0 ___ Monos-6.2 Eos-0.1*
Baso-0.1 Im ___ AbsNeut-4.61 AbsLymp-1.81 AbsMono-0.43
AbsEos-0.01* AbsBaso-0.01
___ 07:55PM BLOOD Glucose-84 UreaN-9 Creat-0.8 Na-139 K-4.2
Cl-101 HCO3-24 AnGap-18
___ 07:55PM BLOOD ALT-10 AST-17 AlkPhos-60 TotBili-0.5
___ 07:55PM BLOOD Lipase-61*
___ 07:55PM BLOOD Albumin-4.6 Calcium-9.5 Phos-2.7 Mg-2.1
___ 08:04PM BLOOD Lactate-1.8
DISCHARGE:
___ 06:55AM BLOOD WBC-6.5 RBC-4.28 Hgb-12.6 Hct-36.9 MCV-86
MCH-29.4 MCHC-34.1 RDW-12.0 RDWSD-37.9 Plt ___
___ 06:55AM BLOOD Neuts-77.3* Lymphs-14.2* Monos-7.2
Eos-0.6* Baso-0.2 Im ___ AbsNeut-5.06 AbsLymp-0.93*
AbsMono-0.47 AbsEos-0.04 AbsBaso-0.01
___ 06:55AM BLOOD Glucose-78 UreaN-8 Creat-0.7 Na-139 K-4.3
Cl-103 HCO3-25 AnGap-15
___ 06:55AM BLOOD ALT-7 AST-13 LD(LDH)-128 AlkPhos-54
TotBili-0.5
___ 06:55AM BLOOD Albumin-3.7 Calcium-8.7 Phos-2.6* Mg-1.9
___ 07:15AM BLOOD ___ pO2-51* pCO2-46* pH-7.37
calTCO2-28 Base XS-0
___ 07:15AM BLOOD Lactate-1.0
STUDIES:
CT ABD/PELVIS w/ CONTRAST ___:
1. No acute intra-abdominal pathology.
2. Incidental 19 x 14 mm left adrenal nodule, which can be
evaluated via MRI, as an outpatient.
RECOMMENDATION(S): Outpatient MRI to evaluate the left adrenal
lesion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. levonorgestrel-ethinyl estrad 0.15 - 0.03 - 0.01 oral DAILY
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
2. levonorgestrel-ethinyl estrad 0.15 - 0.03 - 0.01 oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Abdominal pain
Nausea and Vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with LUQ pain and diffuse tenderness on exam. Splenic
infarction? infection? inflammation?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. Oral contrast was not administered.Coronal and
sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 404 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is 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: There is a left adrenal nodule measuring 19 x 14 mm measuring 89
Hounsfield units (02:14). The right adrenal gland is normal.
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 not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. 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. No acute intra-abdominal pathology.
2. Incidental 19 x 14 mm left adrenal nodule, which can be evaluated via MRI,
as an outpatient.
RECOMMENDATION(S): Outpatient MRI to evaluate the left adrenal lesion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Left upper quadrant pain
temperature: 98.4
heartrate: 96.0
resprate: 16.0
o2sat: 100.0
sbp: 139.0
dbp: 96.0
level of pain: 9
level of acuity: 3.0 | ___ s/p appendectomy ___ years ago in ___ presents with
L-sided ABD pain, nausea, and vomiting. The abdominal pain was
intermittent, with periods of severe pain followed by sudden
abatement, possibly consistent with renal colic. UHCG negative.
The patient had CT ABD/PELVIS with contrast that revealed no
acute pathology, however was not optimized to evaluate for
stones. She was observed overnight with some tachycardia up to
130 at highest. She was given 1L IVF and managed symptomatically
with Zofran, Tylenol, and ranitidine. Her pain and accompanying
tachycardia resolved by the following morning at which time we
did not feel repeating a CT for stone protocol would be
worthwhile as it seems she passed the stone, if there ever was
one there. She tolerated PO diet. She was discharged in stable
condition. Unclear etiology of this episode, but would recommend
urology follow-up for evaluation of possible kidney stones. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Rectal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
3 days ago started having severe pain in rectum "deep". felt
like
"she was having a baby". ___. pain worse with trying to
defecate, but did not resolve when she was off commode. there
all
the time. after 3 days felt she had to come in.
When I saw her in am, pain had resolved. received morphine in ED
last night. slept well and ate breakfast without an issue.
also associated with bloating feeling and nausea when she eats.
has not been eating well, lost 5lbs, not drinking. feels very
weak when she stands up. fell 2x in last week when she lost her
balance. no ns, fevers. blood in stool.
complains of constant dry mouth
hx of constipation, but never severe or had symptoms similar
12 pt ROS otherwise negative
Past Medical History:
BREAST CANCER
Breast CA s/p lumpetomy in ___ (invasive tubular adenoCA grade
___, ER/PR+, Her 2 neu neg, -LVI, - margins), declined XRT,
previously taking arimidex. Annual mammogram due in ___.
CARPAL TUNNEL SYNDROME
CATARACTS
DAUGHTER ___ ___
___
DUODENAL ULCER
GASTROESOPHAGEAL REFLUX
HEMORRHOIDS
HYPERTENSION
HYPOTHYROIDISM
LEG EDEMA
OSTEOARTHRITIS
SPINAL STENOSIS
STROKE ___ -Left sided deficit
URINARY INCONTINENCE
VARICOSE VEINS
VERTIGO AND DISEQUILIBRIUM
CERVICAL SPONDYLOSIS
HYPERCHOLESTEROLEMIA
DIABETES MELLITUS
Social History:
___
Family History:
no abd issue
Physical Exam:
afeb 132/63 578-77 98-99% RA
CONS: NAD, comfortable, very anxious
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-distended, bowel sounds present, no rebound
tenderness or guarding, mild TTP in epigastrum
GU- no foley
no anal fissure, tear, healed hemorrhoids, rectal exam
reproduced
pain, large amount of stool in rectal vault,
disimpacted and removed large amount of stool, no blood
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal, felt very
weak when she stood up. unwilling to take a step because she was
afraid she would fall.
Pertinent Results:
labs normal except slightly elevated glucose
===========================
ADMISSION ABDOMINAL CT SCAN:
IMPRESSION:
1. No acute intra-abdominal process.
2. Moderate amount of stool is noted in the colon and rectum.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 25 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Levothyroxine Sodium 88 mcg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Hydrocortisone Acetate Suppository 1 SUPP PR TID pain
7. Allopurinol ___ mg PO DAILY
8. Atorvastatin 10 mg PO QPM
9. NexIUM (esomeprazole magnesium) 20 mg oral Q24H
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Gabapentin 600 mg PO QHS
12. Lisinopril 10 mg PO DAILY
13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
14. Vesicare (solifenacin) 5 mg oral Q24H
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Hydrocortisone Acetate Suppository ___ID:PRN
pain/itching
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Lisinopril 10 mg PO QHS
Please give in evening.
6. Metoprolol Succinate XL 50 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Simethicone 80 mg PO QID:PRN gas/epigastric pain
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with chest pain // r/o ptx, pna r/o ptx,
pna
IMPRESSION:
Compared to chest radiographs since ___, most recently one ___
Mild cardiomegaly has probably increased although some of the differences due
to difference in radiographic projection and semi-erect positioning. Mild
interstitial abnormality, particularly bronchial cuffing and possible
bronchospasm suggest mild congestive heart failure and possibly cardiac
asthma. There is no focal consolidation or appreciable pleural effusion.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Constipation
Diagnosed with Unspecified abdominal pain, Other specified diseases of anus and rectum
temperature: 96.7
heartrate: 63.0
resprate: 18.0
o2sat: 100.0
sbp: 178.0
dbp: 69.0
level of pain: 10
level of acuity: 3.0 | ___ admitted with rectal pain.
#Based on CT/exam (large amount of stool in vault and pain
reproduced on exam) Likely due to impacted stool. After
disimpaction felt better. Pain recurred and with enema several
large bowel movements. Since that point no recurrence of rectal
pain.
Start miralax. After touching base with PCP stopped ___ of her
meds that she was neither taking or intermittently.
Anti-cholinergic effect of meds for urinary incontinence might
have been culprit.
Did have intermittent epigastric/chest pain/bloating. Unclear
whether related to constipation. Did check EKG/CXR/troponin.
Improved with simethicone.
Would recommend also checking TSH in case contributing to
constipation.
# HTN - did have elevated BP in morning before taking meds.
Recommend takes ACE at night and beta blocker in morning. SBP in
160's but did not increase meds given age and wide pulse
pressure and concern about weakness and falls.
#DM - continue home metformin. glucoses reasonable
#Hyponatremia - mild. with hydration resolved from 132 -> 139
#Weakness - attributed to poor POs for some time and not getting
out of bed. ___ eval felt unsafe to go home and therefore
transfer to rehab.
# Anxiety - during hospital stay, patient became very worried
about many issues - BP, headache, abd pain and idea of going to
rehab. Per family this is baseline.
#TRANSITION
- check TSH |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Lisinopril
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Fluoro-guided lumbar puncture
History of Present Illness:
Pt with Stage IV Follicular Lymphoma and prostate CA treated
with one cycle of Bendamustine and Rituxan (R on ___ who
presents to the ER with fever to 103 and rigors.
The patient reports having a cough after his first dose of
Bendamustine on ___ which was productive of white sputum. CXR
___ was negative for acute process, and his cough has resolved
without any therapy. The patient was supposed to have his
second cycle of chemotherapy on ___ (by his report), but was
dehydrated; he was given IVF in clinic as well as Ceftriaxone 1g
IV for presumed UTI. He also received his first dose of
Rituxan. He was discharged on Cipro 500mg PO BID for 14 days;
UA since that time shows no evidence of infection. The patient
is not the best historian, but reports feeling "just awful" for
the past few days. He denies any dysuria, diarrhea, pain,
cough, sick contacts, or focal symptoms concerning for a focus
of infection. He does not have a port. His temperature on the
evening of ___ was elevated and the next day reached a max of
103.4. He states that he has neck and head soreness that
accompanied his cough but this has since subsided.
.
Vitals in the ER: 99.8 106 131/61 16 95% RA
Pt received Cefepime 2g IV, Tylenol ___ PO, and 2L IVF.
.
REVIEW OF SYSTEMS:
(+) Per HPI; constipation
(-) Denies recent weight loss or gain. Denies headache,
rhinorrhea or congestion. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, or weakness. Denies
nausea, vomiting, diarrhea, abdominal pain. Denies dysuria,
arthralgias or myalgias. Denies rashes or skin changes. All
other ROS negative
.
Past Medical History:
ONCOLOGIC HISTORY
Mr. ___ is a ___
gentleman with a history of newly diagnosed follicular lymphoma
with bulky lymphadenopathy, both above and below the diaphragm.
Did have a PET scan on ___, which revealed extensive
disease with bulky lymphadenopathy above and below the diaphragm
as well as some splenomegaly and osseous involvement. Also,
upon
initial presentation, he did have a question of some muscle
wasting, fatigue and sweat. His oncologist then had decided to
monitor him
off treatment with plan for repeat PET scan in approximately a
month from his prior one. However, the patient called two weeks
ago to report new/worsening pain in left shoulder, chest and
axilla region. They repeated a CT scan of his torso, which
revealed some further progression of his disease and also the
patient reported feeling somewhat more fatigued with some
worsening night sweats as well as some ongoing poor appetite and
it was decided that they would initiate treatment. He did have
a
bone marrow biopsy as part of staging of his disease, which
revealed extensive involvement of his lymphoma.
- ___ C1 D1 Bendamustine
- Rituxan ___
Past Medical History:
1. Gout.
2. Hypertension.
3. Obstructive sleep apnea.
4. Hx. Supraventricular tachycardia.
5. Prostate cancer.
6. CKD
7. Diastolic Dysfunction
Past Surgical History:
1. Procedure on his right elbow.
2. Procedure on his left knee.
Social History:
___
Family History:
His older brother had ___ lymphoma and
his younger brother had colon cancer.
Physical Exam:
Vitals: T98.2 bp 132/70 HR 81 RR 18 SaO2 96 RA
GEN: NAD, awake, alert
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions; eyes have puffy appearance which is chronic, heridetary
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, NT, ND, bowel sounds present
EXT: normal perfusion
SKIN: warm, dry
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: flat affect, cooperative
Vital signs stable, afebrile
Pertinent Results:
ADMIT LABS:
--------------------
___ 09:30PM LACTATE-1.0
___ 09:26PM GLUCOSE-122* UREA N-14 CREAT-1.4* SODIUM-134
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-14
___ 09:26PM WBC-5.1 RBC-3.85* HGB-11.0* HCT-33.4* MCV-87
MCH-28.5 MCHC-32.9 RDW-14.6
___ 09:26PM NEUTS-65 BANDS-2 ___ MONOS-7 EOS-2
BASOS-0 ATYPS-3* METAS-1* MYELOS-0
___ 09:26PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 09:26PM PLT SMR-LOW PLT COUNT-81*
___ 09:26PM ___ PTT-29.5 ___
___ 09:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 09:10PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:10PM URINE HYALINE-28*
___ 09:10PM URINE MUCOUS-MANY
.
DISCHARGE LABS:
------------------
___ 10:15AM BLOOD WBC-2.1* RBC-2.78* Hgb-7.7* Hct-24.4*
MCV-88 MCH-27.8 MCHC-31.7 RDW-14.7 Plt ___
___ 10:15AM BLOOD Neuts-66.4 ___ Monos-8.7 Eos-1.9
Baso-0.1
___ 10:15AM BLOOD Plt ___
___ 10:15AM BLOOD ___ PTT-33.2 ___
___ 10:15AM BLOOD Glucose-162* UreaN-11 Creat-1.1 Na-137
K-3.9 Cl-105 HCO3-25 AnGap-11
___ 10:15AM BLOOD ALT-50* AST-25 LD(LDH)-119 AlkPhos-85
TotBili-0.4
___ 10:15AM BLOOD Albumin-3.0* Calcium-8.6 Phos-2.6* Mg-2.0
.
MICRO:
___ B D Glucan NEGATIVE
___ Galactomannan NEGATIVE
___ and ___ Adenovirus PCR NEGATIVE
___ Mycoplasma pneumo IgG POSITIVE, IgM NEGATIVE
___ EBV NEGATIVE
CSF:
___
CMV, EBV, HSV negative
___ 11:00AM CEREBROSPINAL FLUID (CSF) WBC-9 RBC-4400*
Polys-36 ___ Monos-15 Eos-1
___ 11:00AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-5725*
Polys-44 ___ Monos-15 Eos-1
___ 11:00AM CEREBROSPINAL FLUID (CSF) TotProt-56*
Glucose-70
.
IMAGING:
CXR - no acute intrathoracic process
.
___ CT CHEST:
IMPRESSION:
1. No obvious evidence of active infectious or inflammatory
process in the neck or chest. No evidence of pneumonia.
2. Significant decrease in size of bilateral axillary lymph
nodes which no longer meet CT size criteria for pathological
enlargement. Interval increase in the degree of minimal fat
stranding surrounding lymph nodes likely represents
post-treatment change.
3. A single focus of minimally enlarged lymph nodes in the IIb
cervical
station on the right with minimal fat stranding, also likely
represents
post-treatment change given the morphologic similarity to the
changes in the axillary lymph nodes.
.
___. No obvious evidence of active infectious or inflammatory
process in the neck or chest. No evidence of pneumonia.
2. Significant decrease in size of bilateral axillary lymph
nodes which no longer meet CT size criteria for pathological
enlargement. Interval increase in the degree of minimal fat
stranding surrounding lymph nodes likely represents
post-treatment change.
3. A single focus of minimally enlarged lymph nodes in the IIb
cervical
station on the right with minimal fat stranding, also likely
represents
post-treatment change given the morphologic similarity to the
changes in the axillary lymph nodes.
.
___ CHEST
IMPRESSION: Small bilateral pleural effusions with bibasilar
consolidations concerning for pulmonary edema or pneumonia.
.
___ ___
No evidence of deep vein thrombosis in the right lower
extremity.
___
CT ABD PELVIS
1. No acute intra-abdominal pathology identified.
2. Interval development of new small bilateral pleural
effusions with
associated subsegmental atelectasis. For further details of the
chest, please refer to dedicated report of CT chest done same
day.
3. Slight interval improvement in retroperitoneal, periportal
and inguinal lymphadenopathy.
4. Other chronic findings such as mild splenomegaly as above.
.
___ CT CHEST
IMPRESSION:
1. Small bilateral pleural effusions and residual dependent
pulmonary edema, new since ___.
2. No evidence of intrathoracic infection.
3. No central adenopathy. Left axillary adenopathy improved
since ___.
4. Probable anemia.
.
___ CT HEAD
1. No evidence of acute intracranial abnormalities.
2. Moderate diffuse ventricular enlargement, out of proportion
of sulcal
enlargement. This could reflect cerebral atrophy with central
predominance. Alternatively, this could reflect communicating
hydrocephalus. If subependymal lymphomatous involvement or
other intracranial lymphomatous involvement is highly suspected,
then further evaluation would be best performed by MRI. MRI
would also be more sensitive for intracranial infection.
3. 6 x 4 mm sclerotic lesion in the outer table of the left
parietal bone at the vertex most likely represents an osteoma.
Given the history of lymphoma, follow-up could be obtained to
assess stability.
.
___ CT SINUS
1. A single right middle ethmoid air cell contains mild
aerosolized
secretions, which is in the absence of associated fluid is a
nonspecific
finding with regard to the possibility of acute sinusitis. No
fluid in the
paranasal sinuses to clearly suggest acute sinusitis.
2. Mild mucosal thickening in the paranasal sinuses indicates
mild chronic
inflammation.
.
___ MR HEAD
No evidence of mass, mass effect or abnormally enhancing
lesions.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Losartan Potassium 50 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO HS
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. sildenafil *NF* 100 mg Oral daily PRN sex
8. Aspirin 81 mg PO DAILY
9. Tamsulosin 0.8 mg PO HS
10. albuterol sulfate *NF* 90 mcg/actuation Inhalation q4 PRN
dyspnea
11. Vitamin D 1000 UNIT PO DAILY
12. Ciprofloxacin HCl 500 mg PO Q12H
starting ___ for 14 days
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
4. Tamsulosin 0.8 mg PO HS
5. Vitamin D 1000 UNIT PO DAILY
6. albuterol sulfate *NF* 90 mcg/actuation Inhalation q4 PRN
dyspnea
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet extended release 24
hr(s) by mouth daily Disp #*90 Tablet Refills:*0
9. Sildenafil *NF* 100 mg ORAL DAILY PRN sex
___. Levofloxacin 750 mg PO DAILY
please stop taking this medication after ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Fever of unknown origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Trauma and cough/fever.
COMPARISON: ___.
FINDINGS:
No focal consolidation, pleural effusion, or evidence of pneumothorax is seen.
The cardiac and mediastinal silhouettes are unremarkable. The hilar contours
are stable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ man with history of follicular lymphoma and prostate
cancer, presenting with fever and cough. The patient uses CPAP at home with
water from the tap.
COMPARISONS: CT of the torso from ___.
TECHNIQUE: MDCT-acquired axial images were obtained of the neck and chest,
from the level of the temporomandibular joints through the lung bases. Image
acquisition performed after administration of 75 cc Omnipaque intravenous
contrast material. Coronal and sagittal reformats prepared and reviewed.
DLP: 983.29 mGy-cm.
FINDINGS:
NECK: There is no evidence of soft tissue mass or fluid collection within the
neck. The pharynx, larynx, and trachea are patent, without significant
narrowing or mass effect. There is no definitive evidence of acute
inflammatory change in the soft tissues of the neck. A minimally enlarged
cervical lymph node at level IIb on the right measures 1.4 x 1.4 cm and
features minimal surrounding fat stranding present (2:17). There is no other
significant lymphadenopathy in the cervical lymph node stations. The parotid
and submandibular glands appear normal. The lingular and palatine tonsils are
not enlarged. There is no retropharyngeal soft tissue thickening. The
carotid arteries and jugular veins in the neck are patent and enhance
normally. Trace mucosal thickening is seen in the imaged portion of the right
maxillary sinus (2:3). Limited images of the remainder of the paranasal
sinuses and nasal passageways are unremarkable. There are no destructive
osseous lesions in the cervical spine, which would be concerning for
malignancy. No paraspinal fluid collection is identified.
CHEST: The thyroid gland appears normal. There has been interval resolution
of lymphadenopathy in the right axilla when compared to the ___
study. For example, a pathologically enlarged lymph node with surrounding fat
stranding was 2.3 x 1.7 cm on the prior study is now only 6 mm in the short
axis with normal fatty hilum on the current study (2:43). There is a similar
reduction in size in left axillary lymph nodes, for example, an 18 x 12 mm
lymph node now measures only 5 mm in short axis with a more normal-appearing
fatty hilum (2:39). There is, however, minimally increased fat stranding
around the bilateral axillary lymph nodes in comparison to prior study. There
is no supraclavicular, mediastinal or hilar lymphadenopathy. Gynecomastia is
noted. The heart size is normal and there is no pericardial effusion. There
are minimal coronary arterial calcifications. The great vessels are
unremarkable. Limited views of the upper abdominal structures are also
unremarkable.
The airways are patent to the subsegmental level. The lungs are clear. There
are no concerning pulmonary nodules. There is no pneumothorax or pleural
effusion.
There are no destructive osseous lesions within the chest, concerning for
malignancy or infection.
IMPRESSION:
1. No obvious evidence of active infectious or inflammatory process in the
neck or chest. No evidence of pneumonia.
2. Significant decrease in size of bilateral axillary lymph nodes which no
longer meet CT size criteria for pathological enlargement. Interval increase
in the degree of minimal fat stranding surrounding lymph nodes likely
represents post-treatment change.
3. A single focus of minimally enlarged lymph nodes in the IIb cervical
station on the right with minimal fat stranding, also likely represents
post-treatment change given the morphologic similarity to the changes in the
axillary lymph nodes.
Radiology Report
INDICATION: Follicular lymphoma status post chemotherapy, presenting with
fevers and cough.
COMPARISON: CT chest, ___, chest radiograph ___.
FINDINGS: The cardiomediastinal and hilar contours are stable. There are new
small bilateral pleural effusions with basilar consolidations, which may
represent pulmonary edema or pneumonia. There are no other signs of pulmonary
edema, such as engorgement of the mediastinal vessels or change in the size of
the cardiac silhouette.
IMPRESSION: Small bilateral pleural effusions with bibasilar consolidations
concerning for pulmonary edema or pneumonia.
Dr. ___ these results with Dr. ___ on ___ at 9:28 AM
via telephone.
Radiology Report
HISTORY: ___ man with female presenting with fevers and clinical
concern for right lower extremity DVT.
COMPARISON: Ultrasound from ___.
FINDINGS:
Grayscale and color Doppler ultrasonography of the bilateral common femoral
veins as well as the right femoral, popliteal, posterior tibial, and peroneal
veins were performed. All imaged vessels demonstrated normal compressibility,
flow, and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the right lower extremity.
Radiology Report
HISTORY: ___ year old man with CLL /SLL presents wtih fevers to 103 for 3d,
and headaches with ?sinus pressure REASON FOR THIS EXAMINATION: assess for
evidence of infection or lymphoma in chest, pelvis, abd CONTRAINDICATIONS for
IV CONTRAST: Cr increasing
COMPARISON: CT torso ___
TECHNIQUE: Standard departmental protocol CT of the chest abdomen pelvis was
performed without intravenous contrast administration. Coronal and sagittal
reformats were obtained. Total exam DLP 936 mGy-cm.
FINDINGS:
Abdomen: Interval development of new small bilateral pleural effusions, with
associated bibasilar subsegmental atelectasis. For further details of the
chest, please refer to dedicated report of CT chest done same day. Mild
diffuse heterogeneity of the liver parenchyma is noted on this limited non
contrast exam. Mild splenomegaly measuring 14.9 cm in length appears
unchanged. Normal-appearing gallbladder, pancreas, bilateral adrenal glands.
Mild bilateral perinephric fat stranding, nonspecific. Mild calcific
atherosclerosis of a normal caliber abdominal aorta. Borderline prominent
mesenteric, retroperitoneal and periportal lymph nodes appear slightly
improved since prior, measuring up to 10 mm in short axis. Normal-appearing
small bowel. No evidence of intraperitoneal ascites. Mild misty mesentery
unchanged.
Pelvis: Normal-appearing partially full urinary bladder. Normal-appearing
prostate and seminal vesicles. Pelvic phleboliths. No evidence of pelvic
free fluid. Mildly prominent bilateral inguinal chain lymph nodes appear
slightly improved, measuring up to 15 mm in short axis. Normal-appearing
colon and appendix. Moderate bilateral hip joint osteoarthritis.
IMPRESSION:
1. No acute intra-abdominal pathology identified.
2. Interval development of new small bilateral pleural effusions with
associated subsegmental atelectasis. For further details of the chest, please
refer to dedicated report of CT chest done same day.
3. Slight interval improvement in retroperitoneal, periportal and inguinal
lymphadenopathy.
4. Other chronic findings such as mild splenomegaly as above.
Radiology Report
SINUS CT WITHOUT CONTRAST, ___
INDICATION: CLL/SLL, presenting with fever of 103 for three days, headache,
sinus pressure. Assess for sinusitis.
COMPARISON: None.
TECHNIQUE: Axial non-contrast multidetector CT images of the paranasal
sinuses with sagittal and coronal reformatted images.
FINDINGS: There is mild mucosal thickening in the inferior frontal sinuses,
extending into the frontoethmoidal recesses. There is minimal mucosal
thickening in some of the anterior ethmoidal air cells bilaterally. A right
middle ethmoid air cell contains aerosolized secretions. There is mild
mucosal thickening in the right maxillary sinus and minimal mucosal thickening
along the floor of the left maxillary sinus. The ostiomeatal units are well
aerated. There is minimal mucosal thickening in bilateral sphenoid sinuses.
The sphenoethmoidal recesses are well aerated. There is no fluid in the
paranasal sinuses. There is no evidence of erosion or sclerosis in the walls
of the paranasal sinuses. The nasal septum is deviated to the left with an
osseous spur. The lamina papyracea and cribriform plates are intact
bilaterally. There is no evidence of abnormal soft tissue densities in the
nasal cavity.
There is no evidence of periapical lucencies in the maxillary alveolar ridge.
The orbits are unremarkable on non-contrast assessment. The mastoid air cells
are well aerated.
Concurrent head CT is reported separately.
IMPRESSION:
1. A single right middle ethmoid air cell contains mild aerosolized
secretions, which is in the absence of associated fluid is a nonspecific
finding with regard to the possibility of acute sinusitis. No fluid in the
paranasal sinuses to clearly suggest acute sinusitis.
2. Mild mucosal thickening in the paranasal sinuses indicates mild chronic
inflammation.
Radiology Report
NON-CONTRAST HEAD CT, ___
INDICATION: CLL/SLL, now with fever of 103 for three days, headaches, sinus
pressure. Assess for evidence of lymphoma or other acute infection.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no acute intracranial hemorrhage. There is no evidence of
edema, mass effect, or loss of gray/white matter differentiation. There is
moderate ventricular enlargement, out of proportion to the size of the sulci.
A 6 x 4 mm cortical-density lesion in the outer table of the left parietal
bone at the vertex (image 2:28) probably represents an osteoma. No suspicious
lytic bone lesions are seen. The mastoid air cells are well aerated. The
paranasal sinuses are better assessed on the concurrent sinus CT.
IMPRESSION:
1. No evidence of acute intracranial abnormalities.
2. Moderate diffuse ventricular enlargement, out of proportion of sulcal
enlargement. This could reflect cerebral atrophy with central predominance.
Alternatively, this could reflect communicating hydrocephalus. If
subependymal lymphomatous involvement or other intracranial lymphomatous
involvement is highly suspected, then further evaluation would be best
performed by MRI. MRI would also be more sensitive for intracranial
infection.
3. 6 x 4 mm sclerotic lesion in the outer table of the left parietal bone at
the vertex most likely represents an osteoma. Given the history of lymphoma,
follow-up could be obtained to assess stability.
Radiology Report
HISTORY: Follicular lymphoma and prostate carcinoma, fever, suspect
pneumonia.
TECHNIQUE: Multidetector helical scanning of the chest was performed without
need for intravenous contrast agent, reconstructed as contiguous 5 and 1.25-mm
thick axial and 5-mm thick coronal and parasagittal images, compared to CT
scanning of the chest on ___ and ___.
FINDINGS: Small layering nonhemorrhagic bilateral pleural effusions are new
since ___. The very mild increase in ground-glass opacification at the right
lung base below the level of the inferior pulmonary veins accompanied by
smoothly thickened septae is attributable to mild residual edema rather than
infection. There is also some increase in dependent atelectasis seen three
days ago. There is no good evidence for intrathoracic infection--no
consolidation, nodulation, bronchial wall thickening, or evidence of
bronchiolitis.
Largest imaged lymph nodes, in the axilla, are smaller than from ___,
ranging in diameter up to only 22 x 19 mm, on the left, 2:19, where there were
numerous lymph nodes of equivalent size in ___, most involuted. Numerous
central lymph nodes range up to 7mm in the left upper paratracheal station,
2:13, 9mm in the left upper paratracheal station, 2:10, 8-mm in right lower
paratracheal station, 2:19, all stable since at least ___ 5-mm lower
paraesophageal node, 2:44, was 7 mm in ___.
Pericardial effusion is physiologic. Relative hypoattenuation of the cardiac
contents suggests anemia, not appreciated on the previous contrast-enhanced
study. Study is not designed for subdiaphragmatic evaluation, but shows no
adrenal mass. Splenomegaly has improved since ___.
IMPRESSION:
1. Small bilateral pleural effusions and residual dependent pulmonary edema,
new since ___.
2. No evidence of intrathoracic infection.
3. No central adenopathy. Left axillary adenopathy improved since ___.
4. Probable anemia.
Radiology Report
HISTORY: ___ man with CLL /CLL. Evaluate for evidence of
intracranial lymphoma.
COMPARISON: Head CT from ___.
TECHNIQUE : Multiplanar T1, T2, susceptibility, and diffusion-weighted MR
images were obtained pre contrast. After intravenous administration of
gadolinium based contrast, axial T1 and sagittal MPRAGE sequences were
obtained, the latter with coronal and axial reformations.
FINDINGS:
There is no diffusion abnormality to suggest acute infarction. No intra- or
extra-axial fluid collections or blood is identified. Principal intracranial
vascular flow voids are preserved. The ventricles appear more prominent as
compared to the sulci suggesting central atrophy. No intracranial mass or
abnormally enhancing lesions are identified. Confluent periventricular and
scattered subcortical white matter FLAIR hyperintensities are nonspecific but
likely reflect sequelae of chronic small vessel ischemic disease.
The brainstem, posterior fossa, and cervical medullary junction are preserved.
The orbits, sella turcica, and parasellar regions are normal. No abnormality
of the skull base or calvarium is identified. Mild mucosal thickening is seen
within the right maxillary sinus. Mastoid air cells are partially opacified
on the right.
IMPRESSION:
No evidence of mass, mass effect or abnormally enhancing lesions.
Radiology Report
INDICATION: Fever/neck pain. Failed bedside attempt.
PROCEDURE: Fluoroscopically guided lumbar puncture
PHYSICIANS: Dr. ___, Dr. ___, NP
ANESTHESIA: Local anesthesia with 1% lidocaine.
PROCEDURAL DETAILS AND FINDINGS: Prior to the procedure, written informed
consent was obtained and the patient showed good understanding of the
indications, risks, benefits and alternatives. Upon arrival in the
fluoroscopy suite, a 'time-out' was performed using standard ___ protocol.
The patient was placed prone on the fluoroscopy table and his lower back was
prepped and draped in the typical sterile fashion. Local anesthesia was
obtained using 1% lidocaine. A 22g spinal needle was inserted into the spinal
canal under fluoroscopic guidance at the $-5level. In total, 16cc of
serosanguinous fluid was drained.The stylet of the spinal needle was replaced,
and the needle was then removed. Excellent hemostasis was achieved and the
patient
was transferred from the fluoroscopy suite in stable condition.
IMPRESSION: Successful fluoroscopically guided lumbar puncture, draining 16
cc of cerebrospinal fluid. Laboratory analysis is pending.
Dr. ___ was present and supervsing for the entire procedure.
___, NURSE PRACTITIONER
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, LYMPHOMA NEC UNSPEC SITE, CA PROSTATE
temperature: 99.8
heartrate: 106.0
resprate: 16.0
o2sat: 95.0
sbp: 131.0
dbp: 61.0
level of pain: 4
level of acuity: 2.0 | ___ with PMH HTN, h/o SVT, stage IV follicular lymphoma and
prostate CA presents wtih fevers to 102 for 2 days and neck pain
with cough.
.
#Fever and rigors - Pt presented with fevers to 102-103, and
with headache, neck pain, drenching nightsweats and poor PO
intake. Extensive infectious work-up was undertaken for
bacterial, viral, and fungal causes without any positive tests.
Headache/neck pain was not thought to be meningitis, as pt was
tender on lateral posterior neck and tender on scalp in
occipital area, without any visual disturbances. Pt was
empirically treated with vanc/unasyn, evetually on
vanc/zosyn/levofloxacin/tamiflu. Pt underwent extensive imaging
including CT head, neck, chest, abd, pelvis which were only
notable for ventriculomegaly in head. Subsequent MRI was
negative for acute hydrocephalus or other evidenec of acute
disease. As culture data returned, vanc/zosyn/tamiflu were
stopped. Pt underwent LP, for ? lymphoma in brain without any
abnormalities concerning for infection or lymphoma. Pt seemed to
defervesce spontaneously. At discharge, it is thought that pt
likely had a viral infection, which caused his illness.
.
In the setting of getting IVF for fevers and poor PO intake, pt
developed some pulm edema requiring O2, but was given 40iv lasix
with complete resolution of O2 requirement.
.
# Pancytopenia: Pt's pancytopenia is attributed to his acute
viral illness. Outpatient team may recheck CBC and consider BM
biopsy is this does not resolve within ___ weeks of discharge.
.
#Stage IV Follicular Lymphoma s/p ___ C1 D1 Bendamustine
and Rituxan ___. Pt did not receive any chemotherapy while
hospitalized.
.
#Prostate CA - ___ 6, no active treatment at this time. Pt
was continued on flomax.
.
#CKD III with mild Cr elevation (Cr 1.2 -> 1.4): Losartan was
stopped on admission due to worsening Cr and was not resumed as
pt's SBPs were in 100-120s and metoprolol was increased for SVT.
.
#Hx of SVT - Pt had episode of SVT in 130-150s which terminated
spontaneously. Pt only minimally symptomatic and HD stable.
Metoprolol was incrased from 25mg po xl to 75 po xl.
. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Influenza Virus Vacc,Specific
Attending: ___.
Chief Complaint:
Falls and balance disturbance
Major Surgical or Invasive Procedure:
___ PICC line placement
___ PICC line removal
History of Present Illness:
Ms. ___ is an ___ year old female with a history of
breast cancer ER/PR positive, HER2 negative diagnosed in ___
s/p resection/XRT/hormonal treatment, prior history of ovarian
cancer (treated with chemo in ___, seizure disorder and Factor
V Leiden complicated by DVTx2 on warfarin, who presented to OSH
neurology for frequent falls with back pain.
During the evaluation she was found to have diffuse disease that
appears to be metastases to the lung and liver on CT. These
findings prompted transfer to the ___ ED.
Her history of falls began one month ago when she had her
initial fall with head strike and was thought to have had a
concussion. Since that event, she has had difficulty with
balance and multiple falls. At home she intermittently uses a
cane. Her most recent fall was 5 days prior to ED visit. It was
described by her daughter as mechanical in nature, without loss
of consciousness or headstrike.
She corroborates that she "lost her balance." She had an MRI/MRA
of the brain on ___ at ___ which reportedly did not show any
acute processes. Echo was also performed as part of evaluation.
Denies fever no urinary incontinence, retention or fecal
incontinence or retention. No back pain. Mild subjective
weakness in her lower extremtities after standing for a while.
She's noticed a slight "flap" in her hands occassionally. No
numbness, tingling, or saddle anesthesia.
In the ED:
Initial Vitals: 8 98.4 92 131/67 18 97%
Transfer Vitals: 5 97.5 91 131/68 16 93% RA
Meds: None given
Studies: OSH films being uploaded
Labs: Per OSH records below
Fluids: None
Access: ___
She currently feels well. She is comfortable. She has
"heaviness" in her breathing. Her husband noted some increased
abdominal girth. She denies CP, cough, dysuria, N/V/D.
Past Medical History:
1. History of right invasive ductal carcinoma, with ductal and
lobular features, moderately differentiated ___
___, grade 1), ER/PR positive, HER2 negative ___. Treated with
partial mastectomy, partial breast irradiation by Dr. ___
___ ___ years of hormonal therapy with Arimidex. Lung and liver
mets in ___, discharged home with hospice after declining
liver biopsy and further treatment.
2. Distant history of ovarian cancer in ___, stage I, treated
with adjuvant chemotherapy (likely carboplatin and paclitaxel).
3. History of deep vein thrombosis x 2, heterozygous for Factor
V Leiden on anticoagulation.
4. History of pernicious anemia, on chronic B12.
5. Seizure disorder
6. osteoporosis, treated with many years of intravenous
bisphosphonate
7. GERD
8. Asthma
Social History:
___
Family History:
No family history of malignancy in the immediate family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T: 97.6 BP: 142/86 HR: 94 RR: 22 02 sat: 97% on RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, dry MM, nontender
supple neck, no LAD, no JVD
CARDIAC: Normal rate, regular rhythm, s1/S2, no murmurs
RESPIRATORY: CTAB, no wheezes, rales, rhonchi, breathing
comfortably without use of accessory muscles
GI: mildly distended, tympanitic, non-tender, firm mass to
palpation over the RUQ near her past CCY scar - scar tissue vs
palpable liver, no rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, few beat nystagmus to the right, one
beat asterixis, ___ strength in the upper and lower extremities,
sensation intact throughtout upper and lower extremities. Finger
to nose normal, slightly uncoordinated on the left with heel to
shin
SKIN: warm and well perfused, no excoriations, ecchymoses over
the buttocks
DISCHARGE PHYSICAL EXAM:
VS: T98.7 BP144/65-171/58 HR90 RR20 92RA
GENERAL: No acute distress, pleasant
HEENT: anicteric sclera, moist mucous membranes
CARDIAC: RRR, normal s1/S2, no murmurs
LUNGS: diffuse crackles, no wheezes
ABD: +BS, mildly distended, nontender, large palpable mass
RUQ/epigastric area
EXT: moving all extremities well, no cyanosis, clubbing or edema
PULSES: 2+ DP and ___ pulses bilaterally
NEURO: CN II-XII grossly intact, + mild asterixis, AOx3
SKIN: warm well perfused
Pertinent Results:
ADMISSION LABS:
___ 07:05AM BLOOD WBC-10.8 RBC-3.86* Hgb-11.9* Hct-36.4
MCV-94 MCH-30.7 MCHC-32.6 RDW-14.5 Plt ___
___ 07:05AM BLOOD ___ PTT-38.6* ___
___ 07:05AM BLOOD Glucose-104* UreaN-25* Creat-1.1 Na-132*
K-4.6 Cl-99 HCO3-20* AnGap-18
___ 07:05AM BLOOD ALT-34 AST-89* TotBili-0.9
___ 07:05AM BLOOD Albumin-2.7* Calcium-8.1* Phos-3.6 Mg-1.8
PERTINENT LABS:
___ 05:42AM BLOOD Osmolal-281
___ 07:05AM BLOOD Osmolal-275
___ 07:00AM BLOOD TSH-2.7
___ 07:05AM BLOOD CEA-69* ___ ___*
URINE:
___ 01:11AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:11AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 01:11AM URINE RBC-1 WBC-5 Bacteri-MOD Yeast-NONE Epi-1
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of 2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_______________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 12:38PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:38PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 12:38PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 12:38PM URINE CastHy-56*
URINE CULTURE (Final ___: NO GROWTH.
___ CT CHEST WITH CONTRAST
1. Large 3.4 x 5.3 cm left lower lobe lesion, along with left
upper lobe and right lower lobe nodules are highly suspicious
for metastatic disease.
2. Multiple enlarged left hilar, lower paratracheal and upper
paratracheal
nodes are lymph node metastatic involvement.
3. There are no bone metastases.
4. Moderate-to-severe coronary artery calcification.
5. Mild centrilobular, paraseptal emphysema and mild diffuse
bronchial
thickening are likely smoking related.
___ CT ABD PELVIS WITH CONTRAST
1. 3.9 cm asymmetric right breast soft tissue mass seen at the
visualized
lower thorax. Correlation with mammography and clinical exam is
recommended.
2. 5.5 cm irregular soft tissue attenuation mass abutting the
posterior
pleural surface in the left lower lobe. Few epicardial lymph
nodes identified on the visualized lung bases.
3. Innumerable ill-defined hypodense masses throughout the liver
parenchyma, in keeping with diffuse metastases.
4. Pancreatic head is heterogenous in attenuation. No
pancreatic ductal
dilatation. Metastases or primary pancreatic neoplasm is not
excluded.
5. 7 mm hyperdense lesion at the pancreatic body may relate to
interdigitation of fat versus a small cystic lesion such as
IPMN.
6. 1.1 cm rounded lesion at the lateral limb of the left adrenal
gland is
suspicious for metastatic deposit.
7. No lymphadenopathy. No evidence of osseous metastases in the
abdomen and pelvis.
___ PORTABLE CXR
Single frontal view of the chest. Left PICC terminates in the
lower SVC.
Heart size and cardiomediastinal contours are stable. Lung
volumes have
slightly improved, though still hypoinflated. There is
bibasilar atelectasis without focal consolidation, pleural
effusion, or pneumothorax.
___ CXR
A left-sided PICC line terminates at the cavoatrial junction.
The
lung volumes are low with mild relative elevation of the right
hemidiaphragm that appears unchanged. The cardiac, mediastinal,
and hilar contours appear stable including mediastinal and left
hilar lymphadenopathy. There is no definite pleural effusion or
pneumothorax. There is a persistent medial left basilar opacity
with a rounded contour, suggesting a pleural-based mass
concerning for malignancy. Smaller nodules are not well
depicted on radiographs.
IMPRESSION: Stable appearance of the chest including
lymphadenopathy and a left lower lobe opacity worrisome for
malignancy.
___ RUQ ULTRASOUND (prelim)
1. Diffusely infiltrative hepatic metastases were better
delineated on recent CT
2. No visualized flow in the left portal vein. This vessel,
which was atretic on the recent CT, is likely being compressed
by adjacent metastases.
DISCHARGE LABS:
___ 02:35AM BLOOD WBC-14.0* RBC-3.35* Hgb-10.2* Hct-32.4*
MCV-97 MCH-30.6 MCHC-31.6 RDW-16.3* Plt ___
___ 02:35AM BLOOD ___ PTT-65.7* ___
___ 08:30AM BLOOD PTT-51.4*
___ 02:35AM BLOOD Glucose-143* UreaN-22* Creat-1.0 Na-136
K-3.7 Cl-100 HCO3-20* AnGap-20
___ 02:35AM BLOOD ALT-29 AST-98* AlkPhos-168* TotBili-1.2
___ 02:35AM BLOOD Albumin-2.4* Calcium-7.8* Phos-4.4 Mg-1.9
___ 11:49AM BLOOD Ammonia-88*
___ 07:05AM BLOOD CEA-69* ___ CA125-785*
___ 11:49AM BLOOD Phenyto-11.5 Phenyfr-PND
___ 11:49AM BLOOD Phenyto-11.5
___ 05:29AM BLOOD Phenoba-31.6 Phenyto-13.2
___ 09:45AM BLOOD Lactate-4.5*
___ 06:00PM BLOOD Lactate-4.1*
___ 01:24PM BLOOD Lactate-4.0*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pamidronate 90 mg IV Q3 MONTHS
2. AtroVENT (ipratropium bromide) 0.06 % nasal TID: PRN PND
3. Docusate Sodium 50 mg PO HS
4. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
5. Warfarin 2 mg PO DAILY16
6. Phenytoin Sodium Extended 400 mg PO HS
7. Furosemide 10 mg PO 3X/WEEK (___)
8. Psyllium Wafer 1 WAF PO DAILY
9. PHENObarbital 129.6 mg PO HS
10. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
11. Mag 64 (magnesium chloride) 64 mg oral daily
12. Diazepam 5 mg PO DAILY:PRN anxiety/seizure
13. Cyanocobalamin 1000 mcg IM/SC QMONTH
14. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
2. PHENObarbital 129.6 mg PO HS
3. Phenytoin Sodium Extended 400 mg PO HS
4. AtroVENT (ipratropium bromide) 0.06 % nasal TID: PRN PND
5. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q2H:PRN
pain
6. OLANZapine (Disintegrating Tablet) 5 mg PO Q4H:PRN
delirium/restlessness
RX *olanzapine 5 mg 1 (One) tablet,disintegrating(s) by mouth
every four (4) hours Disp #*30 Tablet Refills:*0
7. Scopolamine Patch 1 PTCH TD Q72H
RX *scopolamine base [Transderm-Scop] 1.5 mg/72 hour Apply to
dry area of skin Q 72 hours Disp #*30 Each Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QAM painful area
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) apply to painful
area once a day (12 hours on, 12 hours off) Disp #*30 Each
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Breast cancer most likely metastatic to liver and lung
-Urinary tract infection
-Hyponatremia
SECONDARY:
-Factor V ___
-History of DVTs
-Seizure 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
HISTORY: ___ woman with history of breast and ovarian cancer with new
breast, liver and lung masses. For staging, an planning for biopsy of mass.
COMPARISON: No prior CT abdomen is available for comparison.
TECHNIQUE: Multi detector CT imaging was of the abdomen and pelvis was
performed prior to and following intravenous contrast administration.
Multiplanar reformats were also obtained. Oral contrast was administered.
DOSE: DLP of 1250.50 mGy-cm
FINDINGS:
ABDOMEN:
A 3.9 x 3.8 cm asymmetric right breast soft tissue mass is identified (3:1,
13:1). Prominent reticulations are identified at the lung bases, which may
relate to chronic inflammatory change or fibrosis. A 5.5 x 2.9 cm irregular
soft tissue attenuation mass is identified abutting the posterior pleural
surface in the left lower lobe (6:41, 13:13). A few epicardial lymph nodes
are identified on the visualized lung bases (13:6). There is evidence of
background centrilobular emphysema. Please refer to the CT chest from the
same day for further details.
The liver demonstrates innumerable ill-defined hypodense masses throughout its
parenchyma. Some of the subcapsular masses result in bulging of the liver
contour (13:30). These are in keeping with diffuse metastatic deposits. The
portal veins remains patent. Hepatic veins are also patent however, there is
mass effect at the confluence of the right and middle hepatic vein with a
focal mass (06:44). The gallbladder is not visualized. No intrahepatic or
extrahepatic biliary ductal dilatation. A 7 mm hypodense lesion is identified
at the pancreatic body (6:66), which may relate to interdigitation of fat
versus a small cystic lesion such as IPMN. The pancreatic head is slightly
heterogenous in attenuation (6:67). No pancreatic ductal dilatation is noted.
A 1.1 cm rounded lesion is identified at the lateral limb of the left adrenal
gland (06:50). The right adrenal gland is unremarkable. The spleen is
unremarkable. The right kidney is slightly malrotated. No suspicious renal
lesions are identified. A tiny 6 mm hyperdense lesion is identified in the
interpolar region of the left kidney (13:34), too small to characterize,
however likely related to simple cyst. No hydronephrosis. The caliber of
small and large bowel is within normal limits. No mesenteric or
retroperitoneal lymphadenopathy. Moderate atheromatous calcification of the
abdominal aorta is noted, predominately at the infrarenal level.
PELVIS:
Urinary bladder is unremarkable. There is evidence of moderate colonic
diverticulosis, however no diverticulitis is identified. No pelvic free
fluid. No inguinal or pelvic lymphadenopathy.
OSSEOUS STRUCTURES:
Mild S-shape scoliosis of the spine is noted. No suspicious osteolytic or
osteoblastic lesions are identified. Mild to moderate facet degenerative
changes are identified at the L5-S1 level.
IMPRESSION:
1. 3.9 cm asymmetric right breast soft tissue mass seen at the visualized
lower thorax. Correlation with mammography and clinical exam is recommended.
2. 5.5 cm irregular soft tissue attenuation mass abutting the posterior
pleural surface in the left lower lobe. Few epicardial lymph nodes identified
on the visualized lung bases. Please refer to the CT chest from the same day
for further details.
3. Innumerable ill-defined hypodense masses throughout the liver parenchyma,
in keeping with diffuse metastases.
4. Pancreatic head is heterogenous in attenuation. No pancreatic ductal
dilatation. Metastases or primary pancreatic neoplasm is not excluded.
5. 7 mm hyperdense lesion at the pancreatic body may relate to interdigitation
of fat versus a small cystic lesion such as IPMN.
6. 1.1 cm rounded lesion at the lateral limb of the left adrenal gland is
suspicious for metastatic deposit.
7. No lymphadenopathy. No evidence of osseous metastases in the abdomen and
pelvis.
Radiology Report
REASON FOR EXAM: ___ years old woman with history of breast cancer and ovarian
cancer with new breast cancer and liver and lung masses. Staging, planning
for biopsy of masses.
TECHNIQUE: Multi-detector helical scanning of the chest during the infusion
of Omnipaque non-ionic contrast material agent. Images were reconstructed as
contiguous 5- and 1-mm thick axial helical, 5-mm thick coronal and
parasagittal, and 8 x 8 mm MIPs projections.
RADIATION DOSE: The total DLP is reported in concurrent CT abdomen and
pelvis.
COMPARISON: Exam is compared to chest CT of ___.
FINDINGS: Asymmetric enlargement of the right thyroid lobe with small
hypodense thyroid nodules ranging up to 5 mm (series 6: Image 5) is
compatible with multinodular goiter. Fluid density lesion in the right breast
measure 2 x 1.5 cm (6:25).
There are no pathologically enlarged lymph nodes in the axillary region. A
left supraclavicular node (6:3) is 7 x 11 mm; left upper paratracheal node
(6:9) is 9 x 13 mm; right upper paratracheal node (6:11) is 13 x 11 mm; right
lower paratracheal node (6:17) is 18 x 19 mm; prevascular node (6:24) is 9 x
11 mm. Subcarinal node (6:23) is 17 x 22 mm. Left hilar node (6:23) is 15 x
32 mm. Second left hilar node, 6:24, is 19 x 22 mm; left paraesophageal node
(6:24) is 14 x 19 mm. Supradiaphragmatic node (6:35 has short axis of 5 mm).
Ascending aorta is top normal, measuring 3.7 cm, main pulmonary artery is
normal. Heart size is normal. Moderate-to-severe coronary artery
calcifications involve all three coronary arteries (6:26). There is no
pericardial effusion or pleural effusion.
Multiple hypodense liver lesions are described in report of concurrent CT
abdomen and pelvis, clip ___. Small hiatal hernia (6:39).
BONES: T2 and T9 lytic lesion with sclerotic margin (series 6: Image 6 and
37) are compatible with Schmorl's nodes.
LUNGS AND AIRWAYS: Airways are patent to the subsegmental level bilaterally.
Lobulated and irregularly marginated pleural-based solid nodule in the
posterobasal segment of the left lower lobe (7:184) is 3.4 x 5.3 cm, and
highly suspicious of metastatic lesion. 6 mm solid subpleural nodule is in the
right lower lobe (7:143). 10 x 12 mm solid nodule is in the apicoposterior
segment of the left upper lobe (7:79). These two nodules are also presumed
metastasis. Mild centrilobular emphysema, upper lobe predominant and mild
diffuse bronchial wall thickening are likely smoking related.
IMPRESSION:
1. Large 3.4 x 5.3 cm left lower lobe lesion, along with left upper lobe and
right lower lobe nodules are highly suspicious for metastatic disease.
2. Multiple enlarged left hilar, lower paratracheal and upper paratracheal
nodes are lymph node metastatic involvement.
3. There are no bone metastases.
4. Moderate-to-severe coronary artery calcification.
5. Mild centrilobular, paraseptal emphysema and mild diffuse bronchial
thickening are likely smoking related.
6. Please refer to concurrent CT abdomen and pelvis for detailed description
of abdominal findings.
Radiology Report
INDICATION: Left PICC placement.
COMPARISON: ___.
FINDINGS: Again seen is the opacity at the left medial lower hemithorax which
on prior study may represent a lesion at the costophrenic angle. The left
PICC ends in the left brachiocephalic vein. There may be mild increase in
interstitial markings. Heart size is normal. The cardiomediastinal and hilar
contours are normal. No pleural effusion or pneumothorax is seen.
IMPRESSION: Left PICC ends in the left brachiocephalic vein. Again seen is
opacity overlying the left lower hemithorax medially consistent with known
mass. Mild interstitial opacities are decreased from prior study and may
represent resolving edema.
Radiology Report
INDICATION: Left PICC.
COMPARISON: ___ at 12:24 p.m.
FINDINGS: The left PICC has been advanced and now ends at the confluence of
the left and right brachiocephalic veins. Lung volumes are significantly
lower, which crowd pulmonary vasculature. Previously seen mass at the left
lung base is not as well seen on this study due to the low lung volumes. The
cardiomediastinal and hilar contours are normal. There is no pneumothorax.
IMPRESSION: Left PICC now ends at the confluence of the brachiocephalic
veins.
Radiology Report
HISTORY: Power PICC exchange.
COMPARISON: Multiple prior chest radiographs, most recently ___ at
13:08.
FINDINGS:
Single frontal view of the chest. Left PICC terminates in the lower SVC.
Heart size and cardiomediastinal contours are stable. Lung volumes have
slightly improved, though still hypoinflated. There is bibasilar atelectasis
without focal consolidation, pleural effusion, or pneumothorax.
IMPRESSION:
Left PICC terminates in the lower SVC.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Question metastatic breast cancer to lungs and liver with new
hypoxia.
COMPARISONS: ___.
TECHNIQUE: Chest, portable AP semi-upright.
FINDINGS: A left-sided PICC line terminates at the cavoatrial junction. The
lung volumes are low with mild relative elevation of the right hemidiaphragm
that appears unchanged. The cardiac, mediastinal, and hilar contours appear
stable including mediastinal and left hilar lymphadenopathy. There is no
definite pleural effusion or pneumothorax. There is a persistent medial left
basilar opacity with a rounded contour, suggesting a pleural-based mass
concerning for malignancy. Smaller nodules are not well depicted on
radiographs.
IMPRESSION: Stable appearance of the chest including lymphadenopathy and a
left lower lobe opacity worrisome for malignancy.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: RUQ US with Doppler. Evaluate structure, bile ducts, patency
TECHNIQUE: Grey scale and Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LIVER: The liver has a markedly heterogeneous echotexture. Several hypoechoic
masses correspond to the diffuse metastases which were better seen on the
recent CT. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilatation. The CBD measures 7
mm.
LIVER DOPPLER:
PORTAL VEINS: The main, anterior right, and posterior right portal veins are
patent with normal color Doppler and appropriate hepatopetal flow. The no flow
in the left portal vein is visualized. This vessel is atretic on the recent
CT.
MAIN HEPATIC ARTERY: Patent with normal Doppler waveform.
HEPATIC VEINS: The right, middle, and left hepatic veins are patent with
appropriate hepatofugal flow.
IMPRESSION:
1. Diffusely infiltrative hepatic metastases were better delineated on recent
CT
2. No visualized flow in the left portal vein. This vessel, which was atretic
on the recent CT, is likely being compressed by adjacent metastases.
.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with OTHER MALAISE AND FATIGUE, HISTORY OF FALL, LONG TERM USE ANTIGOAGULANT
temperature: 98.4
heartrate: 92.0
resprate: 18.0
o2sat: 97.0
sbp: 131.0
dbp: 67.0
level of pain: 8
level of acuity: 2.0 | ___ with history of breast cancer (___), ovarian cancer (___),
Factor V Leiden on warfarin for history of two DVTs, and seizure
disorder with two recent falls who presented for concern of
metastatic malignancy. She was discharged home with hospice.
# Mental status changes. During admission, patient became more
restless and unable to concentrate or focus. She was
intermittently alert and oriented x3, and mental status waxed
and waned throughout the day. This was likely multifactorial and
may be related to hospital delirium, liver dysfunction due to
tumor burden, decreased clearance of sedating medications
(diazepam, narcotic pain meds), seizure disorder or possible
leptomeningeal disease (MRI negative). During admission she
developed new asterixis and abnormal lfts, most c/w greater
burden of disseminated intrahepatic disease than seen on
imaging. She was treated with lactulose with mild improvement.
No obvious infection was found. Neuro Oncology was consulted and
Dr. ___ the patient. MRI brain at OSH negative.
# Metastases to the lung and liver, new. Primary is unknown.
Based on history of breast and ovarian cancers, these are most
likely. However, given pace of disease, a more aggressive tumor
is favored. T
She was at high risk for clotting given her history of clots
and metastatic malignancy. Her warfarin was held, and she was
started on a heparin drip to prepare for liver biopsy to guide
further management. However, on day of biopsy, patient stated
she did not want any further diagnostic or therapeutic tests.
After discussion with her family, the patient changed her mind
and the biopsy was scheduled for the following day. On the day
of the rescheduled biopsy, the patient again stated she did not
was the procedure and wanted to go home. After a family
discussion, the biopsy was postponed until she felt better.
During the the rest of her admission, the goals of care changed
the biopsy was no longer pursued.
# Factor V Leiden on warfarin. She had supratherapeutic INR on
admission. INR 3.8 at OSH. INR 2.9 on admission here. Warfarin
was held. Heparin gtt was started. Liver biopsy was not
ultimately pursued. Given change in goals of care,
anticoagulation was discontinued.
# UTI. Complained of urinary frequency. She did have chief
complaint on admission of falls and balance issues. UA with
moderate bacteria, small leuks. UCx >100k pansensitive Ecoli.
She was treated with ceftriaxone 1g Q24H from ___ to ___.
Recheck of UA (given ongoing mental status changes) showed no
UTI.
# Hyponatremia. Resolved after 1L IVF. Serum and urine osm low.
Urine Na 24. Consistent with hypovolemic picture. Less
consistent with SIADH.
# Falls. This appeared to be mechanical in nature. Exam shows
full strength and mildly uncoordinated heel to shin on left. She
has intact sensation and no signs of cord compression or cauda
equina on exam. She would require MRI imaging or a bone scan to
evaluate for bony disease. Physical Therapy recommended patient
be discharged to rehab. Her goals of care changed, and she was
discharged to home with hospice.
# Seizure disorder: No seizures since ___. Continue home
phenobarbital and phenytoin. Drug levels were within normal
range.
ACCESS: ___ placed ___ and removed on ___ on discharge
EMERGENCY CONTACT:
Next of Kin: ___
Relationship: DAUGHTER
Phone: ___
Other Phone: ___
### TRANSITIONAL ISSUES ###
-Home with hospice.
-Symptomatic medications - olanzapine, morphine, scopolamine,
lidocaine patch.
-Avoid hepatically-cleared medications given ongoing
encephalopathy.
-Anticoaguation discontinued given hospice goals.
-Inpatient neurologist Dr. ___ these changes to
reduce sedation, but we will defer to outpatient neurologist:
- stop Phenytoin Sodium Extended 400 mg PO HS
- start Phenytoin 150mg in the morning and 200mg at bedtime |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Bronchoscopy with tracheal dilitation with IP ___
History of Present Illness:
Ms. ___ is a ___ ___ speaking lady with idiopathic
tracheal stenosis s/p multiple silicone stent placement,
removal, and revisions (last on ___ with multiple admissions
for dyspnea presenting with dyspnea.
Patient has chronic tracheal stenosis s/p multiple silicone
stent placement/removal/revision (atleast 3 times), most
recently stent removed on ___ by Dr. ___. Her
procedure was without complication and since discharge she felt
well without dyspnea for nearly 3 weeks-able to climb a flight
of stairs slowly and manage household activities. Two days PTA,
she felt SOB with neck tightness similar to prior episodes of
tracheal stenosis. Also had increased work of breathing, back
soreness with inspiration without improvement with albuterol
nebs, ankle edema despite daily lasix. Her chronic yellow sputum
stopped with onset of dyspnea.
No fevers, chills, rhinorrhea, sore throat, sinus congestion,
hemoptysis, chest pain, orthopnea, or other complaints.
Patient initially went to ___ ED and was transferred without
paperwork. Per ___ ED and patient, at ___ she had stable
vitals (98-99% sats) but stridor on forced inspiration. Labwork
showed slightly elevated D-dimer but low suspicion for PE. She
was given an intramuscular injection (possibly steroid) with
mild improvement but no improvement with nebulizer treatment.
Then transferred to ___ for continuity of care.
In the ED, initial vitals: T 97.9, HR 75, BP 118/65, RR18, 100%
RA
Noted to have mild inspiratory stridor. Consulted interventional
pulmonology who asked for duonebs q6h and steroids. CT chest
showed recurrent stenosis. NPO at midnight. Also given 1L NS. No
antibiotics.
On transfer, vitals were: T98.7, HR78, BP134/85, RR21,
On arrival to the MICU, patient was resting comfortabley in bed
talking on her cell phone.
Past Medical History:
Idiopathic tracheal stenosis
Asthma
Depression
s/p bilateral tubal ligation
History of Tracheal Stenosis
============================
___ Cervical tracheal resection and reconstructive.
___: Balloon dilatation, Application of ciprodex, Rigid
Dilatation
___: Rigid tracheoscopy Flexible bronchoscopy Tracheal 12x30
mm silicone stent placed and fixed with prolene
___: follow up bronchoscopy no intervention
___: Cryodebridment was used to remove the granulation
tissue at the distal end of the stent
___: Granulation tissue was removed with cryo debridement
and
flexible forceps
___: Underwent mechanical tumor destruction of granulation
tissue with cryotherapy and flexible forceps. This was followed
by intralesional solumedrol injection 30mg x3 (___). This was
followed by balloon dilatation 13.5 mm x3 and silicone stent
placement in the proximal trachea (12x30 mm), which was
externally fixated using a 0 prolene suture.
___: The cryotherapy probe was advanced and cryotherapy was
applied to the granulation tissue with 3 rounds of 20 seconds of
freezing for tumor destruction.
___ and mechanical debridement were used to
remove granulation tissue at the distal end of the tracheal
stent. Therapeutic aspiration of secretions was performed at the
proximal end of the stent
___ Flexible bronchoscope was inserted through LMA and airway
examined revealing well positioned stent with no granulation
tissue at either end of the stent. Lesion (likely granulation
tissue) was visualized at the main carina. No other
abnormalities
seen. Thin secretions suctioned. Then mechanical debridement of
granulation tissue was performed with flexible forceps.
___: Airway exam notable for stent in good positioning,
with mild surrounding granulation tissue and thick secretions.
Tracheal wash performed and sent for micro studies. Granulation
tissue cleaned with cytology brush and forcep debridement.
Therapeutic aspiration of secretions.
Social History:
___
Family History:
There is no history of lung or airway disease.
Physical Exam:
Admission Physical Exam
PHYSICAL EXAM:
Vitals: T:98.5 BP:111/66 P:84 R: 18 O2:97%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Horizontal scar abovesternal notch well healed, supple,
JVP not appreciated, no LAD
LUNGS: Bronchial breath sounds throughout, no wheezes, rales
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, mild pitting edema to mid
calf, no clubbing, cyanosis
SKIN: Intact, no rashes or bruising
NEURO: CN ___ Grossly intact, PERRL, Strength grossly ___ UE
and ___, sensation intact to light touch
Discharge Physical Exam
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Horizontal scar abovesternal notch well healed, supple,
JVP not appreciated, no LAD
LUNGS: CTAB
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, mild pitting edema to mid
calf, no clubbing, cyanosis
SKIN: Intact, no rashes or bruising
NEURO: CN ___ Grossly intact, PERRL, Strength grossly ___ UE
and ___, sensation intact to light touch
Pertinent Results:
___ 04:30PM GLUCOSE-128* UREA N-12 CREAT-0.7 SODIUM-137
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-22 ANION GAP-16
___ 04:30PM WBC-9.3 RBC-4.78 HGB-12.8 HCT-40.1 MCV-84
MCH-26.8 MCHC-31.9* RDW-14.1 RDWSD-43.0
___ 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 04:30PM URINE RBC-4* WBC-32* BACTERIA-NONE YEAST-NONE
EPI-10
CT Scan ___:
1. Status post tracheal stent removal with recurrent tracheal
stenosis,
beginning approximately 2.5 cm below the level of the vocal
cords and spanning
a craniocaudal dimension of 3 cm. There is associated marked
circumferential
but smooth tracheal wall thickening at the level of the
stenosis, and
differentiating tracheal wall thickening from granulation tissue
is difficult
to determine on this examination. Minimal linear tracheal
secretion is noted
and the distal airways remain patent.
2. Enlarged, nodular thyroid, as seen previously. As seen
previously, the
inferior aspect of the thyroid encircles the anterior aspect of
the trachea at
the superior aspect of the tracheal stenosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetylcysteine 20% ___ mL NEB Q12H
2. Albuterol Inhaler 2 PUFF IH BID
3. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. HydrOXYzine 50 mg PO QID:PRN allergies
6. Omeprazole 40 mg PO BID
7. Sertraline 100 mg PO DAILY
8. TraZODone 50 mg PO QHS:PRN sleep
9. Guaifenesin ER 1200 mg PO Q12H
10. sodium chloride 0.9 % inhalation Q6H
11. sodium chloride 3.5 % inhalation Q12H
Discharge Medications:
1. Acetylcysteine 20% ___ mL NEB Q12H
2. Albuterol Inhaler 2 PUFF IH BID
3. Guaifenesin ER 1200 mg PO Q12H
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. HydrOXYzine 50 mg PO QID:PRN allergies
6. Omeprazole 40 mg PO BID
7. Sertraline 100 mg PO DAILY
8. TraZODone 50 mg PO QHS:PRN sleep
9. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
10. sodium chloride 0.9 % inhalation Q6H
11. Sodium Chloride 3.5 % INHALATION Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Idiopathic Tracheal Stenosis
Secondary Diagnosis:
- Asthma
- Depression
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/O CONTRAST
INDICATION: ___ year old woman with tracheal stenosis and recent stent removal
presents with dyspnea
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.
Images were obtained at end inspiration.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.0 s, 39.1 cm; CTDIvol = 18.0 mGy (Body) DLP = 704.2
mGy-cm.
Total DLP (Body) = 704 mGy-cm.
COMPARISON: CT trachea dated ___, CT chest dated ___.
FINDINGS:
The thyroid is heterogeneous and diffusely enlarged with a dominant 1.0 cm
hypodense nodule in the right lobe (03:21), unchanged from ___. As before,
the inferior aspect of the thyroid encircles the anterior aspect of the
trachea. Supraclavicular, axillary, mediastinal and hilar lymph nodes are not
enlarged. Aorta and pulmonary arteries are normal size. Cardiac configuration
is normal and there is no appreciable coronary artery calcification.
There is no evidence of pericardial effusion. No pneumothorax or pleural
effusion is identified. Lung windows demonstrate mild dependent bibasilar
atelectasis.
The patient is status post interval removal of a tracheal stent. At
approximately 2.5 cm below the level of the vocal cords, there is a 3 cm long
segment of relatively smooth tracheal narrowing with associated marked
circumferential wall thickening, measuring up to 6 mm in thickness. The
minimum diameter of the tracheal lumen is noted to be 5 mm within the stenotic
segment (4:85) with a cross-sectional diameter of 50 mm2, as compared to 15 mm
more inferiorly at the level of the aortic arch with a cross sectional
diameter of 211 mm2. While the majority of the tracheal narrowing is smooth,
a single focal linear opacity within the left lateral aspect of the tracheal
lumen may reflect linear secretion (4:93). Otherwise, no additional
endoluminal secretions are identified. Remainder of the airways are patent to
the level of the segmental bronchi bilaterally.
No suspicious osseous lesions are identified. This examination is not tailored
for the evaluation of subdiaphragmatic contents. Within this limitation, the
included portions of the upper abdomen demonstrate a small hiatal hernia and
diffuse low-attenuation of the liver.
IMPRESSION:
1. Status post tracheal stent removal with recurrent tracheal stenosis,
beginning approximately 2.5 cm below the level of the vocal cords and spanning
a craniocaudal dimension of 3 cm. There is associated marked circumferential
but smooth tracheal wall thickening at the level of the stenosis, and
differentiating tracheal wall thickening from granulation tissue is difficult
to determine on this examination. Minimal linear tracheal secretion is noted
and the distal airways remain patent.
2. Enlarged, nodular thyroid, as seen previously. As seen previously, the
inferior aspect of the thyroid encircles the anterior aspect of the trachea at
the superior aspect of the tracheal stenosis.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with OTHER DISEASES OF TRACHEA AND BRONCHUS, ASTHMA, UNSPECIFIED, HYPERTENSION NOS
temperature: 97.2
heartrate: 62.0
resprate: 16.0
o2sat: 99.0
sbp: 121.0
dbp: 97.0
level of pain: 0
level of acuity: 2.0 | BRIEF HOSPITAL COURSE
___ old never smoker with known idiopathic tracheal stenosis
s/p cervical tracheal resection and resconstruction in ___,
silicone stent placement and removal at least three times, last
removal ___ complicated by granulation tissue
requiring multipledebridements, who presents with progressive
dyspnea similar to prior episodes of tracheal stenosis. A CT was
performed which confirmed a diagnosis of re-stenosis. The
patient underwent flexible bronchoscopy on ___, with serial
tracheal dilations. No stent was placed. The patient with plan
to followup in the operating room in ___ days for possible
cryotherapy. Her home medications for asthma and depression were
continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
? antihistamine / demedrol
Attending: ___.
Chief Complaint:
acute pe
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ visiting from ___ who experienced several days of
sub-xyphoid discomfort as well as two weeks of L sided chest
discomfort. Her pain was not pleuritic or worsened by activity
or position. SHe has a chronic cough that is unchanged. She
has not had SOB, DOE, dizziness, palpitations, fever or weight
loss. She has not had hemoptysis. She flew in from ___ in
___ and has not had any prolonged immobility since that
flight and she walked on the flight in the aisle. She noticed
some bilateral mild ankle edema after the flight that has since
improved. She presented to the ED with the above symptoms and
torso CTA disclosed a L main to segmental non-occlussive PE and
Left lower lobe bronchiectasis. She received IV heparin.
13pt ROS otherwise negative. no past h/o PE, no h/o recent
surgery, has not had colonoscopy before, no easy bruising or
bleeding or rectal bleeding, no sore throat, no recent
vomitting, walks 10,000 steps daily, very active physically
Past Medical History:
no chronic illnesses
hospitalized in ___ for a variety of acute infections
including
influenza
appendicitis s/p appendectomy
ovarian abscess s/p oopherectomy
sepsis
hernia repair
HCV
Social History:
___
Family History:
no FH of blood clots or cancer
mother, father deceased with MI
Physical Exam:
118/72 72 99% RA
calm, cooperative, not confused, interviewed in presence of
___ interpreter
face symmetric
symmetric mobile <1cm submandibular lymphadenopathy, not tender
or fixed, otherwise no palpable adenopathy in remainder of neck,
axilla or groin
slight erythema in back of pharynx without exudate
L basal crackles
no wheezes
regular s1 and s2
no hepato-splenomegaly
no peripheral edema
some dry patch/red on R cheek
99%RA
few insp crackles at L base
maintains full conversation
not dyspnic
regular pulse
Pertinent Results:
___ 09:47PM BLOOD WBC-7.3 RBC-3.92* Hgb-13.6 Hct-38.8
MCV-99* MCH-34.6* MCHC-35.0 RDW-14.1 Plt ___
___ 09:47PM BLOOD Glucose-93 UreaN-13 Creat-1.2* Na-138
K-4.2 Cl-99 HCO3-26 AnGap-17
___ 09:47PM BLOOD ALT-37 AST-70* AlkPhos-60 TotBili-0.9
___ 09:47PM BLOOD Lipase-59
___ 09:47PM BLOOD Albumin-4.6
Final Report
EXAMINATION: CTA chest and CT abdomen and pelvis with contrast
INDICATION: Wedge-shaped density in the left base on
radiograph. Epigastric
pain with radiation to the back and left side. Nausea without
emesis.
TECHNIQUE: Axial helical multi detector CT images were acquired
of the chest,
abdomen and pelvis after the intravenous administration of
contrast. Chest
images were acquired in the arterial phase. Abdomen and pelvis
images were
acquired in the portal venous phase. Multiplanar reformats were
generated in
the coronal and sagittal planes. Chest images were additionally
reformatted
into bilateral oblique maximum intensity projection images.
DOSE: 767.29 mGy cm
COMPARISON: Chest radiograph ___.
FINDINGS:
CTA chest: The thyroid is not evaluable due to extensive beam
hardening
artifact from adjacent venous contrast material.
Heart size is normal with trace pericardial fluid. Thoracic
aortic arch and
main pulmonary arteries are normal caliber. No evidence of
aortic dissection
or aneurysm. Nonobstructive pulmonary embolus leads from the
distal left main
pulmonary artery into the mid left lower lobar pulmonary artery
(28:49, 50,
51, 601b:34 though the distal branches are well opacified.
Remainder of the
pulmonary tree is well opacified to the subsegmental level
without evidence of
additional embolic focus. No CT evidence of right heart strain.
Supraclavicular, axillary, hilar and mediastinal lymph nodes are
not
pathologically enlarged.
Distal bilateral lower lobe bronchi are mildly ectatic, with
mild segmental
bronchiectasis in the left lower lobe. There are scattered areas
of left lower
lobe segmental airways bronchial impaction with surrounding
peribronchial
consolidation and ground-glass in. Right base atelectasis is
trace. No
pulmonary infarct. Two subpleural nodules in the anterior
segment of the right
upper lobe measure 3 mm (3:114, 121). Tree in ___ nodularity is
peripherally
focal in the posterior base of the right upper lobe (3:99). No
pleural
effusion or pneumothorax.
Hiatal hernia is small. Esophagus is mildly ectatic.
CT abdomen with contrast: Liver enhances homogeneously without
focal mass or
biliary dilatation. Gallbladder is normal. Portal vein is
patent.
Spleen, pancreas and adrenal glands are normal.
Kidneys present symmetric nephrograms and excretion of contrast
without focal
mass, hydronephrosis or perinephric abnormality.
Stomach, duodenum and remainder of the small bowel is normal
caliber without
obstruction. Sigmoid colon is redundant. Large bowel is
collapsed distally,
thin walled without pericolonic fat stranding or fluid
collection.
Abdominal aorta is normal caliber with focally moderate as
sclerotic calcific
burden distally into the iliacs. Mesenteric and retroperitoneal
lymph nodes
are not enlarged. Diffuse mesenteric fat stranding is in keeping
with the
superficial soft tissue fat stranding compatible with trace
anasarca. No
ascites, pneumoperitoneum or ventral abdominal hernia.
CT pelvis with contrast: Bladder is prominently distended.
Uterus and rectum
are unremarkable. Ovaries are not definitively characterized. No
free pelvic
fluid or air. Inguinal and pelvic sidewall lymph nodes are not
enlarged.
Calcifications in the gluteal soft tissues are consistent with
injection
granuloma.
Bones and soft tissues: Vertebral body hemangioma involves the
T6 vertebral
body. No suspicious focal bone lesion. Thoracolumbar
degenerative changes are
focally moderate in the lumbar spine, most prominent at L5-S1.
Thoracic
dextrocurvature is minimal. Lumbar levocurvature is minimal.
IMPRESSION:
1. Nonobstructing pulmonary embolus extending from the distal
left main
pulmonary artery to the distal left lower lobar pulmonary
artery. No
associated pulmonary infarct. No CT evidence of right heart
strain.
2. No acute aortic abnormality.
3. Left lower lobe bronchiectasis with focal areas of mucous
impaction and
peribronchial consolidations along with ___ nodularity
at the base of
the right upper lobe in the setting of a small hiatal hernia
with mildly
ectatic esophagus, this most likely represents multifocal
aspiration
pneumonia. Ectatic esophagus and hiatal hernia can be further
evaluated with
nonemergent barium esophagram, if clinically indicated.
4. Two 3 mm subpleural nodules in the right upper lobe lack
suspicious
features. These do not require followup in the absence of high
risk factors.
If high risk factors, such as smoking are present, followup CT
in ___ year is
advised per ___ recommendations.
5. No acute findings in the abdomen or pelvis.
6. Trace, diffuse mesenteric fat and superficial soft tissue
stranding,
consistent with trace anasarca.
7. Prominent bladder distension. Correlate clinically to exclude
neurogenic
bladder.
8. Trace S shaped thoracolumbar curvature.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
bid with food for 21 days, then 20mg tablet with dinner for 6
months
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth use as directed on packet Disp #*1 Dose Pack Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA chest and CT abdomen and pelvis with contrast
INDICATION: Wedge-shaped density in the left base on radiograph. Epigastric
pain with radiation to the back and left side. Nausea without emesis.
TECHNIQUE: Axial helical multi detector CT images were acquired of the chest,
abdomen and pelvis after the intravenous administration of contrast. Chest
images were acquired in the arterial phase. Abdomen and pelvis images were
acquired in the portal venous phase. Multiplanar reformats were generated in
the coronal and sagittal planes. Chest images were additionally reformatted
into bilateral oblique maximum intensity projection images.
DOSE: 767.29 mGy cm
COMPARISON: Chest radiograph ___.
FINDINGS:
CTA chest: The thyroid is not evaluable due to extensive beam hardening
artifact from adjacent venous contrast material.
Heart size is normal with trace pericardial fluid. Thoracic aortic arch and
main pulmonary arteries are normal caliber. No evidence of aortic dissection
or aneurysm. Nonobstructive pulmonary embolus leads from the distal left main
pulmonary artery into the mid left lower lobar pulmonary artery (28:49, 50,
51, 601b:34 though the distal branches are well opacified. Remainder of the
pulmonary tree is well opacified to the subsegmental level without evidence of
additional embolic focus. No CT evidence of right heart strain.
Supraclavicular, axillary, hilar and mediastinal lymph nodes are not
pathologically enlarged.
Distal bilateral lower lobe bronchi are mildly ectatic, with mild segmental
bronchiectasis in the left lower lobe. There are scattered areas of left lower
lobe segmental airways bronchial impaction with surrounding peribronchial
consolidation and ground-glass in. Right base atelectasis is trace. No
pulmonary infarct. Two subpleural nodules in the anterior segment of the right
upper lobe measure 3 mm (3:114, 121). Tree in ___ nodularity is peripherally
focal in the posterior base of the right upper lobe (3:99). No pleural
effusion or pneumothorax.
Hiatal hernia is small. Esophagus is mildly ectatic.
CT abdomen with contrast: Liver enhances homogeneously without focal mass or
biliary dilatation. Gallbladder is normal. Portal vein is patent.
Spleen, pancreas and adrenal glands are normal.
Kidneys present symmetric nephrograms and excretion of contrast without focal
mass, hydronephrosis or perinephric abnormality.
Stomach, duodenum and remainder of the small bowel is normal caliber without
obstruction. Sigmoid colon is redundant. Large bowel is collapsed distally,
thin walled without pericolonic fat stranding or fluid collection.
Abdominal aorta is normal caliber with focally moderate as sclerotic calcific
burden distally into the iliacs. Mesenteric and retroperitoneal lymph nodes
are not enlarged. Diffuse mesenteric fat stranding is in keeping with the
superficial soft tissue fat stranding compatible with trace anasarca. No
ascites, pneumoperitoneum or ventral abdominal hernia.
CT pelvis with contrast: Bladder is prominently distended. Uterus and rectum
are unremarkable. Ovaries are not definitively characterized. No free pelvic
fluid or air. Inguinal and pelvic sidewall lymph nodes are not enlarged.
Calcifications in the gluteal soft tissues are consistent with injection
granuloma.
Bones and soft tissues: Vertebral body hemangioma involves the T6 vertebral
body. No suspicious focal bone lesion. Thoracolumbar degenerative changes are
focally moderate in the lumbar spine, most prominent at L5-S1. Thoracic
dextrocurvature is minimal. Lumbar levocurvature is minimal.
IMPRESSION:
1. Nonobstructing pulmonary embolus extending from the distal left main
pulmonary artery to the distal left lower lobar pulmonary artery. No
associated pulmonary infarct. No CT evidence of right heart strain.
2. No acute aortic abnormality.
3. Left lower lobe bronchiectasis with focal areas of mucous impaction and
peribronchial consolidations along with ___ nodularity at the base of
the right upper lobe in the setting of a small hiatal hernia with mildly
ectatic esophagus, this most likely represents multifocal aspiration
pneumonia. Ectatic esophagus and hiatal hernia can be further evaluated with
nonemergent barium esophagram, if clinically indicated.
4. Two 3 mm subpleural nodules in the right upper lobe lack suspicious
features. These do not require followup in the absence of high risk factors.
If high risk factors, such as smoking are present, followup CT in ___ year is
advised per ___ society recommendations.
5. No acute findings in the abdomen or pelvis.
6. Trace, diffuse mesenteric fat and superficial soft tissue stranding,
consistent with trace anasarca.
7. Prominent bladder distension. Correlate clinically to exclude neurogenic
bladder.
8. Trace S shaped thoracolumbar curvature.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Epigastric pain
Diagnosed with CHEST PAIN NOS, ABDOMINAL PAIN OTHER SPECIED
temperature: 97.9
heartrate: 67.0
resprate: 18.0
o2sat: 97.0
sbp: 187.0
dbp: 103.0
level of pain: 5
level of acuity: 3.0 | ___ with acute pulmonary embolism. This is likely cause of her
symptoms of chest pain. She also has a pattern of bronchiectasis
on CT chest, but describes a chronic unchanged cough and is
without fever or worsened breathing.
#PE
The most notable risk factor for PE is airplane travel but that
was over 2 months ago. She flew from ___ to ___ 2 months
ago and then spent 8 hours in a car driving to ___ 8 days
before admission. Immediate work up for inheritable
hypercoagulable states would not change immediate management.
Since she has not had colonoscopy before, she should undergo
colon cancer screening in future. No clinical evidence of
right heart strain so no echo performed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Ambien / shellfish derived
Attending: ___.
Chief Complaint:
Found down at home
Major Surgical or Invasive Procedure:
___ Right upper extremity PICC line placement
History of Present Illness:
Mr. ___ is a ___ year old male with a history of advanced
dementia who was found down at home with a fever and abdominal
tenderness and brought to ___. His trauma
work up included a CT abdomen/pelvis which showed inflammation
and stranding around the left iliac artery at site of prior
external iliac to femoral bypass graft. He was transferred to
___ in ___ and admitted to
the vascular surgery service.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Systolic Heart failure- (LVEF = 35 %) ___
- CAD s/p CABG in ___
- Mitral Valve replacement due to severe MR in ___
(Bioprosthetic)
- Syncopal episode leading to MVA. Suspected to be due to VT/VF
s/p dual chamber ICD at ___ in ___.
- Atrial fibrillation s/p AV junctional ablation and placement
of a biventricular ICD device in ___
3. OTHER PAST MEDICAL HISTORY
- Hypothyroid
- Cholelithiasis
- Anemia
- PVD / Femoral aneurysm
- OSA on home CPAP
- Depression
- Cervical spondylosis
- Gout
- Sigmoid diverticulitis
PAST SURGICAL HISTORY:
- EVAR ___ coil embolization ___
- Left external iliac to femoral bifurcation bypass ___.
- CABG ___
- MVR ___ Bioprosthetic
- B/l cataracts
- Dual chamber ICD ___ (___)
- Trach/PEG s/p MVC ___, now removed
Social History:
___
Family History:
father with cardiac disease, specifics unknown
Physical Exam:
PHYSICAL EXAM:
VS - 98.2, 78, 152/69, 18, 100% RA
GEN: NAD, comfortable
ABD: Soft, non-tender
EXT: Warm, no edema
PULSES: fem / pop / DP / ___
R - p p p p
L - p p p p
Pertinent Results:
LABS:
___ 04:21AM BLOOD WBC-5.2 RBC-2.60* Hgb-8.0* Hct-25.1*
MCV-97 MCH-30.8 MCHC-31.9* RDW-14.6 RDWSD-51.1* Plt ___
___ 06:00AM BLOOD WBC-5.5 RBC-2.63* Hgb-8.1* Hct-25.1*
MCV-95 MCH-30.8 MCHC-32.3 RDW-14.6 RDWSD-50.6* Plt ___
___ 07:20AM BLOOD WBC-4.9 RBC-2.72* Hgb-8.5* Hct-26.2*
MCV-96 MCH-31.3 MCHC-32.4 RDW-14.5 RDWSD-51.0* Plt ___
___ 11:10AM BLOOD Hct-25.5*
___ 07:00AM BLOOD WBC-4.0 RBC-2.49*# Hgb-7.8*# Hct-23.4*#
MCV-94# MCH-31.3 MCHC-33.3 RDW-14.3 RDWSD-49.2* Plt ___
___ 06:00AM BLOOD WBC-6.4 RBC-3.41*# Hgb-10.7*# Hct-35.3*#
MCV-104*# MCH-31.4 MCHC-30.3* RDW-14.7 RDWSD-56.1* Plt ___
___ 06:01AM BLOOD Hct-24.4*
___ 02:12AM BLOOD WBC-5.3 RBC-2.32* Hgb-7.3* Hct-22.2*
MCV-96 MCH-31.5 MCHC-32.9 RDW-14.6 RDWSD-50.9* Plt ___
___ 01:31PM BLOOD Hct-24.2*
___ 08:20PM BLOOD WBC-8.0 RBC-3.34*# Hgb-10.3* Hct-32.6*#
MCV-98 MCH-30.8 MCHC-31.6* RDW-14.6 RDWSD-52.5* Plt ___
___ 04:21AM BLOOD Glucose-96 UreaN-13 Creat-1.5* Na-144
K-3.6 Cl-109* HCO3-20* AnGap-19
___ 06:00AM BLOOD Glucose-118* UreaN-13 Creat-1.4* Na-145
K-3.6 Cl-111* HCO3-21* AnGap-17
___ 07:20AM BLOOD Glucose-130* UreaN-14 Creat-1.5* Na-145
K-3.9 Cl-110* HCO3-22 AnGap-17
___ 03:20PM BLOOD Glucose-97 UreaN-15 Creat-1.2 Na-142
K-3.6 Cl-110* HCO3-23 AnGap-13
___ 07:00AM BLOOD Glucose-116* UreaN-14 Creat-1.2 Na-140
K-2.8* Cl-108 HCO3-21* AnGap-14
___ 06:00AM BLOOD Glucose-149* UreaN-19 Creat-1.1 Na-140
K-3.5 Cl-110* HCO3-16* AnGap-18
___ 02:12AM BLOOD Glucose-122* UreaN-23* Creat-1.3* Na-144
K-3.7 Cl-113* HCO3-17* AnGap-18
___ 11:46AM BLOOD UreaN-23* Creat-1.0 K-3.7
___ 03:40AM BLOOD Glucose-129* UreaN-31* Creat-1.6* Na-141
K-2.7* Cl-111* HCO3-17* AnGap-16
___ 08:20PM BLOOD Glucose-162* UreaN-34* Creat-1.6* Na-137
K-4.0 Cl-103 HCO3-17* AnGap-21*
IMAGING:
___ CT abdomen/pelvis: Patient is status post
aortobi-iliac graft. Adjacent to the right proximal common
iliac artery and stent just distal to the aortic bifurcation,
there is a circumferential intermediate density rounded area
with significant peripheral stranding suspicious for impending
rupture. However, assessment for a leak or active extravasation
is limited on this study due to poor contrast timing.
___ CT abdomen/pelvis:
1. Unchanged appearance of small circumferential fluid around
common iliac
artery grafts site with adjacent fatty stranding concerning for
graft site
infection.
2. Patient is status post aorta bi-iliac stent graft placement
with no
evidence of leak or rupture.
3. Diverticulosis without diverticulitis.
___ Chest Xray: Right PICC terminates at the cavoatrial
junction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Pravastatin 40 mg PO QAM
5. Tamsulosin 0.4 mg PO DAILY
6. Torsemide 10 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Ferrous Sulfate 325 mg PO BID
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Rivaroxaban 15 mg PO DAILY
Discharge Medications:
1. Nafcillin 2 g IV Q4H
2. Torsemide 30 mg PO DAILY
RX *torsemide 10 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
3. Allopurinol ___ mg PO DAILY
4. Ferrous Sulfate 325 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Pravastatin 40 mg PO QAM
10. Rivaroxaban 15 mg PO DAILY
11. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Suspected infection of left external iliac to femoral
bifurcation bypass graft
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old man with abdominal pain// eval for abscess around old
iliac stent/graft
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 3.1 s, 48.7 cm; CTDIvol =
2.5 mGy (Body) DLP = 122.5 mGy-cm. 2) Spiral Acquisition 3.1 s, 48.7 cm;
CTDIvol = 11.8 mGy (Body) DLP = 572.6 mGy-cm. 3) Stationary Acquisition 7.1 s,
0.5 cm; CTDIvol = 31.1 mGy (Body) DLP = 15.6 mGy-cm. Total DLP (Body) = 711
mGy-cm.
COMPARISON: CTA abdomen pelvis from ___
FINDINGS:
VASCULAR:
There is an infrarenal aortic aneurysm measuring up to 3.5 x 3.4 cm, status
post aorto bi-iliac stent graft placement which is not seen be changed in
appearance from prior study without evidence of leak or rupture with patency
throughout the lower aorta and bilateral common iliac arteries. There is
persistent circumferential fluid layer surrounding the right common iliac
graft site with adjacent fatty stranding concerning for graft site infection
(3:90) and not significantly changed from prior study. This celiac axis, SMA,
___, and bilateral renal arteries are widely patent without evidence of focal
stenosis or occlusion. There is moderate calcium burden in the abdominal aorta
and great abdominal arteries.
LOWER CHEST: There are small bilateral pleural effusions with adjacent
atelectasis. There is no pleural or pericardial effusion. Median sternotomy
wires are seen about the lower chest wall.
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 contains stones, without
evidence of gallbladder wall thickening or pericholecystic fluid.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is enlarged measuring 15.1 cm, but with normal attenuation
throughout, and without evidence of focal lesions. Significant calcifications
are seen within the splenic artery
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 are bilateral simple renal cysts measuring up to 2.5 cm in the right
lower pole and up to 2.4 cm left lower pole. There is no evidence of
hydronephrosis. There are no urothelial lesions in the kidneys or ureters.
There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is diverticulosis without evidence of bowel
wall thickening or adjacent fatty stranding. Appendix contains air, has
normal caliber without evidence of fat stranding. There is no evidence of
mesenteric lymphadenopathy.
RETROPERITONEUM: There is a small simple fluid collection in the
retroperitoneum appears slightly greater than prior study (3:85). There is no
evidence of retroperitoneal lymphadenopathy.
PELVIS: Small foci of air are seen within the bladder lumen likely secondary
to interval placement of indwelling Foley catheter. There is no evidence of
pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
BONES: Patient is status post rod and femoral neck screw fixation of the left
proximal femur with adjacent heterotopic ossification and no definite evidence
of hardware related complications. Multilevel degenerative changes are seen
in the lumbar spine without evidence of worrisome osseous lesions or acute
fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Unchanged appearance of small circumferential fluid around common iliac
artery grafts site with adjacent fatty stranding concerning for graft site
infection.
2. Patient is status post aorta bi-iliac stent graft placement with no
evidence of leak or rupture.
3. Diverticulosis without diverticulitis.
Radiology Report
INDICATION: ___ year old man with picc// s/p r 37cm picc ___ ___ Contact
name: ___: ___
TECHNIQUE: Frontal view of the chest
COMPARISON: Chest radiograph from outside hospital ___
FINDINGS:
Right PICC terminates at the cavoatrial junction. Left pectoral pacemaker and
its leads are in unchanged positions. Sternotomy wires are intact. Mildly
prominent pulmonary vessels, heart size are similar to before. There is no
consolidation, pneumothorax, or large pleural effusion.
IMPRESSION:
Right PICC terminates at the cavoatrial junction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Transfer
Diagnosed with Infect/inflm react d/t oth cardi/vasc dev/implnt/grft, init, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 99.9
heartrate: 80.0
resprate: 16.0
o2sat: 99.0
sbp: 151.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old male with a history of advanced
dementia who was found down at home with a fever and abdominal
tenderness and brought to ___. His trauma
work up included a CT abdomen/pelvis which showed inflammation
and stranding around the left iliac artery at site of prior
external iliac to femoral bypass graft.
He was transferred to ___ in
___ and admitted to the vascular surgery service. His home
xarelto was initially held due to concern for possible bleed. He
was started on broad spectrum intravenous antibiotics and was
eventually narrowed to nafcillin when his cultures resulted
positive for MSSA. Repeat CTA of his abdomen/pelvis was stable.
He had a transesophageal echocardiogram which was negative for
signs of infection of his artificial mitral valve or pacemaker
leads. A right upper extremity PICC line was placed for
long-term intravenous antibiotics. His Xarelto was restarted on
___.
He was able to tolerate a regular diet, get out of bed and
ambulate without assistance, void without issues, and pain was
controlled on oral medications alone. He was deemed ready for
discharge, and was given the appropriate discharge and follow-up
instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
1) Headache
2) Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with
metastatic renal cell carcinoma currently on nivolumab (S/p 3
cycles) with progressive disease. In early ___, he was found to
have B/l pulmonary embolism when he presented with shortness of
breath at ___. He was initiated on therapeutic
enoxaparin 150 mg BID (1 mg/kg BID). About two weeks ago, with
progressive shortness of breath, he was admitted to ___ and found to have severe volume overload. He was
diuresed over 15 pounds and discharged on oral lasix. In the
last
two weeks he has developed new neurologic symptoms. He describes
headaches off-and-on, but mainly morning, sometimes associated
with fogginess or confusion. He has also had occasional blurry
of
vision, although he can not describe if it is restricted to one
eye or a particular visual field. He also describes a sensation
of his tongue being thick and weak. He finds it relatively
difficult to speak. He has also had some dysphagia, although no
episodes of coughing, choking on food or water/liquids. In the
past week, he has also had bladder symptoms, particularly
decreased control and urge incontinence. He denies any bowel
incontinence. He denies any facial droop/weakness, muscle or
limb
weakness, gait problems, cognitive issues, falls. He has had
some
numbess over the left thigh, infrequently, but no other
peripheral neuropathy.
His respiratory symptoms are somewhat improved since his last
admission, but they are worse today. He has not taken his lasix
today. He has been having increased wheezing and has significant
limitation of activity due to shortness of breath. He denies
orthopnea or PND. He has not had chest pain, although he has
some
localized rib tenderness. He denies any cough. After using his
nebs in the morning, he brings out small quantity of sputum,
which is blood tinged. Today, it was bright red, although small
in quantity. He has not had any hemoptysis since then.
He denies any fevers, sweats, anorexia, weight loss, nausea,
vomiting, abdominal pain. He has bone pain, which is stable. He
has constipation from opioids, stable as well. He denies
lightheadedness or dizziness or presyncopal symptoms.
He was scheduled to have MRI head today, but given worsening of
his symptoms, he has been admitted for expediting his management
plan.
Review of symptoms - A comprehensive review of systems is
otherwise negative
Past Medical History:
Past oncologic history - Mr. ___ presented in ___
with
left flank pain and gross hematuria. CT scan revealeD a 7-8 cm
left kidney mass with associated lymphadenopathy. Chest imaging
revealed pulmonary nodules suggestive of metastatic disease. On
___, he underwent left radical nephrectomy at ___. Pathology revealed a 13.5 cm mass, ___ grade III,
clear cell histology with negative margins. He enrolled in the
ARGOS trial involving dendritic cell vaccine and sunitinib. He
received four dendritic cell vaccines and completed three cycles
of sunitinib therapy (four weeks on and two week off). His
first
CT scan on the trial was reportedly stable. He had a second
torso CT performed on ___, showing disease
progression including increase in pulmonary nodules; increase in
supraclavicular, mediastinal and hilar adenopathy; increase in
abdominal lymphadenopathy, increase in size of bone lesions as
well as new bony metastases. He was referred here by Dr. ___
at ___ and Dr. ___ at ___ to discuss IL-2
therapy. He underwent radiation to four sites of bony metastatic
disease (right humerus, right rib, ? bilateral hips) during the
week of ___.
He started high dose IL-2 on ___, receiving ___/b ARF and pulmonary edema. He did not receive week 2 of
therapy due to ongoing pulmonary issues and increased bony pain,
c/w disease progression. He started off protocol nivolumab on
___. He received additional XRT to the sternum, lower back
and right knee in mid-late ___.
In early ___, he presented with worsening dyspnea and saw
Dr. ___ was found to have bilateral pulmonary emboli. He
was started on lovenox. In mid ___, he was hospitalized for pain
control and was found to have a pathologic fracture of the right
humerus, improved with immobilization and increased narcotics.
In early ___, he was hospitalized for pulmonary edema and
pleural effusions and started on diuresis.
Other past medical history -
- Bronchial asthma
- Morbid obesity
Social History:
___
Family History:
not relevant to the current hospitalization
Physical Exam:
Admission Exam:
General - Sitting by the bed side. Not in any acute distress
Vitals - Afebrile. PR 98/min RR 18/min SpO2 95% on RA
Eyes - Pallor and icterus absent. Pupils normal/equal in size
and
reaction. Eye movements normal.
Oral cavity - Moist. No rashes. Assymetric tongue. Uvual
central.
Neck - Supple. Large, firm to hard, left supraclavicular mass.
No
JVD.
Chest - Vesicular breath sounds, absent over the left base. No
crackles or wheezes. No stridor.
___ - Pulse regular, tachycardia, good volume. S1 and S2 normal.
ESM over the aortic area. Pericardial rub present.
Abdomen - Obese. Soft. Non tender. No palpable organomegaly.
Normal bowel sounds.
Extremities - Edema. Chronic venous stasis dermatitis. No calf
or
thigh tenderness.
Skin - No other rashes or nail changes.
Back and spine - No tenderness or deformity
Neurological - Normal higher mental function. Cranial nerves II
to XII intact, except tongue assymetry. No meningeal signs.
Strength ___ in all extremities (except right upper that has a
pathologic humerus fracture). Sensation normal to gross touch.
DTR (knee) normal. No cebellar signs. Normal gait.
Pertinent Results:
___ 11:55AM BLOOD WBC-14.1* RBC-3.24* Hgb-8.8* Hct-29.1*
MCV-90# MCH-27.2 MCHC-30.2* RDW-18.3* RDWSD-58.7* Plt ___
___ 11:55AM BLOOD ___ PTT-31.7 ___
___ 11:55AM BLOOD Glucose-101* UreaN-18 Creat-1.2 Na-135
K-4.1 Cl-92* HCO3-28 AnGap-19
___ 05:46AM BLOOD ALT-19 AST-44* LD(LDH)-233 AlkPhos-75
TotBili-0.5
___ 05:46AM BLOOD Albumin-3.9 Calcium-10.9* Phos-3.2 Mg-2.4
ECHO ___:
Mildly dilated LA. RA pressure >=15. LVEF 75%. RVH. Severe PA
hypertension. No effusion
MRI ___ T/L Spine:
1. Overall, extensive metastatic disease is re- demonstrated
throughout the thoracic a lumbar spine. New metastatic
involvement is seen involving T7, T8, and T9 vertebral bodies
compared to the prior CT from ___.
2. Involvement of metastatic disease with T12 also appears to be
new compared to the prior exam. Although no definite cord
signal
abnormalities are identified, extensive soft tissue is seen
extending into the spinal canal, and left neural foramen causing
mass effect on the spinal cord. However, please
note that this study is limited due to lack of IV contrast.
3. Extensive metastatic disease is re- demonstrated involving
the vertebral bodies the lumbar spine, including pathologic
fragmentation of the L3 vertebral body. No definite cord
abnormalities identified within lumbar spine.
4. Although evaluation of the posterior chest wall masses is
limited on this exam, there appears to be progression of
disease.
A dedicated chest CT could be helpful for further evaluation.
MRI ___ Brain:
Unchanged oval-shaped extra-axial parafalcine lesion in the left
convexity, associated with other lesions as described above
involving the frontal calvarium, right side of the clivus and
left temporomandibular condyle, consistent with metastatic
disease, the examination is limited without contrast.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO Q8H:PRN constipation
2. Prochlorperazine 10 mg PO Q8H:PRN nausea
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing or
shortness of breath
4. Lidocaine 5% Patch 1 PTCH TD 12 HOURS ON/WE HOURS OFF
5. ALPRAZolam 0.25 mg PO TID:PRN anxiety
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. Furosemide 40 mg PO DAILY
9. Fentanyl Patch 300 mcg/h TD Q48H
10. Morphine Sulfate ___ 15 mg PO Q6H:PRN dyspnea
11. OxycoDONE (Immediate Release) 40 mg PO Q3H:PRN pain
12. Enoxaparin Sodium 150 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Medications:
1. ALPRAZolam 0.25 mg PO TID:PRN anxiety
2. Fentanyl Patch 300 mcg/h TD Q48H
3. Furosemide 40 mg PO DAILY
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing or
shortness of breath
5. Lactulose 15 mL PO Q8H:PRN constipation
6. Lidocaine 5% Patch 1 PTCH TD 12 HOURS ON/WE HOURS OFF
7. Morphine Sulfate ___ 15 mg PO Q6H:PRN dyspnea
8. OxycoDONE (Immediate Release) 40 mg PO Q3H:PRN pain
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Prochlorperazine 10 mg PO Q8H:PRN nausea
11. Senna 8.6 mg PO BID:PRN constipation
12. Dexamethasone 2 mg PO Q12H
RX *dexamethasone 2 mg 1 tablet(s) by mouth twice a day Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Renal Cell Carcinoma
Brain Metastases
Hemoptysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with renal cell cancer and dural met, with headache, evaluate
brain mass, ICH.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 892 mGy-cm.
COMPARISON: None available.
FINDINGS:
Three hyperdense foci are identified, all of which are intimately associated
with the dura. A right frontal lesion measures approximately 2.0 x 0.8 cm
with an associated bone defect suggesting metastatic disease (___). A
similar larger lesion is seen superior to this measuring approximately 2.5 x
0.6 cm, with a larger associated bony defect. This likely represents an
additional metastatic lesion. A rounded hyperdensity arises from the the left
aspect of the falx, measuring 1.4 x 1.0 cm (02:23). All 3 of these lesions
appear to be metastatic, however prior images are not available for comparison
to establish chronicity or interval growth.
There is no intra-axial or extra-axial hemorrhage, midline shift, or acute
major vascular territorial infarct. Gray-white matter differentiation is
preserved. Ventricles are symmetric and unremarkable. Basilar cisterns are
patent.
Included paranasal sinuses and mastoids are clear.
IMPRESSION:
1. Three dural-based hyperdense metastatic lesions identified within the head.
Correlation with prior imaging (not available at the time of this
interpretation) is required to evaluate for chronicity or interval growth.
2. No evidence of infarction, hemorrhage, or edema.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: ___ with metastatic renal cell cancer, lung mets, also bilateral
PE, with increased SOB x 3 days evaluate for worsening PE, interval change in
lung mets.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
Total DLP (Body) = 975 mGy-cm.
COMPARISON: CT of the chest, abdomen, and pelvis dated ___, and
chest CT dated ___.
FINDINGS:
Extensive metastatic disease has increased compared with the immediate prior
study, in size and extent. Destructive osseous lesions are identified
involving the right scapula (8.7 x 7.6 cm 5:37, previously 7.6 x 5.8 cm), the
sternum (05:59), multiple ribs bilaterally with the largest rib lesions in the
right third rib (5.4 x 4.3 cm 5:30, previously 3.6 x 2.5 cm) and the right
ninth rib (7.7 x 4.8 cm 5:112, previously 7.0 x 5.0 cm). Multiple lytic
lesions are noted within the spine as well, most prominently at T6-T8
(601b:46, 48). Additional ill-defined soft tissue metastases are seen at the
level of the thoracic inlet measuring approximately 7.7 x 4.0 cm (5:1), and
throughout the subcutaneous tissues of the thorax (5: 32, 71, 75, 81, 86, 93,
112, et al.). Extensive mediastinal, hilar, and retroesophageal
lymphadenopathy has increased as well. Innumerable pulmonary parenchymal
metastasis also appear to increased size. Bilateral adrenal metastases, and
extensive periaortic and celiac axis adenopathy are also more prominent than
on the prior study.
The aorta is normal in course and caliber.
Evaluation for pulmonary emboli is very limited due to poor bolus timing in
spite of attempting a repeat bolus. Coalescent hilar masses appear to extend
as tumor thrombus into the lower lobe segmental arteries bilaterally. This
finding was present on the prior study but is more extensive, now with a small
right pleural effusion and a moderate left pleural effusion with associated
compressive atelectasis of the left lower lobe. There is no evidence of
pericardial effusion.
IMPRESSION:
1. Interval increase in the number and size of innumerable metastatic lesions
to the bones, soft tissues, and pulmonary parenchyma.
2. Coalescent hilar adenopathy extends into the lower lobe vasculature as
tumor thrombus bilaterally with new pleural effusions and associated
compressive atelectasis bilaterally, left greater than right.
3. Limited evaluation for pulmonary emboli due to poor bolus timing.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with progressive metastatic renal cell carcinoma
with new neurological symptoms and evidence of dural mets on CT head //
Evaluate for metastatic disease
TECHNIQUE: Images were obtained, axial FLAIR, axial T2, axial magnetic
susceptibility and axial diffusion-weighted images.
COMPARISON: Head CT dated ___.
FINDINGS:
Limited examination without contrast. There is an unchanged oval-shaped 9 x
12 mm left parafalcine extra-axial lesion, abutting the sulci with no
significant mass effect (image number 19, series 12 and 13), there is no
evidence of vasogenic edema. Additionally there is a calvarial lesion on the
right frontal region, abutting the dura at the right frontal lobe, previously
demonstrated by CT. The skullbase is notable for focal lesion in the right
clivus (image number 5, series 12), measuring approximately 11 x 13 mm in
transverse dimension, a similar lesion is identified in the left temporal
mandibular condyle (image 4, series 12) measuring approximately 6 by 5 mm in
transverse dimension. There is no evidence of intracranial hemorrhage, the
ventricles are normal in size and configuration for the patient's age. The
major vascular flow voids are present and demonstrate normal distribution.
The orbits are unremarkable, the paranasal sinuses are clear as well as the
mastoid air cells.
IMPRESSION:
Unchanged oval-shaped extra-axial parafalcine lesion in the left convexity,
associated with other lesions as described above involving the frontal
calvarium, right side of the clivus and left temporomandibular condyle,
consistent with metastatic disease, the examination is limited without
contrast.
Radiology Report
EXAMINATION: MRI THORACIC AND LUMBAR
INDICATION: ___ year old man with progressive metastatic renal cell carcinoma
with new bladder symptoms // metastatic disease.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T1 and T2 imaging was performed.
Please note that the patient had anxiety/shortness of breath, and asked to be
removed from the scanner, before IV contrast could be administered. I was
called to the MRI scanner, vitals were stable, and after discussion with Dr.
___ patient was given Albuterol inhaler, which provided symptomatic
relief to the patient. The patient was then transferred to the care of the
EMT's for transport to the ___. P. ___.
COMPARISON: CT chest abdomen and pelvis from ___
FINDINGS:
Thoracic spine: Spine labeling has been provided on series 26, image 7.
Although this study is limited by the lack of IV contrast, new metastatic
disease is seen involving T7, T8, and T9 vertebral bodies compared to the
prior CT from ___. Metastases to T6 appears similar to the prior
exam. Mild compression of the anterior and middle column of T6 is also
similar to the prior exam. There is no evidence of retropulsion of fragments.
There is no increased T2 or STIR signal to suggest acuity of the fracture.
Involvement of metastatic disease with T12 also appears to be new compared to
the prior exam however lack of increased T2/stir signal suggests that this may
be subacute in nature. Although no definite cord signal abnormalities are
identified, extensive soft tissue is seen extending into the spinal canal and
left neural foramen, causing mass effect on the spinal cord.
Incompletely evaluated are the patient's posterior chest wall masses. For
example at the level of T6/T7, there is a posterior chest wall mass which
measures 1.3 cm x 2.6 cm, series 28, image 27, increased in size compared to
the prior exam.
Incidental note is made of multiple lung metastases, also incompletely
evaluated on this exam.
Lumbar spine: Extensive metastatic disease is again seen involving the
vertebral bodies of the lumbar spine. Pathologic fragmentation of the L3
vertebral body is re- demonstrated. No definite cord abnormalities are
identified. The cauda equina appears to be unremarkable. Multiple soft
tissue retroperitoneal lesions are seen, also incompletely evaluated on this
exam.
Multiple retroperitoneal metastatic lesions are incompletely evaluated on this
exam.
IMPRESSION:
1. Overall, extensive metastatic disease is re- demonstrated throughout the
thoracic a lumbar spine. New metastatic involvement is seen involving T7, T8,
and T9 vertebral bodies compared to the prior CT from ___.
2. Involvement of metastatic disease with T12 also appears to be new compared
to the prior exam. Although no definite cord signal abnormalities are
identified, extensive soft tissue is seen extending into the spinal canal, and
left neural foramen causing mass effect on the spinal cord. However, please
note that this study is limited due to lack of IV contrast.
3. Extensive metastatic disease is re- demonstrated involving the vertebral
bodies the lumbar spine, including pathologic fragmentation of the L3
vertebral body. No definite cord abnormalities identified within lumbar spine.
4. Although evaluation of the posterior chest wall masses is limited on this
exam, there appears to be progression of disease. A dedicated chest CT could
be helpful for further evaluation.
NOTIFICATION: ___ were d/w Dr. ___ by Dr. ___ by phone at 5:35p
on the day of the exam.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Headache, Hemoptysis
Diagnosed with HEADACHE, SHORTNESS OF BREATH, SEC MAL NEO BRAIN/SPINE
temperature: 97.9
heartrate: 101.0
resprate: 20.0
o2sat: 98.0
sbp: 130.0
dbp: 45.0
level of pain: 4
level of acuity: 2.0 | PRIMARY REASON FOR HOSPITALIZATION:
====================================
Mr ___ is a ___ yo M with metastatic renal cell carcinoma with
progressive disease on nivolumab, who was admitted with
headache, dyaarthria
and hemoptysis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cefazolin / Penicillins / Motrin / ciprofloxacin
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with severe CAD (CTO
mid-LCx since ___, repeated PCI to RCA for ___ stenosis,
last POBA ___, CVA (left periventricular subcortical infarct
post cath ___, HTN, HLD, AF not on anticoagulation, ESRD on HD
MWF, who presents with a four day history of emesis.
He was recently hospitalized from ___ to ___ with nausea and
vomiting which was thought to be most likely related to viral
gastroenteritis. Digoxin toxicity was also considered. He
reports the vomiting occurs several minutes after eating and is
nonbloody. He was discharged home on ___ and felt well.
However, his son made him some fish and after eating and
drinking some
water he immediately had emesis again. His son encouraged him to
return to the ED given concern that these persistent symptoms
would not resolve. Prior to this week he has never had similar
symptoms and is not sure what to attribute the change to. He has
not made changes to his diet or had sick contacts or recent
travel.
He denies abdominal pain and loose stools. Notably, he denies
chest pain after his coronary intervention on ___. He also
denies dyspnea, orthopnea, palpitations, syncope and edema.
EMERGENCY DEPARTMENT COURSE
Initial vital signs were notable for:
- T 98.5, HR 56, BP 100/63, RR 16, O2 100% RA
Labs were notable for:
- Digoxin 2.6
- Trop-T 0.15 -> 0.14
Consults:
- Cardiology
Vital signs prior to transfer:
- T 97.7, HR 56, BP 134/52, RR 20, O2 94% RA
Upon arrival to the floor:
- He reports feeling well and not wanting to be in the hospital.
He does not want to have a stress test but will do so if he has
to. He feels up to trying breakfast.
=================
REVIEW OF SYSTEMS
=================
Complete ROS obtained and is otherwise negative.
Past Medical History:
-CAD s/p multiple RCA PCIs: ___ completely occluded LCx
(unchanged since ___, 50% lesion LAD (vs 30% prior) &
completely stenotic RCA; ___ 2 Xience DES to RCA
after rotablation of heavily calcified artery; ___ DES to
mid-RCA complicated by stroke; ___ RCA ___ for 95%
___ restenosis; ___ ___ mid RCA for 90%
___ restenosis; ___ ___ RCA 3.5 Promus with POBA
to distal RCA; ___ rotational atherectomy and ___
proximal RCA/mid RCA stenting, ___ restenosis distal RCA;
___ ___ placed; ___ balloon angioplasty RCA
-subdural Hematoma (___)
-CVA (left periventricular subcortical infarct) with RUE
weakness about ~18 hours after ___ catheterization
-Atrial fibrillation: not on anticoagulation
-ESRD ___ glomerulonephritis, failed RUE AVF, has working LUE
AVF
-ILD: ? chronic eosinophilic pneumonia
-PUD: Duodenal ulcers with UGIB ___ (H.pylori +)
-Chronic anemia
-Hypertension
-Bronchospasm
-Hx positive PPD
-Diverticulitis ___
-Mild aortic stenosis
-Mild mitral regurgitation
-hyperparathyroidism
-gout
-Hyperlipidemia
-lung nodules
-hypogonadism
Social History:
___
Family History:
Father with diabetes ___. No family history of early
cardiomyopathy, sudden cardiac death
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VITALS: T 98.5; BP 147/72, HR 59; RR 18; O2 95 RA
GENERAL: Well appearing, sitting up in bed speaking to me in no
distress
HEENT: Pupils equal and reactive, no scleral icterus, moist
mucous membranes
NECK: IV in neck
CARDIAC: S1/S2 regular, loud and harsh systolic murmur,
LUNGS: Faint rales at bilateral bases, possibly atelectasis.
Otherwise clear
ABDOMEN: Soft, non-distended, non-tender to deep palpation, no
organomegaly
EXTREMITIES: Warm, no lower extremity edema
NEUROLOGIC: A+Ox3, moving all 4 extremities, conjugate gaze,
appropriate affect
=======================
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 1122)
Temp: 97.4 (Tm 99.1), BP: 150/70 (109-150/54-70), HR: 54
(54-70), RR: 18, O2 sat: 97% (96-98), O2 delivery: RA
GENERAL: Well appearing, sitting up in bed, no acute distress
HEENT: MMM
NECK: IV in right neck
CARDIAC: RRR, + ___ systolic murmur RUSB
LUNGS: CTAB
ABDOMEN: Soft, non-distended, non-tender to deep palpation
EXTREMITIES: Warm, no lower extremity edema
NEUROLOGIC: A+Ox3, moving all 4 extremities, conjugate gaze,
appropriate affect
Pertinent Results:
ADMISSION LABS
=========================
___ 08:25PM BLOOD WBC-7.9 RBC-3.45* Hgb-10.4* Hct-33.9*
MCV-98 MCH-30.1 MCHC-30.7* RDW-14.7 RDWSD-53.1* Plt ___
___ 08:25PM BLOOD Neuts-44.7 ___ Monos-14.7*
Eos-11.8* Baso-1.1* Im ___ AbsNeut-3.54 AbsLymp-2.17
AbsMono-1.16* AbsEos-0.93* AbsBaso-0.09*
___ 08:25PM BLOOD Glucose-130* UreaN-11 Creat-4.8*# Na-138
K-4.3 Cl-95* HCO3-28 AnGap-15
___ 08:25PM BLOOD ALT-8 AST-17 CK(CPK)-49 AlkPhos-110
TotBili-0.4
___ 08:25PM BLOOD CK-MB-1 cTropnT-0.15*
___ 08:25PM BLOOD Albumin-3.7 Calcium-8.0* Phos-2.3* Mg-2.0
___ 08:25PM BLOOD Digoxin-2.6*
___ 08:42PM BLOOD Lactate-1.5
RELEVANT LABS
=========================
___ 02:10AM BLOOD cTropnT-0.14*
RELEVANT IMAGING
=========================
1. No evidence of acute process involving the abdomen or pelvis.
2. Colonic diverticulosis without evidence of acute
diverticulitis.
3. Stratification of the wall of the urinary bladder is
unchanged since ___, and may be related to chronic
inflammation.
4. Changes related to avascular necrosis of both femoral heads
again noted.
RELEVANT IMAGING
=========================
___ 07:25AM BLOOD WBC-6.9 RBC-3.55* Hgb-10.7* Hct-35.7*
MCV-101* MCH-30.1 MCHC-30.0* RDW-14.9 RDWSD-54.2* Plt ___
___ 07:25AM BLOOD Glucose-90 UreaN-9 Creat-4.4*# Na-138
K-4.2 Cl-94* HCO3-28 AnGap-16
___ 07:25AM BLOOD ALT-11 AST-24 LD(LDH)-226 AlkPhos-108
TotBili-0.5
___ 07:25AM BLOOD Albumin-3.8 Calcium-7.4* Phos-2.3* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Cinacalcet 60 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN
cough/wheeze/chest/congestion/SOB
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Montelukast 10 mg PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Ranitidine 300 mg PO QHS
13. sevelamer CARBONATE 2400 mg PO TID W/MEALS
14. albuterol sulfate 90 mcg/actuation inhalation ASDIR
15. Allopurinol ___ mg PO EVERY OTHER DAY
16. Docusate Sodium 100 mg PO BID
17. Guaifenesin-CODEINE Phosphate 10 mL PO Q4H:PRN cough
18. Lactulose 30 mL PO TID:PRN constipation
19. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES
QID:PRN pruritus
20. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral DAILY:PRN
21. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
22. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO DAILY
23. Senna 8.6 mg PO BID
24. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
25. Tetracaine 0.5% Ophth Soln 1 DROP BOTH EYES Q4H:PRN pruritus
26. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
3. albuterol sulfate 90 mcg/actuation inhalation ASDIR
4. Allopurinol ___ mg PO EVERY OTHER DAY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO DAILY
7. Cinacalcet 60 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Guaifenesin-CODEINE Phosphate 10 mL PO Q4H:PRN cough
11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN
cough/wheeze/chest/congestion/SOB
12. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
13. Lactulose 30 mL PO TID:PRN constipation
14. Lisinopril 5 mg PO DAILY
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Montelukast 10 mg PO DAILY
17. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES
QID:PRN pruritus
18. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral DAILY:PRN
19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
20. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO DAILY
21. Pantoprazole 40 mg PO Q12H
22. Ranitidine 300 mg PO QHS
23. Senna 8.6 mg PO BID
24. sevelamer CARBONATE 2400 mg PO TID W/MEALS
25. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
26. Tetracaine 0.5% Ophth Soln 1 DROP BOTH EYES Q4H:PRN
pruritus
27. Triphrocaps (B complex with C#20-folic acid) 1 mg oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
#Nausea, vomiting
#Coronary artery disease
#Elevated troponin
SECONDARY DIAGNOSES
#End-stage renal disease on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ with severe CAD, CVA, HTN, HLD, AF not on AC, ESRD on HD MWF,
who presented with ___ h/o anorexia and several day h/o nausea, emesis with
meals.// please assess for etiology of anorexia n/v, including gastric
outlet obstruction
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
without intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.5 s, 46.2 cm; CTDIvol = 13.1 mGy (Body) DLP = 602.9
mGy-cm.
Total DLP (Body) = 603 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: Mostly reticular opacities appear unchanged at each lung base,
probably due to lower airway inflammation. Coronary arteries are heavily
calcified.
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 native kidneys are atrophic. Few small hypodense foci are mostly
too small to characterize, but unchanged and doubtful in clinical
significance. Small simple cyst along the right lower pole measures 15 mm in
diameter, however, amenable to characterization. The transplant kidney in the
right lower quadrant has continued atrophy since the prior exam in ___.
There is no perinephric abnormality. No hydronephrosis.
GASTROINTESTINAL: There is a small hiatal hernia. Moderate to large duodenal
diverticulum noted along the second portion. Small bowel loops demonstrate
normal caliber and wall thickness throughout. There is moderate colonic
diverticulosis without evidence of acute diverticulitis. The appendix is
normal. Fat containing left paraumbilical hernia with a wide neck, increased
in size, without fluid or stranding..
PELVIS: Stratification of the wall of the urinary bladder is unchanged since
___, and may be related to chronic inflammation as previously suggested.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: Changes related to avascular necrosis of both femoral heads are again
noted. No acute osseous abnormality is identified.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of acute process involving the abdomen or pelvis.
2. Colonic diverticulosis without evidence of acute diverticulitis.
3. Stratification of the wall of the urinary bladder is unchanged since ___,
and may be related to chronic inflammation.
4. Changes related to avascular necrosis of both femoral heads again noted.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with Nausea with vomiting, unspecified
temperature: 98.5
heartrate: 56.0
resprate: 16.0
o2sat: 100.0
sbp: 100.0
dbp: 63.0
level of pain: 0
level of acuity: 3.0 | ===================
PATIENT SUMMARY
===================
___ with severe CAD (CTO mid-LCx since ___, repeated PCI to RCA
for ___ stenosis, last POBA ___, CVA (left
periventricular subcortical infarct post cath ___, HTN, HLD,
AF not on anticoagulation, ESRD on HD
MWF, who presents with a several-day history of nausea and
vomiting associated with food intake. Of note, he had been just
admitted to Cardiology for the same presentation. At that time,
the etiology of his nausea/vomiting was unclear. During this
admission, GI was consulted. CT A/P was obtained, which did not
show evidence of gastric outlet obstruction or other significant
abnormality. The patient was able to tolerate PO intake with PRN
antiemetic zofran. He was discharged home with plan for
outpatient GI follow up and EGD.
===================
TRANSITIONAL ISSUES
===================
[] The patient will need outpatient GI follow up with EGD for
workup of his anorexia and nausea/vomiting. This is being
arranged through GI office.
[] Cardiology recommended a stress test, ideally with exercise
MIBI, although most likely will be a pharmacological stress
(patient reports he is unable to exercise).
===================
ACUTE ISSUES
===================
#Anorexia
#Nausea, vomiting
Patient presented with a 2-month history of anorexia and a
several-day history of nausea/vomiting that occurs immediately
after eating. Denies any abdominal pain, diarrhea, hematemesis,
dysphagia, or early satiety. He stated that certain foods, e.g.
oatmeal and cornmeal, trigger this, while he is able to tolerate
other foods, including eggs and bagels. He endorsed a 20-lbs
weight loss during the past two months, though ___ records do
not show a significant weight change. The etiology remains
unclear. GI was consulted. CT A/P did not show evidence of
gastric outlet obstruction though on review with Radiology, did
show significant calcifications of his celiac artery and SMA.
However, chronic mesenteric ischemia was felt to be unlikely
given the lack of pain. Other differential for his presentation
includes persistent digoxin effect; worsening metaplastic
changes of esophagus (though no dysphagia), worsening PUD
(though no abdominal pain); worsening ___
ulcers vs. progressive intrusion of hiatal hernia. By ___, the
patient was able to tolerate multiple meals without emesis, and
as such it was felt to be reasonable to discharge the patient
home with outpatient gastroenterology follow-up and EGD. He was
also provided with PO Zofran 4 mg q8H PRN nausea. QTc 360.
# Coronary artery disease
# Elevated troponin to 0.15, which downtrended to 0.14. EKG
without acute ischemic changes; changes were thought to be c/w
dignoxin. He did not have any chest pain this admission.
Cardiology recommended stress testing with exercise v. pharm
mibi.
===================
CHRONIC ISSUES
===================
#End-stage renal disease on hemodialysis
Received hemodialysis per his usual ___ schedule.
#CODE: Full, presumed
#CONTACT: ___, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right acetabular fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
ORTHOPAEDICS HPI:
___ w/severe dementia and hx multiple medical comorbidities
including CKD and CAD, and prior right cephalomedullary nail for
R hip fx approx ___ years ago at ___, now s/p unwitnessed fall at
___ approx midnight last night. He was taken to ___,
where workup was reportedly negative, and XR initially read as
negative. The patient was discharged per wife was able to walk
but with pain in R hip and was favoring right side. XR was later
noted to reveal a right acetabular fx, and patient was contacted
and asked to come to ___ for evaluation.
Per his wife he is ambulatory with a walker at baseline,
occasionally with wheelchair for long distances.
CT head and Cspine were negative at OSH.
MEDICINE HPI:
Mr. ___ is a very pleasant ___ year old gentleman with a
history of CKD, CAD, BPH, dementia with multiple falls who
presented following unwitnessed fall c/b non-operative
acetabular fracture tranferrred via ___ pathway for medical
management.
Per report, Mr. ___ was found on floor at his assisted care
facility at midnight prior to admission(New___ on ___
where he had been down for an unclear amoutn of time. He was
taken ___, where workup CT head and Cspine were negative
for fracture or bleed, and femur XR initially read as negative.
Labs notable for cr up to 2.3, most recent baseline 1.9 last
year. The patient was discharged per wife was able to walk but
with pain in R hip and was favoring right side. femur XR was
later over-read as having a right acetabular fx, and patient was
contacted and asked to come to ___ for evaluation.
In the ED he was seen by ortho, who recommended non-operative
management. HE was admitted for further management. Overnight he
was not given home antihypertensives, only hydralazine IV. He
was noted to be delerious, hypertensive, agitated. He is now
transferred to the medicine service for further management.
Of note, according to his wife he is ambulatory with a walker at
baseline, occasionally with wheelchair for long distances.
On the floor, patient reports severe discomfort with foley.
Endorses hip pain. No shortness of breath or chest pain.
Endorses mild thirst.
Past Medical History:
- mild OSA,
- moderate CKD,
- hyothyroidism,
- dementia (with concern for NPH given ventriculomegaly )
- prior right cephalomedullary nail for R hip fx approx ___ years
ago at OSH
- Aortic Stenosis,
- HTN,
- T2DM,
- CAD,
- BPH followed by Urology
- osteoporosis
- elevated PSA
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION / ORTHOPAEDIC PHYSICAL EXAM:
==============================================
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Right lower extremity:
- Skin intact
- pain w/logroll, right hip flexion/extension
- Soft, non-tender thigh and leg
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- WWP distally
No tenderness to palpation in other extremities.
DISCHARGE / MEDICINE PHYSICAL EXAM:
=================================================
Vitals: 98.1 164-176/55-67 ___ 20 98RA
IO - MN: 180/300
IO - 24: 1400/1400
General: Alert, oriented to self, ___, ___. States month
is ___. Year is ___. Appears comfortable sitting in chair.
HEENT: Sclera anicteric, MMM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: Unlabored and bibasalar crackles. No wheezes
CV: Regular rate and rhythm, normal S1 + S2, II/VII SEM at RUSB,
no rubs, or gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds
normoactive, no rebound tenderness or guarding, no organomegaly
GU: condom catheter
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Dry. No rash.
NEURO: AOx2. MAE. Normal sensation. Moves all 4 extremities
equally. Right hip is soft, nontender in thigh and leg but some
tenderness of groin. Normal sensation.
Pertinent Results:
ADMISSION LABS:
===========================
___ 10:00AM BLOOD WBC-11.3*# RBC-3.16* Hgb-9.9* Hct-28.3*
MCV-90 MCH-31.3 MCHC-34.9 RDW-15.1 Plt ___
___ 10:00AM BLOOD Neuts-84.0* Lymphs-6.8* Monos-4.0
Eos-4.6* Baso-0.6
___ 10:00AM BLOOD ___ PTT-30.6 ___
___ 10:00AM BLOOD Glucose-165* UreaN-41* Creat-2.4* Na-139
K-4.2 Cl-106 HCO3-22 AnGap-15
___ 10:00AM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.7 Mg-1.9
___ 05:50AM BLOOD calTIBC-191* Ferritn-254 TRF-147*
___ 10:00AM BLOOD TSH-8.9*
___ 05:50AM BLOOD Free T4-1.2
___ 10:00AM BLOOD CK-MB-26* MB Indx-5.5 cTropnT-0.20*
___ 10:00AM BLOOD CK(CPK)-475*
___ 05:50AM BLOOD CK-MB-26* MB Indx-4.6 cTropnT-0.53*
___ 05:50AM BLOOD CK(CPK)-561*
___ 04:50AM BLOOD CK-MB-13* MB Indx-3.2 cTropnT-0.70*
___ 04:50AM BLOOD CK(CPK)-411*
URINALYSIS
=======================
___ 09:49AM URINE Color-BROWN Appear-Cloudy Sp ___
___ 09:49AM URINE Blood-LG Nitrite-NEG Protein-300
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 09:49AM URINE RBC->182* WBC-182* Bacteri-NONE
Yeast-NONE Epi-0
___ 09:37AM URINE Hours-RANDOM UreaN-629 Creat-65 Na-96
K-39 Cl-99 Phos-28.1
MICROBIOLOGY:
==============================
__________________________________________________________
___ 9:49 am URINE Site: NOT SPECIFIED
ADDED TO SPECIMEN ___ ON ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 10:40 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
+ PELVIS W/JUDET VIEWS (3V): Partially imaged is patient status
post ORIF of the right femur. There is now acetabular fracture
on the right, better assessed on subsequent CT. The pubic
symphysis and sacroiliac joints are not widened. No frank
dislocation is seen.
IMPRESSION: Right acetabular fracture.
+ CXR: The cardiac silhouette is enlarged. Mediastinal contours
are stable. There is persistent mild prominence of the hila
which may be due to central pulmonary vascular engorgement. No
definite focal consolidation is seen. There is no large pleural
effusion or pneumothorax. There is subtle suggestion of a hiatal
hernia.
+ CT PELVIS:
1. There is a comminuted Both-column fracture of the right
acetabulum and a nondisplaced fracture of the superior pubic
ramus.
2. Patient is status post right hip arthroplasty.
3. Left inguinal hernia containing a loop of small bowel without
evidence of complication.
4. Prostate is massively enlarged there is moderate thickening
of the bladder wall.
+ CT PELVIS 3D:
There is redemonstration of a complex, comminuted fracture
involving the
anterior and posterior walls as well as the anterior and
posterior columns of the right acetabulum. The previously
demonstrated right superior pubic ramus fracture is better
assessed on the recent CT scan. A gamma nail construct is again
noted transfixing a right proximal femoral fracture. IMPRESSION:
Redemonstration of a complex, comminuted fracture involving the
anterior and posterior walls as well as the anterior and
posterior columns of the right acetabulum. Please see the report
from the recent prior CT of the pelvis from ___ for
further characterization.
+ RENAL U/S:
The right kidney measures 9.6 cm. There is no hydronephrosis,
stones, or
masses. Mild cortical atrophy is noted. Corticomedullary
differentiation is preserved. The left kidney measures 10.1 cm.
A 1.7 x 1.5 x 1.4 cm simple exophytic cyst is seen off the upper
pole of the left kidney. There is no hydronephrosis, stones, or
masse. This minimal cortical atrophy is noted. Corticomedullary
differentiation is preserved. The bladder is only minimally
distended and can not be fully assessed on the current study.
Bilateral ureteral jets were not visualized. The prostate is
enlarged and measures at least 9cm in width. IMPRESSION:
1. Mild bilateral cortical renal atrophy, right greater than
left.
2. No hydronephrosis.
3. 1.7 cm simple left renal cyst.
4. Enlarged prostate, measuring at least 9 cm in width.
+ EKG: Normal sinus rhythm at 88bpm, Prolonged PR interval, Left
bundle branch block
DISCHARGE LABS:
========================
___ 04:30AM BLOOD WBC-6.5 RBC-2.89* Hgb-9.2* Hct-26.3*
MCV-91 MCH-31.8 MCHC-34.9 RDW-15.0 Plt ___
___ 04:20AM BLOOD Neuts-64.2 Lymphs-13.8* Monos-7.8
Eos-13.3* Baso-0.9
___ 04:20AM BLOOD ___ PTT-31.1 ___
___ 04:30AM BLOOD Glucose-166* UreaN-47* Creat-2.3* Na-139
K-4.3 Cl-104 HCO3-23 AnGap-16
___ 04:30AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2
___ 05:50AM BLOOD calTIBC-191* Ferritn-254 TRF-147*
___ 04:50AM BLOOD WBC-7.0 RBC-2.89* Hgb-9.1* Hct-26.4*
MCV-92 MCH-31.6 MCHC-34.6 RDW-15.0 Plt ___
___ 04:50AM BLOOD Glucose-184* UreaN-49* Creat-2.2* Na-140
K-4.2 Cl-105 HCO3-26 AnGap-13
___ 04:50AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.4
___ 04:50AM BLOOD CK-MB-7 cTropnT-1.30*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Labetalol 200 mg PO BID
3. Tamsulosin 0.4 mg PO QHS
4. BuPROPion (Sustained Release) 150 mg PO QAM
5. Amlodipine 2.5 mg PO DAILY
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Pramipexole 0.125 mg PO DAILY
8. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Pramipexole 0.125 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Vitamin D ___ UNIT PO DAILY
10. Acetaminophen 650 mg PO QID
RX *acetaminophen 325 mg 2 tablet(s) by mouth four times a day
Disp #*100 Tablet Refills:*0
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*40 Capsule Refills:*0
12. Enoxaparin Sodium 30 mg SC Q24H Duration: 14 Days
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 30 mg/0.3 mL 30 mg once a day Disp #*14 Syringe
Refills:*0
13. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral DAILY
14. TraMADOL (Ultram) 25 mg PO Q12H:PRN pain
15. OxycoDONE (Immediate Release) 2.5 mg PO DAILY:PRN 30
minutes prior to physical therapy
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
16. Labetalol 100 mg PO TID
17. Artificial Tears Preserv. Free ___ DROP BOTH EYES BID eye
itching
18. Ferrous GLUCONATE 324 mg PO DAILY
19. Finasteride 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: Right acetabular fracture
SECONDARY: Chronic Kidney Disease, Anemia,
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 hip fx // characterize R acetabular fx
TECHNIQUE: Three views of the pelvis
COMPARISON: Right hip radiographs from earlier today, ___ at 01:44
FINDINGS:
Partially imaged is patient status post ORIF of the right femur. There is now
acetabular fracture on the right, better assessed on subsequent CT. The pubic
symphysis and sacroiliac joints are not widened. No frank dislocation is seen.
IMPRESSION:
Right acetabular fracture.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hip fx. can't do PA/lat due to hip fx //
acute intrathoracic process? Surg: ___ (possible hip fracture repair)
TECHNIQUE: Single frontal view of the chest
COMPARISON: Earlier today, ___ at 01:37
FINDINGS:
The cardiac silhouette is enlarged. Mediastinal contours are stable. There is
persistent mild prominence of the hila which may be due to central pulmonary
vascular engorgement. No definite focal consolidation is seen. There is no
large pleural effusion or pneumothorax. There is subtle suggestion of a hiatal
hernia.
IMPRESSION:
No significant interval change from earlier this same date.
Radiology Report
INDICATION: History: ___ with R hip pain, known acetabular fx // eval
fracture pattern, ? occult pelvic fx
TECHNIQUE:
Contiguous thin section helically acquired images were obtained through
thepelvis, from iliac crest to the proximal femoral and reconstructed using
both bone and soft tissue algorithm. Coronal and sagittal reformats were also
generated.
DOSE: DLP 1322.59 mGy-cm
COMPARISON: Pelvis radiographs dated ___
FINDINGS:
The patient is status post ORIF of an old healed fracture of the right
proximal femur, transfixed by short IM rod and femoral neck screw. There is
surrounding metal artifact. Allowing for this, no hardware displacement or
loosening is detected. No proximal femur fracture is seen.
There is a highly comminuted fracture of the right acetabulum with components
involving the anterior column, roof, posterior column, and anterior-posterior
walls. While many of these fractures are minimally displaced, there is a
fragment involving much of the quadrilateral plate, that shows full-thickness
displacement into the pelvis anteriorly. There is calcification at the base of
the pulvinar (8:74). A tiny fragment is seen along the superior posterior
lateral femoral head, in the joint space (3:62). Otherwise, no intra-articular
components are identified. Narrowing of the joint space likely reflects
background degenerative change.
In addition, there is fracture of the right parasymphyseal superior pubic
ramus (500 b: 43). Minimal irregularity along the inferior pubic ramus could
also represent an acute nondisplaced fracture (3:94). There is a small to
moderate high density right femora is joint effusion. There is soft tissue
swelling seen in the musculature surrounding the acetabulum.
No other fractures are detected about the pelvic girdle or in the visualized
portion of the left proximal femur. No sacral fracture and no SI joint or
pubic symphysis diastasis is seen. There is mild degenerative narrowing of the
left hip.
Note is made of a small to moderate size left inguinal hernia, containing
bowel. No dilated loops of bowel to suggest obstruction or identified. There
is also a small right inguinal hernia, which likely also contains a small
amount bowel.
The prostate is massively enlarged. The bladder wall is thickened even in the
setting of latter dilatation.
No free fluid is identified, though there is stranding in the perirectal
region (4:76) and hazy density in the bowel in the right lower quadrant
(04:45).
There is dense vascular calcification.
There are advanced degenerative changes in the lower lumbar spine, with disc
space narrowing and disc bulging seen at the presumptive L4/5 and L5/S1 disc
levels, with associated neural foraminal narrowing.
No focal lytic or sclerotic lesion suggestive of metastasis is identified.
IMPRESSION:
1. Comminuted fracture of the the right acetabulum, with involvement of almost
the entire acetabulum. Interior displacement the anterior portion of the major
quadrilateral fragment. 2 tiny calcific densities seen within the
femoroacetabular joint, detailed above.
2. Fractures of the right parasymphyseal superior pubic ramus and probably
also a nondisplaced fracture of the right inferior pubic ramus.
3. Status post ORIF old healed right proximal femur fracture. No hardware
loosening or displacement identified.
4. Bilateral bowel containing hernias, left larger than right. No dilated
loops to suggest obstruction.
5. Non-specific soft tissue stranding in the perirectal region and in the
right lower quadrant of the abdomen.
6. Marked enlargement of the prostate, with bladder wall thickening. Clinical
correlation is requested.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with severe BPH, ___. Assess for obstruction.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT pelvis ___.
FINDINGS:
The right kidney measures 9.6 cm. There is no hydronephrosis, stones, or
masses. Mild cortical atrophy is noted. Corticomedullary differentiation is
preserved.
The left kidney measures 10.1 cm. A 1.7 x 1.5 x 1.4 cm simple exophytic cyst
is seen off the upper pole of the left kidney. There is no hydronephrosis,
stones, or masse. This minimal cortical atrophy is noted. Corticomedullary
differentiation is preserved.
The bladder is only minimally distended and can not be fully assessed on the
current study. Bilateral ureteral jets were not visualized.
The prostate is enlarged and measures at least 9cm in width.
IMPRESSION:
1. Mild bilateral cortical renal atrophy, right greater than left.
2. No hydronephrosis.
3. 1.7 cm simple left renal cyst.
4. Enlarged prostate, measuring at least 9 cm in width.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new O2 requirement, possible aspiration //
CHF, aspiration CHF, aspiration
COMPARISON: Chest radiographs since ___, most recently ___.
IMPRESSION:
Since ___ severely enlarged cardiac silhouette has gotten bigger, moderate
right pleural effusion has developed, pulmonary edema is new, predominantly in
the lower lungs where there is also new heterogeneous consolidation. Overall
findings suggest concurrent pneumonia and cardiac decompensation.
Radiology Report
INDICATION: ___ year old man with rt acetab fx // eval fx please do vert
rotation and tumble digital subtraction of femur
TECHNIQUE: 3D volumetric reformatted images of the pelvis were obtained via
the 3D imaging lab off of source images from the prior CT pelvis of ___.
COMPARISON: CT pelvis ___.
FINDINGS:
There is redemonstration of a complex, comminuted fracture involving the
anterior and posterior columns of the right acetabulum. The previously
demonstrated right superior pubic ramus fracture is better assessed on the
recent CT scan. A gamma nail construct is again noted transfixing a right
proximal femoral fracture.
IMPRESSION:
Redemonstration of a complex, comminuted fracture involving the anterior and
posterior columns of the right acetabulum. Please see the report from the
recent prior CT of the pelvis from ___ for further characterization.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Hip fracture
Diagnosed with FRACTURE ACETABULUM-CLOS, UNSPECIFIED FALL, AORTIC VALVE DISORDER, HYPERTENSION NOS
temperature: 98.4
heartrate: 66.0
resprate: 20.0
o2sat: 97.0
sbp: 178.0
dbp: 53.0
level of pain: 13
level of acuity: 3.0 | HOSPITAL COURSE:
============================
___ with HTN, CKD, BPH, dementia with multiple recent falls who
presnted with right acetabular fracture in the setting of a
fall, mangaging non-operatively, hospitalization complicated by
acute on chronic kidney injury.
# Right Acetabular Fracture: Traumatic in setting of recurrent
falls and known osteoporosis. Seen by orthopaedics who feel that
fracture can be managed non-operatively. Specifically they feel
that joint is currently set in a way as to facilitate healing
with touch down weight bearing status on the Right Lower
extremity and that surgical intervention would not result is a
shorter duration of recovery or greater short term mobility.
# Recurrent Falls/Dementia: Long standing history of falls.
Thought to be related to underlying dementia and deconditioning.
Evaluated by Neurology in the past with concern for NPH though
no formal diangosis. Infectious workup negative during admission
# Acute on Chronic Kidney Injury: Creatinine on admission 2.3
and has been stable since. Baseline creatinine 1.8. CK not
signficantly elevated. No hydronephrosis seen on renal US. FeNa
2.5% suggestive of renal sodium wasting and likely ATN.
Creatinine downtrending on discharge.
# Hypertension: On lisinopril, labetolol, and amlodipine at
home, but lisinopril was held on admission in setting of ___. In
absence of lisinopril, he was noted to be more hypertensive
especially in the mornings that was thought be exacerbated by
pain and anxiety. During admission, labetalol was from 200mg BID
to ___ TID and amlodipine increased from 2.5mg to 5mg daily
with goal BP <150/90. Restart lisinopril as an outpatient
pending stability in renal function.
# Troponinemia: Patient has reported history of CAD, though
history unclear. CK initially elevated in setting of fall with
unclear duration of immobility, CK-MB index was normal. The
patient was asymptomatic without chest pain or dyspnea, EKG with
LBBB block but no Sgarbossa criteria thus thought not to reflect
active ischemia. Troponin continued to elevate in the absence of
ischemia thought to reflect decreased renal clearance with low
grade troponin leak from hypertension. He was continued on
aspirin.
CHRONIC ISSUES:
# BPH: Followed by Dr. ___ Urology. Continue tamsulosin and
recently started finasteride.
# Hypothyroidism: TSH was elevated in acute illness but free T4
normal. Was continued on levothyroxine.
# Iron deficiency anemia: Hct stable during admission. Started
ferrous sulfate daily.
# Muscle spasms: continued pramipexole.
# Osteoporosis: continued calcium and vitamin D
TRANSITIONAL:
- Touch down weight bearing on the right lower extremity for two
months.
- Followup with Dr. ___ in 2 weeks for repeat imaging
- Enoxaparin for ___ weeks at least. Course to be determined as
outpatient with Dr. ___ Orthopaedics.
- Please discuss with Dr. ___ lisinopril pending
stablity in renal function.
- Pain control with acteaminophen 650mg PO QID, tramadol 25mg PO
q12h:PRN pain, and oxycodone 2.5mg PO daily:prn 30min prior to
___. Ensure ongoing bowel regimen to prevent constipation.
- Continue calcium and vitamin D
- consider starting memantine as an outpatient
CORE MEASURES:
# Diet: pureed/thin liquid diet
# PPX: Enoxaparin
# CODE: DNR/DNI
# CONTACT/HCP: ___ (Wife): ___ or
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
"I Need dialysis"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx HTN, HLD, ESRD on HD ___, last dialysis ___ in
___, since ___ via left AV fistula) presents to ED
with dyspnea and need for dialysis because his usual dialysis
center "did not have paperwork about his ___ dialysis."
He was recently in the ___ for the past two weeks where he
last received HD on ___. When he returned ___
this week, he went to ___ dialysis on ___ where they
did not have space for him to receive HD as the patient had not
been to the ___ one month. Therefore, the patient was
told to come to ___ for further management.
In the ED vitals were 98.2, hr67, BP 207/96, 100% RA
- CXR showed mild to moderate pulmonary edema with small
bilateral pleural effusions.
- He required femoral stick for labs which showed: Na 135, K
7.2, HCO3 19, Glu 93, Phos 11, BUN 96
- EKG showed sinus rhythm with rates in ___. Has TWI in lateral
leads and mild peaking of T waves in V2-V3 which is unchanged
from prior.
- Nephrology was informed and they will plan to dialysis here
On arrival to the floor, the patient states that he feels like
he is volume overloaded with mild shortness of breath. Denies
abdominal pain, nausea, vomiting, or diarrhea. No headache or
changes in vision. He is currently being set up with bedside
dialysis
Past Medical History:
PAST MEDICAL HISTORY:
- ESRD on HD ___ at ___ followed by Dr.
___
- ___
- Hyperlipidemia
- Presumed endocarditis episode with possibly bacteremia from a
central vein catheter in ___,
- headaches.
- Unclear if he has a history of OSA, he reports to me that he
thinks he was tested and the tests were negative for sleep
apnea.
- No history of diabetes, cardiovascular disease, CVA,
hepatitis, lung disease, cancer or tuberculosis exposure.
SURGICAL HISTORY: Appendectomy, left AV fistula.
Social History:
___
Family History:
Mother ___ years old with history of hypertension and diabetes.
Father was assassinated when the patient was six months old.
One sister died with liver problems, unclear cause, one sister
is alive ___ years old and is healthy. His children are old, all
healthy.
Physical Exam:
PHYSICAL EXAM:
===============
Vitals: 97.4 168/99 73 22 95% RA Weight = 145.7kg
General: Laying in bed, speaking in full sentences, NAD
HEENT: NC/AT, EOMI, PERRL, no LAD
CV: RR, +S1/S2, no m/r/g
Lungs: Faint crackles at the bases bilaterally. Breathing
comfortably on RA without accessory muscle use.
Abdomen: Obese, soft, ND, NTTP, +BS throughout
GU: No foley
Ext: Warm, dry, and well perfused. Skin is firm without edema.
Neuro: CN II-XII grossly intact. Moving all extremities with
purpose. Non focal
Skin: Dry skin throughout; left AV fistula with palpable thrill
Pertinent Results:
ADMISSION LABS:
================
___ 02:26PM BLOOD WBC-7.1 RBC-2.71* Hgb-8.1* Hct-25.2*#
MCV-93# MCH-29.9 MCHC-32.1 RDW-15.7* RDWSD-53.2* Plt ___
___ 02:26PM BLOOD Glucose-111* UreaN-99* Creat-16.4*#
Na-140 K-6.2* Cl-94* HCO3-21* AnGap-31*
___ 11:50AM BLOOD Phos-11.0*# Mg-2.3
___ 11:57AM BLOOD Glucose-93 Na-135 K-7.2* Cl-98
calHCO3-19*
DISCHARGE LABS:
================
___ 07:10PM BLOOD Glucose-163* UreaN-55* Creat-10.0*#
Na-135 K-4.0 Cl-91* HCO3-26 AnGap-22*
___ 07:10PM BLOOD Calcium-10.3 Phos-6.2*# Mg-2.0
IMAGING:
==========
CXR ___:
Pulmonary vascular congestion in the upper lungs without overt
edema. Small bilateral pleural effusions.
EKG: NSR with HR in ___, TWI in lateral leads and mild peaked T
waves in V2-V3 which is unchanged from prior
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. Cinacalcet 30 mg PO DAILY
4. Doxazosin 2 mg PO HS
5. Labetalol 300 mg PO TID
6. Lisinopril 20 mg PO DAILY
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Cinacalcet 30 mg PO DAILY
3. Doxazosin 2 mg PO HS
4. Labetalol 300 mg PO TID
5. Nephrocaps 1 CAP PO DAILY
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Endstage renal disease requiring HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiographs
INDICATION: History: ___ with dyspnea // acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison made with chest radiographs from ___.
FINDINGS:
There are low lung volumes. There is congestion of the pulmonary vasculature
in the upper lungs, without overt edema. There small are bilateral effusions.
There is no pneumothorax. The cardiomediastinal silhouette is moderately
enlarged, similar prior exam
IMPRESSION:
Pulmonary vascular congestion in the upper lungs without overt edema. Small
bilateral pleural effusions.
NOTIFICATION: Updated findings from original wet read were communicated to
Dr. ___ at 12:21 p.m. on ___ by phone.
Radiology Report
INDICATION: History: ___ with acute on chronic hip pain
TECHNIQUE: AP view of the pelvis, two views of the left hip
COMPARISON: None.
FINDINGS:
Cross-table lateral view of the proximal left femur is somewhat limited by
overlying body habitus. No definite acute fracture or dislocation is present.
Mild narrowing of the left femoral acetabular is noted. No diastasis of the
pubic symphysis or sacroiliac joints is present. No concerning lytic or
sclerotic osseous abnormality is visualized. Vascular calcifications are
noted diffusely along with calcified phleboliths.
IMPRESSION:
No definite acute fracture or dislocation.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Hyperkalemia
Diagnosed with Acute kidney failure, unspecified
temperature: 98.2
heartrate: 67.0
resprate: 16.0
o2sat: 100.0
sbp: 207.0
dbp: 96.0
level of pain: 10
level of acuity: 2.0 | Brief Hospital Course:
___ year old male with PMH of HTN, HLD and ESRD on ___, Th, ___
HD who presented to the ED with volume overload and hyperkalemia
(7.2) in the setting of missed HD. The patient had been
traveling abroad and did not arrange for HD upon return. He
presented to his prior HD center who did not have room for him
and instructed him to go to the ED. Prior to his presentation,
his last HD session was in the ___ on ___. Upon
arrival to the ED, the dialysis/renal team was consulted and the
patient was admitted for bedside HD. EKG on admission unchanged
from prior. Patient complained of mild SOB but denied any
nausea, vomiting, or abdominal pain His K improved from 7.2 on
arrival to 4.0 three hours after HD was completed. It was
arranged for him to have his next session at ___ in
___ on ___ at 5:00pm and the patient was discharged
home following his session.
Of note, the patient was hypertensive to SBPs 200 upon admission
in the setting of volume overload. His pressures improved to
SBPs 140s with dialysis. In addition, the patient's HgB 8.1
which is lower than expected than someone with CKD on EPO
(baseline appears to be ~9). No signs of active bleed and
patient HD stable. Would consider further work-up as an
out-patient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia, weakness
Major Surgical or Invasive Procedure:
___ Upper endoscopy
History of Present Illness:
___ male past medical history ___ disease,
prostate cancer (with reportedly negative recent PET scan),
hypertension, and hyperlipidemia who presents with a chief
complaint of lightheadedness and a recent fall today.
Patient is accompanied by son, ___, and wife who give most of
the history. Patient reports that he last felt normal and well
approximately 2 weeks ago. His wife reports that the patient
"looked a little yellow," but otherwise was doing well prior to
2 weeks before arrival. The patient traveled from ___ to
___ to visit family, 2 weeks ago. He was scheduled for a
trip to ___, which he left for 2 days ago. Over these past 2
weeks, he has felt progressively unwell and weak. He felt the
worse 2 days ago in ___, with worsening fatigue and dyspnea
on exertion. He went to a local hospital, where he was found to
be anemic down to a hemoglobin reported at 5, for which he was
given 1 unit of packed red blood cells and some fluid. Given
that he was feeling so unwell, he cut his trip to ___ short
and came to ___ to visit his family.
After arriving in ___ on the evening of ___, patient
reports that he had one episode where he slipped and fell
backwards with head strike. He did not lose consciousness
during this fall. He reports that as a mechanical fall, without
prodrome prior.
Although the patient denies most symptoms, his son and wife
report that he has described over the past 2 weeks periods of
palpitations, cold sweats, diffuse weakness, intermittent
diffuse abdominal pain, a sensation of constipation, and
worsening bilateral foot swelling (the swelling usually gets
better after
sleeping propping the feet for night; it has progressed). The
patient does endorse several days of black stools. Both patient
and family deny fevers, chest pain, nausea/vomiting/diarrhea,
dysuria, hematuria, and focal numbness/weakness. Per the patient
and his wife, there were no ill contacts while the patient was
staying with family in ___.
Per family, patient had colonoscopy and upper endoscopy ___
months ago which was reportedly negative.
In the ED, initial VS were: T 96.9 BP 127/48 HR 103 RR 17 O2
100% on RA
Exam notable for:
"Dark brown Guaiac positive stool."
EKG:
No priors available for comparison. Normal sinus rhythm at a
rate of 87bpm. Normal axis. RBBB. Left atrial abnormality.
Labs showed: Hb 5.6, WBC 5.6; BUN 37, Cr 1.6; trop-T pending;
coags WNL.
Imaging showed:
CT HEAD WITHOUT CONTRAST (___):
1. No acute large territorial infarction or hemorrhage.
2. Mild paranasal sinus disease, as described above
CT C-SPINE W/O CONTRAST (___):
No fracture or malalignment. Multilevel degenerative
discbdisease.
Consults: None
Patient received: 2uPRBC
Transfer VS were: T 98.1 BP 126/66 HR 84 RR 14 O2 100% on RA
On arrival to the floor, patient reports the above history.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- ___ disease
- Hypertension
- Prostate cancer; somewhat recently diagnosed, with a reported
negative PET scan within the recent past
- Hyperlipidemia
Social History:
___
Family History:
Family history of eosinophilic esophagitis; patient reports that
his brother, and his son, both have this disease. Other
relatives have it as well, though he is not sure who they are.
Physical Exam:
===============================
EXAM ON ADMISSION
===============================
VS: ___ 2248 Temp: 97.9 PO BP: 118/69 L Sitting HR: 82 O2
sat: 98% O2 delivery: Ra
GENERAL: Heavyset Caucasian male, sitting up in bed. Speaking
with his family intermittently in ___ and in ___. Alert
and oriented ×3. Tired appearing.
HEENT: Sclerae anicteric. Mucous membranes moist.
NECK: No frank JVD. Difficult to assess JVP due to habitus.
HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNGS: Bibasilar crackles, otherwise clear.
ABDOMEN: Normoactive bowel sounds. Abdomen is soft,
nondistended, nontender in all quadrants, no rebound/guarding,,
no hepato-splenomegaly.
EXTREMITIES: 3+ pitting edema to the knees bilaterally, 2+ the
posterior thigh. Extremities warm and well perfused. Negative
___ sign, no palpable cords.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. Normal
finger-nose-finger. No pronator drift.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
===============================
EXAM ON ADMISSION
===============================
VS: 97.9, HR 95, BP 121/71, RR 18, 99%RA
GENERAL: Ambulating around floor, NAD
HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNGS: Bibasilar crackles, otherwise clear.
ABDOMEN: Normoactive bowel sounds. Abdomen is soft,
nondistended, nontender in all quadrants, no rebound/guarding,
no hepato-splenomegaly.
EXTREMITIES: 3+ pitting edema to the knees bilaterally, 2+ the
posterior thigh. Extremities warm and well perfused.
Pertinent Results:
===========================
LABS ON ADMISSION
===========================
===========================
LABS ON DISCHARGE
===========================
===========================
MICROBIOLOGY
===========================
===========================
IMAGING
===========================
___ CT C-spine w/o contrast:
A retention cyst is visualized in the lower right maxillary
sinus. No fracture or malalignment is seen within the cervical
spine. There is degenerative disc disease at multiple levels
most notably C5-6 and C6-7.
Prevertebral soft tissues appear normal. There is no critical
central spinal canal or neural foraminal narrowing. The lung
apices partially visualized appear normal. The thyroid gland is
unremarkable.
IMPRESSION: No fracture or malalignment. Multilevel
degenerative disc disease.
___ NCHCT
1. No acute large territorial infarction or hemorrhage.
2. Mild paranasal sinus disease, as described above.
___ Upper Endoscopy
Impression: Mild (Grade A) esophagitis in the lower esophagus
Large hiatal hernia
Erythema and erosions in the stomach
Ulcers in the body and ulcer
No active bleeding, red blood, dark blood, or high risk stigmata
of bleeding were seen.
Polyps in the body
Otherwise normal EGD to third part of the duodenum
Recommendations: Rule out H pylori with stool test.
high dose PO BID PPI
Erosive gastritis could be source of black stools.
Recommend outpatient EGD in ___ months as cannot exclude
___ esophagus in setting of esophagitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Carbidopa-Levodopa (___) 0.75 TAB PO BID
4. Pramipexole 4.5 mg PO DAILY
5. Rasagiline 1 mg PO DAILY
6. bisoprolol fumarate 1.25 oral DAILY
7. valsartan-hydrochlorothiazide 80-12.5 mg oral DAILY
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
2. Atorvastatin 20 mg PO QPM
3. bisoprolol fumarate 1.25 oral DAILY
4. Carbidopa-Levodopa (___) 0.75 TAB PO BID
5. Pramipexole 4.5 mg PO DAILY
6. Rasagiline 1 mg PO DAILY
7. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you have your blood counts rechecked
8. HELD- valsartan-hydrochlorothiazide 80-12.5 mg oral DAILY
This medication was held. Do not restart
valsartan-hydrochlorothiazide until you talk to your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- acute blood loss anemia, ___ upper GI bleed
Secondary Diagnoses
- acute kidney injury, likely prerenal
- lower extremity edema
- Parkinsons disease
- hypertension
- hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with lightheadedness and fall with headstrike// ?bleed or
fracture
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction,hemorrhage,edema,or
discrete mass. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses is notable for mild mucosal thickening of the ethmoid air cells. The
remainder 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 large territorial infarction or hemorrhage.
2. Mild paranasal sinus disease, as described above.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with lightheadedness and fall with headstrike// ?bleed or
fracture
TECHNIQUE: Noncontrast CT cervical spine with axial, coronal, sagittal
reformations.
Dose total DLP (Body) = 590 mGy-cm.
COMPARISON: None
FINDINGS:
A retention cyst is visualized in the lower right maxillary sinus. No
fracture or malalignment is seen within the cervical spine. There is
degenerative disc disease at multiple levels most notably C5-6 and C6-7.
Prevertebral soft tissues appear normal. There is no critical central spinal
canal or neural foraminal narrowing. The lung apices partially visualized
appear normal. The thyroid gland is unremarkable.
IMPRESSION:
No fracture or malalignment. Multilevel degenerative disc disease.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Anemia, Weakness
Diagnosed with Gastrointestinal hemorrhage, unspecified, Anemia, unspecified, Weakness
temperature: 96.9
heartrate: 103.0
resprate: 17.0
o2sat: 100.0
sbp: 127.0
dbp: 48.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ gentleman with a past medical
history of ___ disease, prostate cancer, and high blood
pressure presents with 2 weeks of subacute and worsening fatigue
and dyspnea on exertion, likely ___ anemia from GI bleed.
========================= |
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, fever
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ yo w/Klatskin tumor diagnosed ___ presents with worsening
abdominal pain and leukocytosis. Pt presented in ___ with
jaundice, weight loss and abdominal pain. ERCP w/ stent
placement relieved symptoms. Biopsy showed malignancy with
spread to lymph nodes, lungs and liver. Pt had planned to start
palliative chemo however her bilirubin was elevated and then she
had a fall at home and was admitted to rehab. She has not yet
received any treatment.
While at rehab pt began to have worsening pain, fever w/Tmax
102.4 and leukocytosis. She was started on Augmentin on ___ and
it appears that fevers resolved, however WBC count continued to
rise as well as LFTs. On ___ pt also began to complain of
worsening RUQ pain.
On arrival to ED pt afebrile, LFTs slightly increased from prior
rehab values, elevated WBC count. Pt given unasyn for possible
cholangitis and ERCP team was contacted. Pt also fell from bed
in ED and CT of head and neck were unremarkable. Vitals prior to
transfer 98.3 147/76 99 16
On arrival to floor pt reports RUQ pain. Denies nausea/emesis.
+Constipation, last BM 2 days ago.
ROS: 10 systems reviewed and negative except as above
Past Medical History:
Metastatic Gallbladder carcinoma
HLD
HTN
s/p hysterectomy
s/p right wrist surgery
Social History:
___
Family History:
Sister has "heart problems." Father and mother had "cancer" but
she is unsure what kind.
Physical Exam:
Physical Examination:
VS: 97.6 142/69 85 20 98%RA
GEN: Alert, oriented to name, place and situation but
occasionally confused. hard of hearing. no acute signs of
distress.
HEENT: sclerae non-icteric, o/p clear, MMM.
Neck: Supple, no JVD, no thyromegaly.
Lymph nodes: No cervical, supraclavicular or axillary LAD.
CV: S1S2, reg rate and rhythm with frequent early beats, no
murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, mildly distended, + bowel sounds.
EXTR: 2+ lower extremity pitting edema bilaterally
DERM: No active rash.
Pertinent Results:
___ Labs
___ Tbili 2.2 Alk607 AST62 ALT55
___ Blood Cx no growth
___ Tbili 2.0 Alk381 AST48 ALT43
___ 06:50PM WBC-18.0* RBC-3.30* HGB-9.1* HCT-28.7*
MCV-87# MCH-27.6# MCHC-31.7 RDW-16.7*
___ 06:50PM NEUTS-89.5* LYMPHS-6.2* MONOS-3.6 EOS-0.5
BASOS-0.2
___ 06:50PM PLT COUNT-504*
___ 08:45PM ___ PTT-32.6 ___
___ 07:01PM LACTATE-1.2
___ 06:50PM GLUCOSE-97 UREA N-9 CREAT-0.6 SODIUM-133
POTASSIUM-4.2 CHLORIDE-91* TOTAL CO2-29 ANION GAP-17
___ 06:50PM ALT(SGPT)-48* AST(SGOT)-64* ALK PHOS-579* TOT
BILI-2.3*
___ 06:50PM LIPASE-19
___ 06:50PM ALBUMIN-2.9*
___ 06:50PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 06:50PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-20
___ 07:05AM BLOOD WBC-11.1* RBC-3.28* Hgb-9.0* Hct-28.6*
MCV-87 MCH-27.5 MCHC-31.6 RDW-17.2* Plt ___
___ 07:05AM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-133
K-3.6 Cl-93* HCO3-31 AnGap-13
___ 07:05AM BLOOD ALT-37 AST-43* AlkPhos-556* TotBili-1.9*
___ 07:05AM BLOOD Albumin-2.8*
CXR FINDINGS: AP and lateral views of the chest were provided.
There is no consolidation, effusion, or pneumothorax. Mild
scoliosis is again noted. The cardiomediastinal silhouette
appears normal. Bony structures are intact. Within the imaged
portion of the upper abdomen, a metallic stent is partially
imaged
Final Report
HISTORY: ___ woman status post fall with head strike,
here to
evaluate for acute cervical spine injury.
COMPARISON: No prior studies available.
TECHNIQUE: Multidetector CT axial imaging of the cervical spine
was obtained
without intravenous contrast. Multiplanar reformatted images
were generated
and reviewed.
FINDINGS:
There is no evidence of acute fracture of the cervical spine.
There is 2 mm
anterolisthesis of C3 on C4 and 2mm retrolisthesis of C5 on its
neighbors,
which is likely chronic and degenerative in etiology given
multilevel
degenerative changes of the cervical spine. No prevertebral or
paraspinal
soft tissue swelling or large hematoma is detected. The
vertebral body
heights are grossly preserved. The atlanto- occipital and
-axial
articulations are maintained.
Multilevel moderate degenerative disease of the cervical spine
are noted.
There is complete fusion of the right and near-complete fusion
of the left C2
and C3 facets. There is multilevel bilateral facet joint
disease. Loss of
intervertebral disc space, endplate sclerosis and osteophyte
formation is most
pronounced from C4 to T1 with the worst level at C5-6.
The imaged lung apices demonstrate mild biapical scarring. The
thyroid gland
is slightly heterogeneous with a coarse calcification in the
right lobe
(02:54) but no dominant nodule identified.
IMPRESSION:
1. No acute fracture of the cervical spine.
2. Multilevel malalignment with 2 mm anterolisthesis of C3 on
C4 and
retrolisthesis of C5 on its neighbors, likely chronic and
degenerative given
the multilevel, multifactorial degenerative disease throughout
the cervical
spine.
NOTE ADDED IN ATTENDING REVIEW: There is significant narrowing
of the ventral
canal with effacement of the thecal sac and indentation of the
right ventral
aspect of the cord, due to a lobulated disc herniation at the
level of the
C4-5 retrolisthesis (2:33, 602b:9). This places the patient at
at further risk
of spinal cord injury, with appropriate traumatic mechanism, and
should be
closely correlated with any clinical evidence of new myelopathy.
The study and the report were reviewed by the staff radiologist.
Final Report
HISTORY: ___ woman status post fall with head strike;
evaluate for
acute intracranial hemorrhage.
COMPARISON: No prior studies available.
TECHNIQUE: Multidetector CT axial imaging of the head was
obtained without
intravenous contrast. Coronal and sagittal reformatted images
as well as thin
section images in a bone window algorithm were generated and
reviewed.
DLP: 1,154 mGy-cm.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema,
mass effect or
shift of normally midline structures. The gray-white matter
interface is
preserved without evidence of acute major vascular territorial
infarct. The
ventricles and sulci are mildly enlarged compatible with age
related
parenchymal volume loss. The basal cisterns are patent.
Atherosclerotic
calcification of the bilateral carotid siphons is noted. The
orbits and
globes are unremarkable.
A left concha bullosa is incidentally noted. The visualized
paranasal sinuses
are well aerated. There is under pneumatization of the left
mastoid air cells
with dense sclerotic bone, which appears chronic. The bilateral
middle ear
cavities and right mastoid air cells are clear. The bony
calvaria appear
intact. No acute fracture is detected.
IMPRESSION:
1. No acute intracranial abnormality.
2. Global atrophy, likely age-related, and moderate sequelae of
chronic small
vessel ischemic disease.
The study and the report were reviewed by the staff radiologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
3. Morphine SR (MS ___ 15 mg PO Q12H
4. Docusate Sodium 100 mg PO BID
5. Pindolol 5 mg PO BID
6. Acetaminophen 650 mg PR Q4H:PRN pain/fever
7. Bisacodyl 10 mg PR HS:PRN constipation
8. Fleet Enema ___AILY:PRN constipation
9. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
indigestion
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. TraZODone 25 mg PO HS
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 2 TAB PO HS
Discharge Medications:
1. Acetaminophen 650 mg PR Q4H:PRN pain/fever
2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
indigestion
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Fleet Enema ___AILY:PRN constipation
6. Milk of Magnesia 30 mL PO Q6H:PRN constipation
7. Morphine SR (MS ___ 15 mg PO Q12H
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
9. Pindolol 5 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 2 TAB PO HS
12. TraZODone 25 mg PO HS
13. Aspirin 81 mg PO DAILY
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*10 Tablet Refills:*0
16. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 5 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
cholangitis
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
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Fever and elevated WBC, question pneumonia.
FINDINGS: AP and lateral views of the chest were provided. There is no
consolidation, effusion, or pneumothorax. Mild scoliosis is again noted. The
cardiomediastinal silhouette appears normal. Bony structures are intact.
Within the imaged portion of the upper abdomen, a metallic stent is partially
imaged.
Radiology Report
HISTORY: ___ woman status post fall with head strike; evaluate for
acute intracranial hemorrhage.
COMPARISON: No prior studies available.
TECHNIQUE: Multidetector CT axial imaging of the head was obtained without
intravenous contrast. Coronal and sagittal reformatted images as well as thin
section images in a bone window algorithm were generated and reviewed.
DLP: 1,154 mGy-cm.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect or
shift of normally midline structures. The gray-white matter interface is
preserved without evidence of acute major vascular territorial infarct. The
ventricles and sulci are mildly enlarged compatible with age related
parenchymal volume loss. The basal cisterns are patent. Atherosclerotic
calcification of the bilateral carotid siphons is noted. The orbits and
globes are unremarkable.
A left concha bullosa is incidentally noted. The visualized paranasal sinuses
are well aerated. There is under pneumatization of the left mastoid air cells
with dense sclerotic bone, which appears chronic. The bilateral middle ear
cavities and right mastoid air cells are clear. The bony calvaria appear
intact. No acute fracture is detected.
IMPRESSION:
1. No acute intracranial abnormality.
2. Global atrophy, likely age-related, and moderate sequelae of chronic small
vessel ischemic disease.
Radiology Report
HISTORY: ___ woman status post fall with head strike, here to
evaluate for acute cervical spine injury.
COMPARISON: No prior studies available.
TECHNIQUE: Multidetector CT axial imaging of the cervical spine was obtained
without intravenous contrast. Multiplanar reformatted images were generated
and reviewed.
FINDINGS:
There is no evidence of acute fracture of the cervical spine. There is 2 mm
anterolisthesis of C3 on C4 and 2mm retrolisthesis of C5 on its neighbors,
which is likely chronic and degenerative in etiology given multilevel
degenerative changes of the cervical spine. No prevertebral or paraspinal
soft tissue swelling or large hematoma is detected. The vertebral body
heights are grossly preserved. The atlanto- occipital and -axial
articulations are maintained.
Multilevel moderate degenerative disease of the cervical spine are noted.
There is complete fusion of the right and near-complete fusion of the left C2
and C3 facets. There is multilevel bilateral facet joint disease. Loss of
intervertebral disc space, endplate sclerosis and osteophyte formation is most
pronounced from C4 to T1 with the worst level at C5-6.
The imaged lung apices demonstrate mild biapical scarring. The thyroid gland
is slightly heterogeneous with a coarse calcification in the right lobe
(02:54) but no dominant nodule identified.
IMPRESSION:
1. No acute fracture of the cervical spine.
2. Multilevel malalignment with 2 mm anterolisthesis of C3 on C4 and
retrolisthesis of C5 on its neighbors, likely chronic and degenerative given
the multilevel, multifactorial degenerative disease throughout the cervical
spine.
NOTE ADDED IN ATTENDING REVIEW: There is significant narrowing of the ventral
canal with effacement of the thecal sac and indentation of the right ventral
aspect of the cord, due to a lobulated disc herniation at the level of the
C4-5 retrolisthesis (2:33, 602b:9). This places the patient at at further risk
of spinal cord injury, with appropriate traumatic mechanism, and should be
closely correlated with any clinical evidence of new myelopathy.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVERS/ABD PAIN
Diagnosed with CHOLANGITIS
temperature: 98.6
heartrate: 84.0
resprate: 20.0
o2sat: 97.0
sbp: 140.0
dbp: 80.0
level of pain: 8
level of acuity: 2.0 | ASSESSEMENT & PLAN: ___ yo w/Klatskin tumor diagnosed ___
presents with worsening abdominal pain and fever secondary to
cholangitis.
#Cholangitis
The patient was admitted to the medicine service and was given
IV fluids, nothing by mouth, with antiemetics and narcotics as
needed. She was given Zosyn empirically and was afebrile. She
was taken to the ERCP suite on the morning of ___ which had the
following impression:
A metal stent placed in the biliary duct was found in the major
papilla just inside the bile duct. Cannulation of the biliary
duct was successful and deep with a balloon catheter. There
were small filling defects inside the metal stent at the biliary
tree. The common hepatic duct above the metal stent and the left
and right hepatic ducts were normal. No discrete stricture was
noted. Normal intrahepatics.
Several balloon sweeps were performed. Small amount of
debris/sludge was extracted successfully using a balloon. Final
cholangiogram showed no filling defects.
Given the patient symptoms and the early obstruction of the
recent placed metal stent, a decision was made to place a 5cm by
___ double pig tail biliary stent inside the metal stent.
Excellent flow of bile was noted.
.
The patient returned to the floor and advanced to a full diet
with no problems by the following day. She will be discharged
home on PO cipro/flagyl to complete a 7 day course.
#Gallbladder carcinoma - patient has an appointment to see Dr.
___ on ___ to discuss treatment options
#falls at home: pt admitted from rehab. seen by ___, okay to go
home with home ___ and 24h family support
# Dispo:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
____________________________________
___, MD, pager ___ |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right arm bleeding
Major Surgical or Invasive Procedure:
___: Bedside drainage of Right arm hematoma
___: Right arm exploration and evacuation
History of Present Illness:
___ y.o. ___ gentleman with HTN, CAD s/p 3v CABG
in ___, MVR w/ mechanical valve, Afib on coumadin s/p PVI and
ICD, systolic cardiomyopathy LVEF 40% ___, and ___
Disease as well as recent admission to the ___ service ___
- ___ for acute sCHF exacerbation and negative work-up for
cardiac sarcoidosis with RH catheterization, c/b development of
compartment syndrome ___ at cath site requiring fasciotomy and
skin graft ___, now presenting with significant bleeding from
graft site and increased swelling starting this evening. This
was accompanied by some numbness in his fingers which has
currently resolved. He had supratheraputic INRs since his
discharge from the hospital.
Patient is on coumadin for h/o afib and mechanical valve. Given
that patient is supratherapeutic on his INR, plastic surgery
wanted to know if there is anything that can be done to bring
down his INR (vitamin K, FFP, etc), but given mechanical valve,
reversal was deferred in the ED. ED also discussed ___ Cards
on phone. Not comfortable with reversal, recommend slowly
allowing INR to trend down unless concern for vascular
compromise.
Evaluated by plastics who noted large muscular hematoma on ulnar
aspect of proximal forearm and threatened skin graft. They
opened prior incision along ulnar aspect of graft and entered
large hematoma cavity with diffuse muscular bleeding, no focal
vessel. Irrigated and packed with Surgicel/QuickClot.
Vitals in the ED: ___ 72 102/65 18 100%
Labs notable for: BUN 45, cre 1.5. HCT 28, INR 4.0
Patient given: percocet 1 tab, cefazolin 1g
Vitals prior to transfer:
On the floor, the patient denies any pain and is filling out a
lottery ticket. He states the previous numbness in his fingers
has resolved.
Past Medical History:
-Coronary artery disease status post coronary artery bypass
grafting x3
-Atrial fibrillation status post pulmonary vein isolation with
Maze procedure
-Mitral regurgitation status post mechanical mitral valve
replacement
-Chronic systolic heart failure, last dry weight 52.2kg
-Rate controlled atrial flutter
-Parkinsons disease
-Hypertension
-Hyperlipidemia
-Hemorrhoidal lower gastrointestinal bleed
-Erectile dysfunction
-Hypoprolactinemia
-Essential tremor
- Subdural hematoma s/p fall ___, readmitted ___ for
craniotomy and SDH evacuation
- Permanent Pacemaker / ICD placement (___)
Social History:
___
Family History:
No family history of premature coronary artery disease or sudden
death.
Physical Exam:
On Admission:
Vitals: 98 97/65 76 18 100%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, II/VI holosystolic murmur.
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. R arm bandaged. R leg graft donor site
with overlying eschar, mild surrounding erythema symmetrically.
PULSES: 2+ DP pulses bilaterally. R hand with palpable radial
pulse. Ulnar pulse easily dopplerable with triphasic waveform.
NEURO: CN II-XII intact. Sensation to light touch intact in
right hand. Motor strength in hand is full.
On Discharge:
Vitals: 98.1/98.1; 91-113/50-74; 56-73; ___ 99-100% RA
Today's weight: Not charted
GENERAL: Pleasant, no acute distress.
HEENT: Sclera clear, MMM, no oropharyngeal lesions.
NECK: Supple with JVP of 7cm.
CARDIAC: RRR. Murmur at LUSB and at Left axilla, similar to
yesterday. Normal S1 and S2.
CHEST: Well-healed sternotomy scar. Posterior exam notable for
mild bilateral inspiratory crackles R>L. No wheezing or rhonci.
ABDOMEN: Soft, NT, ND. Normoactive bowel sounds.
EXTREMITIES: RH warm with normal capillary refill. 1+ radial
pulse. Neuro function intact, sensation intact. 2+ L radial
pulse. Right arm with clean bandage intact. Otherwise, inability
to fully close Right hand. Right thigh graft site open, CDI,
with minimal surrounding erythema. No ___ edema
SKIN: Hyperpigmented skin changes in ___.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
On Admission:
___ 09:25PM BLOOD WBC-7.6 RBC-2.90* Hgb-9.1* Hct-28.0*
MCV-96 MCH-31.3 MCHC-32.5 RDW-15.3 Plt ___
___ 09:25PM BLOOD Neuts-84.6* Lymphs-8.9* Monos-5.5 Eos-0.7
Baso-0.2
___ 09:25PM BLOOD ___ PTT-44.8* ___
___ 09:25PM BLOOD Glucose-176* UreaN-45* Creat-1.5* Na-133
K-5.0 Cl-98 HCO3-31 AnGap-9
On Discharge:
___ 05:55AM BLOOD WBC-4.7 RBC-2.62* Hgb-8.5* Hct-25.1*
MCV-96 MCH-32.7* MCHC-34.0 RDW-17.5* Plt ___
___ 01:36PM BLOOD ___ PTT-133.0* ___
___ 05:55AM BLOOD Glucose-87 UreaN-24* Creat-1.3* Na-133
K-4.1 Cl-100 HCO3-25 AnGap-12
___ 05:55AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.1
Coags:
___ 09:25PM BLOOD ___ PTT-44.8* ___
___ 07:45AM BLOOD ___ PTT-47.1* ___
___ 03:05PM BLOOD ___ PTT-46.8* ___
___ 07:30AM BLOOD ___ PTT-40.7* ___
___ 07:35AM BLOOD ___ PTT-94.8* ___
___ 02:09AM BLOOD ___ PTT-79.2* ___
___ 04:06AM BLOOD ___ PTT-77.5* ___
___ 07:10AM BLOOD ___ PTT-60.2* ___
___ 07:55AM BLOOD ___ PTT-56.9* ___
___ 03:15AM BLOOD ___ PTT-84.8* ___
___ 03:40AM BLOOD ___ PTT-65.2* ___
___ 04:01AM BLOOD ___ PTT-69.1* ___
___ 05:55AM BLOOD ___ PTT-69.2* ___
___ 01:36PM BLOOD ___ PTT-133.0* ___
CBCs:
___ 09:25PM BLOOD WBC-7.6 RBC-2.90* Hgb-9.1* Hct-28.0*
MCV-96 MCH-31.3 MCHC-32.5 RDW-15.3 Plt ___
___ 07:45AM BLOOD WBC-8.4 RBC-2.77* Hgb-8.7* Hct-26.6*
MCV-96 MCH-31.4 MCHC-32.7 RDW-15.3 Plt ___
___ 07:30AM BLOOD WBC-9.8 RBC-2.98* Hgb-9.4* Hct-28.8*
MCV-97 MCH-31.6 MCHC-32.8 RDW-15.7* Plt ___
___ 07:35AM BLOOD WBC-9.5 RBC-2.71* Hgb-8.7* Hct-25.9*
MCV-96 MCH-32.0 MCHC-33.4 RDW-15.8* Plt ___
___ 09:30PM BLOOD WBC-8.4 RBC-2.57* Hgb-8.0* Hct-24.5*
MCV-95 MCH-31.2 MCHC-32.8 RDW-15.5 Plt ___
___ 12:03AM BLOOD WBC-8.1 RBC-2.46* Hgb-7.8* Hct-22.4*
MCV-91 MCH-31.6 MCHC-34.7 RDW-15.6* Plt ___
___ 06:08AM BLOOD WBC-8.5 RBC-2.58* Hgb-8.1* Hct-24.9*
MCV-97 MCH-31.4 MCHC-32.5 RDW-15.7* Plt ___
___ 05:40PM BLOOD WBC-8.5 RBC-2.40* Hgb-7.4* Hct-22.9*
MCV-95 MCH-30.7 MCHC-32.2 RDW-15.9* Plt ___
___ 11:50PM BLOOD WBC-7.2 RBC-2.36* Hgb-7.3* Hct-22.6*
MCV-95 MCH-30.8 MCHC-32.3 RDW-16.1* Plt ___
___ 04:06AM BLOOD WBC-9.9 RBC-2.45* Hgb-7.6* Hct-23.6*
MCV-97 MCH-31.0 MCHC-32.1 RDW-16.0* Plt ___
___ 03:05PM BLOOD WBC-11.0 RBC-2.28* Hgb-7.2* Hct-21.9*
MCV-96 MCH-31.5 MCHC-32.9 RDW-16.3* Plt ___
___ 11:45PM BLOOD WBC-9.0 RBC-2.15* Hgb-6.7* Hct-20.7*
MCV-96 MCH-31.3 MCHC-32.6 RDW-16.6* Plt ___
___ 07:10AM BLOOD WBC-6.8 RBC-2.15* Hgb-6.7* Hct-20.9*
MCV-97 MCH-31.2 MCHC-32.2 RDW-17.4* Plt ___
___ 03:20PM BLOOD WBC-8.0 RBC-2.66* Hgb-8.7*# Hct-24.7*
MCV-93 MCH-32.8* MCHC-35.4* RDW-16.9* Plt ___
___ 11:41PM BLOOD WBC-8.1 RBC-2.37* Hgb-7.8* Hct-21.7*
MCV-92 MCH-32.7* MCHC-35.7* RDW-17.0* Plt ___
___ 07:55AM BLOOD WBC-6.9 RBC-2.60* Hgb-8.3* Hct-24.3*
MCV-94 MCH-31.9 MCHC-34.0 RDW-17.0* Plt ___
___ 09:37PM BLOOD WBC-5.7 RBC-2.47* Hgb-7.8* Hct-23.6*
MCV-96 MCH-31.7 MCHC-33.2 RDW-16.9* Plt ___
___ 03:15AM BLOOD WBC-4.8 RBC-2.48* Hgb-7.9* Hct-23.8*
MCV-96 MCH-31.8 MCHC-33.2 RDW-17.0* Plt ___
___ 03:40AM BLOOD WBC-5.7 RBC-2.47* Hgb-7.9* Hct-23.5*
MCV-95 MCH-32.1* MCHC-33.8 RDW-17.1* Plt ___
___ 04:01AM BLOOD WBC-4.6 RBC-2.43* Hgb-7.7* Hct-23.6*
MCV-97 MCH-31.5 MCHC-32.6 RDW-17.3* Plt ___
___ 05:55AM BLOOD WBC-4.7 RBC-2.62* Hgb-8.5* Hct-25.1*
MCV-96 MCH-32.7* MCHC-34.0 RDW-17.5* Plt ___
IMAGING:
___ Echo:
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is top
normal/borderline dilated. There is mild global left ventricular
hypokinesis (LVEF = 45-50 %). The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. A bileaflet mitral
valve prosthesis is present. The mitral prosthesis appears well
seated, with normal disc motion and transvalvular gradients.
Torn mitral chordae are present.. No mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Well seated, normal functioning bileaflet mitral
valve prosthesis. Borderline left ventricular cavity dilation
with mild global hypokinesis. Mild pulmonary artery systolic
hypertension. Right ventricular cavity dilation with free wall
hypokinesis. Mildly dilated ascending aorta.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
___ CXR:
IMPRESSION:
In comparison with the study of ___, there is again is
substantial enlargement of the cardiac silhouette in a patient
with valve replacement and dual-channel pacer with leads
extending to the right atrium and apex of the right ventricle.
Blunting of the left costophrenic angle is again seen. No
definite vascular congestion or acute focal pneumonia.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Losartan Potassium 50 mg PO QHS
5. Metoprolol Succinate XL 25 mg PO DAILY
6. pramipexole 3 mg oral QDAILY
7. Torsemide 20 mg PO DAILY
8. Warfarin 1.5 mg PO ONCE
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Losartan Potassium 50 mg PO QHS
5. Metoprolol Succinate XL 25 mg PO DAILY
6. pramipexole 3 mg oral QDAILY
7. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Warfarin 1.5 mg PO DAILY16
9. Outpatient Lab Work
Please draw DAILY INR from ___. Results should
be sent to ___ Anticoagulation Clinic
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Right arm hematoma
- Supratherapeutic INR
Secondary:
- Chronic systolic CHF
- Atrial fibrillation, s/p PVI and Maze with ___ ligation
___
- Mitral regurgitation, s/p mechanical MVR (27 mm St. ___
- Parkinsons disease
- Hypertension
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chest pain // please eval for volume
overload please eval for volume overload
IMPRESSION:
In comparison with the study of ___, there is again is substantial
enlargement of the cardiac silhouette in a patient with valve replacement and
dual-channel pacer with leads extending to the right atrium and apex of the
right ventricle. Blunting of the left costophrenic angle is again seen. No
definite vascular congestion or acute focal pneumonia.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with HEMATOMA COMPLIC PROCEDURE, ABN REACT-PROCEDURE NOS, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 98.5
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 102.0
dbp: 65.0
level of pain: 5
level of acuity: 2.0 | ___ y.o. ___ gentleman with HTN, CAD s/p 3v CABG
in ___, MVR w/ mechanical valve, Afib on coumadin s/p ICD,
systolic cardiomyopathy LVEF 40% ___, and ___
Disease as well as recent admission to the ___ service ___
- ___ for acute sCHF exacerbation and negative work-up for
cardiac sarcoidosis with RH catheterization, c/b development of
compartment syndrome ___ at cath site requiring fasciotomy and
skin graft ___, who presented with significant bleeding from
graft site and increased swelling.
#Right arm bleeding: On presentation, pt with significant
bleeding and swelling from graft site in the setting of
supratherpeutic INR. In the emergency department, pt was
evaluated by plastic surgery who performed bedside drainage of
Right arm hematoma. Post-procedurally, pt was admitted to ___,
where his warfarin was held and his INR was reversed with
vitamin K. Pt was bridged with heparin when he became
subtherapeutic. TTE did not show any thrombi on the mitral
valve. Pt underwent Right arm exploration and evacuation by hand
surgery on ___, which showed good hemostasis. Notably, pt
was found to have difficulty closing his Right hand
post-procedurally, although perfusion of the hand otherwise
appeared normal. He was restarted on warfarin with heparin
bridge. INR became therapeutic on ___, and pt was
discharged with a plan to follow up with ___ of plastic
surgery. Of note, pt was also discharged with a plan to obtain
occupational therapy as an outpatient.
#sCHF: Pt appeared to be euvolemic on exam. Pt's torsemide was
decreased to 10mg Qday this hospitalization, and he remained
roughly euvolemic on this dose. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
latex / coband
Attending: ___.
Chief Complaint:
neck soreness and headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, the patient states that he was lifting heavy boxes on
___ when he noticed a sudden soreness of his neck and
posterior
head. On ___, he developed a significant headache. On ___,
he
had several bouts of emesis which led him to present for
evaluation. While at the OSH, he was noted to be hypertensive
with a SBP>200 and with an INR of 3.4. He received 2400 units of
K-centra for reversal and was transferred to ___ for further
evaluation. He last took aspirin yesterday.
Currently, he reports moderate nausea, mild neck pain, and a
___
headache. He notes that the nausea is more severe while flat.
His
most recent INR is 1.2.
Past Medical History:
PMHx:
- mechanical aortic valve
- HTN
- DM2
- BKA
Social History:
___
Family Hx:
Is there a family history of Aneurysms?
[X]No
[ ]Yes
Family History:
Mother with CAD
Father with ___
Physical Exam:
On discharge:
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension intact: [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
Right555***
Left55___
*Patient has below the knee amputation on right side
[x]Sensation intact to light touch
Pertinent Results:
Please see OMR
Medications on Admission:
atorvastatin 40 mg/day, isosorbide mononitrate ER 45 mg,
metformin 500 mg (HOLDING), Tamsulosin 0.4 mg, insulin 15 u/day,
metoprolol succinate ER 25 mg, gemfibrozil 600 mg BID, warfarin
1 mg
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
4. Docusate Sodium 100 mg PO BID
5. Senna 17.2 mg PO HS
6. Atorvastatin 40 mg PO QPM
7. Gemfibrozil 600 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 45 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Metoprolol Succinate XL 25 mg PO BID
11. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
intraventricular hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with known ICH // eval for ICH expansion
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Multiple CT head evaluations dated ___ and ___.
FINDINGS:
Small amount of layering hyperdense material is again seen within the right
occipital horn of the lateral ventricle. No change in ventricular size. No
new site of intra or extra-axial hemorrhage. No evidence of acute major
vascular territorial infarction. Imaged paranasal sinuses, mastoid air cells
and middle ear cavities remain well aerated. The bony calvarium is intact.
IMPRESSION:
Small volume intraventricular hemorrhage, right-sided. No change in
ventricular size.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with headache // eval for causes of IPH/IVH/SAH
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.9 mGy (Body) DLP =
10.0 mGy-cm.
3) Spiral Acquisition 5.1 s, 40.2 cm; CTDIvol = 15.2 mGy (Body) DLP = 612.1
mGy-cm.
Total DLP (Body) = 622 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Reference head CT ___ at 22:28
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is redemonstration of acute intraventricular hemorrhage layering
dependently in both lateral ventricles, similar to slightly increased in the
right lateral ventricle and more conspicuous on the left. There is
redemonstration of hyperdense hemorrhage along the right temporal lobe,
possibly subarachnoid with mild regional sulcal effacement, more conspicuous
on this exam. No acute infarction or midline shift. There is similar mild
prominence of the ventricles compared with ___, likely related to
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, with
the exception of prior lens surgery.
CTA HEAD:
There is extensive calcified atherosclerotic plaque in the cavernous and
supraclinoid internal carotid arteries resulting in mild luminal irregularity
without high-grade stenosis. A 2 mm posteriorly projecting conical
outpouching of the left carotid terminus (series 3, image 253) demonstrates
small vessel arising from a compatible with an infundibulum. There is mild
focal narrowing at the origin of the left MCA. The vessels of the circle of
___ and their principal intracranial branches otherwise appear patent
without stenosis, occlusion, or aneurysm. The dural venous sinuses are
patent.
CTA NECK:
There are atherosclerotic calcifications along the aortic arch and origins of
the major vessels including the left common carotid and left subclavian
arteries resulting in mild to moderate right and mild left stenosis. There is
mild atherosclerotic stenosis at the origin of the left vertebral artery and
moderate atherosclerotic stenosis at the origin of the right vertebral artery.
Bilateral carotid and vertebral artery origins are otherwise patent.
The patient is status post right carotid endarterectomy. There is luminal
hyperplasia in the proximal right internal carotid artery results in
approximately 55% stenosis by NASCET criteria. Predominantly calcified
atherosclerotic plaque in the proximal left internal carotid artery results in
approximately 40% stenosis by NASCET criteria.
Both vertebral arteries are patent without evidence of occlusion or
dissection. There is mild calcified and noncalcified plaque in the left
greater than right V4 vertebral artery segments that results in mild luminal
irregularity without high-grade stenosis.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Similar extent of intraventricular hemorrhage layering dependently in the
lateral ventricles, slightly more conspicuous in the left occipital horn since
the prior study and small amount of evolving subarachnoid hemorrhage in right
temporal sulci with mild regional edema. No significant mass effect, midline
shift or large territory infarction.
2. Stable ventricular size since the prior study from ___.
3. Atherosclerotic plaque of the bilateral intracranial ICA resulting in mild
left and mild-to-moderate right ICA stenosis.
4. Mild stenosis at the left MCA origin, likely related to atherosclerotic
disease.
5. Otherwise patent circle of ___ without evidence of high-grade
stenosis,occlusion,or aneurysm.
6. Atherosclerotic narrowing results in 40% stenosis of the left ICA by NASCET
criteria. Intimal hyperplasia results in resulting in 55% stenosis of the
right cervical internal carotid artery. The patient is status post right
carotid endarterectomy.
7. Mild-to-moderate atherosclerotic narrowing of the bilateral vertebral
artery origins and mild narrowing of the left subclavian artery origin.
8. Otherwise patent cervical and vertebral arteries without evidence of
occlusion, dissection or aneurysm.
9. Additional findings described above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SAH
Diagnosed with Headache
temperature: 97.0
heartrate: 67.0
resprate: 18.0
o2sat: 96.0
sbp: 180.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | ___ was admitted to the hospital from the emergency
room after signs and symptoms and imaging were consistent with
an intraventricular hemorrhage. He was observed in the hospital
with frequent neuro checks as well as repeat imaging to assess
for worsening symptoms of which there were none. His headache
was improving, he was ambulating on his own, and remained stable
clinically throughout his hospitalization.
___ was consulted while he was inpatient and titrated and
adjusted his diabetes medications accordingly and made
recommendations for his home regimen.
___ was consulted and saw him on ___. They recommended home
upon discharge after ___ more visits.
He was discharged on ___. At the time of discharge he was
ambulating with assistance, voiding independently, tolerating PO
diet and pain meds, and his vital signs were stable.
He will restart his Aspirin on ___ and will restart his
coumadin on ___.
He should follow up with his PCP regarding diabetes and otitis
media. Patient will follow up with Dr. ___ on ___. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
morphine / Empirin W/Codeine / Betadine / Plaquenil / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Left parafalcine SDH s/p mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a lovely ___ year old female with a history of HTN,
RA, hypothyroidism, right leg neuropathy, and right foot drop
who presents to ___ status-post fall with head strike. The
patient reports that she was getting out of bed around 3AM this
morning to go to the bathroom ("I have a bladder problem"), was
using her walker, and prior to getting to the bathroom fell
backwards hitting her head on the floor, which had a rug on it.
Mrs. ___
had no loss of consciousness before, during, or after the
incident, had no change in her vision, no chest pain, no
shortness of breath prior to the fall. She is unsure why she
fell, but does believe it is related to her baseline poor
balance. She subsequently called her emergency response line,
and was then taken to the ED by EMS. On presentation, the
patient was also complaining of "crushing" chest pain, and was
worked up by the ED for this.
Mrs. ___ is currently not complaining of any head pain, no
dizziness, no nausea or vomiting, no change in her
vision/hearing. She does have mild neck stiffness, however. Mrs.
___ has a history of recent falls. She reports falling at
least 4 times since ___ when she moved to her assisted
living facility. She participates in balance classes twice
weekly and does home exercises to improve her balance. At home
during the day she uses a cane to ambulate, and at night she
uses a walker or a walker with wheels. She is able to walk a
city block with a cane without having to stop and without losing
her
balance.
Past Medical History:
Hypertension
Rheumatoid arthritis
Hypothyroidism
Right foot drop since ___ (wears orthotic)
Neuropathy on right foot
Hx of multiple toe fractures s/p falls
Hx of cataract surgery in ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
AVSS
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5-->1.5 bilaterally, equal, round and reactive
EOMs full, no nystagmus
Neck: Supple. No pain with bony palpation.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Right middle toe with obvious
deformity at distal phalanx.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
II-XII: intact bilaterally
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout, except right foot.
Right TA and ___ ___. No pronator drift
Sensation: Intact to light touch, propioception, and vibration
bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
On Discharge:
AVSS
Gen: WDWN, comfortable, NAD
HEENT: PERRLA bilaterally, EOMS full
Lungs: CTA bilaterally
Cardiac: RRR, nml S1/S2
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Right middle toe with obvious
deformity at distal phalanx.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Neuro:CN ___ intact bilaterally, strength ___ throughout,
except right foot. Right TA and ___ ___. No pronoator drift.
Sensation intact bilaterally.
Pertinent Results:
___ 10:07AM GLUCOSE-80 UREA N-15 CREAT-0.8 SODIUM-135
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-16
___ 10:07AM cTropnT-<0.01
___ 10:07AM WBC-7.0 RBC-4.94 HGB-14.7 HCT-46.3 MCV-94
MCH-29.7 MCHC-31.7 RDW-14.4
___ : Non-contrast CT head (OSH): small, left-sided parafalcine
subdural
hematoma with no mass effect, no mid-line shift. Significant
brain atrophy with widened sulci.
___: Non-contrast CT head: Stable left parafalcine subdural
hematoma
Medications on Admission:
verapamil 240mg QAM, levothyroxine 75mcg QAM, indapomide 1.25mg
daily, mirtazipine 7.5 mg QHS, cymbalta 60mg daily, omeprazole
20mg daily, vesicare 10mg QHS
Discharge Medications:
1. Duloxetine 60 mg PO DAILY
2. Indapamide 1.25 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO QAM
4. Mirtazapine 7.5 mg PO HS
5. Omeprazole 20 mg PO DAILY
6. Verapamil 240 mg PO QAM
7. Acetaminophen 650 mg PO TID
8. Vesicare (solifenacin) 10 mg oral QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left parafalcine subdural hematoma
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: Patient with chest pain. Evaluate for CHF.
FINDINGS: There is mild bilateral mid to lower lung linear
atelectasis/scarring, left greater than right. Possible underlying minimal
intersitial edema present. No focal opacity concerning for pneumonia is
identified. There is no pleural effusion or pneumothorax. The
cardiomediastinal and hilar contours are unremarkable.
Radiology Report
INDICATION: Patient status post fall with pain in the third digit. Evaluate.
COMPARISON: None available.
TECHNIQUE: Right foot, three views.
FINDINGS: On the background of diffuse osteopenia, there is no evidence of
new fracture or dislocation. Deformity in the distal shaft of the fifth and
fourth metatarsals is due to healed fractures. Moderate-to-severe
degenerative changes are more pronounced at the first TMT and first MTP joint,
with resulting hallux valgus deformity. Inferior and posterior calcaneal
spurs are present. Vascular calcifications are noted in the posterior aspect
of the distal leg. There is no radiopaque foreign object.
IMPRESSION: No evidence of fracture. Deformity in the ___ and ___
metatarsals is due to old healed fractures. Moderate degenerative changes,
most pronounced at the first TMT and first MTP joint with resulting hallux
valgus.
Radiology Report
HISTORY: Subdural hemorrhage.
COMPARISON: Head CT ___.
TECHNIQUE: Axial MDCT images were obtained through the brain without the
administration of IV contrast. Coronal and sagittal reformats as well as
axial bone algorithm reconstructed images were acquired.
DLP: 1025.72 mGy-cm.
CTDIvol: 63.23 mGy.
FINDINGS:
Small left parafalcine subdural hemorrhage has remained stable with maximum
thickness of 6 mm. No other hemorrhage is seen. The ventricles and sulci are
mildly prominent, consistent with age-related atrophy. A cavum septum
pellucidum is noted. Periventricular white matter hypodensities are
nonspecific but consistent with small vessel ischemic changes.
There is no evidence of fracture. The visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear.
IMPRESSION:
Stable left parafalcine subdural hematoma.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with TRAUMATIC SUBDURAL HEM, UNSPECIFIED FALL, CHEST PAIN NOS
temperature: 97.9
heartrate: 72.0
resprate: 16.0
o2sat: 98.0
sbp: 158.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | The patient was transferred to ___ from an OSH with a
non-contrast CT head demonstrating a small left parafalcine
subdural hematoma without shift. The patient was admitted to
neurosurgery on ___ for close monitoring. A repeat non-contrast
CT head was performed on ___, which demonstrated a stable SDH.
The patient remained neurologically stable and her home
medications were restarted on the morning of ___. Physical
therapy was consulted and worked with the patient. They
recomended discharging the patient back to her assisted living
facility with continued ___. It was recommended the patient
change her home environment to have a commode at bedside, but
the patient refused this change.
On ___, the patient was discharged to her assisted living
facility with continued physical therapy. On discharge, she was
tolerating a regular diet, her pain was well controlled, she was
voiding, and was neurologically stable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Egg White / House Dust
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old homeless woman who presents with cough, night sweats
and chills. She has had cough intermittently since ___.
She was recently seen at the ___ and diagnosed with
atypical pneumonia and was treated with 5 days of azithromycin,
which improved her symptoms. Over the past few days, she has
non-productive cough, shortness of breath and hot flashes
alternating with chills. Has had night sweats. She has nasal
congestion/rhinorrhea and general malaise. Poor appetite. No
chest pain. No lower extremity swelling or erythema, no recent
travel. She is living in the shelter with her son.
In the ___, initial VS: 98.6 ___ 16 100%. Labs within
normal limits, diff on CBC shows 52.1 lymphocytes. Peak flow 320
(expected is 460)CXR showed small nodule in mid right lung; no
calcification, not typical but cannot rule out TB. ECG without
ST/T changes. Given albuterol nebulizer with symptom
improvement.
Upon arrival to the floor, she is tired, has cough and nasal
congestion. Requesting nicotine patch
Past Medical History:
Fibromyalgia and chronic pain
Iron deficiency
Depression, anxiety, PTSD
Gonorrhea/chlamydia ___ and Gonorrhea ___
Abnormal Pap in ___
Bed bug bites
Social History:
___
Family History:
son has asthma
Physical Exam:
VS - 98.6, 89, 116/74, 16, 100% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear, no rhinorrhea
NECK - supple, no cervial LAD
LUNGS - CTA bilat, no r/rh/wh, good air movement
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
___ 09:55PM WBC-6.3 RBC-4.10* HGB-13.5 HCT-40.9 MCV-100*
MCH-32.9* MCHC-32.9 RDW-12.3
___ 09:55PM NEUTS-36.3* LYMPHS-52.1* MONOS-6.5 EOS-4.7*
BASOS-0.5
___ 09:55PM GLUCOSE-96 UREA N-13 CREAT-0.7 SODIUM-139
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
microbiology:
___: sputum:
no AFB seen on concentrated smear, culture pending
CXR: ___
Patchy right upper lobe opacity in a patient of this age is more
worrisome for pneumonia as opposed to underlying lesion. No
prior is available for comparison to assess for interval change.
In the appropriate clinical setting, tuberculosis is not
excluded.
ppd: implanted ___ and read ___
negative
Medications on Admission:
Ibuprofen p.r.n.
acetaminophen p.r.n.
medroxyprogesterone
prenatal vitamins
calcium 600mg BID
vitamin D 1000 units daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. medroxyprogesterone 150 mg/mL Syringe Sig: One (1) syringe
Intramuscular q 3 months.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: ___ puffs Inhalation Q4H (every 4 hours) as
needed for SOB/wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
shortness of breath
Secondary Diagnosis:
anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of cough, dyspnea,
recent pneumonia.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest are obtained. Patchy right
upper lobe opacity is seen. No priors available for comparison to assess for
interval change in this patient with reported recent history of pneumonia.
The left lung is clear. No pleural effusion or pneumothorax is seen. Cardiac
and mediastinal silhouettes are unremarkable, albeit the hilar contours.
IMPRESSION: Patchy right upper lobe opacity in a patient of this age is more
worrisome for pneumonia as opposed to underlying lesion. No prior is
available for comparison to assess for interval change. In the appropriate
clinical setting, tuberculosis is not excluded.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: RESPIRATORY SX
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 98.6
heartrate: 110.0
resprate: 16.0
o2sat: 100.0
sbp: 92.0
dbp: 61.0
level of pain: 0
level of acuity: 3.0 | ___ year old homeless woman who was admitted with cough, night
sweats and chills accompanied by RUL infiltrate on CXR.
# Dyspnea: Patient's dyspnea was felt to be secondary to an
upper respiratory URI with associated bronchospasm, which was
relieved with Albuterol. Although an infiltrate was noted on
CXR, this was likely an old pneumonia for which patient was
already treated. In addition, she was afebrile without
leukocytosis or hypoxia during entire hospitalization, making an
acute process less likely, especially she had already been
treated with a full antibiotic course. There was initial
suspicion for active tuberculosis with fever and night sweats,
but this was felt to be clinically unlikely based on history,
physical and radiographic appearance of the infiltrate. Due to
risk factors for acquiring latent TB, a ppd was planted and
returned negative, which also reinforced low clinical concern
for tuberculosis. Patient was discharged with prescription for
albuterol. She should have further evaluation for suspected
reactive airway disease vs. asthma with outpt PFTs. She should
also have repeat CXR in ___ weeks to assess for interval
resolution of RUL infiltrate. If infiltrate persists or
symptoms worsen, would recommend further evaluation with CT
chest and consideration of outpt Pulmonary evaluation.
# Tobacco dependence: While in hospital, patient maintained on
nicotine patch prn. Upon discharge, patient continued on
patches with follow up arranged with PCP for continued
management.
# Psychosocial concerns: Patient reports difficulty finding
housing and stress caring for her young son with significant
social support structures. She was seen by social work while in
the hospital who recommended case management services through
___ Health or a community mental health agency. The patient
was given information on how to obtain these services and will
follow up as outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Motor vehicle collision versus tree
Major Surgical or Invasive Procedure:
___: Repair of scalp laceration
History of Present Illness:
___ male brought by ambulance from scene after MVC at
moderate speed against tree, unknown restrain but +airbag
deployment, unknown LOC, no recollection of event
Past Medical History:
Hypertension.
Past surgical history:
Left knee surgery and vasectomy
Social History:
___
Family History:
No family history of sudden cardiac death, seizures or frequent
syncopal events
Physical Exam:
On admission,
HR: 103 BP: 146/83 Resp: 18 O(2)Sat: 98 Normal
Constitutional: boarded, c-collar
Head / Eyes: 3 cm R parietal laceration, pupils 6-5 mm equal and
reactive bilaterally, no hemotympanum
ENT: OP WNL, no blood in oral cavity
Resp: airway intact, breath sounds equal bilaterally
Cards: circulation intact, sternum stable
Abd: S/NT, mild distention, FAST negative
Rectal: normal sphinctal tone, normal prostate, no gross blood
Pelvis: pelvis stable
Skin: no rash
Ext: bilateral femurs stable, mild swelling on right, bilateral
tib/fib stable, palpable DP pulses
Back: no tenderness to t-spine or l-spine, no step-offs or
deformities.
Neuro: speech fluent
Psych: normal mood
Upon discharge,
General: AVSS, well-appearing, in no acute distress
HEENT: Neck supple. PERRLA, EOMI. Right frontoparietal
laceration with nylon sutures in place, appears clean, dry and
intact. No tenderness to palpation
Cardiopulmonary: RRR, normal S1 and S2 without murmurs, rubs or
gallops. CTAB
Abdomen: Soft, non-tender, non-distended
Extremities: Atraumatic. No clubbing, cyanosis or edema
Neurologic: Grossly intact. Alert and oriented x 3
Pertinent Results:
___ 03:00PM WBC-9.6 RBC-4.80 HGB-13.8* HCT-42.9 MCV-89
MCH-28.7 MCHC-32.1 RDW-14.0
___ 03:00PM PLT COUNT-161
___ 03:00PM ___ PTT-32.5 ___
___ 03:00PM ___ 03:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:00PM LIPASE-29
___ 03:16PM GLUCOSE-103 LACTATE-3.2* NA+-143 K+-3.3
CL--102 TCO2-25
___ 03:00PM UREA N-25* CREAT-1.3*
CXR (___)
Evaluation of the chest markedly limited by low lung volumes,
but no gross abnormality is detected. No fracture or dislocation
is seen in the pelvis.
ECG (___)
Sinus tachycardia, rate 105. Left axis deviation. Poor quality
tracing. Isolated Q wave in lead III. Otherwise, within normal
limits. No previous tracing available for comparison
CT Head/Neck (___)
Right subgaleal scalp hematoma and laceration. No evidence of
acute intracranial process, hemorrhage, or edema. No evidence of
acute fracture or dislocation. Multilevel degenerative changes.
Medications on Admission:
- Amlodipine 10 mg PO/NG DAILY
- Hydrochlorothiazide 25 mg PO/NG DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth every 8 hours Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Motor vehicle crash resulting in right parietal scalp laceration
and underlying subgaleal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Motor vehicle collision. Evaluate for acute injury.
COMPARISON: None.
FINDINGS: Portable supine frontal radiographs of the chest and pelvis.
CHEST: The lung volumes are extremely low. Within these limitations, there
is no focal opacity, pleural effusion or pneumothorax detected. The heart is
not enlarged. However, its size is exaggerated by AP technique and low lung
volumes.
PELVIS: There is no fracture of dislocation. There are mild-to-moderate
degenerative changes in the hip joints bilaterally, right greater than left.
The SI joints and pubic symphysis appear intact. There are phleboliths in the
pelvis.
IMPRESSION:
1. Evaluation of the chest markedly limited by low lung volumes, but no gross
abnormality is detected.
2. No fracture or dislocation is seen in the pelvis.
These results were communicated in person to Dr. ___ by ___ at 3:40
p.m., ___.
Radiology Report
INDICATION: Motor vehicle collision. Evaluate for acute injury.
COMPARISON: None.
TECHNIQUE: Axial helical MDCT images were obtained through the brain without
IV contrast. Multiplanar coronal and thin-section bone algorithm
reconstructed images were acquired. There is significant motion artifact on
the initial scan and several slices were repeated with better outcome.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect or large
territorial infarction. The ventricles and sulci are normal in size and
configuration. The basal cisterns are patent and there is preservation of
gray-white differentiation.
There is laceration and subgaleal hematoma involving the right parietal scalp.
No underlying bone fracture is detected. There is mucosal thickening
involving all the paranasal sinuses, but no air-fluid levels are detected.
The mastoid air cells and middle ear cavities are clear. The globes are
unremarkable.
IMPRESSION: Right subgaleal scalp hematoma and laceration. No evidence of
acute intracranial process, hemorrhage, or edema.
These results were given in person to Dr. ___ by Dr. ___ at 3:40 p.m.,
___.
Radiology Report
INDICATION: Motor vehicle collision. Evaluate for acute injury.
COMPARISON: None.
TECHNIQUE: Contiguous helical MDCT images were obtained through the cervical
spine from the skull base through the T2 level without IV contrast.
Multiplanar axial, coronal, sagittal and thin section bone algorithm
reconstructed images were generated.
TOTAL BODY DLP: 878 mGy-cm.
FINDINGS: There is no evidence of acute fracture or dislocation. The
atlantodental interval is preserved. The dens is normally positioned between
the lateral masses of C1. There is no prevertebral or paravertebral soft
tissue edema detected. Normal cervical lordosis is preserved. Multilevel
multifactorial degenerative changes maximally result in neural foraminal
narrowing as a result of uncovertebral and facet joint hypertrophy most severe
at C5-C6 and C6-C7. Additionally, there is disc height loss most prominent at
C5-C6 and C6-C7.
The thyroid is unremarkable. There is no cervical lymphadenopathy. The lung
apices are clear.
IMPRESSION:
1. No evidence of acute fracture or dislocation.
2. Multilevel degenerative changes as detailed above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P MVC
Diagnosed with OPEN WOUND OF SCALP, MV COLLISION NOS-DRIVER, SYNCOPE AND COLLAPSE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr ___ arrived at our institution brought in by ambulance
after a motor vehicle collision as an unrestrained driver
against a tree at low-moderate speed, reportedly losing
consciousness. Basic trauma protocol was activated upon his
arrival to the emergency department. Physical exam and imaging
studies performed, namely CT of the head and neck, were within
normal limits but to a right frontoparietal scalp laceration
with an underlying subgaleal hematoma. This was repaired
successfully with nylon sutures shortly after arrival.
Patient was admitted for observation overnight. Given no
recollection of the accident or what led to it, an internal
medicine consult was requested for proper workup of a possible
syncopal episode. After thorough evaluation, they deemed
unlikely that patient had syncopated prior to the event. All
tests performed, including ECG, telemetry, and blood work were
reassuring. It was later reported by one of the family members
that the police report had stated that another car had been
involved in the accident, leading to Mr ___ collision
with a tree. No further medical workup was required and he was
cleared from that standpoint. A tertiary survey done 24 hours
after admission failed to reveal other injuries.
On discharge, patient was doing remarkably well. He was afebrile
with stable vital signs. His pain was minimal and
well-controlled, and he was tolerating a regular diet,
ambulating and voiding without assistance. 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:
Codeine / Desipramine / Lisinopril / Erythromycin Base /
Tetracycline / Oxycodone / Tramadol / Propoxyphene / Zocor /
Hydrocodone / Phenothiazines / Hydroxychloroquine /
ciprofloxacin / morphine
Attending: ___.
Chief Complaint:
low grade fever, abdominal pain, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p living related kidney transplant ___ with
hyperparathyroidism now s/p neck exploration and removal of b/l
upper parathyroid glands on ___. She was discharged on ___
doing well. She notes that since surgery she has had a headache
unlike her migraines. The day of presentation, ___, she also
notes some abdominal pain and nausea, no emesis. No bowel
movement since prior to surgery. She states that her urine seems
"slower" but making a normal amount, no dysuria/hematuria. No
pain over transplant. Some chills and low grade temperature at
home to 100.5. No trouble breathing, erythema at neck site,
dyspnea, cough, chest pain, diarrhea. Does note a sore throat.
Past Medical History:
PMH: Renal failure due to glomerulonephritis, connective tissue
disease undifferentiated, MS since ___ w/spacicity,
w/deficits include dysequilibrium, numbness, weakness of left
side), psoriasis, restless legs syndrome, migraine,
fibromyalgia, affecting upper back, spine; back pain,
arthritis/DJD of spine pancreatitis, ___ esophagus,
sinus disease
PSH: deviated septum repair in ___, ERCP for gallstones,
CCY/appendectomy in her ___
Social History:
___
Family History:
Father with DM. He died suddenly in his ___ of unclear causes.
Her mother died of dementia in her ___. Her brother committed
suicide.
Physical Exam:
VS: 98.6, 73, 102/58, 16, 96% RA
Gen: NAD
HEENT: neck incision covered w/ steri-strips. incision is c/d/i
without erythema, fluctuance, crepitus, or hematoma
CV: RRR
Pulm: CTA b/l
Abd: soft, nontender, nondistended; no tenderness over
transplant. old scars are well healed
Ext: no edema
Pertinent Results:
___ 05:11PM BLOOD WBC-8.6 RBC-4.14* Hgb-13.5 Hct-40.6
MCV-98 MCH-32.5* MCHC-33.2 RDW-13.3 Plt ___
Medications on Admission:
1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
2. NexIUM (esomeprazole magnesium) 40 mg oral BID
3. Tacrolimus 1.5 mg PO Q12H
4. Zolpidem Tartrate 10 mg PO QHS
5. DiphenhydrAMINE 25 mg PO Q6H:PRN pruritis
6. Baclofen 10 mg PO BID:PRN spacicity
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Azathioprine 50 mg PO DAILY
9. Atenolol 25 mg PO DAILY
10. Amlodipine 5 mg PO DAILY
11. Acetaminophen 1000 mg PO Q6H:PRN pain
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Azathioprine 50 mg PO DAILY
4. Baclofen 10 mg PO BID:PRN spasticity
5. DiphenhydrAMINE 12.5 mg PO Q6H:PRN itching
6. Omeprazole 40 mg PO BID
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
8. Tacrolimus 1.5 mg PO Q12H
9. Zolpidem Tartrate 10 mg PO QHS
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Acetaminophen 650 mg PO Q6H:PRN pain
12. Nystatin Oral Suspension 5 mL PO QID thrush Duration: 7 Days
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Viral syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with fever, recent surgery // eval for infiltrate
TECHNIQUE: Chest PA and Lateral
COMPARISON: ___
FINDINGS:
The lungs are clear. There is no evidence of pneumonia, pneumothorax or
pulmonary edema. There are however small bilateral pleural effusions. Cardiac
size is normal.
IMPRESSION:
Small bilateral pleural effusions.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Nausea, BODY ACHES
Diagnosed with FEVER, UNSPECIFIED, KIDNEY TRANSPLANT STATUS
temperature: 100.0
heartrate: 88.0
resprate: 16.0
o2sat: 99.0
sbp: 139.0
dbp: 70.0
level of pain: 7
level of acuity: 2.0 | Mrs. ___ is a ___ year old woman with LRRT who presents with
postoperative fever. She was admitted for observation. Nl WBC.
Negative UA (UCx contaminated). Negative BCx while in house.
Noted some abdominal discomfort that resolved with
maalox/lidocaine. Wound did not seem to be source of
bacteremia. Renal transplant was consulted and agreed with
observation, thinking that she has no localizing signs, and her
story, particularly with sick contacts, best fits a viral
etiology for her fever. She did have thrush, but it did not
contribute to her fevers. Mild elevation in T resolved by HD2.
The patient was discharged home in stable condition with written
instructions concerning precautionary instructions and the
appropriate follow-up care. All questions were answered prior
to discharge and the patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ibuprofen / Codeine
Attending: ___.
Chief Complaint:
Tongue ulcerations and white plaque
Major Surgical or Invasive Procedure:
EGD ___
Tongue biopsy ___
History of Present Illness:
___ yo male with a pmh of renal transplant, iddm who presents
with a tongue infection.
He reports being on nystatin for thrush for years. Over the
past 7 days, he has had worsening pain in his mouth, tongue, and
difficulty swallowing, leading to very minimal PO intake. He has
made an effort to swallow saliva but that is mostly it.
He denies f/c/neck pain/diarrhea/dysuria/rash. He has not had a
BM in 7 days due to not eating. He reports working regular
___ prior to these symptoms (7 days on, 12 hour days).
He saw an ID doctor ___, Dr. ___ in ___, who
recommended admission for IV treatment of his mouth. He came
here because he was told he would likely be transferred here
from another facility once admitted there.
In the ED, initial vitals were: 97.7 92 135/79 18 97% RA
- Exam notable for severe ulcerations on tongue concerning for
- Labs notable for: WBC 9.2, HGB 17, Plt 293, Potassium 3.2, Cr
2.1, Lactate 2.7
- Imaging was notable for: no imaging obtained
- Case discussed with ID and planned for fluconazole iv 400
q24h if renal function normal
- Patient was given: 1L NS, Maalox/Diphenhydramine/Lidocaine 30
mL
- Vitals prior to transfer: 99.3 98 116/72 16 94% RA
Upon arrival to the floor, patient reports the mouth in the ED
helped his symptoms greatly. He denies other complaints.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- DM since senior year of high school, on insulin
- Diabetic nephropathy s/p living unrelated kidney
transplantation in ___
- Patient told many years ago that he had had a silent heart
attack and has been on medications for it since
- HLD
- squamous cell carcinoma in situ of the left ear s/p
resection/___ surgery ___
- ___
- Hepatitis C positivity. Before transplant, he was treated
with interferon. his viral load was negative in ___.
- Hep B Core positive, DNA and repeat testing negative ___
Social History:
___
Family History:
(per MEDICAL RECORDS) Negative for kidney disease, kidney
stones, and CAD. His mother has COPD and developed diabetes late
in her life.
Physical Exam:
ADMISSION EXAM:
Vital Signs: 98.3 151 / 85 90 18 98 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, OP with white exudate on tongue,
roof of mouth, and spaces between teeth with ulcerations on both
sides of tongue, no surrounding erythema or drainage
Neck: Supple. JVP not elevated.
CV: Regular rate and rhythm.
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, no pain over transplant
site
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: Grossly intact
DISCHARGE EXAM:
Vital Signs: 98.3 151 / 85 90 18 98 RA
General: Alert, oriented, no acute distress
HEENT: Oropharynx with diffuse white exudate on tongue and roof
of mouth. Symmetric ulceration/erosions on the lateral aspects
of the tongue (both sides) as well a smaller ulcer at the left
tip.
Neck: Soft, supple. JVP not elevated.
CV: Regular rate and rhythm. No m/r/g
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: Grossly intact
Pertinent Results:
=========================
ADMISSION LABS
=========================
___ 08:30PM BLOOD Calcium-10.1 Phos-3.4 Mg-2.1
___ 10:10AM BLOOD ALT-18 AST-32 AlkPhos-162* TotBili-0.9
___ 08:30PM BLOOD Glucose-146* UreaN-24* Creat-2.1* Na-139
K-3.2* Cl-88* HCO3-30 AnGap-24*
___ 08:30PM BLOOD Plt ___
___ 08:30PM BLOOD WBC-9.2 RBC-6.26* Hgb-17.0 Hct-51.4*
MCV-82 MCH-27.2 MCHC-33.1 RDW-13.7 RDWSD-40.1 Plt ___
============================
KEY INTERIM LABS
============================
___ 10:10AM BLOOD rapmycn-17.0*
___ 05:00PM BLOOD rapmycn-17.4*
___ 06:10AM BLOOD rapmycn-8.8
___ 06:25AM BLOOD rapmycn-8.8
___ 05:55AM BLOOD rapmycn-5.7
___ 05:06PM BLOOD ___ pO2-41* pCO2-28* pH-7.47*
calTCO2-21 Base XS--1
___ 06:18AM BLOOD Lactate-2.7*
___ 05:06PM BLOOD Lactate-1.6
========================
DISCHARGE LABS
========================
___ 05:55AM BLOOD WBC-5.6 RBC-5.27 Hgb-14.4 Hct-43.1 MCV-82
MCH-27.3 MCHC-33.4 RDW-13.9 RDWSD-40.6 Plt ___
___ 08:30PM BLOOD Neuts-68.5 Lymphs-15.4* Monos-14.3*
Eos-0.2* Baso-0.5 Im ___ AbsNeut-6.31* AbsLymp-1.42
AbsMono-1.32* AbsEos-0.02* AbsBaso-0.05
___ 05:55AM BLOOD Plt ___
___ 05:55AM BLOOD Glucose-49* UreaN-11 Creat-1.1 Na-142
K-3.5 Cl-103 HCO3-27 AnGap-16
___ 06:10AM BLOOD ALT-17 AST-25 AlkPhos-150* TotBili-0.6
___ 05:55AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
========================
MICROBIOLOGY
========================
No growth on the following cultures:
___ TISSUE VIRAL CULTURE-PENDING; VIRAL
CULTURE: R/O CYTOMEGALOVIRUS-PENDING
___ TISSUE GRAM STAIN-FINAL; TISSUE-PRELIMINARY
{MIXED BACTERIAL FLORA}; ANAEROBIC CULTURE-PRELIMINARY;
POTASSIUM HYDROXIDE PREPARATION-PRELIMINARY; FUNGAL
CULTURE-PRELIMINARY
___ SWAB VIRAL CULTURE: R/O HERPES SIMPLEX
VIRUS-PENDING
___ Direct Antigen Test for Herpes Simplex
Virus Types 1 & 2 Direct Antigen Test for Herpes Simplex Virus
Types 1 & 2-FINAL
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ IMMUNOLOGY HBV Viral Load-FINAL
=========================
IMAGING
=========================
Renal transplant ultrasound ___:
Normal renal transplant ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
2. Atorvastatin 20 mg PO QPM
3. DULoxetine 60 mg PO DAILY
4. Glargine 20 Units Breakfast
Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Sirolimus 3 mg PO DAILY
6. Mycophenolate Mofetil 500 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. metroNIDAZOLE 0.75 % topical BID
11. Omeprazole 20 mg PO BID
12. Furosemide 40 mg PO DAILY
13. Furosemide 40 mg PO 3X/WEEK (___)
14. ALPRAZolam 1 mg PO TID:PRN anxiety
15. Cyclobenzaprine 10 mg PO TID:PRN spasm
Discharge Medications:
1. Lidocaine Viscous 2% 15 mL PO Q3H:PRN sore throat
RX *lidocaine HCl [Lidocaine Viscous] 2 % take 15 mL every 3
horus as needed Refills:*0
2. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
RX *nystatin 100,000 unit/mL 5 ml by mouth every 4 horurs
Refills:*0
3. ValACYclovir 1000 mg PO Q12H
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every 12 hours
Disp #*36 Tablet Refills:*0
4. Sirolimus 1 mg PO DAILY
Daily dose to be administered at 5pm
RX *sirolimus 1 mg 1 tablet by mouth daily Disp #*30 Tablet
Refills:*1
5. ALPRAZolam 1 mg PO TID:PRN anxiety
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Cyclobenzaprine 10 mg PO TID:PRN spasm
9. DULoxetine 60 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Furosemide 40 mg PO 3X/WEEK (___)
12. Glargine 20 Units Breakfast
Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
13. Metoprolol Tartrate 25 mg PO BID
14. metroNIDAZOLE 0.75 % topical BID
15. Mycophenolate Mofetil 500 mg PO BID
16. Omeprazole 20 mg PO BID
17. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19.Outpatient Lab Work
Please check sirolimus level at 5PM on ___. Fax
results to Dr. ___ ___. ICD-10 Z94.0
History of renal transplant.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Candidiasis
Throat pain
Acute kidney injury
SECONDARY DIAGNOSIS:
Renal transplant
End-stage renal disease s/p transplant
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old man with left renal transplant and ___// transplant
eval
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Abdominal ultrasound from ___.
FINDINGS:
The left iliac fossa transplant renal morphology is normal. Specifically, the
cortex is of normal thickness and echogenicity, pyramids are normal, there is
no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection. An anechoic lower pole
simple renal cyst measures 2.1 x 2.6 x 2.0 cm.
The resistive index of intrarenal arteries ranges from 0.63 to 0.67, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 188. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: TONGUE PAIN
Diagnosed with Acute kidney failure, unspecified, Candidal stomatitis, Dehydration
temperature: 97.7
heartrate: 92.0
resprate: 18.0
o2sat: 97.0
sbp: 135.0
dbp: 79.0
level of pain: 8
level of acuity: 3.0 | ___ h/o ESRD ___ diabetic nephropathy s/p LURT ___ on
MMF/sirolimus, IDDM, ___ of left ear s/p Mohs in ___, NSTEMI
who presents with sore throat, found to have ulcerations and
white plaque on exam. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
___
Attending: ___.
Chief Complaint:
Penile swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ male w/ history of ulcerative colitis and
history of Peyronie's disease of the penis who is transferred
from OSH ED for penile bleeding/ edema. He recently underwent
the second injection of Xiaflex (collagenase clostridium
histolyticum)for treatment of the Peyronie's and had a dressing
in place for four hours after the procedure. Subsequently, the
patient DC'd the dressing and noted significant bleeding and
swelling of the penis, mainly from the left side. The patient
notes voiding normally w/ no evidence of hematuria. Denies n/v,
f/c but endorses significant penile pain.
Past Medical History:
PMH:
Ulcerative Colitis including microperforation ___ yrs ago managed
conservatively
Frozen left shoulder
Chronic back pain
Peyronie's Disease
PSH:
L Finger tendon repair
Social History:
___
Family History:
Father with prostate cancer (alive). No other GU malignancies
Physical Exam:
Afebrile.
Abdomen is soft, nontender w/ mild suprapubic fullness.
Chest exam reveals RRR, no accessory muscle use or IWOB.
GU exam is notable for erythematous, echymotic penis. There is
skin breakdown at left mid shaft with resolving hematoma.
Extremities are warm, well perfused.
Pertinent Results:
___ 08:53PM NEUTS-79.6* LYMPHS-15.3* MONOS-4.5 EOS-0.2
BASOS-0.3
___ 08:53PM PLT COUNT-163
___ 08:53PM ___ PTT-23.3* ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine ___ 1200 mg PO TID
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Humira (adalimumab) 40 mg/0.8 mL subcutaneous Q WEEKLY UC
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth Q12 Disp #*28 Tablet
Refills:*1
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*1
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4 hrs Disp #*45
Tablet Refills:*0
5. Humira (adalimumab) 40 mg/0.8 mL subcutaneous Q WEEKLY UC
6. Mesalamine ___ 1200 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Penile hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
RETROGRADE URETHROGRAM
INDICATION: ___ year old man with pneumaturia after xiaflex injection.
COMPARISON: None.
CONTRAST: 100 cc Cysto-Conray
PROCEDURE: The patient was placed in the RPO position on the fluoroscopy
table. The urethral meatus was steriley prepped and a 5 ___ HSG catheter
with an inflatable balloon was placed 1 cm into the uretheral meatus. The
balloon was inflated to 1 cc. Next, water soluble contrast was hand injected
into the catheter. Images of contrast filling the anterior urethera including
the penile and bulbous portions are noted. There is thin opacification of the
membranous and prostatic portions. Frontal and RPO projection showed no
evidence of urethral irregularity or contrast extravasation.
IMPRESSION: No urethral stricture or disruption.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PENILE BLEEDING
Diagnosed with HEMORR COMPLIC PROCEDURE, ABN REACT-SURG PROC NEC
temperature: 98.0
heartrate: 70.0
resprate: 16.0
o2sat: 100.0
sbp: 133.0
dbp: 82.0
level of pain: 9
level of acuity: 2.0 | The patient was admitted from the emergency department after an
evening of observation to Dr. ___ service for
hematoma management and monitoring.
The ED checked the patient's hematocrit which was completely
stable upon admission and through his time of stay. The ED
managed the patient overnight with IV dilaudid and a compresion
dressing. The patient was extremely sedated and required
catheterization with Foley urethral catheter likely from
significant narcotic doses and significant compressive dressing.
On the AM of HD1, this dressing was removed and a liquified
hematoma was evacuated from the left side of the patient's
penis. The dressing was replaced with a sterile gauze dressing
and some minor spotting persisted. He was converted to oral pain
medications and given tylenol as needed. Penile edema and
echymoses were stable and edema was decreasing by time of
discharge. At discharge, patient's pain was controlled with oral
pain medications, he was tolerating regular diet, he was
ambulating without assistance, and voiding without difficulty -
a retrograde uretherogram showed no defect in the urethra
(patient had reported some question of pneumaturia). Skin at
hematoma site was stable and did not appear infected. Specific
instructions about wound care were given in addition to home ___
were prescribed. This was also included in this discharge
summary.
Pt should call to arrange/confirm your follow-up appointment AND
if you have any urological questions. |
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 ___ M with DM2, obesity, HCV/EtOH cirrhosis with a
recent diagnosis of pancreatic adenocarcinoma who presents with
fever, chills, confusion and malaise.
He was recently admitted on ___ ___ Surgical
Service) after being transferred from ___
due to ___ for pancreatic malignancy. He underwent EGD/EUS
on ___ with biopsies which confirmed the diagnosis of
adenocarcinoma. He was subsequently discharged home with
oncology follow-up but was readmitted on ___ (Medicine)
for cholangitis. On that admission ERCP was performed (___)
with stent placement and dilation of malignant-appearing
stricture. He subsequently followed-up with oncology as an
outpatient on ___ at which time treatment options were
discussed, although his hepatic function was cited as a concern.
In the last several days since that appointment he has been
living with his brother who is his HCP and primary caregiver.
Unfortunately he has developed worsening abdominal pain ___
in severity), nausea, poor PO intake, jaundice. He has also
noted chills but has not measured any fevers. He denies any
diarrhea and has been moving his bowels. He has also been
sleepy but ___ states this is his recent baseline.
In the ED, initial vitals: 96.0 102 148/86 26 94% 2L Nasal
Cannula
- ERCP was consulted and recommended NPO @ MN for possible ERCP
in AM
- Labs notable for T-bili 10.3 (8.2 two days ago), ALT 141, AST
307, Alk-phos 328, lipase 27, lactate 1.5
- Diagnostic paracentesis was performed showing 1425 WBCs (15%
PMNs) but was noted to be cloudy appearing
- He was given 4.5g IV pipercillin-tazobactam
Vitals prior to transfer: 99 158/90 20 93% Nasal Cannula
Currently, he is sleepy but endorses mild ___ abdominal pain
radiating to his back. ___ reports ___ has had no EtOH to
drink in several weeks. In the ED it was noted that the patient
was hallucinating that he was seeing spiders, but he currently
denies this. ___ states he has had these type of
hallucinations previously. He denies any history of EtOH
withdrawal.
Past Medical History:
- Pancreatic adenocarcinoma
* Presented to ___ ___ with obstructive
jaundice.
* CTA (___) showed 4.2 x 2.9 cm "hypoenhancing
pancreatic head/neck mass concerning for adenocarcinoma" and
results in "encasement of celiac axis" and liver lesions
"concerning but not diagnostic for metastases"
* FNA (___) confirms adenocarcinoma
- Hepatitis C/EtOH cirrhosis
* Previously on ledipasvir-sofosbuvir
- Morbid obesity
- Obstructive sleep apnea: On CPAP
- Bipolar disorder
- Anxiety disorder
- History of alcohol abuse
- Hypertension
Social History:
___
___ History:
No history of pancreatic cancer, maternal grandfather died of
cancer but patient does not know what type.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.5 BP 135/84 HR 97 RR 18 SpO2 98% on RA
___: Sleepy but rouses to voice
HEENT: Conjunctival icterus present
RESP: CTAB, distant breath sounds
CV: RRR, distant heart sounds, no m/r/g
ABD: Distended, obese, tense, +fluid wave
GU: No foley
EXT: 3+ edema R=L
NEURO: Sleepy, rouses to voice, oriented x 3. +Asterixis
SKIN: Mild jaundice appreciated
DISCHARGE PHYSICAL EXAM:
GEN: disheveled male in no acute distress
HEENT: tacky mucous membranes
PULM: coarse breath sounds without distress
COR: RRR (+)S1/S2
ABD: Obese, diffuse mild tenderness
EXTREM: Warm, well-perfused
NEURO: AOx1-2, difficult to understand speech
Pertinent Results:
ADMISSION LABS
___ 10:55AM BLOOD WBC-9.1# RBC-3.91* Hgb-12.1* Hct-37.3*
MCV-95 MCH-30.9 MCHC-32.4 RDW-16.9* Plt ___
___ 10:55AM BLOOD Neuts-82.1* Lymphs-10.7* Monos-5.8
Eos-0.9 Baso-0.6
___ 04:57PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 10:55AM BLOOD ___ PTT-26.4 ___
___ 10:55AM BLOOD Plt ___
___ 04:57PM BLOOD ___
___ 12:05AM BLOOD ___
___ 10:55AM BLOOD Glucose-144* UreaN-10 Creat-0.6 Na-137
K-4.1 Cl-100 HCO3-26 AnGap-15
___ 10:55AM BLOOD ALT-141* AST-307* AlkPhos-328*
TotBili-10.3* DirBili-6.5* IndBili-3.8
___ 10:55AM BLOOD Lipase-27
___ 10:55AM BLOOD Albumin-3.1* Calcium-9.0 Phos-2.3* Mg-2.3
___ 10:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
TROPONIN TREND
___ 10:55AM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD cTropnT-<0.01
LACTATE TREND
___ 11:11AM BLOOD Lactate-1.5
___ 05:43PM BLOOD Lactate-4.2*
___ 12:15AM BLOOD Lactate-5.7*
___ 05:01AM BLOOD Lactate-7.0*
___ 11:24AM BLOOD freeCa-1.10*
URINE
___ 03:15PM URINE Color-DkAmb Appear-Hazy Sp ___
___ 03:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-8* pH-6.5 Leuks-NEG
___ 03:15PM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-1
ASCITIC FLUID
___ 11:38AM ASCITES WBC-1425* RBC-2200* Polys-15*
Lymphs-66* Monos-0 Eos-1* Atyps-1* Plasma-1* Mesothe-2*
Macroph-12* Other-2*
___ 11:38AM OTHER BODY FLUID TotProt-1.7 Glucose-155
LD(LDH)-124 Albumin-LESS THAN
MICROBIOLOGY
MICROBIOLOGY DATA:
__________________________________________________________
___ 4:57 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): gram negative rods
__________________________________________________________
___ 4:57 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): gram negative rods
__________________________________________________________
___ 4:57 pm URINE Source: Catheter.
URINE CULTURE: negative
__________________________________________________________
___ 10:55 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:45 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:40 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:40 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
VIRIDANS STREPTOCOCCI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 2 R
PENICILLIN G---------- 0.5 I
VANCOMYCIN------------ 0.25 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0631 ON ___ - ___.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
__________________________________________________________
___ 11:38 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 10:55 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
VIRIDANS STREPTOCOCCI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___-___
___.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___ - ___.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
__________________________________________________________
___ 6:36 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:01 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:02 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
CTA chest (___):
1. Limited exam due to suboptimal opacification of the pulmonary
arteries
however acute pulmonary emboli are noted bilaterally including
lobar and
segmental branches on the right and segmental branches on the
left. No
evidence of right heart strain.
2. Small left pleural effusion with bibasilar consolidations may
reflect
atelectasis or aspiration.
3. Pneumobilia status post stent placement which is in
appropriate position.
4. Heterogeneous attenuation of the liver with new vague
hypodensity within
segment 6 of the liver is noted and given the short-term
development is
unlikely to represent metastases and may be perfusion
abnormality. Portal
veins are not assessed on this exam but the prior study
mentioned a possible
right portal venous thrombus.
5. Unchanged pancreatic head and neck mass with lymphadenopathy
in the
periportal, retroperitoneal and mesenteric stations.
6. Increasing moderate ascites.
EKG (___): Sinus tachycardia with prolonged QTc
CXR (___): Bibasilar opacities, likely representing
atelectasis on the right, however the opacities in the left
lower lung are slightly more confluent and may represent
atelectasis or pneumonia. Mild to moderate cardiomegaly.
LIVER U/S (___): Limited exam. Irregular liver suggesting
background cirrhosis. No focal defect identified but this is
not excluded
ERCP (___):
Scout film was showed a previously placed metal stent. No
plastic stent was seen. The common bile duct, common hepatic
duct, right and left hepatic ducts, and biliary radicles were
not filled with contrast. Only a few scattered intrahepatic
radicals were opacified after full injection cholangiography. A
single irregular stricture that was 2.5 cm long was seen from
the proximal end of the metal stent to the bifurcation extending
to both the R and L hepatic ducts. These findings are consistent
with a Bismuth type IV lesion. Scant biliary drainage was seen
endoscopically.
Radiologic interpretation:
I supervised the acquisition and interpretation of the
fluoroscopic images. The quality of the fluoroscopic images was
good.
Impression:
No plastic stent was seen.
The common bile duct, common hepatic duct, right and left
hepatic ducts, and biliary radicles were not filled with
contrast.
Only a few scattered intrahepatic radicals were opacified after
full injection cholangiography.
A single irregular stricture that was 2.5 cm long was seen from
the proximal end of the metal stent to the bifurcation extending
to both the R and L hepatic ducts.
These findings are consistent with a Bismuth type IV lesion.
Scant biliary drainage was seen endoscopically.
ERCP (___):
Impression: The scout film revealed a plastic and a metalic
biliary stent in place.
The plastic stent was removed using a polypectomy snare.
Contrast extended to the CBD and CHD and left IHD. Patency of
the metalic stent was noted.
A 3mm long stricture was seen above the stent in the proximal
CHD with mild post-obstructive dilation - likely from
porta-hepatis lymph nodes.
A 4mm Hurricane balloon was introduced through the guidewire for
dilation under flouroscopy successfully.
A ___ X 9cm double pig tailed plastic stent was placed
successfully traversing the proximal stricture.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acamprosate 666 mg PO TID
2. Amlodipine 2.5 mg PO DAILY
3. ARIPiprazole 30 mg PO DAILY
4. Citalopram 40 mg PO DAILY
5. ClonazePAM 2 mg PO BID
6. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
7. Famotidine 20 mg PO BID
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Gabapentin 800 mg PO TID
10. Nicotine Patch 14 mg TD DAILY
11. QUEtiapine Fumarate 100 mg PO QAM
12. Venlafaxine 100 mg PO BID
13. Docusate Sodium 100 mg PO BID
14. Milk of Magnesia 30 mL PO Q6H:PRN constipation
15. Polyethylene Glycol 17 g PO DAILY
16. QUEtiapine Fumarate 100 mg PO QHS
17. Senna 8.6 mg PO BID
18. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
19. Ciprofloxacin HCl 750 mg PO Q12H
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Milk of Magnesia 30 mL PO Q6H:PRN constipation
3. Nicotine Patch 14 mg TD DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID
6. Lorazepam 0.5-1 mg PO Q4H:PRN dyspnea, anxiety
RX *lorazepam 2 mg/mL 0.5-1 mg by mouth every four (4) hours
Refills:*0
7. Morphine Sulfate (Concentrated Oral Soln) 20 mg PO Q4H
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 20 mg by mouth
every four (4) hours Refills:*0
8. Morphine Sulfate (Concentrated Oral Soln) 10 mg PO Q1H:PRN
pain, dyspnea
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 10 mg by mouth
q1h Refills:*0
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Dyspnea/wheezing
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY: metastatic pancreatic adenocarcinoma, cholangitis
Secondary: Hepatitis C, Alcoholic Cirrhosis, OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with dyspnea // PNA?
TECHNIQUE: AP view of the chest.
COMPARISON: ___.
FINDINGS:
There is bibasilar opacities, likely representing atelectasis on the right,
however the opacities in the left lower lung are slightly more confluent and
may represent atelectasis or pneumonia. No large pleural effusion or
pneumothorax. Mild to moderate cardiomegaly. The cardiomediastinal and hilar
contours are stable.
IMPRESSION:
Bibasilar opacities, likely representing atelectasis on the right, however the
opacities in the left lower lung are slightly more confluent and may represent
atelectasis or pneumonia. Mild to moderate cardiomegaly.
Radiology Report
INDICATION: ___ year old man with pancreatic ca who c/o chest pain, shortness
of breath, has tachycardia, increased jaundice // evaluate for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast. Subsequently delayed imaging was obtained through the abdomen and
pelvis.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 935.5 mGy-cm
COMPARISON: CT chest abdomen pelvis from ___.
FINDINGS:
CTA chest: The aorta and its major branch vessels are patent, with no evidence
of stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The study is very limited due to poor opacification of the pulmonary arteries
by contrast. Filling defects are seen within a right upper lobe segmental
branch (series 4P, image 59) right middle lobe lobar branch (series 4p, image
74) and within right lower lobe segmental branches (series 4p, image 91).
Filling defects are noted within the left upper lobe pulmonary artery
segmental branches (series 4p, image 43). There is no evidence of right heart
strain or pulmonary infarctions.
A 4 mm nodule in the right upper lobe is unchanged from the prior study. There
is there is a small left pleural effusion with left lower lobe consolidation,
likely atelectasis since slightly increased since the prior study. Right lower
lobe opacity may represent atelectasis or aspiration. Ground-glass opacities
within the right upper lobe have improved since the prior exam. A 6 mm right
middle lobe pulmonary nodule is unchanged since the prior study. The airways
are patent to the subsegmental levels.
No supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The
thyroid gland appears unremarkable.
CT ABDOMEN: The liver is nodular and shrunken. Pneumobilia is noted as can be
expected after biliary stent placement. There is new vague hypodensity within
segment 6 of the liver (series 9, image 42) not clearly visualized on the
prior exam. Given the short-term interval development this may represent
perfusion abnormality from possible right portal venous thrombosis as
described on the prior study. Vague hypodensity within segment 8 and 5 again
is noted. There is no intra or extrahepatic biliary dilatation. The common
bile duct stent is in appropriate position. The gallbladder remains
significantly distended. Hypoenhancing mass within the pancreatic head and
neck is unchanged measuring 3.9 x 3.0 cm. Multiple celiac axis,
retroperitoneal and periportal lymph nodes are again noted. The spleen is
enlarged measuring 16.5 cm, unchanged since the prior study. The left adrenal
gland is thickened and nodular. The right adrenal gland is unremarkable. The
kidneys enhance excrete contrast symmetrically without any focal lesions or
hydronephrosis. Stomach, small and intra-abdominal large bowel are grossly
unremarkable without evidence of obstruction. The plastic common bile duct
stent is noted within the sigmoid colon. There is no intraperitoneal free air.
Moderate amount of simple ascites has increased in the prior exam particularly
within the right pericolic gutter. The aorta is of normal caliber without
evidence of aneurysm.
CT PELVIS: The bladder is collapsed. Rectum is unremarkable. There is a
moderate amount of free fluid within the pelvis. There is no free air
lymphadenopathy.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. Limited exam due to suboptimal opacification of the pulmonary arteries
however acute pulmonary emboli are noted bilaterally including lobar and
segmental branches on the right and segmental branches on the left. No
evidence of right heart strain.
2. Small left pleural effusion with bibasilar consolidations may reflect
atelectasis or aspiration.
3. Pneumobilia status post stent placement which is in appropriate position.
4. Heterogeneous attenuation of the liver with new vague hypodensity within
segment 6 of the liver is noted and given the short-term development is
unlikely to represent metastases and may be perfusion abnormality. Portal
veins are not assessed on this exam but the prior study mentioned a possible
right portal venous thrombus.
5. Unchanged pancreatic head and neck mass with lymphadenopathy in the
periportal, retroperitoneal and mesenteric stations.
6. Increasing moderate ascites.
NOTIFICATION: These findings were communicated via telephone by Dr. ___
___ to Dr. ___ at 05:50 on ___, approximately 10 minutes after
review.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man p/w sepsis in the setting of possible acute
cholangitis ?PNA on intial CXR // ?acute intrapulmonary process ?PNA
?acute intrapulmonary process ?PNA
IMPRESSION:
In comparison with the study of ___, the atelectatic changes at the right
base have improved. Left basilar opacification is again consistent with volume
loss in the left lower lobe and pleural effusion. In the appropriate clinical
setting, it would be difficult to exclude pneumonia in this region, especially
in the absence of a lateral view.
Continued enlargement of the cardiac silhouette without definite vascular
congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with adenocarcinoma // R/O CHF, R/O pneumonia
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Left basal consolidation appears to be slightly more pronounced than on the
prior study in might reflect progression of infectious process. Small amount
of left pleural effusion is noted. There is no pneumothorax. Cardiomediastinal
silhouette is stable
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Jaundice, Dyspnea
Diagnosed with ALTERED MENTAL STATUS , JAUNDICE NOS, MALIG NEO PANCREAS NOS
temperature: 96.0
heartrate: 102.0
resprate: 26.0
o2sat: 94.0
sbp: 148.0
dbp: 86.0
level of pain: 13
level of acuity: 2.0 | ___ M with DM2, obesity, OSA, HCV/EtOH cirrhosis, recent
diagnosis of pancreatic adenocarcenoma (___) and cholangitis
s/p ERCP (___) with stent placement found to have presumed
cholangitis and multisystem organ failure in the setting of
overwhelming sepsis. Given his poor prognosis, the patient was
transitioned to comfort measure and discharged on hospice.
#) PANCREATIC ADENOCARCINOMA: Stage III/IV based on T4 tumor
size (tumor encases celiac vessels and is >4cm) and +LNs seen on
imaging, but full formal staging has not yet taken place. When
it became clear that PTBD would not be placed due to patient's
persistent decompensation, patient and family decided to
transition to hospice.
#) SEPSIS: Patient was admitted with chills, confusion and
malaise along with worsening abdominal pain ___ in
severity), nausea, poor PO intake and jaundice concerning for
cholangitis. He was started on IV vancomycin and pip/tazo upon
admission. ERCP was significant for malignant-appearing
strictures as well- unfortunately ERCP revealed blockage of
biliary drainage with no possible endoscopic intervention. PTBD
scheduled ___ was deferred in the setting of continued
decompensation. Pip/tazo was d/c on ___. Of note, blood
cultures from admission were consistent with strep viridans and
subsequent blood cultures from ___ were consistent with gram
negative rods, presumably from GI source. Patient was started on
meropenem on ___ for concern of sepsis in the setting of
fever, tachycardia, and respiratory distress while awaiting
PTBD. Interventional radiology subsequently concluded that
patient is longer candidate for PTBD due to respiratory issues
and concern for instability under anesthesia. Antibiotics were
discontinued upon transitioned to comfort measures.
#) RESPIRATORY DISTRESS: While in the PACU awaiting PTBD on
___, patient developed tachycardia and increasing respiratory
distress with increasing O2 requirements to 10L facemask. The
operation was held and he transferred to the MICU. Symptoms were
presumably from sepsis and PE. Patient was initially restarted
on heparin gtt at lower goal but this was discontinued within
___ given worsening coagulopathy.
#) PULMONARY EMBOLUS: On ___ CTA C/A/P showed acute PE
bilaterally in lobar and segmental branches for which patient
was started on heparin gtt. Heparin gtt was discontinued
midnight prior to anticipated PTBD on ___. Heparin gtt was
briefly restarted on heparin gtt at lower goal the evening that
procedure was deferred but this was again within 12h given
worsening coagulopathy.
#) HEPATITIS C/ETOH CIRRHOSIS: Peritoneal fluid studies are not
consistent with SBP. Scheduled for liver bx with ___ but
deferring in setting of acute illness. SAAG>1.1 suggesting
likely secondary to portal hypertension.
# Communication: HCP:Brother/HCP ___ (___)
# Code: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin / trazodone / diphenhydramine
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with ESRD (on HD MWF), NASH
cirrhosis (EGD ___ (-)varices, (+)GAVE & portal HTN
gastropathy), history of GIB (EGD ___ (+)antral erosions &
AVMs), CAD s/p CABG (LIMA to LAD and SVG to PDA ___, pAF
(not on anticoagulation), HFpEF, T2DM, who presented with
pleuritic chest pain and is admitted for workup and management
of
chest pain.
The patient reports 2 weeks of intermittent, non-exertional
chest
pain that began to increase in frequency over the past 3 days.
The pain is located underneath her sternum in the ___ her
chest. It starts spontaneously, typically at rest, and lasts for
5 minutes and occurs once per day. It does not radiate, is not
associated with dyspnea, nausea, palpitations, lightheadedness,
or with exertion. She can not identify any exacerbating factors
but it has occurred occasionally after a large meal. She has
told
previous providers that the pain is somewhat pleuritic but she
denies pleuritic component currently. She has not noticed
any decreased exercise tolerance. She is able to walk from her
living room to her kitchen without difficulty. If she walks
further she feels fatigued, but this is not associated with
chest
pain and has been stable for several months. She has not had any
fevers, chills, cough, or night sweats. She presented to her PCP
with the complaints of chest pain and she was directed to the
___ ED.
Past Medical History:
1. CAD s/p CABG (LIMA to LAD and SVG to PDA ___ for UA
2. PAF not on anticoagulation
3. Hypertension.
4. Type 2 diabetes ___ A1c)
6. Mixed dyslipidemia
7. Cirrhosis
8. GI AVM
9. OSA
10. Asthma
11. ESRD on HD MWF
12. HFpEF
13. GERD
14. Dementia
15. Visual hallucinations
16. Depression
17. Anemia of chronic kidney disease
Social History:
___
Family History:
Maternal grandmother and two aunts with diabetes, lung cancer in
uncle.
Physical Exam:
ADMISSION PHYSICAL EXAM:
___ Temp: 97.9 PO BP: 148/78 L Sitting HR: 75 RR: 20
O2
sat: 96% O2 delivery: Ra
GENERAL: NAD
HEENT: L eyelid droop (chronic per patient), AT/NC, anicteric
sclera, MMM
NECK: supple, no LAD, JVP difficult to assess d/t habitus
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, obese, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, no fluid wave or
shifting dullness
EXTREMITIES: no cyanosis, clubbing. 1+ edema in b/l ___,
symmetric, no tenderness to palpation of ___
___: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1105)
Temp: 97.8 (Tm 98.5), BP: 125/51 (117-148/51-78), HR: 65
(60-90),
RR: 20 (___), O2 sat: 97% (92-98), O2 delivery: RA, Wt: 218.25
lb/99 kg
GENERAL: sitting in chair, eating food, no acute distress
HEENT: L eyelid droop (chronic per patient), AT/NC, anicteric
sclera, MMM
NECK: supple, no LAD, JVP difficult to assess d/t habitus
CV: RRR, S1/S2, no murmurs, gallops, or rubs; chest pain
reproducible on palpation of anterior chest
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, obese, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, minimal edema in b/l ___, symmetric,
no
tenderness to palpation of ___
___: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
ADMISSION LABS:
___ 05:45PM BLOOD WBC-4.6 RBC-2.51* Hgb-8.3* Hct-26.6*
MCV-106* MCH-33.1* MCHC-31.2* RDW-14.4 RDWSD-55.0* Plt ___
___ 05:45PM BLOOD Neuts-68.2 Lymphs-16.1* Monos-12.4
Eos-2.2 Baso-0.7 Im ___ AbsNeut-3.14 AbsLymp-0.74*
AbsMono-0.57 AbsEos-0.10 AbsBaso-0.03
___ 05:45PM BLOOD Glucose-112* UreaN-31* Creat-5.6* Na-140
K-5.3 Cl-98 HCO3-29 AnGap-13
___ 05:45PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8
___ 06:05PM BLOOD Lactate-1.3
___ 05:45PM BLOOD CK-MB-2 cTropnT-0.04*
___ 02:00AM BLOOD cTropnT-0.04*
DISCHARGE LABS:
___ 04:50PM BLOOD WBC-5.8 RBC-2.49* Hgb-8.6* Hct-27.1*
MCV-109* MCH-34.5* MCHC-31.7* RDW-14.6 RDWSD-58.1* Plt ___
___ 08:20AM BLOOD Glucose-125* UreaN-40* Creat-7.1*# Na-145
K-5.3 Cl-102 HCO3-28 AnGap-15
___ 08:20AM BLOOD Calcium-9.0 Phos-4.9* Mg-1.9
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with cp// eval for infiltrate
TECHNIQUE: Frontal and lateral views of the chest
COMPARISON: Multiple prior comparisons, most recent from ___
FINDINGS:
Median sternotomy wires are unchanged in alignment. There is an unchanged
fracture of the most superior mediastinal wire, which is unchanged compared to
prior.
Lung volumes are low. There is bibasilar atelectasis without definite focal
consolidation. Pulmonary markings and cardiomediastinal silhouette are
crowded due to low lung volumes, there is suspected component of superimposed
vascular congestion. Pleural spaces are normal.
IMPRESSION:
Low lung volumes with suspected superimposed vascular congestion. Bibasilar
atelectasis without definite focal consolidation.
Gender: F
Race: HISPANIC/LATINO - COLUMBIAN
Arrive by AMBULANCE
Chief complaint: Chest pain, R Calf pain
Diagnosed with Chest pain, unspecified, Athscl heart disease of native coronary artery w/o ang pctrs, End stage renal disease
temperature: 98.7
heartrate: 61.0
resprate: 20.0
o2sat: 98.0
sbp: 101.0
dbp: 55.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ woman with ESRD (on HD MWF), NASH
cirrhosis (EGD ___ (-)varices, (+)GAVE & portal HTN
gastropathy), history of GIB (EGD ___ (+)antral erosions &
AVMs), CAD s/p CABG (LIMA to LAD and SVG to PDA ___, pAF
(not on anticoagulation), HFpEF, T2DM, who presented with
non-pleuritic chest pain and is admitted for workup and
management of chest pain. Most likely etiology is
musculoskeletal given reproducibility on exam.
# Chest pain.
Given that the pain is reproducible on exam, most likely
musculoskeletal in nature. Trop 0.04x2, CKMB2. Does not seem to
be cardiac chest pain given that it is non-exertional, no
radiation, and no associated nausea or diaphoresis. Does not
need nuclear stress test at this time. The patient can follow-up
with outpatient cardiologist if pain has new exertional
component. Can treat pain with diclofenac sodium topical gel
post-discharge.
# ESRD on HD.
ESRD ___ to T2DM. On HD since ___ - MWF. Had HD w/ 1L UF on
___.
- Continued Calcium Acetate 1334 mg PO tid with meals
- Continued Hectorol 11 mcg IV q HD
- Continued vitamin D 1000 units daily
# CAD s/p CABG. Continued ASA, metop, imdur, statin.
# History Afib (not on anticoagulation ___ GIB). CHADS2VASC 5.
Continued metop. Currently in sinus.
# DMII. ISS while in hospital.
# Anemia: Multifactorial - anemia of renal disease, known GI
bleeding. Hgb 8.3 on admission. Hgb 8.6 on discharge, no signs
of bleeding.
- Continued Venofer 50 mg IV q ___
- Continued Epogen 8000 units q HD
# HTN: Normotensive
- Continued Amlodipine 10 mg, Isosorbide mononitrate ER 30 mg,
Metoprolol succinate XL 150 mg
# Nutrition: Low Na, Low K, Low P diet, water restriction to
1.5L per day. Nephrocaps 1 CAP daily.
# NASH Cirrhosis (MELD-Na 23) - Patient does not have a history
of varices. No clinical e/o decompensation. Patient follows with
Dr. ___.
# Asthma
- Continued home albuterol, fluticasone inhalers.
# Depression
- Continued home paroxetine.
# GERD.
- Continued pantoprazole. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / morphine
Attending: ___.
Chief Complaint:
Dyspnea, L Leg Swelling, Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of Stage
II SCC of the lung on C2D3 of ___, CAD s/p stent,
interstitial fibrosis, HIV on HAART, COPD on home O2 2L NC
presenting today with increasing SOB and L foot swelling.
Patient reports for past two days he has been having increased
SOB with difficulty breathing. His 02 requirement has increased
to 3L. He also notes new onset of L ankle swelling and non
bloody diarrhea. Per PCP, pt has a history of Cdiff. Patient
denies any chest pain or palpitations. No fevers, no chills.
In the ED, initial vitals:
98.6 ___ 96% Nasal Cannula
- Labs were notable for: wbc 2.1 (80% PMN 6 bands) h/h
9.1/28.2, plts 116, bicarb 18, trop <0.01, ddimer 1202, lactate
2.0, pH ___
ECG sinus tachycardia without ST, TW changes
- Imaging:
CXR Stable chest radiograph. No new focal lung consolidation.
CTA negative for PE, Right lower lobe reticular and nodular
interstitial opacities concerning for infection or sequelae of
aspiration in the appropriate clinical setting.
- Patient was given: 2.5L NS, vanc, cefepime, Bactrim, 1G
acetaminophen, albuterol neb
- Access: 20G RH, 18G LH
Vitals on transfer: 102.5 150 ___ 95% RA
On arrival to the MICU, Mr. ___ is feeling better but
continues to have shortness of breath. He denies cough or
productive cough. No chest pain, palpitations. He denies
abdominal pain. No recent travel or sick contacts.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Mr. ___ began to experience worsening dyspnea at the end
of ___, resulting in an increased O2 requirement. Thinking he
had
a COPD exacerbation, he presented to the ED on ___. CXR showed
mild pulmonary edema superimposed on a background of chronic
interstitial lung disease and he was admitted.
PE and CHF ruled out in ED via D-Dimer and BNP respectively.
CXR
suggestive of possible PNA in L hilar region. CT showed
partially
collapsed LUL. A bronchoscopy on ___ showed oozing and
collapse likely secondary to lung cancer. He was treated with
neublizers, Prednisone 40 mg daily (D5: ___, and
Azithromycin/Ceftriaxone (D5: ___ for COPD exacerbation and
then
for post-obstructive pneumonia (based on visualization on
bronch)
with Augmentin 875 Q12H (D8: ___ for 8 day course. Urine
legionella and strep pneumonia were negative.
EBUS/TBNA demonstrated SCC. MRI brain on ___ did not reveal any
e/o metastatic disease. PET/CT demonstrated that in the left
hilus there are 2 areas of focally increased uptake (SUV max 4.0
and 4.4) likely represent areas of involvement. There was no
supraclavicular, axillary, mediastinal or right hilar
lymphadenopathy seen on PET/CT.
___ C1D1 ___
PAST MEDICAL HISTORY:
COPD
ANXIETY
DEPRESSION
PTSD
TRAUMATIC MAXILLARY FRACTURE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
HIV in ___ on HAART since ___
OBSTRUCTIVE SLEEP APNEA
R HIP FX
PAIN
PAST SURGICAL HISTORY:
MULTIPLE CERVICAL AND LUMBAR SPINAL SURGERIES
CHOLECYSTECTOMY
Social History:
___
Family History:
Siblings: No known history of cancer or blood disorders
Mother: No known history of cancer or blood disorders
Father: No known history of cancer or blood disorders
Aunts: No known history of cancer or blood disorders
Uncles: ___ cancer
___ Grandmother: No known history of cancer or blood
disorders
Maternal Grandfather: No known history of cancer or blood
disorders
Paternal Grandmother: No known history of cancer or blood
disorders
Paternal Grandfather: No known history of cancer or blood
disorders
Children: No known history of cancer or blood disorders
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================================
Vitals: 98.3 110 106/54 67 25 96% on 3L
GENERAL: frail appearing older gentleman speaking in raspy voice
in full sentences in NAD
HEENT: PERRL, EOMI, no conjunctival pallor or scleral icterus,
dry mucous membranes, oropharynx without erythema, exudate, no
drooling
NECK: supple, no JVD, no anterior cervical lymphadenopathy
LUNGS: scant rhonchi, prolonged expiratory phase, no crackles or
wheezes
CV: tachycardic, regular, no murmurs, rubs, gallops
ABD: soft, non distended, normoactive bowel sounds, non tender
to palpation
EXT: warm, well perfused, trace edema in bilateral ankles, L>R
SKIN: warm, well perfused, no rashes
NEURO: axox3, CNII-XII intact, moving all 4 extremities without
deficits
ACCESS: 2 PIV
DISCHARGE PHYSICAL EXAM
==============================================
Pertinent Results:
ADMISSION LAB RESULTS
======================================
___ 04:47PM BLOOD WBC-2.1* RBC-2.93* Hgb-9.1* Hct-28.2*
MCV-96 MCH-31.1 MCHC-32.3 RDW-14.6 RDWSD-50.5* Plt ___
___ 04:47PM BLOOD Neuts-80* Bands-6* Lymphs-9* Monos-4*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-1.81
AbsLymp-0.19* AbsMono-0.08* AbsEos-0.00* AbsBaso-0.00*
___ 04:47PM BLOOD Glucose-108* UreaN-14 Creat-0.9 Na-137
K-3.9 Cl-103 HCO3-18* AnGap-20
___ 04:47PM BLOOD ALT-30 AST-38 LD(LDH)-391* AlkPhos-96
TotBili-1.4
___ 04:47PM BLOOD Calcium-7.6* Phos-3.0 Mg-1.4*
___ 04:47PM BLOOD D-Dimer-1202*
___ 06:52PM BLOOD ___ pO2-49* pCO2-26* pH-7.39
calTCO2-16* Base XS--7
DISCHARGE LAB RESULTS
=========================================
STUDIES
=====================================
___ CTA
1. Evaluation of the distal subsegmental pulmonary arterial
branches supplying the bilateral lower lobes due to respiratory
motion artifact. Otherwise, no evidence of pulmonary embolism.
No acute aortic syndrome.
2. Emphysema dependent reticular opacities at the right lung
base, potentially atelectasis. Given chronicity, these could
represent sequelae of aspiration or infection in the appropriate
clinical setting.
3. Moderate to severe luminal narrowing of the proximal left
subclavian artery secondary to noncalcified atherosclerotic
plaque.
4. 9 mm AP window lymph node is decreased in size from prior
exam from ___, previously 11 mm.
5. Persistent narrowing of the left upper lobe bronchus and
partial left upper lobe, lingular atelectasis.
6. Mild intra and extrahepatic biliary ductal dilation is
partially imaged
however unchanged from prior exams, better evaluated on prior
dedicated
abdominal imaging.
CXR ___:
The cardiomediastinal silhouette is stable, reflective of mild
cardiomegaly. Lung volumes are slightly low. The hila are
unremarkable. Opacity at the medial right lung base is
unchanged and likely reflects atelectasis. Also re-
demonstrated is opacity at the left lung base appearing to
involve the lingula, likely reflecting atelectasis. There is no
new superimposed focal lung consolidation. There is no
pulmonary edema. There is no pneumothorax or sizable pleural
effusion. Cervical spinal fusion hardware is partially imaged.
UNILAT LOWER EXT VEINS ___:
No evidence of deep venous thrombosis in the left lower
extremity veins.
MICROBIOLOGY
=======================================
___ Blood Culture x2:
___ Cdiff negative
___ Urine Culture:
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ARIPiprazole 10 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Darunavir 800 mg PO DAILY
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO QPM
5. Prazosin 1 mg PO QPM
6. QUEtiapine extended-release 200 mg PO QHS
7. Ranitidine 150 mg PO DAILY
8. RiTONAvir 100 mg PO QPM
9. Venlafaxine XR 75 mg PO DAILY
10. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
11. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
12. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN
abdominal pain
13. Pantoprazole 40 mg PO Q24H
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
15. Torsemide 40 mg PO DAILY
16. Aspirin 325 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Potassium Chloride 20 mEq PO DAILY
19. Potassium Chloride 40 mEq PO QHS
Discharge Medications:
1. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn L. upper
back
2. Lidocaine 5% Patch 1 PTCH TD QPM R chest wall pain
RX *lidocaine 5 % Please apply new patch every night QPM Disp
#*30 Patch Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*23 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 15 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
5. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*30 Capsule Refills:*0
6. Torsemide 20 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
9. ARIPiprazole 10 mg PO DAILY
10. Aspirin 325 mg PO DAILY
11. Atorvastatin 20 mg PO QPM
12. Darunavir 800 mg PO DAILY
13. Emtricitabine-Tenofovir (Truvada) 1 TAB PO QPM
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
15. Pantoprazole 40 mg PO Q24H
16. Potassium Chloride 20 mEq PO DAILY
17. Potassium Chloride 40 mEq PO QHS
Hold for K >
18. Prazosin 1 mg PO QPM
19. QUEtiapine extended-release 200 mg PO QHS
20. Ranitidine 150 mg PO DAILY
21. RiTONAvir 100 mg PO QPM
22. Tiotropium Bromide 1 CAP IH DAILY
23. Venlafaxine XR 75 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
health care associated Pneumonia
severe C. diff colitis
Secondary:
Stage II squamous cell carcinoma of the lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with SOB concerning of PE, CHF // pe chf pna?
TECHNIQUE: Single frontal portable view of the chest.
COMPARISON: Chest x-ray ___.
FINDINGS:
The cardiomediastinal silhouette is stable, reflective of mild cardiomegaly.
Lung volumes are slightly low. The hila are unremarkable. Opacity at the
medial right lung base is unchanged and likely reflects atelectasis. Also re-
demonstrated is opacity at the left lung base appearing to involve the
lingula, likely reflecting atelectasis. There is no new superimposed focal
lung consolidation. There is no pulmonary edema. There is no pneumothorax or
sizable pleural effusion. Cervical spinal fusion hardware is partially
imaged.
IMPRESSION:
Stable chest radiograph. No new focal lung consolidation.
Radiology Report
INDICATION: ___ with SOB, hypoxia hypoT hx of cancer and HIV // concern for
PE, PCP PNA
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) = 497 mGy-cm.
COMPARISON: CTA torso ___.
FINDINGS:
CTA THORAX: The aorta and major thoracic vessels are well opacified. The
aorta demonstrates normal caliber throughout the chest without evidence of
intramural hematoma or dissection. There is mild calcification of the aortic
arch. Major aortic arch branch vessels are patent. There is noncalcified
atherosclerotic plaque moderate to severely narrowing the lumen of the
proximal left subclavian artery (for example see series 3, image 38). The
pulmonary arteries are well opacified. There is no evidence of intraluminal
filling defect to suggest pulmonary embolism to the segmental level. There is
limited evaluation of the more distal subsegmental pulmonary arterial branches
to the lower lobes due to respiratory motion artifact.
CT THORAX: The partially imaged thyroid is within normal limits. The
esophagus is unremarkable. Coronary artery calcifications are seen.
Otherwise, the heart and pericardium are normal. There is no pericardial
effusion. There is a prominent AP window lymph node measuring 9 mm in short
axis (series 2, image 43) ; this was previously 11 mm on ___. There
is no mediastinal, hilar, or axillary lymphadenopathy.
Major airways are patent bilaterally. There is persistent narrowing of the
left upper lobe bronchus (03:10 8) as seen on prior exams. There is left
lower lobe bronchiectasis. There is moderate to severe centrilobular and
paraseptal emphysematous change diffusely involving both lungs, worst at the
lung apices. Reticular interstitial opacities involving the right lower lobe
raise possibility of superimposed chronic interstitial process. Linear
opacity along the left major fissure is consistent with atelectasis, similar
to prior. Ground-glass 3 mm nodule at the left lung base is new seen on the
prior exam and may be inflammatory infectious in nature (series 2, image 67).
A punctate solid pulmonary nodule in the right middle lobe is unchanged
(series 2, image 82). There is no pleural effusion or pneumothorax.
MUSCULOSKELETAL: There is no concerning focal subcutaneous or musculoskeletal
soft tissue abnormality. Moderate to severe wedge deformity of a lower
thoracic vertebral body is unchanged from prior exam, chronic in nature.
Otherwise, the imaged thoracic vertebral bodies are normally aligned and
demonstrate preserved height. No concerning focal lytic or sclerotic osseous
lesions are identified. Abnormal trabecular pattern visualized in the
proximal right humerus is likely due to artifact from high density contrast
injection in the right upper extremity and positioning
Mild intra- and extrahepatic biliary ductal dilation is partially imaged
however unchanged from prior exams. Gallbladder is surgically absent.
Otherwise, the partially imaged upper abdominal solid and hollow viscous
organs are without acute focal abnormality besides calcifications suggestive
nonobstructing calculi at the upper pole the left kidney, unchanged.
IMPRESSION:
1. Evaluation of the distal subsegmental pulmonary arterial branches supplying
the bilateral lower lobes due to respiratory motion artifact. Otherwise, no
evidence of pulmonary embolism. No acute aortic syndrome.
2. Emphysema dependent reticular opacities at the right lung base, potentially
atelectasis. Given chronicity, these could represent sequelae of aspiration
or infection in the appropriate clinical setting.
3. Moderate to severe luminal narrowing of the proximal left subclavian artery
secondary to noncalcified atherosclerotic plaque.
4. 9 mm AP window lymph node is decreased in size from prior exam from ___, previously 11 mm.
5. Persistent narrowing of the left upper lobe bronchus and partial left upper
lobe, lingular atelectasis.
6. Mild intra and extrahepatic biliary ductal dilation is partially imaged
however unchanged from prior exams, better evaluated on prior dedicated
abdominal imaging.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man with lung cancer, COPD, presenting with DOE and
left ankle swelling. Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal 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.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, L Leg swelling, Diarrhea
Diagnosed with Sepsis, unspecified organism
temperature: 98.6
heartrate: 110.0
resprate: nan
o2sat: 96.0
sbp: 98.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with Stage II SCC of the lung who
presented with HCAP and recurrent C. diff infection. He
continued to receive radiation while inpatient. For his HCAP he
was treated with a 7d course of antibiotics (cefepime,
transitioned to augmentin). His C. diff was treated with PO
vancomycin and PO flagyl. He was also having right sided chest
wall pain, associated with swallowing. Rad-onc felt this was
most likely a side effect of his radiation. This was managed
with Oxycodone and a lidocaine patch. ___ also worked with him
while he was here and felt he was strong enough to go home and
did not require ___ rehab. He developed neutropenia during
his hospitalization, likely due to recent chemotherapy. He was
treated with neupogen with normalization of his white blood cell
count.
He developed volume overload while in the hospital, as his home
torsemide was held due to his C. Diff infection. He was treated
with IV Lasix and then transitioned back to his home torsemide.
He developed a mild ___ so his torsemide dose was decreased to
20mg. With this dose, his Cr returned to baseline. Please
continue to assess his volume status and adjust the dose of
torsemide as an outpatient.
Pt's HIV markers were checked as inpatient. His Viral load was
63 copies/mL. His CD4 count was low (64) but his percentage was
normal (32%) so the low CD4 count likely was due to his
leukopenia rather than his HIV burden, so he does not need PCP
___. His CD4 count should be rechecked at a follow-up
appointment once his white count has normalized.
#Acute on chronic respiratory failure secondary to HCAP.
The patient has SCC of the lung and is on 2L NC at home, however
he developed an increasing oxygen requirement and cough. CTA
chest on ___ showed opacities in R lung base that "could
represent pneumonia in the right clinical setting". Because the
patient had an increased O2 requirement, a worsening cough, and
was just discharged from the hospital on ___, he was treated
for HCAP. He was initially started on cefepime, and completed
his 7d course with augmentin. His O2 requirement improved, and
he was actually able to be on room air at times with O2 sat >
93%. He went home on oxygen as he was still intermittently
requiring up to 2L.
#Recurrent C. diff.
The patient had recurrent C. diff which was treated initially
with PO vanc. It was not improving, likely because he was being
treated for HCAP at the same time, so he was started on IV
flagyl. Prior to discharge his diarrhea had decreased in
frequency but was still more than his baseline. Because he has
had recurrent episodes of C. diff, he was set up with an
outpatient appointment with ID to discuss the possibility of
fecal transplant. He was discharged on PO vanc and PO flagyl to
complete a full 14d course from the day he finished the
augmentin for his HCAP.
#Odynophagia.
The patient was complaining of R sided chest wall pain
associated with swallowing. He had a recent endoscopy which
showed esophagitis, which is consistent with his long standing
GERD treated with ranitidine; however, this is not consistent
with R sided chest pain. He had no evidence of oral thrush on
exam; however, he could have had esophageal thrush so he was
treated empirically with nystatin with no improvement in his
symptoms. Rad/onc felt that even though his radiation was
directed at his L chest, this pain could be a side effect of the
radiation. He was treated with oxycodone 15mg PRN and a
lidocaine patch with some improvement of his symptoms. He was
discharged home on this regimen.
#Neutropenia.
Attributed to the ___ he got on ___ and his radiation
therapy. He was given neupogen, which was stopped when his ___
recovered.
#Pitting sacral and lower extremity edema.
The patient's home torsemide was held because he was having >10
loose bowel movements/day from his C.diff infection. He
developed pitting sacral and lower extremity edema. He was
diuresed with IV Lasix and wore TEDS. Prior to discharge he was
restarted on his home torsemide 40mg, but was feeling
lightheaded and had SBP <100. For that reason he was discharged
on half his home dose (Torsemide 20mg).
#HIV.
Pt's HIV markers were checked as inpatient. His Viral load was
63 copies/mL. His CD4 count was low (64) but his percentage was
normal (32%) so the low CD4 count likely was due to his
leukopenia rather than his HIV burden, so he does not need PCP
___. He was continued on his home HIV regimen of
Darunivr, Truvada, Ritonavir.
#Stage II lung squamous cell carcinoma.
Started cycle 2 ___ taxol ___. Continued to receive
daily radiation as an inpatient.
#L foot and ankle swelling.
Minimal swelling on exam without history of trauma, no evidence
of infection. CTA negative for PE and negative ___ for
acute DVT.
#CAD. Continued home ASA, statin
#COPD. Continued home tiotropium and albuterol neb prn
#Depression. Continued quetiapine and venlafaxine.
#GERD. Continued home ranitidine
#Subclavian Stenosis. Noted during previous admission. BPs
softer
in L arm, so BP only checked in R arm. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Optiray 350
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with a history of multiple myeloma/plasmacytoma who
is admitted with increasing back pain. The patient states she
has
been having more pain for the past month which is why she
reestablished care with her oncologist. However she states in
the
last couple of days the pain has gotten much worse and is
interfering with her ambulation. She denies any bowel or bladder
incontinence. She endorsees a possible episode of brief numbness
in her leg while in the ED prior to admission but denies any
other numbness and is very vague about this. She states the pain
is worse with any movement such as going from lying to sitting,
etc. She denies any recent fevers, significant weight loss,
shortness of breath, diarrhea, rashes, or dysuria. She states
she
had not followed up with oncologist because she was scared but
she is not very specific about this.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- Presented in ___ with a left sacral plasmacytoma and IgG
kappa protein spike of a little over 2 g. She was treated with
radiation therapy to the sacral lesion followed by 5 cycles of
Velcade and dexamethasone. She had an excellent response and
then underwent high-dose melphalan therapy followed by
autologous
stem cell rescue in ___.
Treatment:
** Radiation to sacral mass following diagnosis x ~3 months
** Regimen: Hematologic Malignancies/BMT - Bortezomib (Velcade)
- 1.3 mg/m2 (Multiple Myeloma)
- Cycle 1 ___
- Cycle 2 ___
- Cycle 3 ___
- Cycle 4 ___
- Cycle 5 ___
** Regimen: Hematologic Malignancies/BMT - Cytoxan, High Dose
- Cycle 1 ___
Transplant:
- Cell harvest from peripheral blood on ___
Social History:
___
Family History:
Father died young of malignancy - unknown type
Mother - bipolar
2 children - healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: T 98.9 HR 70 BP 114/70 O2 93%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: Soft, NTND
LIMBS: No edema, clubbing, tremors, or asterixis. ___ ROM and
muscle strength decreased secondary to pain. Tenderness to
palpation over lumbar and lower thoracic spine diffusely.
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
DISCHARGE PHYSICAL EXAM:
GEN: Resting in bed comfortably, fatigued
Vs: Tc 98.5 110/70 66 16 97%RA
HEENT: MMM. vesicular lesion on right upper lip, crusted over.
No
OP lesions
CV: RR, NL S1/S2 no S3/S4 MRG
PULM: Non-labored. CTAB
ABD: Soft, NT/ND. Hypoactive BS.
LIMBS: No edema, clubbing, tremors, or asterixis. ___ ROM and
muscle strength decreased secondary to pain. Tenderness to
palpation over lumbar and lower thoracic spine diffusely and
over
bilateral SI joint areas.
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented x 3, no focal deficits. ___ strength
throughout, leg strength is normal and equal. no asterixis
PSYCH: Tearful, concerned about housing placement
Pertinent Results:
LABS:
___ 06:15AM BLOOD WBC-5.8 RBC-4.05 Hgb-12.3 Hct-36.4 MCV-90
MCH-30.4 MCHC-33.8 RDW-12.6 RDWSD-41.3 Plt ___
___ 06:50AM BLOOD WBC-4.7 RBC-3.90 Hgb-11.9 Hct-34.9 MCV-90
MCH-30.5 MCHC-34.1 RDW-12.6 RDWSD-40.8 Plt ___
___ 06:15AM BLOOD WBC-4.1 RBC-3.52* Hgb-10.7* Hct-31.8*
MCV-90 MCH-30.4 MCHC-33.6 RDW-12.5 RDWSD-40.4 Plt ___
___ 01:52PM BLOOD WBC-5.5 RBC-3.61* Hgb-11.0* Hct-32.6*
MCV-90 MCH-30.5 MCHC-33.7 RDW-12.4 RDWSD-41.0 Plt ___
___ 06:25AM BLOOD WBC-4.4 RBC-3.56* Hgb-10.9* Hct-31.9*
MCV-90 MCH-30.6 MCHC-34.2 RDW-12.3 RDWSD-40.5 Plt ___
___ 06:35AM BLOOD WBC-5.5 RBC-3.50* Hgb-10.7* Hct-31.7*
MCV-91 MCH-30.6 MCHC-33.8 RDW-12.4 RDWSD-41.0 Plt ___
___ 10:40AM BLOOD WBC-5.0 RBC-3.84* Hgb-11.6 Hct-34.7
MCV-90 MCH-30.2 MCHC-33.4 RDW-12.7 RDWSD-42.0 Plt ___
___ 12:40PM BLOOD WBC-5.3 RBC-3.84* Hgb-11.7 Hct-34.6
MCV-90 MCH-30.5 MCHC-33.8 RDW-12.9 RDWSD-41.8 Plt ___
___ 06:15AM BLOOD Neuts-56.4 ___ Monos-9.9 Eos-1.6
Baso-0.3 Im ___ AbsNeut-3.24 AbsLymp-1.81 AbsMono-0.57
AbsEos-0.09 AbsBaso-0.02
___ 06:50AM BLOOD Neuts-47.7 ___ Monos-10.4 Eos-2.6
Baso-0.4 Im ___ AbsNeut-2.24 AbsLymp-1.82 AbsMono-0.49
AbsEos-0.12 AbsBaso-0.02
___ 06:15AM BLOOD Neuts-41.0 ___ Monos-12.5 Eos-2.2
Baso-0.5 Im ___ AbsNeut-1.67 AbsLymp-1.78 AbsMono-0.51
AbsEos-0.09 AbsBaso-0.02
___ 06:25AM BLOOD Neuts-34.2 ___ Monos-12.1 Eos-2.5
Baso-0.7 Im ___ AbsNeut-1.50* AbsLymp-2.21 AbsMono-0.53
AbsEos-0.11 AbsBaso-0.03
___ 06:35AM BLOOD Neuts-49.0 ___ Monos-9.5 Eos-1.6
Baso-0.4 Im ___ AbsNeut-2.68 AbsLymp-2.14 AbsMono-0.52
AbsEos-0.09 AbsBaso-0.02
___ 10:40AM BLOOD Neuts-60.8 ___ Monos-7.2 Eos-1.0
Baso-0.2 Im ___ AbsNeut-3.04 AbsLymp-1.53 AbsMono-0.36
AbsEos-0.05 AbsBaso-0.01
___ 12:40PM BLOOD Neuts-47.0 ___ Monos-9.2 Eos-1.3
Baso-0.4 Im ___ AbsNeut-2.50 AbsLymp-2.23 AbsMono-0.49
AbsEos-0.07 AbsBaso-0.02
___ 06:15AM BLOOD Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:15AM BLOOD Plt ___
___ 01:52PM BLOOD Plt ___
___ 06:25AM BLOOD Plt ___
___ 12:43PM BLOOD ___
___ 06:35AM BLOOD Plt ___
___ 10:40AM BLOOD Plt ___
___ 12:40PM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-99 UreaN-17 Creat-0.6 Na-139
K-4.1 Cl-108 HCO3-25 AnGap-10
___ 06:50AM BLOOD Glucose-101* UreaN-12 Creat-0.6 Na-139
K-4.2 Cl-106 HCO3-24 AnGap-13
___ 06:15AM BLOOD Glucose-93 UreaN-14 Creat-0.6 Na-140
K-3.8 Cl-107 HCO3-24 AnGap-13
___ 02:08PM BLOOD Glucose-159* UreaN-11 Creat-0.6 Na-138
K-4.3 Cl-105 HCO3-20* AnGap-17
___ 06:25AM BLOOD Glucose-81 UreaN-13 Creat-0.6 Na-139
K-3.9 Cl-105 HCO3-25 AnGap-13
___ 06:35AM BLOOD Glucose-82 UreaN-14 Creat-0.6 Na-139
K-3.8 Cl-106 HCO3-25 AnGap-12
___ 10:40AM BLOOD Glucose-74 UreaN-22* Creat-0.6 Na-138
K-4.2 Cl-105 HCO3-24 AnGap-13
___ 12:40PM BLOOD Glucose-75 UreaN-16 Creat-0.5 Na-139
K-4.0 Cl-105 HCO3-24 AnGap-14
___ 06:15AM BLOOD ALT-57* AST-60* LD(LDH)-164 AlkPhos-91
TotBili-0.3
___ 06:50AM BLOOD ALT-44* AST-52* LD(___)-164 AlkPhos-85
TotBili-0.4
___ 06:25AM BLOOD ALT-15 AST-20 LD(___)-158 AlkPhos-80
TotBili-0.4
___ 06:35AM BLOOD ALT-12 AST-19 LD(___)-141 AlkPhos-82
TotBili-0.4
___ 10:40AM BLOOD ALT-15 AST-23 LD(___)-142 AlkPhos-91
TotBili-0.5
___ 06:15AM BLOOD Albumin-4.1 Calcium-9.4 Phos-3.6 Mg-2.0
___ 06:50AM BLOOD Albumin-4.0 Calcium-9.5 Phos-4.0 Mg-1.9
___ 06:15AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0
___ 02:08PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.9*
___ 06:25AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.7 Mg-2.0
___ 06:35AM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.3 Mg-2.0
___ 10:40AM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.8 Mg-2.0
___ 02:08PM BLOOD Prolact-8.2
___ 10:40AM BLOOD ___ Fr K/L-0.87
IgG-1315 IgA-194 IgM-81
___ 04:12PM BLOOD Lactate-0.8
IMAGING:
MR ___ ___
FINDINGS:
Please note that the evaluation is somewhat limited in the
absence of axial T1 postcontrast images.
For the purposes of numbering, the lowest well formed
intervertebral disc
space was designated the L5-S1 level. Please note that this
method is note
accurate for surgical planning.
The alignment of the lumbar spine is maintained. The vertebral
body heights are maintained at all levels. In the left hemi
sacrum, again seen is a T1 dark, T2 bright mass lesion measuring
approximately 5.1 by 5.9 x 3.5 cm, unchanged compared to the
prior MRI. The lesion demonstrates peripheral enhancement on
postcontrast images and extends from the level of S1-S3
vertebrae. The previously-seen old healed sacral insufficiency
fracture is vaguely identified. This mass does not extend into
the spinal canal. It however causes mild narrowing of the left
S1-S2 neural foramen. This is better evaluated on concurrent
MRI of the pelvis
The remaining marrow appears unremarkable without new focal
marrow lesions. The visualized lower spinal cord appears
unremarkable with the conus terminating at L1.
The visualized prevertebral, paravertebral and paraspinal soft
tissues appear unremarkable.
From T12-L1, through L4 -L5 levels, intervertebral disc height
and signal is maintained. Bilateral neural foramen and spinal
canal are patent.
At L5-S1, there is loss of disc height and signal with
broad-based disc bulge indenting the ventral thecal sac and
causing moderate left and mild right neural foramen narrowing.
IMPRESSION:
1. Study had to be aborted in between because of patient
discomfort without the acquisition of axial T1 postcontrast
images.
2. Stable left sacral mass in keeping with patient's known
plasmacytoma
causing mild left S1-S2 neural foramen narrowing. This is
better evaluated on concurrent MRI of the pelvis.
3. No new lesions are seen.
4. Stable mild degenerative disease at L5-S1 causing moderate
left and mild right neural foramen narrowing as described above.
MR PELVIS ___
FINDINGS:
Again seen is the known left sacral lesion measuring
approximately 4.3 x 3.7 x 5.3 cm, unchanged in size compared to
MRI of the lumbar spine on ___. The lesion is a T1
hypointense, STIR hyperintense, and demonstrates mild peripheral
enhancement and no internal enhancement. There are some areas
of more thickened peripheral enhancement, predominantly
posteriorly (19, 12 and 14). This is not significantly changed
compared to MRI on ___ given differences in
technique. The mass extends across the posterior aspect
of the left sacroiliac joint, unchanged. There is a chronic
fracture of the anterior left sacrum (13, 14), unchanged. The
mass causes narrowing of the left S1-2 neural foramen and abuts
the exiting left S2 nerve root, unchanged. The mass also abuts
the exiting left S1 nerve root at the L5-S1 level, better
evaluated on concurrent MRI of the lumbar spine.
There is no new fracture. No new suspicious osseous lesion.
There is increase high T2 subchondral signal along the iliac
side of both SI joints, which may reflect degenerative changes,
with fluid signal noted in both SI joints. In addition, there
is patchy high STIR signal both iliac bones which is
non-specific, but, based in comparison to the ___ CT
scan, this may reflect changes due to prior bone marrow
biopsies. A small subchondral cyst is also noted on the left
inferiorly (11:18).
Please refer to concurrent lumbar spine MRI for lumbar spine
findings.
Assessment of the intrapelvic structures is limited,
particularly in light of these of a saturation band. Visualized
portions are grossly unremarkable, without free intrapelvic
fluid or enlarged iliac lymph nodes. Is grossly within normal
limits.
IMPRESSION:
Previously biopsied left sacral plasmacytoma is unchanged in
size or
appearance compared to MRI of the lumbar spine on ___.
The lesion is predominantly nonenhancing and presumed necrotic,
with mostly thin peripheral enhancement, however there are some
mildly thickened areas of peripheral enhancement which could
represent residual plasmacytoma, similar to ___ MRI from
___.
The lesion extends across the posterior left SI joint and also
causes
narrowing of the left L5-S1 and S1-S2 neural foramen, abutting
the exiting
nerve roots at these levels, unchanged.
A chronic fracture of the left anterior sacrum is unchanged.
No new fracture or new suspicious osseous lesion.
Probable mild degenerative changes about both SI joints. In
addition, patchy high STIR signal in both iliac bones --question
related to sites of prior bone marrow biopsy. Attention to this
area on followup exams is requested.
ECG ___
Clinical indication for EKG: Syncope and collapse
Sinus rhythm. Compared to the previous tracing of ___ the
rate is somewhat less. Otherwise, no change.
HEAD CT ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The calcified scalp nodule
within the right parietal region, likely a granuloma come is
unchanged. 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: Normal study.
PET SCAN ___
FINDINGS: HEAD/NECK: There is no abnormal focus of increased
FDG uptake. There is a large mucous retention cyst in the right
maxillary sinus. There is no cervical lymphadenopathy. Mildly
prominent 9 mm right cervical level Ia lymph node demonstrates
no abnormal increased FDG uptake. 12 mm hypodense right lobe
thyroid nodule is unchanged in size compared to prior thyroid
ultrasound.
CHEST: There is no abnormal focus of increased FDG uptake.
Heart size is normal without significant pericardial fluid.
There is no supraclavicular, axillary, hilar or mediastinal
lymphadenopathy. There is mild bibasilar dependent atelectasis.
Lungs are otherwise clear.
ABDOMEN/PELVIS: There is no abnormal focus of increased FDG
uptake. Solid
organs are grossly unremarkable. Bowel loops are normal caliber
without
evidence of obstruction. There is no mesenteric,
retroperitoneal, inguinal or pelvic sidewall lymphadenopathy.
MUSCULOSKELETAL: 4.5 x 2.7 cm lytic lesion of the left sacrum
with chronic
appearing fracture line, surrounding bony remodeling and
sclerosis is unchanged compared to the CT examination from ___. There is borderline increased FDG uptake at the
margins of the lesion without a clear focal area of
asymmetrically increased uptake (SUV max 2.5). There is
otherwise no focus of abnormally increased FDG uptake. Vertebral
body hemangioma is noted at the L4 vertebral level. No other
focal bone lesion is identified.
Physiologic uptake is seen in the brain, myocardium, salivary
glands, GI and GU tracts, liver and spleen.
IMPRESSION:
1. Stable 4.5 x 2.7 cm left sacral plasmacytoma with chronic
fracture, unchanged in appearance compared to ___. The
rim of this
lesion demonstrates borderline increased FDG uptake, possibly
due to bony
remodeling/inflammation, without clear focal area of
differentially increased FDG uptake for biopsy target.
2. Otherwise no focus of FDG avid disease.
3. Stable 12 mm right lobe thyroid nodule, previously assessed
by ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Docusate Sodium 100 mg PO BID Constipation
DO NOT TAKE IF YOU HAVE DIARRHEA
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*10 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
DO NOT TAKE IF YOU HAVE CONSTIPATION
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*1 Packet Refills:*1
4. cane 1 Cane miscellaneous AS DIRECTED
RX *cane 1 straight cane use as directed Disp #*1 Each
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Multiple Myeloma
Secondary: Back Pain
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 ___ AND W/O CONTRAST ___ MR SPINE
INDICATION: ___ w/ MM and a history of left sacral plasmacytoma presenting
with atraumatic bilateral lower back pain x1dIV contrast to be given at
radiologist discretion as clinically needed //
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittalobtained after the
uneventful intravenous administration of 7 mL of Gadavist contrast agent.
Please note that axial T1 weighted postcontrast images could not be acquired
because of patient's discomfort and study had to be aborted in between.
COMPARISON: CT abdomen and pelvis from ___ and MRI of the lumbar
spine from ___.
FINDINGS:
Please note that the evaluation is somewhat limited in the absence of axial T1
postcontrast images.
For the purposes of numbering, the lowest well formed intervertebral disc
space was designated the L5-S1 level.Please note that this method is note
accurate for surgical planning.
The alignment of the lumbar spine is maintained. The vertebral body heights
are maintained at all levels. In the left hemi sacrum, again seen is a T1
dark, T2 bright mass lesion measuring approximately 5.1 by 5.9 x 3.5 cm,
unchanged compared to the prior MRI. The lesion demonstrates peripheral
enhancement on postcontrast images and extends from the level of S1-S3
vertebrae. The previously-seen old healed sacral insufficiency fracture is
vaguely identified. This mass does not extend into the spinal canal. It
however causes mild narrowing of the left S1-S2 neural foramen. This is
better evaluated on concurrent MRI of the pelvis
The remaining marrow appears unremarkable without new focal marrow lesions.
The visualized lower spinal cord appears unremarkable with the conus
terminating at L1.
The visualized prevertebral, paravertebral and paraspinal soft tissues appear
unremarkable.
From T12-L1, through L4 -L5 levels, intervertebral disc height and signal is
maintained. Bilateral neural foramen and spinal canal are patent.
At L5-S1, there is loss of disc height and signal with broad-based disc bulge
indenting the ventral thecal sac and causing moderate left and mild right
neural foramen narrowing.
IMPRESSION:
1. Study had to be aborted in between because of patient discomfort without
the acquisition of axial T1 postcontrast images.
2. Stable left sacral mass in keeping with patient's known plasmacytoma
causing mild left S1-S2 neural foramen narrowing. This is better evaluated on
concurrent MRI of the pelvis.
3. No new lesions are seen.
4. Stable mild degenerative disease at L5-S1 causing moderate left and mild
right neural foramen narrowing as described above.
Radiology Report
INDICATION: ___ w/ MM and a history of left sacral plasmacytoma presenting
with atraumatic bilateral lower back pain x1dIV contrast to be given at
radiologist discretion as clinically needed // ___ w/ MM and a history of
left sacral plasmacytoma presenting with atraumatic bilateral lower back pain
x1d
TECHNIQUE: Multiplanar images were obtained of the pelvis with the without IV
contrast at 1.5 T.
COMPARISON: MRI of the lumbar spine on ___. CT abdomen pelvis on
___.
FINDINGS:
Again seen is the known left sacral lesion measuring approximately 4.3 x 3.7 x
5.3 cm, unchanged in size compared to MRI of the lumbar spine on ___. The lesion is a T1 hypointense, STIR hyperintense, and demonstrates
mild peripheral enhancement and no internal enhancement. There are some areas
of more thickened peripheral enhancement, predominantly posteriorly (19, 12
and 14). This is not significantly changed compared to MRI on ___
given differences in technique. The mass extends across the posterior aspect
of the left sacroiliac joint, unchanged. There is a chronic fracture of the
anterior left sacrum (13, 14), unchanged. The mass causes narrowing of the
left S1-2 neural foramen and abuts the exiting left S2 nerve root, unchanged.
The mass also abuts the exiting left S1 nerve root at the L5-S1 level, better
evaluated on concurrent MRI of the lumbar spine.
There is no new fracture. No new suspicious osseous lesion.
There is increase high T2 subchondral signal along the iliac side of both SI
joints, which may reflect degenerative changes, with fluid signal noted in
both SI joints. In addition, there is patchy high STIR signal both iliac
bones which is non-specific, but, based in comparison to the ___ CT
scan, this may reflect changes due to prior bone marrow biopsies. A small
subchondral cyst is also noted on the left inferiorly (11:18).
Please refer to concurrent lumbar spine MRI for lumbar spine findings.
Assessment of the intrapelvic structures is limited, particularly in light of
these of a saturation band. Visualized portions are grossly unremarkable,
without free intrapelvic fluid or enlarged iliac lymph nodes. Is grossly
within normal limits.
IMPRESSION:
Previously biopsied left sacral plasmacytoma is unchanged in size or
appearance compared to MRI of the lumbar spine on ___.
The lesion is predominantly nonenhancing and presumed necrotic, with mostly
thin peripheral enhancement, however there are some mildly thickened areas of
peripheral enhancement which could represent residual plasmacytoma, similar to
L-spine MRI from ___.
The lesion extends across the posterior left SI joint and also causes
narrowing of the left L5-S1 and S1-S2 neural foramen, abutting the exiting
nerve roots at these levels, unchanged.
A chronic fracture of the left anterior sacrum is unchanged.
No new fracture or new suspicious osseous lesion.
Probable mild degenerative changes about both SI joints. In addition, patchy
high STIR signal in both iliac bones --question related to sites of prior bone
marrow biopsy. Attention to this area on followup exams is requested.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with myeloma and syncope and confusion // eval
for intracranial hemorrhage vs mass effect or intracranial myeloma involvement
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.
COMPARISON: CT head without contrast dated ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
There is no evidence of fracture. The calcified scalp nodule within the right
parietal region, likely a granuloma come is unchanged. 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. Normal study.
NOTIFICATION: Findings were discussed by telephone by Dr. ___ with Dr. ___
at 15:17 ___ immediately upon reviewing the examination.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Lower back pain
Diagnosed with Low back pain
temperature: 97.9
heartrate: 65.0
resprate: 18.0
o2sat: 98.0
sbp: 119.0
dbp: 69.0
level of pain: 10
level of acuity: 3.0 | ASSESSMENT AND PLAN:
___ yo female with a history of multiple myeloma/plasmacytoma who
is admitted with increasing back pain.
#Transaminitis: Noted on ___, slight elevation of ALT/AST. T
bili
normal. Unclear etiology, possibly medication-induced but not
taking much medication now. No abdominal discomfort or fever on
exam. Will monitor closely outpatient.
#Constipation: Had 2 bowel movements this morning. Likely as a
result of opioids given in the setting of back pain. Added
miralax and dulcolax to stool regimen in the past 2 days,
continues with Colace and Senna BID. Now controlled on oxycodone
prn, off oxycontin. Monitoring closely
#Multiple Myeloma/Plasmacytoma/Back Pain:
- Plasmacytoma seen on MRI
- Consulted neurosurgery to see possible interventions that will
help alleviate pain - for now no surgical intervention indicated
per their recs
-PET Scan on ___ showed that the rim of the left sacral lesion
demonstrates borderline increased FDG uptake, possibly due to
bony remodeling/inflammation, without clear focal area of
differentially increased FDG uptake for biopsy target but
otherwise no focus of FDG avid disease. Therefore, no need for
sacral biopsy in addition to Rad ONC evaluation. We offered
patient biopsy of the lesion at the rim as above but patient
refused.
- PRN oxycodone
- uptitrated oxycontin to 10mg q8 over the weekend, used 80mg
total oxycodone in prns/restarted Neurontin 300mg TID on ___
however, discontinued ___ due to AMS/Syncope
- Consider palliative care consult if pain uncontrolled - has
been stable.
- Holding off BM bx as most recent disease markers on ___ are
stable, patient has refused in the past but will defer to
outpatient provider, Dr. ___ she needs procedure done
- ___ consult, rec encourage frequent mobility and maximize
independence in ADLs. Assist of 1 for ambulation and transfers
out of bed to chair 3x/day with a SC.
#Lightheadedness/AMS: Resolved. Likely related to NPO status in
addition to pain medications. Obtained blood cultures ___ to
rule
out infectious process, NTD. Head CT ___ - ruled out acute bleed
or infarct. Now on regular diet, received 1L NS while NPO, will
continue to monitor closely
#Coping: Patient has minimal social support. Son was in ___
custody for 47 days per her report. Daughter is very supportive
but patient reports that she is not able to live with her at the
current apartment. Has financial constraints. On section 8 but
not able to find any suitable housing for now. Consulted ___ for
support. Shelter arrangements in process. Consider family
meeting
with daughter prior to discharge today. Has missed appointments
with Dr. ___ as she was afraid of potential interventions she
will receive at the clinic. She is very anxious about bone
marrow
biopsy and/or needle sticks.
#Anxiety: Regarding healthcare and procedures. continue on
Ativan
prn
#FEN:
- Electrolytes per oncology scales
- Regular diet
#BOWEL REGIMEN:
- Colace/Senna BID + Miralax
#DVT PROPHYLAXIS:
- Heparin 5000 units SC BID, hold if plts < 50K
#ACCESS:
- Peripheral IV
#Disposition: BMT for now, expected discharge post symptomatic
improvement
#Code status: full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transient speech difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with no significant PMH who presented to the ED as a
transfer
from ___ after a transient episode of word finding difficulties.
Neurology was consulted as a code stroke. LKW 4:30pm on ___.
Patient states that she was in her usual state of health, going
about her daily activities. Around 4:30 ___ on ___, she was
talking to her sister-in-law when she found that she was having
trouble expressing herself and answering questions. She was
still
able to say words and short phrases, such as " this is weird",
"what?", "I'm scared". However, she was having difficulty
getting
words out. She tried to write but had trouble putting words down
on paper. Patient states this episode lasted about an hour
(although per OSH records it lasted longer). Her sister in law
drove her to ___ where she still had difficulty speaking and
describing the cookie jar picture on ___ stroke card. FSBG 82.
Tele stroke was called and they decided to give TPA, but while
mixing the medication she had substantial improvement to the
point where her aphasia essentially resolved. TPA was not given
because of this. Patient was transferred to ___ per her
preference.
Patient states that her health has been excellent and she has
never experienced these symptoms before.
Past Medical History:
None
Social History:
___
Family History:
Mother had history of stroke in her ___ as well as heart disease
Father had a history of aneurysm
Physical Exam:
Discharge physical exam:
VSS
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted
Neck: Supple.
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: 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. Able to name all items on the ___ stroke
card
without difficulty. Able to describe cookie picture without
difficulty. No dysarthria. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, temperature,
vibration, or proprioception throughout. No extinction to DSS.
Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 3 2 3 3 2
Plantar response was equivocal.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF.
-Gait: Able to walk independently without issues
Pertinent Results:
___ 10:05PM ___ PTT-29.7 ___
___ 10:05PM PLT COUNT-404*
___ 10:05PM NEUTS-62.1 ___ MONOS-9.3 EOS-2.4
BASOS-0.5 IM ___ AbsNeut-4.75 AbsLymp-1.90 AbsMono-0.71
AbsEos-0.18 AbsBaso-0.04
___ 10:05PM WBC-7.6 RBC-4.43 HGB-13.8 HCT-41.1 MCV-93
MCH-31.2 MCHC-33.6 RDW-12.4 RDWSD-42.3
___ 10:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 10:05PM ALBUMIN-4.7
___ 10:05PM cTropnT-<0.01
___ 10:05PM ALT(SGPT)-17 AST(SGOT)-19 ALK PHOS-67 TOT
BILI-0.5
___ 10:05PM UREA N-12
___ 10:16PM estGFR-Using this
___ 10:16PM GLUCOSE-112* CREAT-0.8 NA+-143 K+-4.1
CL--112* TCO2-22
___ 10:16PM ___ COMMENTS-GREEN TOP
___ 01:42AM URINE MUCOUS-RARE*
___ 01:42AM URINE RBC-0 WBC-30* BACTERIA-FEW* YEAST-NONE
EPI-3
___ 01:42AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 01:42AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 01:42AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 01:42AM URINE HOURS-RANDOM
___ 03:25PM TSH-2.2
___ 03:25PM TRIGLYCER-194* HDL CHOL-68 CHOL/HDL-3.1
LDL(CALC)-102
___ 03:25PM %HbA1c-5.5 eAG-111
___ 03:25PM CHOLEST-209*
EKG:
Normal sinus rhythm left atrial abnormality Nonspecific T wave
abnormality
MRI head without contrast:
IMPRESSION:
1. Study is mildly degraded by motion.
2. Acute to subacute punctate left superior frontal gyrus and
corona radiata
probable infarcts without definite hemorrhagic transformation as
described.
3. Global volume loss and probable microangiopathic changes as
described.
TTE:
IMPRESSION: No definite structural cardiac source of embolism
identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*1
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 (One) tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST PORT ___ MR HEAD
INDICATION: ___ year old woman with transient word finding difficulties
resolved spontaneously after 1 hour// eval for stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON None.
FINDINGS:
Study is mildly degraded by motion.
Punctate left corona radiata and left superior frontal gyrus foci of
restricted diffusion are noted with question minimal associated T2 and FLAIR
hyperintensity for the left superior frontal gyrus lesion. There is no
definite associated increase susceptibility for these lesions.
There is no evidence of acute intracranial hemorrhage, masses, mass effect,
midline shift. There is prominence of the ventricles and sulci suggestive of
involutional changes. Periventricular and subcortical T2 and FLAIR
hyperintensities are noted which may represent small vessel ischemic changes.
IMPRESSION:
1. Study is mildly degraded by motion.
2. Acute to subacute punctate left superior frontal gyrus and corona radiata
probable infarcts without definite hemorrhagic transformation as described.
3. Global volume loss and probable microangiopathic changes as described.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA
Diagnosed with Transient cerebral ischemic attack, unspecified
temperature: 96.9
heartrate: 90.0
resprate: 16.0
o2sat: 95.0
sbp: 153.0
dbp: 90.0
level of pain: Critical
level of acuity: 2.0 | ___ with no significant PMH who presented to the ED as a
transfer
from ___ after a transient episode of word finding difficulties,
initially concerned for TIA. Had been considered a candidate for
tPA via telestroke, but tPA not administered due to significant
improvement in symptoms. Patient was loaded with aspirin and
Plavix. Upon transfer, the patient reported that her speech was
back to baseline without any residual deficits. MRI head showed
acute to subacute punctate left superior frontal gyrus and
corona radiata probable infarcts without evidence of hemorrhagic
transformation. TTE showed no evidence of source of cardiac
embolus. A1c was found to be 5.5 and LDL 102. Patient remained
in her baseline functional status and was discharged home safely
with ongoing aspirin and atorvastatin and a 30-day course of
Plavix. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
Admission Labs:
===============
___ 12:00PM BLOOD WBC-10.7* RBC-3.41* Hgb-9.6* Hct-28.0*
MCV-82 MCH-28.2 MCHC-34.3 RDW-22.9* RDWSD-66.0* Plt ___
___ 12:00PM BLOOD Neuts-60.6 ___ Monos-15.4*
Eos-1.6 Baso-0.9 NRBC-8.0* Im ___ AbsNeut-6.50*
AbsLymp-2.21 AbsMono-1.65* AbsEos-0.17 AbsBaso-0.10*
___ 12:00PM BLOOD ___ PTT-30.0 ___
___ 12:00PM BLOOD Ret Aut-8.5* Abs Ret-0.25*
___ 12:00PM BLOOD Glucose-113* UreaN-7 Creat-0.8 Na-142
K-4.1 Cl-109* HCO3-22 AnGap-11
___ 12:00PM BLOOD ALT-22 AST-35 LD(LDH)-500* AlkPhos-96
TotBili-6.8* DirBili-0.5* IndBili-6.3
___ 12:00PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.6* Mg-1.9
___ 12:00PM BLOOD Hapto-<10*
Imaging:
========
CXR:
Cardiomediastinal silhouette is within normal limits. Increased
bilateral
interstitial opacities with peribronchial thickening and subtle
retrocardiac opacities which may represent pneumonia in
appropriate clinical setting.
There are no pneumothoraces. Sclerosis within the bilateral
humeral heads, may be seen with sickle cell arthropathy.
Discharge Labs:
===============
___ 05:45AM BLOOD WBC-13.5* RBC-3.14* Hgb-8.8* Hct-26.3*
MCV-84 MCH-28.0 MCHC-33.5 RDW-21.6* RDWSD-63.6* Plt ___
___ 05:45AM BLOOD Ret Aut-7.1* Abs Ret-0.25*
___ 05:45AM BLOOD Glucose-95 UreaN-4* Creat-0.8 Na-140
K-4.1 Cl-107 HCO3-22 AnGap-11
___ 05:45AM BLOOD ALT-14 AST-22 AlkPhos-108 TotBili-6.0*
___ 05:45AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.7
___ 05:45AM BLOOD Hapto-11*
Radiology Report
INDICATION: History: ___ with cough, cp // eval for pna
COMPARISON: Prior radiographs ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. Increased bilateral
interstitial opacities with peribronchial thickening and subtle retrocardiac
opacities which may represent pneumonia in appropriate clinical setting.
There are no pneumothoraces. Sclerosis within the bilateral humeral heads,
may be seen with sickle cell arthropathy.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Hb-SS disease with crisis, unspecified, Other pneumonia, unspecified organism, Chest pain, unspecified
temperature: 99.2
heartrate: 87.0
resprate: 18.0
o2sat: 100.0
sbp: 107.0
dbp: 57.0
level of pain: 9
level of acuity: 2.0 | Mr. ___ is a ___ male with a past medical history
notable for severe AS and sickle cell disease who presented with
an acute pain crisis in setting of possible community acquired
pneumonia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
___ EGD
___ Large volume paracentesis
___ Diagnostic paracentesis
___ Diagnostic and Therapeutic paracentesis
___ ___ tube placement
History of Present Illness:
Mr. ___ is a ___ with a POMHx of micronodular cirrhosis
(decompensated by ascites), pancreatic neuroendocrine tumor with
met to cirrhotic liver, HTN, HLD, IDDM and CAD, who presents
with chief complaint of weakness.
Per pt, he has been feeling fatigued for the past several days.
He has also been experiencing dyspnea and cough in addition to a
chronic headache and neck pain. On day of visit, he also
developed diarrhea. Family corroborated that pt has been
lethargic at home, but were not available by phone overnight.
Per pt, he had undergone a therapeutic paracentesis 1d prior to
admission (9L removed).
Pt arrived to the PACU for a TIPS procedure and slipped from his
wheelchair (evidently due to reduced ___ strength). There was no
LOC or head strike. TIPS was deferred due to potential HE.
In the ED, initial vitals were T 100.6 P 66 BP 110/51 R 16 O2
Sat 100%. He was found to have asterixis and brown guaiac
negative stool per GI in the ED. Labs were significant for K
5.2, Na 132, HCO3 20, Cr 2.1, lactate 1.7, WBC 2.6, AST 73,
ascites with 40BWC and 1 poly/62 macrophages, BCx and peritoneal
cultures were sent. CXR shows ?small effusions. EKG showed NSR
at 68bom and low voltage. He received CTX 2g IV x 1 and was
admitted for further management.
ROS: per HPI, denies fever, chills, night sweats, vision
changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
- Micronodular cirrhosis - likley ___ NAFALD
- Pancreatic neuroendocrine tumor (metastatic to liver)
- Diagnosed ___, Whipple procedure aborted because of dx of
cirrhosis, lost to follow-up ___, increasing size of
pancreatic mass ___ with EUS/biopsy demonstrating
locally-advanced, high grade neuroendocrine tumor in pancreatic
mass and lymph node, s/p stereotactic radiosurgery to pancreatic
lesion and lymph node ___, liver metastases ___ s/p TACE
___, and ___, with radiographic evidence of
disease progression ___, initiated everolimus ___ and
held ___, resumed ___ (see above for full details)
- Coronary artery disease s/p stenting ___ years ago.
Previously reported having had unrevealing stress tests
subsequently
- IDDM2 x ___ years
- Hypertension
- Hyperlipidemia
- GERD
- Depression
- SP cervical laminectomy
Social History:
___
Family History:
Father died of CAD, cardiac arrest in his ___. Maternal
grandmother had ? type of cancer, died when pt was 5 (possibly
breast or uterine). Paternal uncle with skin cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: T 98.7, BP 125/64, P 67, R 16, O2 Sat 100%RA
General: Thin, poale/grey man in NAD, A+Ox3, slow to respond
HEENT: PERRL, EOMI, NCAT, MMM, no oral lesions
Neck: JVD at angle of jaw; no bruits, no LAD
CV: RRR, no MRG, nl S1 and S2
Lungs: LCTA-bl, no w/r/r
Abdomen: Distended; +fluid wave; no HSM, non-tender
Ext: FROM; 1+ pedal edema L>R; 2+ DP and radial pulses
Neuro: CNII-XII intact; strength ___ throughout; sensation
intact to LT distally; +asterixis; slow to respond
DISCHARGE PHYSICAL EXAMINATION:
===============================
Vitals: 97.2 | 105/49 | 83 | 98%RA
General: Cachectic, diffusely weak, AAOx3, comfortable in
bed,NAD. HEENT: clear OP, MMM.
CV: RRR, no r/g/m
Chest: Coarse breath sounds b/l, no w/r/r
Abd: Increasingly protuberant and dull to percussion,+BS,
+fluid wave, Soft, no TTP
Ext: WWP, no edema
Neuro: face symmetric, moving all four extremities on command,
no asterixis.
Pertinent Results:
ADMISSION LABS:
===============
___ 02:46PM BLOOD WBC-2.6* RBC-2.75* Hgb-8.0* Hct-22.6*
MCV-82 MCH-29.0 MCHC-35.2* RDW-16.6* Plt ___
___ 02:46PM BLOOD Neuts-71.2* ___ Monos-6.5 Eos-0.3
Baso-0.2
___ 02:46PM BLOOD ___ PTT-29.9 ___
___ 02:46PM BLOOD Glucose-183* UreaN-49* Creat-2.1*#
Na-132* K-5.2* Cl-102 HCO3-20* AnGap-15
___ 02:46PM BLOOD ALT-20 AST-73* AlkPhos-96 TotBili-0.6
___ 03:05PM BLOOD CK-MB-2 cTropnT-0.08*
___ 02:46PM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.0 Mg-2.3
___ 03:00PM BLOOD Lactate-1.7
ASCITIC FLUID LABS:
===================
ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Macroph
___ 16:07 715* 355* 80* 7* 13*
___ 15:41 2115* 325* 83* 3* 0 14*
___ 14:44 88* 454* 7* 35* 0 58*
___ 18:21 40* 378* 1* 37* 0 62*
ASCITES CHEMISTRY TotPro Glucose LD(LDH) TotBili Albumin
___ 16:07 2.7 158 1.8
___ 15:41 2.2 1.3
___ 15:30 2.4 0.3 1.4
___ 18:21 1.6 207
RELEVANT TRENDS:
================
Creatinine
___ 06:45 1.9*
___ 06:30 1.9*
___ 06:50 2.0*
___ 17:15 2.0*
___ 07:20 1.9*
___ 07:50 1.9*
___ 06:15 1.5*
___ 06:35 1.6*
___ 07:00 1.5*
___ 06:25 1.5*
___ 07:00 1.4*
___ 06:50 1.5*
___ 07:00 1.6*
___ 05:35 1.5*
___ 06:25 1.6*
___ 05:45 1.8*
___ 05:20 2.0*
___ 07:15 2.3*
___ 08:00 2.5*
___ 06:45 2.8*
___ 10:15 2.8*
___ 10:30 2.4*
___ 00:48 2.0*
___ 14:46 2.1*
Total Bilirubin
___ 06:45 2.0*
___ 06:30 2.3*
___ 06:50 2.5*
___ 07:20 1.8*
___ 07:50 1.4
___ 06:15 2.0*
___ 06:35 1.9*
___ 07:00 1.9*
___ 06:25 1.5
___ 07:00 1.1
___ 06:50 1.0
___ 07:00 1.4
___ 05:35 1.0
___ 06:25 1.1
___ 05:45 0.8
___ 05:20 0.9
___ 07:15 0.9
___ 08:00 0.8
___ 06:45 0.6
___ 10:15 0.6
___ 10:30 0.6
___ 14:46 0.6
Sodium
___ 06:45 131*
___ 06:30 131*
___ 06:50 131*
___ 17:15 130*
___ 07:20 127*
___ 07:50 133
___ 06:15 133
___ 06:35 133
___ 07:00 135
___ 06:25 134
___ 07:00 143
___ 06:50 140
___ 07:00 140
___ 05:35 139
___ 06:25 139
___ 05:45 139
___ 05:20 137
___ 07:15 140
___ 08:00 143
___ 06:45 138
___ 17:25 138
___ 10:15 140
___ 10:30 137
___ 00:48 137
___ 14:46 132*
DISCHARGE LABS:
===============
___ 06:15AM BLOOD WBC-5.8 RBC-2.53* Hgb-7.1* Hct-23.0*
MCV-91 MCH-27.9 MCHC-30.7* RDW-18.9* Plt ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Glucose-179* UreaN-55* Creat-1.9* Na-128*
K-4.5 Cl-97 HCO3-21* AnGap-15
___ 06:15AM BLOOD ALT-14 AST-36 AlkPhos-135* TotBili-1.8*
DirBili-0.5* IndBili-1.3
___ 06:15AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.9
MICROBIOLOGY:
=============
___ Respiratory Virus Identification (Final ___:
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
Viral antigen identified by immunofluorescence.
___ 2:46 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:21 pm PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 12:50 pm SWAB Source: Rectal swab.
**FINAL REPORT ___
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___:
No VRE isolated.
ENTEROCOCCUS SP.. Sensitivity testing performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
VANCOMYCIN------------ 2 S
___ 1:53 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
PREVOTELLA SPECIES. BETA LACTAMASE POSITIVE.
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (___) 3:20AM
___.
___ 12:23 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST ID REQUESTED BY ___ ___ (___)
___.
___ ALBICANS, PRESUMPTIVE IDENTIFICATION. ~3000/ML.
___ 3:41 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___:
PREVOTELLA SPECIES. BETA LACTAMASE POSITIVE.
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___. ___ ___
14:45.
___ 9:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:10 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:49 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
___ 2:05 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
IMAGING:
========
___ CXR:
------------
FINDINGS: Frontal and lateral views of the chest. The lungs
are clear without focal consolidation or large effusion. There
is mild blunting of the posterior costophrenic angles,
potentially due to small effusions. The cardiomediastinal
silhouette is within normal limits. No acute osseous
abnormality is identified. Anterior cervical fixation hardware
is partially visualized.
___ ___:
-------------
IMPRESSION: No evidence of deep vein thrombosis in either leg.
___ RUQ U/S:
-----------------
IMPRESSION:
1. Patent hepatic vasculature. No portal vein thrombus
identified.
2. Minimal fluid in the pericardial space which does not appear
to represent a significant effusion.
3. Large amount of ascites in the abdomen.
4. Heterogeneous hepatic architecture and small left lobe
lesion, however visualization of the liver is limited due to the
patient's body habitus.
5. Cholelithiasis.
___ CXR:
-------------
FINDINGS: Compared to the study from the prior day, the heart
has increased in size and there is increased pulmonary vascular
re-distribution with some hazy areas of alveolar infiltrate
suggesting fluid overload. There is no focal infiltrate to
suggest infection.
___ Renal U/S:
-------------------
1. No evidence of hydronephrosis or stones.
2. Left renal cyst with a thin septation.
3. Large volume ascites.
___ ECHO:
---------------
IMPRESSION: Normal global and regional biventricular systolic
function. Mild to moderate mitral regurgitation. Moderate
elevation of pulmonary artery hypertension. Compared with the
prior study (images reviewed) of ___, mild to moderate
mitral regurgitation and elevtated pulmonary pressures are seen.
CHEST (PORTABLE AP) Study Date of ___ 12:07 AM
Cardiac silhouette is normal in size. Patchy opacities are
present
at both lung bases medially, with overall interval decrease in
extent compared to the prior radiograph. This may represent
resolving atelectasis, recurrent aspiration or resolving
infection. No new areas of consolidation are identified
elsewhere in the lungs, and there is no definite pleural
effusion or pneumothorax.
CHEST (PORTABLE AP) Study Date of ___ 1:05 AM
Previously questioned bibasilar consolidation is no longer
present. Also
improved is pulmonary vascular congestion. Mediastinal fullness
particularly in the right paratracheal region is a longstanding
finding, due to mediastinal fat deposition primarily. Heart
size is normal. There is no pleural abnormality.
CHEST (PA & LAT) Study Date of ___ 1:50 ___
Frontal view suggests a new very small region of consolidation
at
the base of the left lung projecting over the posterior left
tenth rib. The region is so small, I would not expect to see it
confirmed on the lateral view, which is essentially clear. In
order to verify this finding, we would require oblique views.
Lungs are otherwise clear. Small pleural effusions seen only on
the lateral view with certainty could have been present
previously.
Heart size is normal and pulmonary vasculature is unremarkable.
Mild
mediastinal widening, particularly to the right of midline is
nevertheless due to mediastinal fat deposition demonstrated by
chest CT on ___.
CHEST (PA & LAT) Study Date of ___ 4:06 ___
Persistent small pleural effusions.
CHEST (PORTABLE AP) Study Date of ___ 2:26 ___
NGT terminating within the distal stomach/proximal duodenum.
___ TUBE PLACEMENT (W/FLUORO) ___ 2:49 ___
Successful advancement of the nasointestinal tube to the
post-pyloric location with the tube terminating at the level of
the ligament of Treitz. The tube is ready to use.
PATHOLOGY
=========
___ PERITONEAL FLUID CITOLOGY
NEGATIVE FOR MALIGNANT CELLS.
Macrophages and mesothelial cells.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 30 mg PO DAILY
2. everolimus 10 mg oral daily
3. Glargine 12 Units Dinner
4. Lisinopril 5 mg PO DAILY
5. Nadolol 40 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Spironolactone 50 mg PO BID
8. Vitamin E 400 UNIT PO BID
9. Furosemide 40 mg PO DAILY
10. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Citalopram 30 mg PO DAILY
2. Glargine 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 650 mg PO Q6H:PRN fever
4. Aspirin 325 mg PO DAILY
5. Benzonatate 100 mg PO TID
6. Betamethasone Dipro 0.05% Cream 1 Appl TP BID Duration: 3
Weeks
7. Ciprofloxacin HCl 500 mg PO Q12H
last day at this dose is ___, then 250mg q24h for life
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last day is ___. Miconazole Powder 2% 1 Appl TP BID
10. Neutra-Phos 2 PKT PO DAILY
11. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone [Oxecta] 5 mg half tablet, oral only(s) by mouth
every six (6) hours Disp #*14 Tablet Refills:*0
12. Pantoprazole 40 mg PO Q12H
13. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*60 Tablet Refills:*0
14. everolimus 10 mg oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
#Influenza A
#Prevotella Sp. spontaneous bacterial peritonitis
#Prevotella Sp. bloodstream infections
#Acute tubular necrosis
#Acute interstitial nephritis
#Hepatic encephalopathy
SECONDARY
#NASH cirrhosis
#Refractory ascites
#Protein-calorie malnutrition
#Pancreatic neuro-endocrine tumour
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS; ___
HISTORY: ___ male with altered mental status and fever.
COMPARISON: ___.
FINDINGS: Frontal and lateral views of the chest. The lungs are clear
without focal consolidation or large effusion. There is mild blunting of the
posterior costophrenic angles, potentially due to small effusions. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormality is identified. Anterior cervical fixation hardware is partially
visualized.
Radiology Report
HISTORY: ___ man with hepatic encephalopathy, evaluate for portal
vein thrombus.
COMPARISON: Abdomen CT ___.
FINDINGS:
There is a large amount of ascites in the abdomen. The liver is
heterogeneous. A small hyperechoic lesion is seen in the left lobe of the
liver measuring 0.5 x 0.6 x 0.4 cm. Note is made that visualization of the
liver is limited due to the patient's body habitus and the presence of
ascites.
No biliary dilatation is seen and the common duct measures 0.3 cm. There are
several gallstones seen within the gallbladder. The gallbladder wall is
mildly edematous likely due to third spacing. The pancreas and midline
structures are not visualized due to overlying bowel gas.
Several additional images were obtained of the pericardium per request of the
clinical team. There is minimal fluid seen within the right inferolateral
pericardium which does not appear to represent a significant effusion.
DOPPLER EXAMINATION: Color Doppler and spectral waveform analysis was
performed. The main, right and left portal veins are patent with hepatopetal
flow. Appropriate arterial waveforms are seen in the main hepatic artery.
The hepatic veins and IVC are patent.
IMPRESSION:
1. Patent hepatic vasculature. No portal vein thrombus identified.
2. Minimal fluid in the pericardial space which does not appear to represent a
significant effusion.
3. Large amount of ascites in the abdomen.
4. Heterogeneous hepatic architecture and small left lobe lesion, however
visualization of the liver is limited due to the patient's body habitus.
5. Cholelithiasis.
Radiology Report
HISTORY: ___ man with lower extremity edema, evaluate for DVT.
COMPARISON: No previous exam for comparison.
FINDINGS:
Grayscale, color and Doppler images were obtained of bilateral common femoral,
femoral, popliteal and tibial veins. Normal flow, compression and
augmentation is seen in all of the vessels.
IMPRESSION:
No evidence of deep vein thrombosis in either leg.
Radiology Report
AP CHEST, 7:27 A.M., ___
HISTORY: A ___ man with fever and cirrhosis.
IMPRESSION: AP chest compared to ___ through ___:
Interval increase in mediastinal caliber at the level of the vascular pedicle,
the pulmonary outflow tract, and upper lobe pulmonary vessels suggest volume
overload. Heart size increased slightly. No pulmonary edema as yet. No
pleural effusion.
Radiology Report
CHEST ON ___
HISTORY: Cirrhosis and flu, question superinfection.
REFERENCE EXAM: ___.
FINDINGS: Compared to the study from the prior day, the heart has increased
in size and there is increased pulmonary vascular re-distribution with some
hazy areas of alveolar infiltrate suggesting fluid overload. There is no
focal infiltrate to suggest infection.
Radiology Report
INDICATION: History of cirrhosis and metastatic neuroendocrine tumor, now
with acute kidney injury and anuria. Evaluate for obstruction or
hydronephrosis.
COMPARISON: CT abdomen and pelvis from ___. MRI of the abdomen
from ___.
FINDINGS: The right kidney measures 11.2 cm and the left kidney measures 11.1
cm. There is no evidence of hydronephrosis, stones or concerning lesions.
There is a cyst within the interpolar region of the left kidney measuring 2.5
x 2.3 x 1.9 cm with a single septation. There is a large volume of ascites in
the lower abdomen. The bladder is not visualized.
IMPRESSION:
1. No evidence of hydronephrosis or stones.
2. Left renal cyst with a thin septation.
3. Large volume ascites.
Radiology Report
HISTORY: Rhonchi on exam. Question pulmonary edema.
___.
FINDINGS:
The heart size continues to be moderately enlarged with prominence to the
central vascularity. There is increased bilateral lower lobe opacity
compatible with volume loss/infiltrate. There is less vascular plethora than
on the study from the prior day.
IMPRESSION:
Bilateral lower lobe opacities/infiltrates that have worsened in the interval.
Radiology Report
PORTABLE CHEST ___
COMPARISON: ___ radiograph.
FINDINGS: Cardiac silhouette is normal in size. Patchy opacities are present
at both lung bases medially, with overall interval decrease in extent compared
to the prior radiograph. This may represent resolving atelectasis, recurrent
aspiration or resolving infection. No new areas of consolidation are
identified elsewhere in the lungs, and there is no definite pleural effusion
or pneumothorax.
Radiology Report
AP CHEST 1:11 A.M., ___
HISTORY: A ___ man with cirrhosis and fever.
IMPRESSION: AP chest compared to ___ through ___:
Previously questioned bibasilar consolidation is no longer present. Also
improved is pulmonary vascular congestion. Mediastinal fullness particularly
in the right paratracheal region is a longstanding finding, due to mediastinal
fat deposition primarily. Heart size is normal. There is no pleural
abnormality.
Radiology Report
PA AND LATERAL CHEST, ___
HISTORY: ___ man with gram-negative bacteremia and cough. Question
new pneumonia.
IMPRESSION: Frontal view suggests a new very small region of consolidation at
the base of the left lung projecting over the posterior left tenth rib. The
region is so small, I would not expect to see it confirmed on the lateral
view, which is essentially clear. In order to verify this finding, we would
require oblique views. Lungs are otherwise clear. Small pleural effusions
seen only on the lateral view with certainty could have been present
previously.
Heart size is normal and pulmonary vasculature is unremarkable. Mild
mediastinal widening, particularly to the right of midline is nevertheless due
to mediastinal fat deposition demonstrated by chest CT on ___.
Radiology Report
PA AND LATERAL CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Cardiomediastinal contours are stable in appearance, and lungs are
clear. Persistent small pleural effusions.
IMPRESSION: Persistent small pleural effusions.
Radiology Report
HISTORY: Cirrhosis with need for post-pyloric feeding tube placement.
COMPARISON: None available.
FINDINGS: Patient presented to the fluoroscopy suite with a ___
tube terminating in the stomach. The right naris was anesthetized with
lidocaine jelly. Under fluoroscopic guidance, the tube was advanced
post-pylorically to the ___ portion of the duodenum. Tube placement was
confirmed with injection of 10 cc of Optiray contrast. Final fluoroscopic
spot image demonstrates nasointestinal tube terminating at the level of the
ligament of Treitz. Patient tolerated the procedure without immediate
post-procedural complications.
IMPRESSION: Successful advancement of a nasointestinal tube to the
post-pyloric position with the tube terminating at the level of the ligament
of Treitz. The tube is ready to use.
Radiology Report
AP CHEST, 10:36 A.M., ___.
HISTORY: ___ man after NG tube placement.
IMPRESSION: AP chest compared to ___:
Examination centered in the low mediastinum excludes the lung apices. Shows
an upper enteric drainage tube ending in the stomach, clear lower lungs,
normal heart size, and no appreciable pleural effusion.
Radiology Report
INDICATION: Post-pyloric tube placement.
COMPARISON: Post-pyloric tube placement fluoro study from ___.
FINDINGS: Patient presents to the fluoroscopy suite with the nasointestinal
tube terminating in the stomach. The right naris was anesthetized with
lidocaine jelly. Under fluoroscopic guidance, the tube was advanced
post-pylorically to the fourth portion of duodenum. Tube placement with
confirmed with injection of 5 cc of Optiray contrast.
IMPRESSION: Successful advancement of the nasointestinal tube to the
post-pyloric location with the tube terminating at the level of the ligament
of Treitz. The tube is ready to use.
Radiology Report
HISTORY: Assess NG tube placement.
TECHNIQUE: Portable, frontal radiographs of the lower thorax and upper
abdomen were acquired.
COMPARISON: Comparison is made to radiographs dated ___.
FINDINGS:
A nasogastric tube is seen terminating within the distal stomach/proximal
duodenum. The visualized portion of the bilateral lower lungs and mediastinum
are grossly unremarkable.
IMPRESSION:
NGT terminating within the distal stomach/proximal duodenum.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WEAKNESS
Diagnosed with OTHER ASCITES
temperature: 100.6
heartrate: 66.0
resprate: 16.0
o2sat: 100.0
sbp: 110.0
dbp: 51.0
level of pain: 0
level of acuity: 2.0 | ___ w/cirrhosis (presumed NASH), pancreatic neuroendocrine tumor
metastatic to liver, coronary artery disease, presents with
weakness and fatigue, found to be influenza positive. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Intraabdominal abscess
Major Surgical or Invasive Procedure:
I and D of intraabdominal abscess by a flank incision.
History of Present Illness:
Ms. ___ is a ___ with progressive MS who was recently
hospitalized for septic shock secondary to ruptured appendicitis
s/p exploratory laparotomy with right hemicolectomy, left in
discontinuity with an open abdomen ___ ___, interval
ileo-colonic anastomosis ___ ___ and delayed
abdominal
wall closure with placement of wound VAC ___ ___. Her
hospital course was complicated by a left common femoral vein
DVT. Heparin gtt and warfarin therapy were attempted but she
developed bright red blood per rectum. An IVC filter was
therefore placed on ___ and anticoagulation was discontinued.
She was discharged to ___ and ___ of
___ on ___. Per her husband, she has progressed
slowly
at rehab but had been tolerating a regular diet. Of note
Coumadin
was restarted at rehab. Over the past week, she has not been
feeling well with malaise, poor PO intake, and occasional nausea
and vomiting. This morning, the nursing staff noticed purulent,
malodorous fluid discharge from her a right posterior flank 2cm
skin opening. She was therefore transferred to ___. CT
scan was obtained which showed a 14 x 4 x 4.6 cm lateral right
abdominopelvic abscess with a cutaneous fistula. She was
subsequently transferred to ___ for further care. On arrival
patient was hypotensive requiring Levophed for pressure support.
She was give IV fluid resuscitation and 1U pRBC for hct 20.8.
Surgery was consulted for further evaluation.
Past Medical History:
- MS
- perforated appendicitis (see below for surgical history)
- left common femoral vein DVT s/p IVC filter
- Hypothyroidism
- recurrent UTI's prev w/ pseudomonas, enterococcus, E coli.
nephrolithiasis
PSH:
- ___: exploratory laparotomy, right hemicolectomy, left
in discontinuity with an open abdomen (___)
- ___: ileo-colonic anastomosis, open abdomen (___)
- ___: Reopening of recent laparotomy, abdominal washout,
abdominal wall closure, and placement of a wound VAC greater
than
50 sq cm, elevation of skin flaps.
- ___ - IVC filter
- ___ - unstable lordosis of c-spine s/p anterior
decompression
and fusion of C5-C6 and posterior decompression and fusion C4-C7
(___)
- ___ - excision of left index ganglion cyst (___)
Social History:
___
Family History:
Mother is still living at age ___
Physical Exam:
Admission Physical Exam:
Vitals: 97.0 ___ 24 99%RA
GEN: AOx2, NAD
HEENT: No scleral icterus, dry mucus membranes
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, will healing midline incision with granulation
tissue,
mild right sided abdominal tenderness, no rebound or guarding,
right posterior 2cm skin opening with malodorous purulent
drainage, minimal surrounding skin erythema, no crepitus
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
Vitals: stable
Gen: Awake, alert, NAD
CV: RRR
Pulm: No resp distress
Abd: Soft, healing midline incision, right sided healing flank
incision with ___ drain in place
Ext: No CCE
Neuro: Grossly intact
Psych: Depressed mood
Pertinent Results:
___ 06:20PM BLOOD WBC-8.7 RBC-2.34* Hgb-5.7* Hct-20.8*
MCV-89 MCH-24.4*# MCHC-27.4* RDW-18.2* RDWSD-58.0* Plt ___
___ 03:30AM BLOOD WBC-7.6 RBC-2.39* Hgb-6.1* Hct-20.4*
MCV-85 MCH-25.5* MCHC-29.9* RDW-16.6* RDWSD-50.7* Plt ___
___ 09:06AM BLOOD WBC-9.1 RBC-3.05*# Hgb-8.2*# Hct-26.2*#
MCV-86 MCH-26.9 MCHC-31.3* RDW-16.4* RDWSD-49.9* Plt ___
___ 02:08AM BLOOD WBC-8.2 RBC-3.22* Hgb-8.6* Hct-27.0*
MCV-84 MCH-26.7 MCHC-31.9* RDW-16.5* RDWSD-49.4* Plt ___
___ 05:30AM BLOOD WBC-5.8 RBC-3.20* Hgb-8.5* Hct-27.4*
MCV-86 MCH-26.6 MCHC-31.0* RDW-16.9* RDWSD-52.3* Plt ___
___ 06:26AM BLOOD WBC-5.9 RBC-3.38* Hgb-9.0* Hct-29.1*
MCV-86 MCH-26.6 MCHC-30.9* RDW-17.0* RDWSD-51.9* Plt ___
___ 05:10AM BLOOD WBC-7.1 RBC-3.66* Hgb-9.9* Hct-31.8*
MCV-87 MCH-27.0 MCHC-31.1* RDW-17.5* RDWSD-53.5* Plt ___
___ 05:20AM BLOOD WBC-6.6 RBC-3.69* Hgb-9.9* Hct-32.3*
MCV-88 MCH-26.8 MCHC-30.7* RDW-17.9* RDWSD-54.0* Plt ___
___ 06:20PM BLOOD ___ PTT-47.3* ___
___ 05:30AM BLOOD ___ PTT-41.6* ___
___ 06:26AM BLOOD ___
___ 05:10AM BLOOD ___
___ 05:20AM BLOOD ___
___ 06:20PM BLOOD Glucose-77 UreaN-14 Creat-0.2* Na-139
K-3.6 Cl-110* HCO3-21* AnGap-12
___ 03:30AM BLOOD Glucose-81 UreaN-11 Creat-0.2* Na-138
K-4.9 Cl-111* HCO3-20* AnGap-12
___ 02:08AM BLOOD Glucose-89 UreaN-4* Creat-0.1* Na-133
K-2.9* Cl-106 HCO3-21* AnGap-9
___ 09:30PM BLOOD Glucose-106* UreaN-3* Creat-0.2* Na-132*
K-3.8 Cl-104 HCO3-22 AnGap-10
___ 05:30AM BLOOD Glucose-80 UreaN-3* Creat-0.2* Na-136
K-3.8 Cl-105 HCO3-23 AnGap-12
___ 06:26AM BLOOD Glucose-88 UreaN-2* Creat-0.1* Na-134
K-3.1* Cl-105 HCO3-23 AnGap-9
___ 05:10AM BLOOD Glucose-101* UreaN-3* Creat-0.1* Na-134
K-4.2 Cl-104 HCO3-23 AnGap-11
___ 05:20AM BLOOD Glucose-87 UreaN-3* Creat-0.2* Na-136
K-3.8 Cl-104 HCO3-25 AnGap-11
___ 03:30AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.6
___ 02:08AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8
___ 09:30PM BLOOD Albumin-1.9* Calcium-7.7* Phos-3.1 Mg-2.1
___ 05:30AM BLOOD Calcium-7.5* Phos-3.3 Mg-2.0
___ 06:26AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.9
___ 05:10AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.2
___ 05:20AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.0
___ CT A/P
IMPRESSION:
1. Status post right hemicolectomy with a right lower quadrant
drain in
appropriate positioning with resolution of the previously
visualized fluid
collection.
2. No residual fluid collection. A small amount of free fluid
in the pelvis.
3. Mild edema of the small bowel loops and gallbladder wall are
likely due to third spacing.
4. Stable hemangioma within the liver.
5. Infrarenal IVC filter in appropriate position.
___ 10:42 pm SWAB Site: ABDOMEN ABDOMEN.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
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
in this
culture.
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. The presence of B.fragilis,
C.perfringens,
and C.septicum is being ruled out.
BACTEROIDES FRAGILIS GROUP. RARE GROWTH. BETA
LACTAMASE POSITIVE.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO DAILY16
2. Metoprolol Tartrate 25 mg PO Q6H
3. Modafinil 100 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Megestrol Acetate 400 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. Mirtazapine 15 mg PO QHS
11. TraZODone 25 mg PO QHS
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Megestrol Acetate 400 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO Q6H
5. Mirtazapine 15 mg PO QHS
6. Modafinil 100 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. TraZODone 25 mg PO QHS
11. Warfarin 5 mg PO DAILY16
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Dronabinol 2.5 mg PO BID
14. Aquaphor Ointment 1 Appl TP TID:PRN dry skin
15. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Abdominal abscess
Acute sepsis
Acute on chronic malnutrition
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with central line placement
COMPARISON: ___.
FINDINGS:
AP portable supine view of the chest. There is a right IJ central venous
catheter with its tip in the region of the mid SVC. Patient is slightly
rotated to the left. Lungs are clear. A nipple shadow projects over the
right lower lung. Cardiomediastinal silhouette appears normal. Surgical
clips and spinal hardware project over the lower neck.
IMPRESSION:
Right IJ central venous catheter tip in the mid SVC region.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with abdominal abscess // eval tubes and lines
IMPRESSION:
In comparison to ___ chest radiograph, the patient has been
intubated with endotracheal tube in standard position. Additionally, a a new
area of consolidation has developed a left retrocardiac region, and it raises
the possibility of aspiration and less likely developing infectious pneumonia.
No other relevant change.
Radiology Report
EXAMINATION: CT abdomen and pelvis with IV and oral contrast.
INDICATION: ___ year old woman with intra-abdominal abscess and sepsis s/p
flank exploration and drainage // eval for residual abdominal abscess to
consider drainage
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 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP =
6.0 mGy-cm.
2) Spiral Acquisition 4.7 s, 51.4 cm; CTDIvol = 12.6 mGy (Body) DLP = 645.0
mGy-cm.
Total DLP (Body) = 651 mGy-cm.
COMPARISON: CT abdomen and pelvis from outside hospital dated ___
FINDINGS:
LOWER CHEST: There are small bilateral nonhemorrhagic pleural effusions with
associated compressive atelectasis. No focal consolidations. No pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The hypodensity within segment VII currently measures 2.3 x 1.4
cm (series 2, image 6), shown to represent a hemangioma on the CTA dated ___. Multiple other hypodensities are too small to characterize, but
stable in size and number, likely representing cysts or biliary hamartomas.
Otherwise, liver demonstrates homogenous attenuation throughout. There is no
evidence of new focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is distended and there is
mild gallbladder wall edema, which is likely due to third spacing.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The 12 mm hypoattenuating lesion within the spleen posteriorly is
stable, likely representing a cyst. Otherwise, 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: An NG tube is seen terminating within the stomach. The
stomach is unremarkable. The small bowel loops are slightly edematous, also
likely due to third spacing. Otherwise in the small bowel loops are within
normal limits. The patient is status post right hemi colectomy.
There is a surgical ___ drain within the right lower quadrant at the site
of the prior fluid collection. There is an expected amount of air adjacent to
the drain. There is no residual fluid collection.
PELVIS: The bladder is decompressed by a Foley catheter. The small locules of
air within the bladder are expected after recent catheterization. There is a
moderate amount of nonhemorrhagic non-loculated free fluid within the pelvis.
REPRODUCTIVE ORGANS: The uterus and adnexal regions appear grossly within
normal limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted, especially at the origin of the renal arteries bilaterally.
An infrarenal IVC filter is visualized, which appears in appropriate position.
BONES: The bones are diffusely osteopenic. The sclerotic foci within the
femoral heads bilaterally likely represent bone islands. There is no evidence
of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Status post right hemicolectomy with a right lower quadrant drain in
appropriate positioning with resolution of the previously visualized fluid
collection.
2. No residual fluid collection. A small amount of free fluid in the pelvis.
3. Mild edema of the small bowel loops and gallbladder wall are likely due to
third spacing.
4. Stable hemangioma within the liver.
5. Infrarenal IVC filter in appropriate position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NGT placement // placement ngt
IMPRESSION:
In comparison to prior radiograph from earlier today, a nasogastric tube has
been placed, coiling within the esophagus, with distal tip directed cephalad.
At the time of this dictation, a separately dictated radiograph has been
subsequently performed which confirms successful repositioning. Exam is
otherwise remarkable for worsening left retrocardiac opacification.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NGT adjustment // NGT placement
IMPRESSION:
In compared to sent to the previous radiograph from earlier today, a
nasogastric tube has been repositioned, now terminating in the stomach. No
other relevant change since the prior study of approximately 1 hr earlier.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with Fistula of intestine
temperature: 97.0
heartrate: 103.0
resprate: 24.0
o2sat: 99.0
sbp: 96.0
dbp: 52.0
level of pain: 3
level of acuity: 2.0 | Briefly, Ms. ___ was admitted to ___ on ___ for
evaluation of a developing abdominal infection. She underwent a
right flank exploration with surgical drainage of an
abdominopelvic abscess on ___, please see operative note for
details. She was admitted to the ICU postoperatively for a
persistent pressor requirement and for close monitoring, please
see daily ICU notes for details. She was transferred to the
floor and her NGT placed post-operatively was removed. Her home
warfarin was restarted and she was noted to be malnourished on
clinical and laboratory exam; she was offered a PEG tube after
failing to take in adequate PO, but refused. Her home
medications were restarted when she was stable, and she had a
Foley catheter during her hospitalization secondary to
persistent post-operative labial swelling and perineal skin
irritiaton. On ___, she was found to be medically stable for
return to rehab. She was discharged in stable condition with
instructions to follow up with her PCP and in ___ clinic.
Hospital Issues
# Abdominal abscess - s/p open I&D, ___ placed ___
be removed at time of clinic visit, abx course completed
(vanc/ceftazidime).
# Malnutrition - pt appears chronically malnourished, will
require supplemental nutrition via Dobhoff vs PEG vs improved PO
intake
# Heel ulcer - Pt has chronic heel ulcers that will require
outpatient podiatry follow up for potential debridement.
# DVT - restart warfarin, INR monitoring continued |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tegaderm / Taxol / Doxil
Attending: ___.
Chief Complaint:
Evaluated ___ at 23:00
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F w/ h/o metastatic breast cancer (liver, skull, and spine
mets), s/p C1D8 eribulin, s/p recent admission for confusion
returns w/ c/o persistent confusion.
Last admitted for confusion and back pain ___. Found to
right frontal bony lesion consistent with metastasis extending
into the adjacent dura, progression of osseous metastatic
lesions in the thoracic and lumbar spine, diffuse hepatic
metastases on imaging. Since d/c, pt reports continued
confusion, reports forgetting date, slowed speech, and
difficulty finding words (sx not worsening, but also not
improving). No h/a, n/v, visual changes, f/c, falls, syncope.
Reports generalized weakness, no focal weakness. Reports
odonyphagia and mouth pain, w/ resulting limited appetite,
unclear if had any weight loss. Denies abd pain, diarrhea,
constipation, dysuria. She was seen in ___ clinic for C1D8
eribulin ___ thought to be improved somewhat in her MS.
___ ED, VS: 99.7 102 123/58 16 92%. Labs w/ neutropenia, elevated
AP/tbili, and K of 3. Was unable to void, so straight cath'd. UA
w/o evidence of UTI, CXR w/o consolidation. Received:
Aluminum-Magnesium Hydrox.-Simethicone, Lidocaine Viscous 2%,
Nystatin Oral Suspension, and Cefepime.
Currently, denies h/a, visual disturbances.
ROS: + chronic back pain (not worse than usual), chronic
parasthesias, otherwise neg.
Past Medical History:
1. BC, metastatic at dx, grade 3 IDC, ER/PR+, HER2 negative,
with left breast, bone, and mediastinal lymph node involvement,
presenting with evidence of spinal cord compression
a. Normal screening mammogram ___ BIRADS 1
b. Presented with back pain and leg weakness ___
c. ___ lumbar MRI; significant for multiple abnormalities
including infiltration of L4 resulting in a compression fracture
with retropulsion of fragments and moderately severe spinal
stenosis, and infiltration of T11 with associated deformity of
the right lateral aspect of the spinal cord.
d. ___ core biopsy of L4 vertebra; malignant cells
consistent with metastatic breast cancer.
e. ___ body CT significant for widespread skeletal
metastases, a 3cm left breast mass, and media___
lymphadenopathy. Most notably, she had multilevel vertebral
involvement including T2, T11, T7 and L4 with the suggestion of
spinal cord involvement at T2 and T11.
f. ___ left breast core biopsy; grade 3 IDC, ER/PR+, HER2
equivocal by IHC and non-amplified by FISH.
g. ___ presented to breast oncology with clinical evidence
of progressive spinal cord involvement, referred for urgent XRT
and received radiation of T10-L5.
h. ___: C7-T4 PSIF with iliac crest bone graft
i. ___: started letrozole
j. ___: L3-5 laminectomy and fusion
k. ___: started zolendronic acid, monthly schedule
l. ___: left arm numbness/tingling found new metastatic foci
involving C7, T1, T3 and T4
m. ___: XRT to spine
n. ___: Taxol x2
OTHER MEDICAL HISTORY:
2. Shingles
3. Facial basal cell skin cancers
4. Hyperlipidemia
5. Neuropathy (hands) ___ to ___
PAST SURGICAL HISTORY:
- Several laminectomies and fusions
Social History:
___
Family History:
Grandson with a malignant brain tumor, being treated at ___,
Mother lung cancer, ___ aunt breast cancer
Physical Exam:
ADMISSION
VS: T99, BP 126/67, HR 94, RR 16, O2 94 RA
Gen: appropriate, slow speech
HEENT: sclera icteric, dry mmm, OP + thrush and two white
plaques on sides of tongue (no vesicular lesions)
Neck: supple
Chest: port-a-cath w/o erythema or ttp
CV: RR, ___ SM
Pulm: sparse bl crackles, no wheeze
Abd: Soft, NT, mild dist, +BS, bulging flanks
Ext: 2+ edema
Spine: TTP in lumbar/sacral region
Neuro: Speech slow, responds to most questions appropriately
though with long pauses and forgets questions asked throughout
conversation, affect flat. Alert, oriented to self/place, has
difficulty w/ month/year though after several tries can state
the date correctly. CN ___ intact. Strength: ___ UE bl, ___+/5 on knee flex bl, ___ dorsiflexion. Gait deferred.
DISCHARGE
VS: ___ 127/70 p94 R20 95%2L-98%RA
GEN: NAD, alert and oriented x 3, slow speech, appropriate,
friendly and cooperative. Makes appropriate eye contact.
___: normal rate, regular rhythm, no murmurs, rubs, gallops
Lungs: Mildly decreased breath sounds at bases, otherwise clear
to auscltation bilaterally, no respiratory distress noted
Abd: Soft, minimal TTP diffusely, mildly distended with bulging
flanks, umbilical protrusion and tympanitic to percusion; BS+
Ext: 1+ edema around ankles, no clubbing or cyanosis.
Back: TTP in L3-5 and sacral through coccyx region; also b/l
posterior iliac crest pain w/ some radiation into hips
Neuro: CN2-12 intact, left forearm numbness, strength ___ and
symmetric UE. However ___ to biltaeral leg raise and weakness to
dorsiflexion of left foot.
Pertinent Results:
___ 07:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-6.5
LEUK-NEG
___ 03:16PM LACTATE-1.9
___ 03:00PM GLUCOSE-145* UREA N-10 CREAT-0.5 SODIUM-134
POTASSIUM-3.0* CHLORIDE-100 TOTAL CO2-27 ANION GAP-10
___ 03:00PM ALT(SGPT)-34 AST(SGOT)-66* ALK PHOS-164* TOT
BILI-4.4*
___ 03:00PM ALBUMIN-2.6*
___ 03:00PM WBC-1.3* RBC-3.23* HGB-11.2* HCT-33.6*
MCV-104* MCH-34.6* MCHC-33.2 RDW-19.0*
___ 03:00PM NEUTS-33* BANDS-2 ___ MONOS-20* EOS-0
BASOS-0 ATYPS-5* ___ MYELOS-0 NUC RBCS-1*
___ 03:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 03:00PM PLT SMR-LOW PLT COUNT-138*
CXR:
FINDINGS: Frontal and lateral views of the chest were obtained.
A
right-sided Port-A-Catheter is seen, unchanged in position,
terminating in the proximal-to-mid SVC. There are low lung
volumes with mild elevation of the right hemidiaphragm.
Crowding of bronchovascular structures is again seen without
overt pulmonary edema. Mild basilar atelectasis. No focal
consolidation. No pleural effusion or pneumothorax. Cardiac
silhouette is mildly enlarged. Mediastinal and hilar contours
are stable. Partially imaged is cervicothoracic spinal hardware
MR ___ &W/O CONTRAST Study Date of ___ 2:14 ___
FINDINGS:
MRI OF THE THORACIC SPINE:
The signal intensity in the bone marrow is heterogeneous with
multiple focal areas of high signal on T2 and low signal on T1,
there is avid enhancement with gadolinium contrast related with
bone metastatic lesions, which are more conspicuous since the
prior study at T4, T7, T9 and T11 levels. The evaluation of the
cervicothoracic spinal cord is limited due to susceptibility
artifact from fixation hardware and post-surgical changes,
grossly there is no evidence of focal or diffuse lesions
throughout the cervical or thoracic spinal cord to indicate
spinal cord edema or cord expansion. No fluid collections are
identified.
MRI OF THE LUMBAR SPINE:
Again post-surgical changes are identified from L2/L3 through
L5/S1 levels, consistent with posterior laminectomies, fixation
hardware is in place. Compression fracture, causing vertebral
plana is noted at L4 with retropulsion of the posterior wall,
causing anterior thecal sac deformity, grossly unchanged since
the prior study. Heterogeneous signal is noted in the vertebral
bodies, consistent with bone metastatic disease, grossly
unchanged since the prior study. At T11/T12 level, there is a
prominent articular joint facet hypertrophy and ligamentum
flavum thickening, impinging the thecal sac posteriorly on the
right and apparently contacting the spinal cord (image #34,
series #15 and image #16, series #4). However, this finding
appears unchanged since the prior examination. An unchanged 64
mm by 25 mm fluid collection is again seen in the surgical bed,
extending from L3 through L5/S1 levels, with no evidence of
enhancement to suggest an abscess formation. Unchanged
heterogeneous signal is noted in the sacroiliac bones related
with metastatic disease, post surgical changes are again seen on
the right iliac crest.
IMPRESSION: 1. Osseous metastatic lesions throughout the
thoracic and lumbar spine, more conspicuous and more avid in the
thoracic spine as described above, from T5 through T11 levels
with no evidence of focal or diffuse lesions throughout the
thoracic spinal cord to indicate spinal cord edema or cord
expansion.
2. Relatively stable metastatic lesions in the lumbar spine
with
post-surgical changes, consistent with laminectomies and
posterior fixation as described above.
3. Unchanged collection in the surgical bed extending from L3
through L5/S1 levels with no evidence of enhancement to suggest
an abscess formation, this collection may represent a seroma,
the possibility of a CSF fistula is also a consideration.
4. Compression fracture at the level of L4 with vertebra plana,
and unchanged retropulsion, causing anterior thecal sac
deformity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Gabapentin 400 mg PO TID
3. Morphine SR (MS ___ 45 mg PO Q12H
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Senna 1 TAB PO BID
6. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit
Oral bid
7. Ibuprofen 100-200 mg PO Q6H:PRN pain
8. Multivitamins 1 TAB PO DAILY
9. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Lorazepam 0.5 mg PO HS:PRN nausea/insomnia
12. Morphine Sulfate ___ 15 mg PO Q2-4HR pain
Every two to four hours as needed for breakthrough pain
Discharge Medications:
1. Lorazepam 0.5 mg PO Q6H:PRN nausea/insomnia
RX *lorazepam 0.5 mg 1 tablet by mouth every four (4) hours Disp
#*60 Tablet Refills:*0
2. Morphine SR (MS ___ 45 mg PO Q12H
RX *morphine [MS ___ 15 mg 3 tablet(s) by mouth every twelve
(12) hours Disp #*84 Tablet Refills:*3
3. Morphine Sulfate ___ 15 mg PO Q2H:PRN Pain
RX *morphine 15 mg 1 tablet(s) by mouth every two (2) hours Disp
#*96 Tablet Refills:*0
4. Morphine Sulfate (Concentrated Oral Soln) ___ mg SL Q1H:PRN
pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg SL every
one (1) hour Disp ___ Milliliter Refills:*2
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 400 mg PO TID
7. Ibuprofen 600 mg PO Q8H
8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Senna 1 TAB PO BID
12. Miconazole Powder 2% 1 Appl TP QID:PRN rash
RX *miconazole nitrate [Lotrimin AF] 2 % Apply to rash four
times a day Disp #*1 Bottle Refills:*0
13. FIRST-Mouthwash BLM *NF* (___)
200-25-400-40 mg/30 mL Mucous Membrane QID:PRN Mouth Pain
RX ___ [FIRST-Mouthwash ___] 400
mg-400 mg-40 mg-25 mg-200 mg/30 mL ___ mLby mouth three times
a day Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Metastatic breast cancer, recent worsening of shortness
of breath.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. A
right-sided Port-A-Catheter is seen, unchanged in position, terminating in the
proximal-to-mid SVC. There are low lung volumes with mild elevation of the
right hemidiaphragm. Crowding of bronchovascular structures is again seen
without overt pulmonary edema. Mild basilar atelectasis. No focal
consolidation. No pleural effusion or pneumothorax. Cardiac silhouette is
mildly enlarged. Mediastinal and hilar contours are stable. Partially imaged
is cervicothoracic spinal hardware.
Radiology Report
STUDY: MRI of the thoracic and lumbar spine.
CLINICAL INDICATION: History of metastatic breast carcinoma with known bony
disease on recent MRI, now with acute urinary retention, lower extremity
weakness bilaterally, evaluate for progression of metastasis.
COMPARISON: Prior MRI of the cervical, thoracic and lumbar spine dated
___.
TECHNIQUE: Pre-contrast sagittal T1, T2 and sagittal IDEAL sequences were
obtained throughout the thoracic and lumbar spine, axial T2-weighted
sequences. The T1-weighted sequences were repeated after the administration
of gadolinium contrast in axial and sagittal projections.
FINDINGS:
MRI OF THE THORACIC SPINE:
The signal intensity in the bone marrow is heterogeneous with multiple focal
areas of high signal on T2 and low signal on T1, there is avid enhancement
with gadolinium contrast related with bone metastatic lesions, which are more
conspicuous since the prior study at T4, T7, T9 and T11 levels. The
evaluation of the cervicothoracic spinal cord is limited due to susceptibility
artifact from fixation hardware and post-surgical changes, grossly there is no
evidence of focal or diffuse lesions throughout the cervical or thoracic
spinal cord to indicate spinal cord edema or cord expansion. No fluid
collections are identified.
MRI OF THE LUMBAR SPINE:
Again post-surgical changes are identified from L2/L3 through L5/S1 levels,
consistent with posterior laminectomies, fixation hardware is in place.
Compression fracture, causing vertebral plana is noted at L4 with retropulsion
of the posterior wall, causing anterior thecal sac deformity, grossly
unchanged since the prior study. Heterogeneous signal is noted in the
vertebral bodies, consistent with bone metastatic disease, grossly unchanged
since the prior study. At T11/T12 level, there is a prominent articular joint
facet hypertrophy and ligamentum flavum thickening, impinging the thecal sac
posteriorly on the right and apparently contacting the spinal cord (image #34,
series #15 and image #16, series #4). However, this finding appears unchanged
since the prior examination. An unchanged 64 mm by 25 mm fluid collection is
again seen in the surgical bed, extending from L3 through L5/S1 levels, with
no evidence of enhancement to suggest an abscess formation. Unchanged
heterogeneous signal is noted in the sacroiliac bones related with metastatic
disease, post surgical changes are again seen on the right iliac crest.
IMPRESSION: 1. Osseous metastatic lesions throughout the thoracic and lumbar
spine, more conspicuous and more avid in the thoracic spine as described
above, from T5 through T11 levels with no evidence of focal or diffuse lesions
throughout the thoracic spinal cord to indicate spinal cord edema or cord
expansion.
2. Relatively stable metastatic lesions in the lumbar spine with
post-surgical changes, consistent with laminectomies and posterior fixation as
described above.
3. Unchanged collection in the surgical bed extending from L3 through L5/S1
levels with no evidence of enhancement to suggest an abscess formation, this
collection may represent a seroma, the possibility of a CSF fistula is also a
consideration.
4. Compression fracture at the level of L4 with vertebra plana, and unchanged
retropulsion, causing anterior thecal sac deformity.
A preliminary report was provided by Dr. ___ communicated to Dr. ___
at 16:40 hours on ___, via phone call at the time of the
discovery of this finding.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: WEAK
Diagnosed with FAILURE TO THRIVE,ADULT, SECONDARY MALIG NEO BONE
temperature: 99.7
heartrate: 102.0
resprate: 16.0
o2sat: 92.0
sbp: 123.0
dbp: 58.0
level of pain: 3
level of acuity: 3.0 | Ms. ___ is a very pleasant ___ yo F with metastatic breast
cancer (spine, liver, cranium) s/p numerous chemo regimens
(letrozole, taxol, capecitabine, doxol, eribulin) and XRT with
progressive disease who has had worsening episodes of confusion
over the last few weeks. During this admission, she was in her
nadir from recent Eribulin and was treated with empiric
antibiotics for neutropenic fever. She also required a
temporary Foley for urinary retentionm. Both of these had
resolved by day of discharge.
The patient may have leptomeningeal involvement of her cancer.
LP was deferred, and patient made the decision to transition to
___ Focused Care with Home Hospice, living with her
children. The goals of care and medications were transitioned
accordingly and patient was set up for home hospice prior to
discharge in good condition, mentating and ambulating well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ativan / Amoxicillin / Bactrim / Codeine / ibuprofen / Lamictal
/ naproxen / Tetanus Toxoid,Fluid / Cephalexin / Peanuts / Sulfa
(Sulfonamide Antibiotics) / golytely / citrate of magnesia /
Lithium
Attending: ___.
Chief Complaint:
Pus in urine
Major Surgical or Invasive Procedure:
HD line placement
PICC line placement
PD catheter removal in the OR
Pigtail drain placement into pelvic abscess
History of Present Illness:
___ y/o F w/ PMH of lithium-induced ESRD on PD, hemorrhoids,
tracheal stenosis, and hypertension recently discharged on ___
after transplant surg admit for diverticulitis (treated
conservatively w/ levo flagyl), and then subsequently admitted
for UTI and treated with meropenam who presents with blood in
BM.
She went to ___, where she underwent a CT
that showed a 10x7 cm pelvic abscess (unchanged from ___, and
then receieved a dose of ertapenam, and was transferred here.
She was initally seen a ___, where a CT
scan was performed that showed a Large deep pelvic abscess
colelction without signficant chance int he size since a study
there in ___. Air is present in the bladder, which was
thought to be secondary to either a recent bladder
cathererization or a colovesicular fistula. There was also free
air described in the peritoneal cavity. At ___ she
recieved 1 gram of ertapenam.
In our ED, she was found to be without fever, chills, nausea, or
vomiting. She endorsed minimal lower abdominal pain made worse
when she bore down to urinate.
.
In the ED, initial VS were 98 76 115/65 18 95%
On transfer, 97.9 75 107/63 16 95%
Labs were notable for a dirty U/A, Na 129, Cr 8.1, Ca 8, Phos 5,
AP 471, HCT 26.1.
On arrival to the floor, she is AAOx3 and about to bite into a
sandwich.
.
10 point ros is negative except per above
Past Medical History:
-tracheostomy ___ for prolonged respiratory failure
-hyponatremic seizure following GoLytely prep ___
-ESRD for lithium toxicity on PD
-bipolar
-GERD
-HTN
-breast cancer
-diverticulosis
PAST SURGICAL HISTORY:
-parathyroidectomy with reimplantation in left arm
-left foot surgery in ___
-right knee surgery in ___
-lumpectomy for breast cancer (DCIS status post radiation
repeat mammograms were all negative
-history of tonsillectomy in the past
Social History:
___
Family History:
Mother with ovarian CA
Father with CAD
Physical Exam:
Admission Exam:
VS: 98.4 BP 100/60 HR 75 RR 18 97 % RA
GENERAL: AOx3, NAD
HEENT: MMM. no LAD. no JVD. neck supple.
HEART: RRR S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: CTAB
ABDOMEN: soft, PD catheter in place, no erythema around site,
nontender. Foley in place w/ pus in tube.
EXT: wwp, 2+ pitting edema B/L to knees, erythema on bilateral
skins
Discharge Exam:
VSS, afebrile
Gen: appears well
HEENT: OP clear MMM
Chest: Patient with HD line on right C/D/I
Lungs: CTAB
HEART: RRR, S1/S2, no m/r/g
Abd: Well healing lesions after removal of PD catheter, Pigtail
drain in lace on left with pus in tubing, mild pain at the old
PD site, soft, NT/ND
Ext: RUE with PICC in place and edematous, LUE without issues,
GU: Foley in place, draining PUS
Pertinent Results:
CBC:
___ 08:15PM BLOOD WBC-6.1 RBC-2.49* Hgb-8.3* Hct-26.1*
MCV-105* MCH-33.3* MCHC-31.7 RDW-18.1* Plt ___
___ 07:05AM BLOOD WBC-4.7 RBC-2.32* Hgb-7.6* Hct-24.4*
MCV-105* MCH-32.6* MCHC-31.0 RDW-17.9* Plt ___
___ 07:36AM BLOOD WBC-4.1 RBC-2.50* Hgb-8.5* Hct-26.5*
MCV-106* MCH-34.2* MCHC-32.3 RDW-18.3* Plt ___
___ 05:25AM BLOOD WBC-4.6 RBC-2.42* Hgb-7.9* Hct-25.8*
MCV-107* MCH-32.8* MCHC-30.8* RDW-19.4* Plt ___
___ 04:12AM BLOOD WBC-4.4 RBC-2.31* Hgb-7.8* Hct-24.9*
MCV-108* MCH-33.8* MCHC-31.4 RDW-19.4* Plt ___
Coags:
___ 07:10AM BLOOD ___ PTT-30.7 ___
___ 05:25AM BLOOD ___ PTT-33.9 ___
BMP:
___ 08:15PM BLOOD Glucose-84 UreaN-46* Creat-8.1*# Na-129*
K-3.8 Cl-91* HCO3-27 AnGap-15
___ 07:20AM BLOOD Glucose-97 UreaN-61* Creat-10.3*# Na-134
K-4.6 Cl-96 HCO3-30 AnGap-13
___ 05:57AM BLOOD Glucose-101* UreaN-80* Creat-11.9* Na-135
K-5.0 Cl-96 HCO3-27 AnGap-17
___ 05:19AM BLOOD Glucose-111* UreaN-61* Creat-8.6*# Na-134
K-5.0 Cl-97 HCO3-26 AnGap-16
___ 04:12AM BLOOD Glucose-107* UreaN-35* Creat-5.3*# Na-135
K-4.3 Cl-98 HCO3-30 AnGap-11
LFTS:
___ 08:15PM BLOOD ALT-9 AST-14 AlkPhos-471* TotBili-0.1
___ 07:20AM BLOOD ALT-7 AST-11 AlkPhos-415* TotBili-0.2
ELECTROLYTES:
___ 08:15PM BLOOD Albumin-2.6* Calcium-8.0* Phos-5.0*
Mg-1.8
___ 07:20AM BLOOD Calcium-7.4* Phos-6.2* Mg-1.8
___ 07:36AM BLOOD Calcium-8.2* Phos-5.0* Mg-2.0
___ 05:25AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.0
___ 04:12AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.1
ANEMIA LABS:
___ 07:10AM BLOOD calTIBC-94* Ferritn-1669* TRF-72*
PTH:
___ 05:25AM BLOOD PTH-777*
HEPATITIS PANEL:
___ 05:19AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 05:19AM BLOOD HCV Ab-NEGATIVE
PPD: NEGATIVE as read on ___
IMAGING:
CT GUIDED DRAINAGE: ___
CONCLUSION: Uncomplicated guided pelvic abscess drainage with
return of air and frank pus. Uncomplicated fistulagram
demonstrating connection between the abscess and the bladder. A
specific connection with the colon could not be well seen during
this examination and could be better characterized with a
water-soluble enema to further assess for connection to the
colon, if needed.
LEFT UPPER EXTREMITY DUPLEX: ___
FINDINGS: Duplex was performed on the left upper extremity
veins. Limited views of the left upper extremity arteries were
obtained. The brachial and radial arterial waveforms are
triphasic. There are no significant calcifications. The
brachial artery measures 4 mm. The radial measures 2.5mm.
There is phasic flow seen in the left subclavian vein. The line
is present in the right neck.
The left cephalic vein is patent with diameters ranging from
3.6-4.9 mm. The basilic is patent with diameters ranging from
2.9-4.2.
RUE U/S: ___
IMPRESSION: No deep vein thrombosis in right upper extremity.
.
Gastrograffin enema ___
IMPRESSION: Colon perforation, into a collection which is
drained/communicating with the pigtail catheter.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.25 mcg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluoxetine 20 mg PO DAILY
5. Lactulose 30 mL PO BID
Please hold for loose stools
6. Lithium Carbonate 150 mg PO BID
7. OLANZapine 10 mg PO BID
8. Senna 1 TAB PO BID:PRN constipation
9. Topiramate (Topamax) 25 mg PO HS
10. DIALYVITE 800 *NF* (B complex-C-folic acid-Zn) 0.8 mg Oral
Daily
11. Epoetin Alfa 40,000 U SC ___ Start: HS
12. Lorazepam 1 mg PO QHS:PRN insomina
13. Miconazole Powder 2% 1 Appl TP BID
14. OLANZapine 5 mg PO ASDIR
Please assess patient for leg tingling, restlessness and give
this additional dose. Will likely need while doing CAPD
15. Tucks Hemorrhoidal Oint 1% 1 Appl PR PR hemorrhoidal pain
16. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
17. Heparin Dwell (1000 Units/mL) 1000 UNIT DWELL UNDEFINED
Dwell to CATH Volume, each 1 liter dwell IP for fibrin
18. MetRONIDAZOLE (FLagyl) 500 mg PO TID
Q8H Duration: 14 Days
Start date ___
19. Omeprazole 20 mg PO BID
20. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Meropenem 500 mg IV Q24H Duration: 3 Weeks
RX *meropenem 500 mg infuse 500mg once daily daily Disp #*10.5
Gram Refills:*0
2. Calcitriol 0.25 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Epoetin Alfa 40,000 U SC ___
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluoxetine 20 mg PO DAILY
7. Heparin Dwell (1000 Units/mL) 1000 UNIT DWELL UNDEFINED
Dwell to CATH Volume, each 1 liter dwell IP for fibrin
8. Lithium Carbonate 150 mg PO BID
9. MetRONIDAZOLE (FLagyl) 500 mg PO TID
Q8H Duration: 14 Days
Start date ___
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*114 Tablet Refills:*0
10. OLANZapine 10 mg PO BID
11. Omeprazole 20 mg PO BID
12. Senna 1 TAB PO BID:PRN constipation
13. Topiramate (Topamax) 25 mg PO HS
14. Fluconazole 200 mg PO Q24H
RX *fluconazole [Diflucan] 200 mg 1 tablet(s) by mouth Daily
Disp #*24 Tablet Refills:*0
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
TID W/ Meals Disp #*90 Tablet Refills:*0
16. Atenolol 25 mg PO DAILY
17. DIALYVITE 800 *NF* (B complex-C-folic acid-Zn) 0.8 mg Oral
Daily
18. Lactulose 30 mL PO BID
Please hold for loose stools
19. Lorazepam 1 mg PO QHS:PRN insomina
20. Miconazole Powder 2% 1 Appl TP BID
21. OLANZapine 5 mg PO ASDIR
Please assess patient for leg tingling, restlessness and give
this additional dose. Will likely need while doing CAPD
22. Tucks Hemorrhoidal Oint 1% 1 Appl PR PR hemorrhoidal pain
23. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Pelvic abscess
Enterovesicular fistula
.
Secondary Diagnosis:
End Stage Renal Disease on Dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with pelvic abscess and likely
enterovesiculofistula, please drain pelvic abscess and evaluate for fistulous
tract.
COMPARISON: Outside CT scan of the abdomen/pelvis, ___.
PHYSICIAN: ___, MD ___, MD fellow was performed the
procedure. ___, MD, attending, was present and supervising the
entire procedure.
MEDICATIONS: Moderate sedation was provided by administering divided doses of
fentanyl total 125mcg Versed total of 2.5mg throughout the total intraservice
time of 45 minutes during which the patient's hemodynamic parameters were
continuously monitored.
PROCEDURES: CT-guided pelvic abscess drainage. CT fistulagram of pelvic
collection.
PROCEDURE DETAILS: Informed consent was obtained from the patient. She was
positioned supine. Initial CT scan was performed. This was used to localize
the area for puncture. The area was then prepped and draped in standard
sterile fashion. Local anesthesia was applied. With CT guidance, a 19-gauge
trocar needle was advanced from the patient's left lateral lower abdomen into
the perisigmoid abscess collection. A wire was then passed through the needle
to coil within the collection. Over this wire, the needle was removed and an
8 ___ ___ pigtail drain was placed. There was return of frank pus as
well as air. About 20 cc of pus and 30 cc of air was aspirated from the
cavity. We then placed a dressing and an adhesive device. We then injected
dilute contrast about 60 cc total volume into the cavity to demonstrate rapid
flow into the bladder with a large defect noted. Please see finding section
for further details. The abscess drain was left to bag for gravity drainage.
The patient left the department in stable condition without any immediate
complication.
FINDINGS: As seen on the prior study, the pre-contrast scan demonstrated air
in the bladder. There was an air- and fluid-filled collection adjacent to the
sigmoid colon, which was notably smaller at the start of the procedure than it
was during the CT scan yesterday, likely having decompressed partially into
the bladder. Small amount of abdominal ascites and pneumoperitoneum most
likely is secondary to peritoneal dialysis. Small amount of the oral contrast
previously ingested had collected in the abscess cavity prior to the procedure
as well. With contrast injection, the patient immediately felt sensation of
fluid in her bladder. CT scan after the contrast injection demonstrated
accumulation of contrast in the bladder, with a clear rent in the dome of the
bladder just right of midline. The connection between the collection and the
colon is not well seen during this examination, and may in fact be closed off
since the cavity formed. As clinically indicated, a water-soluable enema may
help to demonstrate this connection.
SPECIMENS: ___ cc was sent to microbiology for Gram stain and culture.
CONCLUSION: Uncomplicated guided pelvic abscess drainage with return of air
and frank pus. Uncomplicated fistulagram demonstrating connection between the
abscess and the bladder. A specific connection with the colon could not be
well seen during this examination and could be better characterized with a
water-soluble enema to further assess for connection to the colon, if needed.
Radiology Report
PROCEDURE: Right upper extremity PICC placement and right internal jugular
tunnelled hemodialysis line placement.
INDICATION: ___ year-old woman with ESRD on PD with intraabdominal infection
who needs HD and PICC lines.
CLINICIANS: Dr. ___ (resident), Dr. ___ (fellow), Dr.
___ (attending). Dr. ___ was present and supervising.
ANESTHESIA: For the PICC placement, local anesthesia was provided by 1%
lidocaine. For the tunnelled line placement, divided doses of 50 mcg of
fentanyl and 1 mg of Versed were administered during the total intraservice
time of 40 min during which patient's hemodynamic parameters were continuously
monitored. Local anesthesia was provided by 1% lidocaine to the dermis and 1%
lidocaine with epinephrine into the subcutaneous tissues.
RADIATION: 8 min, 51 mGy.
PROCEDURE DETAILS:
Written informed consent was obtained from the patient after explanation of
the risks, benefits, alternatives, and indications of the procedure.
The patient was transported to the angiography suite and positioned supine on
the imaging table. The right neck was prepped and draped in usual sterile
fashion. A preprocedure timeout was performed per ___ protocol.
PICC:
Using sterile technique and local anesthesia, a patent right brachial vein was
punctured under direct ultrasound guidance using a micropuncture set. Hard
copies of ultrasound images were obtained before and immediately after
establishing intravenous access. A peel-away sheath was then placed over a
guidewire, and a single lumen PICC measuring 43 cm in length was then placed
through the peel-away sheath with its tip positioned in the SVC under
fluoroscopic guidance. Position of the catheter was confirmed by a
fluoroscopic spot film of the chest. The peel-away sheath and guidewire were
then removed. The catheter was secured to the skin, flushed, and a sterile
dressing applied. The patient tolerated the procedure well. There were no
immediate complications.
TUNNELED LINE:
After anesthetizing the skin and subcutaneous tissues, a micropuncture needle
was inserted into the right internal jugular vein under ultrasound guidance.
Hard copy ultrasound images were saved for reference. A 0.018 inch nitinol
wire was advanced into the superior vena cava. After additional anesthesia, a
small ___ was made in the skin. The micropuncture needle was exchanged for a
micropuncture sheath. The inner cannula and nitinol wire were removed. A
0.035 inch J-wire was advanced into the right atrium. Appropriate
measurements were made for skin incision four fingerbreadths below the
venotomy site (19 cm tip to cuff catheter was chosen). The wire was then
advanced into the IVC. Attention was now turned to creation of subcutaneous
tunnel which was carefully planned medial enough to the subclavian line to
avoid interference. After additional local anesthesia, a 1-cm skin incision
was made. A tunneled catheter was passed from the incision to the venotomy
site with the aid of a metal tunneling device. The venotomy tract was dilated
with dilators. The peel-away sheath was passed over the wire. The wire and
inner cannula were removed, and the catheter was passed through the peel-away
sheath. The peel-away sheath was removed while the catheter was pushed into
the right atrium. This was confirmed with fluoroscopy demonstrating the
catheter tip in the right atrium. Both lumens withdrew blood and flushed
easily. The catheter was secured with 0 silk sutures. Venotomy site was
closed with a ___ Vicryl subcuticular stitch. Dry sterile dressings were
applied. No immediate post-procedure complications were noted. The patient
tolerated the procedure well.
IMPRESSION:
1. Placement of a 19 cm (tip to cuff) tunneled HD access catheter through a
right internal jugular vein approach. The tip is located in the right atrium,
and the catheter is ready for use.
2. Uncomplicated ultrasound and fluoroscopically guided single lumen PICC
placement via a right brachial venous approach. Final internal length is 43
cm, with the tip positioned in SVC. The line is ready for use.
Radiology Report
STUDY: Unilateral upper extremity venous duplex.
REASON: Preop dialysis access.
FINDINGS: Duplex was performed on the left upper extremity veins. Limited
views of the left upper extremity arteries were obtained. The brachial and
radial arterial waveforms are triphasic. There are no significant
calcifications. The brachial artery measures 4 mm. The radial measures 2.5
mm.
There is phasic flow seen in the left subclavian vein. The line is present in
the right neck.
The left cephalic vein is patent with diameters ranging from 3.6-4.9 mm. The
basilic is patent with diameters ranging from 2.9-4.2.
IMPRESSION:
Patent left cephalic and basilic veins with diameters as noted.
Radiology Report
INDICATION: PICC line right upper extremity as well as hemodialysis line on
the right. Right upper extremity swelling. Assess for deep vein thrombosis.
COMPARISON: Comparison is made to right upper extremity venous ultrasound
performed ___.
FINDINGS: Grayscale and color Doppler sonogram was performed of the right
internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins.
A PICC line was identified within the subclavian and brachial vein. Normal
compressibility, flow and augmentation noted throughout.
IMPRESSION: No deep vein thrombosis in right upper extremity.
Radiology Report
STUDY: Right upper extremity venous duplex.
REASON: Preop dialysis access.
FINDINGS: Duplex was performed of the right upper extremity veins and limited
views of the brachial and radial artery were obtained. There is phasic flow
in the subclavian vein. This is similar to the left subclavian study from
___. The cephalic and basilic veins appear patent. There is a PICC line in
the antecubital fossa. Its cephalic diameters range from 3.3-3.6 in the
forearm and from 3.3-3.7 in the upper arm. Basilic diameters range from
1.6-2.1 in the forearm and from 3.0-3.2 in the upper arm.
The brachial and radial artery had triphasic waveforms with no significant
calcifications, the brachial measures 4.3 mm, the radial measures 2.1 mm.
IMPRESSION: Patent right cephalic and basilic veins with diameters as noted
above.
Radiology Report
STUDY: Gastrografin enema.
COMPARISON: CT abdomen ___.
INDICATION: ___ woman with pelvic abscess secondary to
diverticulitis, needs water-soluble enema to rule out perforation.
FINDINGS: After rectal exam was performed, a catheter was inserted into the
rectum. Gastrografin was then instilled into the patient. Contrast was seen
filling an extraluminal collection adjacent to the colon. The pigtail
catheter was then gently hand injected with contrast, and the same area
opacified.
IMPRESSION: Colon perforation, into a collection which is
drained/communicating with the pigtail catheter.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BLOODY STOOLS/PELVIC ABCESS
Diagnosed with PERITONEAL ABSCESS, URIN TRACT INFECTION NOS
temperature: 98.0
heartrate: 76.0
resprate: 18.0
o2sat: 95.0
sbp: 115.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | ASSESSMENT & PLAN: ___ y/o F w/ PMH of lithium-induced ESRD on
PD, hemorrhoids, tracheal stenosis, and hypertension recently
discharged on ___ after transplant surg admit for
diverticulitis (treated conservatively w/ levo flagyl), and then
subsequently admitted for UTI and treated with meropenum who
presents with blood in BM, and a concerning CT scan for fistula
now s/p drain placement.
# Pelvic Abscess with enterovesicular fistula: s/p drain
placement Currently draining purulent material. Cultures with
polymicrobial infection as well as ___ albicans growing from
abscess. Per surgery, no colectomy during this hospitalization,
will need to follow up as outpatient. Her Foley continued to
drain pus and given the fistula between the abscess and the dome
of the bladder urology was consulted and they felt that the
Foley needed to stay in long term and that with the foley in
place and the pigtail drain, the fistulous tract should resolve
on its own. Given her pelvic abscess, PD was contraindicated.
An HD line was tunelled in the patient's right chest wall and
PICC line was placed on the right as well. The patient went for
surgical removal of her PD catheter and the surgical sites were
healing well at the time of discharge. For antiobiotics of her
infection, she was placed on meropenem and fluconazole. She was
also kept on PO flagyl for her c. diff and she will need to
continue the flagyl for 14 days after the last dose of her other
abx. She will have follow up with ID, Urology, Colorectal
surgery for further management of her abscess. The patient was
discharged home with her sister caring for her.
# ESRD on Dialysis: Ms. ___ was on PD on arrival, but given
her abscess PD was held. She was going to need long term
management of this abscess and so an HD line was placed and she
was started on Hemodialysis. PPD was negative and hep
serologies were sent. She tolerated HD well. PD catheter was
removed and she tolerated the procedure well without
complications. In addition, the renal team was following her
and we started sevelamer 800mg PO TID w/ meals. She otherwise
did very well from a renal standpoint. As changes in the
management of her Dialysis evolved, I constantly updated her
outpatient nephrologist so that he was up to date on the plan
upon discharge. In addition, we started vein preservation on
the LUE and mapping for possible AV fistula vs. graft was done
prior to discharge.
# RUE swelling: RUE swelling was noticed while she was in the OR
having her PD catheter removed. It was initially thought to be
___ blood pressure cuff on that arm, but it did not resolve on
arrival to the floor. She had no erythema or pain in the arm,
but given she had a PICC line and HD line on the right she was
sent for RUE dopplers that was negative for DVT. Unclear why
she was having edema and it will need to be followed in the
outpatient setting.
# UTI: Patient has a history of a fairly sensitive E. Coli in
the past, but required treatment with meropenam because of
allergies. Mixed flora in urine likely realted to fistula. See
abx and management of abscess and fistula as above.
# Guiaic Positive Stool: Patient is reported as having guiaic
positive brown stool. Etiologies include hemmorhoids, which the
patient has a known history of, as well as diverticulitis. HCT
is currently at baseline with the patient remaining
hemodynamically stable. Hct was stable throughout most of her
hospital stay.
# Hyponatremia: Patient appears to be euvolemic, could be
secondary to SIADH. Resovled without significant intervention.
# Macrocytic Anemia: At baseline. Iron studies in ___
suggest ACI.
# C. Diff: Patient was 1 day short of completing an antibiotic
course for c. dif. will continue flagyl for now given on other
abx as well. See above for plan for c. diff management.
Essentially flagyl will be continued for 14 days after
discontinuation of other abx.
# Rash: Appeared to be a fixed drug reaction. The area was
marked and despite not changing any of her medications, the rash
improved. At the time of discharge it was not present.
# PSYCH: Continued home meds:
- Fluoxetine 20 mg PO DAILY
- Lithium Carbonate 150 mg PO BID
- OLANZapine 10 mg PO BID
- Lorazepam 1 mg PO QHS:PRN insomina
- OLANZapine 5 mg PO ASDIR
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with metastatic renal cell
carcinoma, currently on Axitinib with response to therapy seen
on recent CT scan, who present to ___ with generalized
weakness and weight loss. He reports feeling more short of
breath recently with any sort of activity, worse in the past 3
days. He denies chest pain, palpitations or lightheaded
symptoms. He denies nausea, vomiting, diarrhea or constipation.
In the emergency department, initial vitals: 97.7 58 150/103 18
98%. A head CT was unremarkable.
Past Medical History:
ONCOLOGIC HISTORY:
- ___ underwent abdominal CT scan revealing a 7-cm mass
in the lower pole of the right kidney and a 3-cm lymph node near
the aorta.
- ___, he underwent radical right nephrectomy, removal of
retroperitoneal lymph node and adrenalectomy. Pathology revealed
a 7.5 cm mass that invaded into the renal capsule with gross
extension into the renal vein, clear cell renal cell carcinoma,
___ grade 2. Left retroperitoneal lymph node was consistent
with renal cell carcinoma but the right adrenal gland was
negative for metastatic disease.
- ___, he presented with acute pancreatitis treated with
IV antibiotics and workup at that time revealed a pancreatic
mass. He had three more bouts of pancreatitis and had two
unsuccessful EGD's to obtain tissue diagnosis. Interim chest CT
revealed small lung nodules. He had an EGD at ___ on ___
with pathology from the pancreatic mass confirming metastatic
renal cell carcinoma.
- ___ a head CT revealed two small masses in the
subependymal region of the left frontal horn. Brain MRI revealed
minimal enhancement and no mass effect or surrounding edema. He
was seen in consultation by Dr. ___ neuro-oncology who felt
that this did not represent metastatic renal cell carcinoma.
- ___: began IL-2 on the IL-2 Select. Follow up CT
scans at week 11 showed disease progression.
- ___: started Sutent off protocol receiving two cycles with
disease progression noted. Unfortunately he was also found to
have a mass associated with proximal cauda equina on ___ and
completed XRT.
- ___: Avastin/Torisel clinical trial. He has had multiple
complications during this trial including, n/v, fatigue,
anorexia, fever and abdominal pain. Torisel was reduced to 15 mg
IV weekly on ___. Therapy has been on hold due to need for
POC placement on ___ and tooth extraction on ___.
He was taken off of the Avastin/Torisel trail due to nephrotic
syndrome on ___ after 25 cycles of therapy.
- ___: started on pazopanib 200 mg daily and was titrated up
to 800 mg daily on ___. He had disease progression on his
scan of ___
- ___: started axitinib
OTHER PAST MEDICAL HISTORY:
BPH
Hypertension
Hypercholesterolemia
Social History:
___
Family History:
No known history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.0 BP 141/96 HR 67 RR 16 100 RA
GENERAL: alert and oriented, cachectic man, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Gait assessment deferred
Discharge:
VS: 97.5, 122/74, 74, 18, 100% RA
GENERAL: alert and oriented, cachectic man, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Gait assessment deferred
Pertinent Results:
ADMISSION LABS:
___ 05:35PM WBC-5.0 RBC-3.88* HGB-12.4* HCT-37.9* MCV-98
MCH-32.0 MCHC-32.8 RDW-17.9*
___ 05:35PM NEUTS-78.9* LYMPHS-13.8* MONOS-5.1 EOS-1.7
BASOS-0.5
___ 05:35PM PLT COUNT-225
___ 05:35PM ___ PTT-36.7* ___
___ 05:35PM T4-5.6 T3-41*
___ 05:35PM TSH-11*
___ 05:35PM ALT(SGPT)-23 AST(SGOT)-29 LD(LDH)-213 ALK
PHOS-61 TOT BILI-0.5
___ 05:35PM CALCIUM-9.2
___ 05:35PM GLUCOSE-129* UREA N-35* CREAT-2.0* SODIUM-137
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-18* ANION GAP-14
___ 07:05PM URINE MUCOUS-RARE
.
___ 07:05PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:05PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:05PM URINE HYALINE-4*
___ 07:05PM URINE MUCOUS-RARE
.
IMAGING:
___. No intracranial hemorrhage or acute territorial infarction.
2. Stable 6 mm left lateral ventricular lesion, better
characterized on previous MRIs.
___ CXR:
Known right pulmonary and pleural based metastatic lesions are
better depicted on the recent CT exam. No acute cardiopulmonary
abnormality otherwise identified. Unchanged osseous metastasis
involving the right ___ lateral rib.
___ MRI HEAD
IMPRESSION:
1. No evidence of intracranial metastatic disease. No acute
infarct or
hemorrhage.
2. Two tiny non-enhancing left lateral intraventricular
lesions, stable since ___ given the long-term stability, they
likely represent benign etiology such as subependymoma or
hamartoma.
3. Moderate global volume loss with mild sequelae of chronic
microvascular ischemic disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO HS
2. Finasteride 5 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
Hold for SBP < 100.
4. Amlodipine 5 mg PO DAILY
Hold for SBP < 100.
5. Methadone 20 mg PO BID
6. Megestrol Acetate 40 mg PO DAILY
7. Citalopram 40 mg PO DAILY
8. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Oxygen
2L nasal cannula with ambulation for saturations of 79%. Patient
recovers to 92% with 2L oxygen.
Resting room air saturation 98%
Pulse dose for portability
Dx: Metastatic renal cell carcinoma
2. Amlodipine 5 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Methadone 20 mg PO BID
6. Tamsulosin 0.4 mg PO HS
7. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
8. Megestrol Acetate 40 mg PO DAILY
9. Senna 2 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
11. Levothyroxine Sodium 12.5 mcg PO DAILY
RX *levothyroxine 25 mcg 0.5 (One half) tablet(s) by mouth once
a day Disp #*15 Tablet Refills:*0
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
13. Cyanocobalamin 250 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 250 mcg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
14. Dexamethasone 2 mg PO DAILY
RX *dexamethasone 2 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: metastatic renal cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Weakness and history of renal cell carcinoma.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: CT torso ___ and chest radiograph ___.
FINDINGS:
The heart size is normal. The aorta remains tortuous with mild aortic knob
calcifications demonstrated. Mediastinal and hilar contours are otherwise
unchanged. Left-sided Port-A-Cath tip terminates in the lower SVC, unchanged.
The pulmonary vascularity is not engorged. Known scattered right lung nodules
compatible with metastases are better seen on the prior chest CT, with the
largest nodule noted laterally in the right lower lobe measuring 5 mm. Other
pleural based metastatic lesions of the right hemithorax are better assessed
on the recent CT. No focal consolidation, left-sided pleural effusion or
pneumothorax is identified. Trace right pleural effusion appears to be
present. Destruction of the right 7th rib laterally is re- demonstrated.
IMPRESSION:
Known right pulmonary and pleural based metastatic lesions are better depicted
on the recent CT exam. No acute cardiopulmonary abnormality otherwise
identified. Unchanged osseous metastasis involving the right ___ lateral rib.
Radiology Report
HISTORY: Renal cell cancer and worsening confusion.
COMPARISON: Multiple prior exams, most recently MRI head dated of ___.
TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain
without administration of IV contrast. Coronal, sagittal, and thin slice bone
algorithm reformats were reviewed.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large territorial
infarction. The ventricles and sulci are stable in size and configuration,
consistent with age-related volume loss. 6 mm ventricular lesion along the
left frontal horn of the lateral ventricle is unchanged since ___.
A second left ventricular lesion is not appreciated via CT technique. The
basal cisterns appear patent and there is preservation of gray-white matter
differentiation.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The right ocular lens is not well
visualized. The globes are otherwise unremarkable.
IMPRESSION:
1. No intracranial hemorrhage or acute territorial infarction.
2. Stable 6 mm left lateral ventricular lesion, better characterized on
previous MRIs.
Radiology Report
HISTORY: ___ man, with renal cell carcinoma and altered mental
status. Assess for metastatic disease.
COMPARISON: Multiple prior MR head studies with the latest on ___.
TECHNIQUE: Multiplanar, multisequence T1- and T2-weighted images were
acquired through the head before and after administration of IV gadolinium
contrast. Diffusion-weighted images and ADC maps were also obtained for
evaluation.
FINDINGS: Again noted are two tiny non-enhancing intraventricular cystic
lesions in the left lateral ventricle (4:16 and 4:18), stable in appearance
since ___, likely representing benign etiology such as subependymoma or
hamartoma.
In the post-contrast MP-RAGE images, apparent small focus of enhancement is
noted at the left paracentral posterior margin of the medulla (image 900b:34).
However, there is no correlate on either the post-contrast T1 spin-echo or the
FLAIR sequence, and this is regarded as artifactual, likely related to
"wrap-around."
There is no abnormal enhancement to suggest metastasis. The ventricles and
sulci are prominent with "etat crible" appearance of the perivascular spacse,
representing moderate global volume loss with prominent central component.
There is no shift of normally midline structures. Mild confluent
periventricular and scattered subcortical T2-/FLAIR- hyperintensities are
non-specific, but likely represent sequelae of mild chronic microvascular
ischemic changes. The gray-white matter differentiation is preserved. There
is no acute infarct or hemorrhage. Major vascular flow voids are present.
There is mild mucosal thickening in the paranasal sinuses. There is a mild
rightward nasal septal deviation. The right lens is absent.
IMPRESSION:
1. No evidence of intracranial metastatic disease. No acute infarct or
hemorrhage.
2. Two tiny non-enhancing left lateral intraventricular lesions, stable since
___ given the long-term stability, they likely represent benign etiology
such as subependymoma or hamartoma.
3. Moderate global volume loss with mild sequelae of chronic microvascular
ischemic disease.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WEAK
Diagnosed with DEHYDRATION, OTHER MALAISE AND FATIGUE, RENAL & URETERAL DIS NOS, MALIG NEOPL KIDNEY
temperature: 98.8
heartrate: 83.0
resprate: 20.0
o2sat: 100.0
sbp: 122.0
dbp: 82.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ year old man with metastatic renal cell
carcinoma who presented with shortness of breath and overall
weakness, unclear etiology.
#. Fatigue/failure to thrive: Patient presented with worsening
failure to thrive and fatigue over past months. Etiology
unclear, however likely multifactorial secondary to
chemotherapy, deconditioning and hypothyroidism. It is not
clear this is related to progression of disease as his last CT
scan showed improvement in metastatic RCC. TSH elevated with
normal T4 and low T3 so patient started on levothyroxine 12.5 mg
daily. B12 was low on admission so patient was given IM
repletion while here and started on PO supplement on discharge.
Cortisol was normal. Patient was seen by palliative care and
nutrition. Nutrition recommended supplements. Dexamethasone 2 mg
daily was started per palliative care recommendations. An MRI
brain was done to rule out metastatic disease and this was
negative. Patient was gently hydrated with NS at 100 cc/hr.
Axitinib was held as this may be causing some of symptoms, could
consider restarting as outpatient. Citalopram was continued for
depression.
#. Shortness of Breath: Patietn complained of dsypnea on
exertion. Given oncology history there is concern for pulmonary
embolism; however his sats are 100% on room air and he is not
tachycardic. Hypothyroidism may be contributing. Likely he is
deconditioned from weight loss and overall decline. Exam and
chest x-ray were not not concerning for CHF or PNA. Patient
was saturating well and comfortable on room air at rest, however
desaturated with ambulation. It was difficult to assess whether
this was a true desaturation or a poor measurement. Patient was
discharged with home oxygen.
#. Metastatic RCC: Patient responding to Axitinib based on last
CT scan on ___, however functional status as declined. Pain
was adequately controlled with ___ regimen. Axitinib was held
as it may have been contributing to symptoms or overall decline.
Patient was seen by palliative care and started on
dexamethasone.
#. BPH: Continued flomax, finasteride. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Pre-syncope, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with history of HTN, pAF,
CVA, MR, CKD presenting from his PCP's office with pre-syncope.
History was taken with the assistance of the patient's wife and
two children, who are psychiatrists. The patient has reportedly
had labile blood pressures and his antihypertensives have been
adjusted. Currently, he is on carvedilol 6.25 mg BID and
amlodipine 2.5 mg, and an extra dose of 2.5 mg if his blood
pressure remains elevated in the evening. Systolic blood
pressures have been fluctuating around the 150s at home, but he
feels very weak when his BP goes below 150.
The patient emigrated from ___ in ___ of this year. Per
his
family, he has had multiple episodes of pre-syncope/syncope that
were previously evaluated in ___. A few months ago, he had
an episode of syncope at a restaurant while eating with his son.
He reportedly stopped responding, lost consciousness, and CPR
was
performed. He was taken to the hospital, and reportedly regained
consciousness and returned to his baseline.
Per report, he has been feeling weak since starting on
amlodipine
about 1 month ago. He has felt more weak in the past two days.
The weakness is in his legs. He denies any dizziness,
lightheadedeness, chest pain, palpitations, pre-syncope,
syncope,
or falls in the past few days. No fevers, chills, abdominal
pain,
nausea, vomiting, dysuria, frequency, diarrhea. Of note, he
walks
unassisted about ___ minutes per day without difficulty.
He presented to his PCP's office, where "while taking the BP
myself and starting the examination, pt became pale, did not
respond appropriately to questions and commands and had a near
syncope episode, no complete LOC observed." Per PCP notes,
patient was placed on Trendelenburg position, elevated legs,
vitals taken, about 3 min after he responded better and stated
he
felt better. Per patient's wife, he did lose consciousness for
about ___ minutes.
Past Medical History:
- Left-sided stroke with mild residual right-sided hemiparesis
- Mitral regurgitation
- Hypertension
- Atrial fibrillation
- Chronic renal failure
- BPH
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
Admission:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Oropharynx without visible lesion, erythema or exudate
CV: Heart irregular, III/VI blowing systolic murmur, no JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength tested and
grossly full and symmetric bilaterally in all limbs; no weakness
appreciated
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Pleasant, appropriate affect
Discharge:
VITALS: ___: Afebrile, BP 151/71-178/78, HR ___, RR ___,
95% on room air
GENERAL: Alert and in no apparent distress
EYES: Anicteric, EOMI
ENT: Oropharynx without visible lesion, erythema or exudate
CV: Heart irregular rhythm, normal rate, III/VI blowing systolic
murmur heard throughout
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 suprapubic fullness or tenderness to palpation. No foley
MSK: Moves all extremities, no edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, speech fluent, moves
all limbs
PSYCH: Pleasant, appropriate affect, calm, cooperative
Pertinent Results:
ON ADMISSION:
___ 12:35PM BLOOD WBC-7.2 RBC-3.75* Hgb-11.6* Hct-34.9*
MCV-93 MCH-30.9 MCHC-33.2 RDW-13.2 RDWSD-44.8 Plt ___
___ 12:35PM BLOOD Neuts-57.8 ___ Monos-7.6 Eos-6.1
Baso-0.6 Im ___ AbsNeut-4.17 AbsLymp-1.99 AbsMono-0.55
AbsEos-0.44 AbsBaso-0.04
___ 12:35PM BLOOD ___ PTT-28.7 ___
___ 12:35PM BLOOD Glucose-137* UreaN-34* Creat-2.6* Na-140
K-5.4 Cl-105 HCO3-23 AnGap-13
___ 12:35PM BLOOD cTropnT-<0.01
___ 08:00PM BLOOD cTropnT-<0.01
___ 12:35PM BLOOD Calcium-9.4 Phos-2.7 Mg-2.2
___ 12:44PM BLOOD Lactate-2.5*
___ 08:05PM BLOOD Lactate-1.4
ON DISCHARGE:
___ 06:20AM BLOOD WBC-6.7 RBC-2.80* Hgb-8.6* Hct-26.9*
MCV-96 MCH-30.7 MCHC-32.0 RDW-13.9 RDWSD-48.8* Plt ___
___ 06:20AM BLOOD Glucose-95 UreaN-37* Creat-2.5* Na-145
K-4.9 Cl-108 HCO3-27 AnGap-10
___ 07:12AM BLOOD calTIBC-259* VitB12-326 Folate-8
Ferritn-79 TRF-199*
___ 07:12AM BLOOD TSH-4.2
___ 11:00PM URINE Color-Straw Appear-Clear Sp ___
___ 11:00PM URINE Blood-MOD* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:00PM URINE RBC-4* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 11:00PM URINE AmorphX-RARE*
___ 11:11AM URINE Mucous-RARE*
MICRO:
Blood cultures x2 from ___ and x2 from ___: No growth to
date (pending)
Urine culture ___: <10,000 CFU (final)
Urine culture ___: No growth (final)
IMAGING:
CT head without contrast ___:
1. No intracranial hemorrhage. No definite acute large
territorial
infarction, although MRI is more sensitive the detection of
acute infarct.
2. Extensive encephalomalacia centered in the left parietal
lobe, likely
reflecting prior chronic infarct.
CXR ___:
No acute intrathoracic process.
TTE ___:
The left atrium is SEVERELY dilated. The right atrium is mildly
enlarged. There is normal left ventricular wall thickness with a
normal cavity size. There is suboptimal image quality to assess
regional left ventricular function. Overall left ventricular
systolic function is normal. The visually estimated left
ventricular ejection fraction is 60%. Due to severity of mitral
regurgitation, intrinsic left ventricular systolic function
likely be lower. There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus is mildly dilated with mildly
dilated ascending aorta. The aortic arch diameter is normal. 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 are mildly thickened
with mild posterior leaflet systolic prolapse. No valvular
systolic anterior motion (___) is present. There is no mitral
valve stenosis. There is an eccentric, anteriorly directed jet
of moderate [2+] mitral regurgitation. Due to the Coanda effect,
the severity of mitral regurgitation could be UNDERestimated.
The tricuspid valve leaflets are
mildly thickened. There is mild [1+] tricuspid regurgitation.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the prior TTE, mitral regurgitation appears less
prominent.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 6.25 mg PO BID
2. amLODIPine 5 mg PO DAILY
3. Warfarin 2 mg PO 2X/WEEK (___)
4. Warfarin 1 mg PO 5X/WEEK (___)
Discharge Medications:
1. cefPODOXime 200 mg oral DAILY Duration: 2 Days
Take ___ and ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth Daily Disp #*2
Tablet Refills:*0
2. Carvedilol 6.25 mg PO BID
3. HELD- Warfarin 2 mg PO 2X/WEEK (___) This medication was
held. Do not restart Warfarin until hematuria resolves and
you've discussed with your primary doctor
4. HELD- Warfarin 1 mg PO 5X/WEEK (___) This
medication was held. Do not restart Warfarin until hematuria
resolves and you've discussed with your primary doctor
5.Outpatient Lab Work
CBC around ___ to monitor for acute blood loss
anemia (D64.9). Follow up with Dr. ___ ( ___
).
Discharge Disposition:
Home
Discharge Diagnosis:
Pre-syncope
Presumed UTI
Paroxysmal atrial fibrillation
HTN
BPH
Severe mitral regurgitation
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with syncope, slow to respond// r/o bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.6 cm; CTDIvol = 48.4 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: No prior head CT available for comparison at the time of
dictation.
FINDINGS:
There is no definite acute large territorial infarction. There is extensive
encephalomalacia involving the left parietal lobe, likely reflecting prior
chronic infarct. Small chronic left cerebellar infarct is also noted.
Chronic left caudate head and left basal ganglia infarct is noted. There is
no intracranial hemorrhage. There is no mass lesion within the limitation of
an unenhanced exam. There is global parenchymal atrophy.
There is no acute fracture. Mild mucosal thickening is seen in the partially
visualized maxillary sinuses. There is diffuse thickening involving the
ethmoidal air cells. Visualized orbits are unremarkable. Mastoid air cells
are unremarkable. Nonspecific soft tissue density in the middle ear cavities
bilaterally likely represents cerumen.
IMPRESSION:
1. No intracranial hemorrhage. No definite acute large territorial
infarction, although MRI is more sensitive the detection of acute infarct.
2. Extensive encephalomalacia centered in the left parietal lobe, likely
reflecting prior chronic infarct.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with syncope// eval for pna, acute process
TECHNIQUE: AP portable chest radiograph
COMPARISON: Prior chest radiograph dated ___
FINDINGS:
The lungs are clear without focal consolidation. There is no pneumothorax.
There is no significant pulmonary edema or pleural effusion. There is mild
cardiomegaly as well as tortuosity of the descending thoracic aorta. As
before, there are minimally displaced fractures involving the right fifth and
sixth ribs. Patient is status post right shoulder arthroplasty, incompletely
evaluated on the current exam.
IMPRESSION:
No acute intrathoracic process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope, Unresponsive
Diagnosed with Syncope and collapse, Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: unable
level of acuity: 2.0 | Mr. ___ was admitted for presyncope.
#Presyncope:
Telemetry showed only rate-controlled atrial fibrillation.
Cardiology was consulted and given recent extensive cardiac
workup, they felt this episode was unlikely to be cardiac in
origin. TTE was repeated was stable. The most likely cause of
presyncope was either UTI or urinary retention. Urinalysis and
culture were unable to be performed the first day due to foley
trauma with significant hematuria.
#Hematuria, urinary retention, BPH, acute blood loss anemia:
He developed hematuria after traumatic attempts at placing Foley
in the ED. Warfarin was held and initial INR was 2.5.. Urology
was consulted and offered foley, but the patient and his family
refused citing infection risk. Upon discussion with family, it
was agreed to hold warfarin until hematuria resolves and restart
warfarin as an outpatient. The patient endorsed significant
prostate symptoms and started on Flomax but developed
orthostatic hypotension so it was stopped. PVRs improved to
150s. He was not having difficulty urinating at the time of
discharge and urine was non-bloody. Last INR was 1.4 on
___ and hemoglobin was 8.6 on discharge, down from
admission.
#Hypertension:
Amlodipine was stopped due to the patient feeling lower
extremity weakness while on it. Flomax was started for BPH but
he developed relative hypotension, so it was stopped. His BP
was noted to be labile. Due to concern that this was
contributing to presyncope, decision was made to discontinue all
blood pressure meds except for Coreg. His goal systolic blood
pressure was 140s-170s.
#Possible urinary tract infection:
Ceftriaxone were started empirically to treat for possible
urinary infection, given his urinary difficulty earlier in his
hospital course. Urine cultures were negative. He was afebrile
without leukocytosis. He was discharged on Cefpodoxime (renally
dosed) to be completed on ___, for total of 7 days.
#Transition of care issues: I spoke with Dr. ___ by phone
prior to discharge on ___ regarding plan. The patient has
follow up scheduled with his PCP and cardiologist later this
month. He was discharged with ___ services (___).
- Once hematuria has resolved, discuss restarting warfarin.
- Patient was given order for a CBC to be drawn around
___ to assess for worsening anemia.
- Recommend urology referral if persistent hematuria or
difficulty urinating.
- Consider restarting Amlodipine if HTN not adequately
controlled.
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: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
Bronchoscopy with stenting
History of Present Illness:
Ms. ___ is a ___ female with a past medical
history of stage IV NSCLC metastatic to the adrenals, who
presented to clinic with three weeks of dyspnea, cough,
weakness,
and chills.
She was directed to the ED from clinic and eventually admitted
to
the FICU due to hypoxia and hypotension requiring levophed. CT
chest was consistent with post-obstructive pneumonia. She was
started on vanc/zosyn. She required levophed for approximately
24
hours. On initial presentation she required ___ O2 and has
been
weaned to 3L NC during FICU stay. She does not use oxygen at
home. Her hypoxemia was thought to be secondary to pneumonia as
well as underlying lung cancer. She was seen by IP and on ___
underwent flex bronch/rigid bronchoscopy with
electrocautery destruction and removal of the LMS endobronchial
lesion and stent placement in LMS. Copious mucopurulent
secretions were removed from the left and right sides.
During FICU stay she was also started on a stress dose steroids
for possible adrenal insufficiency given hypotension in the
setting of adrenal metastases. FICU course also complicated by
mild hyponatremic, thought to be hypovolemic. In terms of her
metastatic lung cancer, her CT chest showed tumor necrosis and
increase in metastatic disease and lymphadenopathy. She was seen
by At___ oncology and had a long discussion regarding goals of
care. Decision was made to transition to DNR/DNI and to
discharge
on home hospice. She did wish to complete antibiotics for
pneumonia and steroids that were initiated in the FICU.
For complete past medical, social, and family history as well as
a list of home medications, please review FICU admission note.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hypercholesterolemia
Pelvic relaxation due to cystocele
Urinary, incontinence, stress female
Osteopenia
Osteoarthritis
Hypercholesterolemia
LBP (low back pain)
Rotator cuff tear
Aortic stenosis
Macular degeneration, dry
Foot deformity, bilateral
Closed patellar sleeve fracture of left knee
Essential hypertension
History of nonmelanoma skin cancer
Social History:
___
Family History:
Noncontributory to this case
Physical Exam:
DISCHARGE EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
===============
___ 06:13PM BLOOD WBC-31.0* RBC-3.46* Hgb-10.2* Hct-30.9*
MCV-89 MCH-29.5 MCHC-33.0 RDW-13.2 RDWSD-42.9 Plt ___
___ 06:13PM BLOOD Neuts-88* Bands-9* Lymphs-3* Monos-0
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-30.07*
AbsLymp-0.93* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 06:13PM BLOOD Plt Smr-NORMAL Plt ___
___ 06:13PM BLOOD Glucose-98 UreaN-16 Creat-0.5 Na-125*
K-4.2 Cl-87* HCO3-22 AnGap-16
___ 09:26AM BLOOD Calcium-7.9* Phos-4.1 Mg-1.7
___ 06:13PM BLOOD Albumin-3.0*
DISCHARGE LABS:
===============
___ 06:55AM BLOOD WBC-7.9 RBC-2.94* Hgb-8.7* Hct-26.8*
MCV-91 MCH-29.6 MCHC-32.5 RDW-13.3 RDWSD-43.9 Plt ___
___ 04:38AM BLOOD Neuts-100* Bands-0 ___ Monos-0 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-12.10* AbsLymp-0.00*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 06:55AM BLOOD Glucose-124* UreaN-19 Creat-0.5 Na-135
K-4.3 Cl-96 HCO3-26 AnGap-13
___ 04:38AM BLOOD ALT-8 AST-12 LD(LDH)-411* AlkPhos-83
TotBili-0.5
___ 06:55AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.2
IMAGING:
========
TTE ___: Mild symmetric left ventricular hypertrophy with
small biventricular cavity sizes and hyperdynamic systolic
function. Very severe aortic stenosis. Mild aortic
regurgitation. Mild to moderate mitral and tricuspid
regurgitation. Moderate pulmonary hypertension.
CT chest with Contrast ___:
1. The known right middle lobe lung mass demonstrates new
superimposed
infection evidence by a new abscess within it. New right middle
and upper
lobe pneumonia.
2. Mild interval increase in size of adrenal metastases.
3. Right IJ central venous catheter terminates in the ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 300 mg PO QHS
2. Benzonatate 100 mg PO TID
3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
4. FoLIC Acid 1 mg PO DAILY
5. Dexamethasone 4 mg PO Q12H
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Lisinopril 10 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Ferrous Sulfate 325 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
12. Cyanocobalamin 1000 mcg IM/SC 1X/WEEK (___)
Discharge Medications:
1. Hydrocortisone 30 mg PO Q8H
Taper to 20mg on ___ and 10mg on ___ and off on ___
RX *hydrocortisone 10 mg 3 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
2. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. Benzonatate 100 mg PO TID
4. Ferrous Sulfate 325 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 300 mg PO QHS
7. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
8. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
9. Lisinopril 10 mg PO DAILY
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Simvastatin 20 mg PO QPM
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non-small cell lung cancer
Adrenal Insufficiency
Post-obstructive pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fever, cough// Pneumonia
TECHNIQUE: PA and lateral views the chest
COMPARISON: Chest x-ray from ___. PET-CT from ___.
FINDINGS:
In the region of previously seen solid mass centered in the right middle lobe
is now rounded area of opacity with an air-fluid level compatible with
cavitation. There is some adjacent, more peripheral area of consolidation.
There is no pleural effusion. Lungs are otherwise clear. Cardiomediastinal
silhouette is within normal limits. Atherosclerotic calcifications noted at
the aortic arch and there is tortuosity of the thoracic aorta. High-riding
humeral heads noted bilaterally with secondary chronic changes at the distal
clavicle and acromion as seen on prior.
IMPRESSION:
Area of previously seen FDG avid rounded mass centered in the right middle
lobe now demonstrates air-fluid level compatible with cavitation. Superimposed
infection would certainly be possible. In addition, peripheral area of
consolidation could represent adjacent pneumonia.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with line placement.
TECHNIQUE: Frontal view of the chest
COMPARISON: ___ and ___ chest radiographs
___ PET-CT
FINDINGS:
Compared to 6 hours prior, there is been interval placement of a right IJ
central venous catheter with its tip projecting over the expected location of
the superior cavoatrial junction. The proximal to midportion of the catheter
follows a somewhat tortuous course. No pneumothorax or pleural effusion.
Otherwise unchanged appearance of the chest with a right middle lobe lung mass
demonstrating new cavitation and adjacent, somewhat indistinct opacities more
peripherally. Heart size is top-normal. Aortic arch calcifications are
moderate.
IMPRESSION:
1. Interval placement of a right IJ central venous catheter with its tip
projecting over the expected location of the superior cavoatrial junction.
The proximal to midportion of the central venous catheter is somewhat
tortuous, possibly within a distended superior vena cava, less likely arterial
or extravascular. Recommend assessing for blood return and correlating with a
blood gas.
2. Cavitating right middle lobe mass with new cavitation differential
considerations including necrosis or super infection with abscess formation.
3. Indistinct lateral mid to right lower lung opacities could reflect
developing pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at approximately 1:32 am,
0 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST WITH CONTRAST
INDICATION: ___ with cavitary pneumonia, would need CT scan for eval.
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 axial maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 35.0 cm; CTDIvol = 6.5 mGy (Body) DLP = 227.6
mGy-cm.
Total DLP (Body) = 228 mGy-cm.
COMPARISON: ___ PET-CT
Same day chest radiographs
FINDINGS:
HEART AND VASCULATURE: There is a small pericardial effusion. Aortic valve
calcifications are severe. Mitral annulus calcifications are severe.
Coronary artery calcifications are severe, notably involving the left anterior
descending coronary artery. The thoracic aorta is normal in caliber. Thoracic
aorta and great vessel origin calcifications are moderate. No evidence of
dissection or penetrating atherosclerotic ulcer formation. No evidence of
pulmonary embolism. Please note the segmental branches of the right middle
lobe are encased by the known mass.
AXILLA, HILA, AND MEDIASTINUM: No significant change in mediastinal
lymphadenopathy with a precarinal lymph node measuring 2.4 cm and a subcarinal
lymph node measuring 2.2 cm. A right IJ central venous catheter terminates in
the lower SVC. No mediastinal hematoma.
PLEURAL SPACES: A small right pleural effusion is new. No left pleural
effusion.
LUNGS/AIRWAYS: The known right middle lobe mass is probably minimally changed
in size, but demonstrates new necrosis with superimposed infection evidenced
by new gas and fluid within it, the largest of which measures up to 5.2 x 4.2
cm (series 2, image 35). Adjacent to this mass, there are new right middle
lobe consolidative and ground-glass opacities. There are also new, scattered
ground-glass opacities in the right upper lobe. A 4 mm left upper lobe
pulmonary nodules unchanged. There is diffuse bronchial wall thickening and
scattered subsegmental mucous impaction.
ABDOMEN: Large, heterogeneous suprarenal masses are slightly larger than 1
month prior, measuring 10.9 x 8.7 cm on the left and 10.0 x 7.2 cm on the
right, previously 10.3 x 7.9 cm and 8.8 x 6.5 cm, respectively.
BONES: No suspicious osseous abnormality is seen.? There are moderate
thoracic spine degenerative changes.
IMPRESSION:
1. The known right middle lobe lung mass demonstrates new superimposed
infection evidence by a new abscess within it. New right middle and upper
lobe pneumonia.
2. Mild interval increase in size of adrenal metastases.
3. Right IJ central venous catheter terminates in the SVC.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough, Fever
Diagnosed with Sepsis, unspecified organism, Pneumonia, unspecified organism
temperature: 99.0
heartrate: 124.0
resprate: 20.0
o2sat: 95.0
sbp: 108.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with a history of newly
diagnosed stage IV non small cell lung cancer with metastases to
the adrenals, severe aortic stenosis (area 0.8cm2), HLD, and HTN
who presented from clinic with 3 weeks of shortness of breath,
cough, weakness and was initially admitted to the ICU with
hypoxemia and hypotension, now stable after IP stenting for
post-obstructive pna and subsequently tx'ed to the floor.
# SEPTIC SHOCK
# POST-OBSTRUCTIVE PNA
# LEFT BRONCHUS LESION
The patient presented with cough, shortness of breath, and
evidence of pneumonia on CXR. She was also hypotensive d/t
septic shock and required pressors briefly in the FICU. She was
started on Vancomycin and Zosyn for post-obstructive pneumonia.
CT scan revealed an enlarged left mainstem bronchus tumor. This
was removed by interventional pulmonology via rigid bronchoscopy
in the OR on ___. A pulmonary stent was placed to maintain the
patency of the airway. The patient was given BID mucomist and
saline treatments per pulmonology recommendations. Her
breathing and pna improved significantly post-procedure. Her
abx were narrowed to PO levaquin for completion of 5 day course
on discharge.
# HYPONATREMIA
The patient was noted to hyponatremic on arrival based on the
review of baseline Atrius records that revealed a sodium level
that varied between 129-131. Her current presentation was
thought to be likely SIADH in the setting of her lung cancer,
with possible component of hypovolemia. Na stable/improved at
135 on dischare.
# METASTATIC LUNG CANCER
# GOC
A CT chest on admission showed likely tumor necrosis and slight
increase in size of suprarenal metastases, unchanged mediastinal
lymphadenopathy, and an unchanged 4mm pulmonary nodule. It also
revealed an occlusive left main stem bronchus tumor that was
removed with subsequent placement of a pulmonary stent on ___
by interventional pulmonology. On ___, the patient expressed a
desire to go home with hospice care. After goals of care
conversation with family, HCP, and Atrius oncologist it was
decided not to pursue any further tests/treatments per patient's
wishes. Pt was discharged with home hospice services.
# ADRENAL ISUFFICEINCY
Pt was started on empiric stress dose steroids in the ICU due to
hypotension and known adrenal metastases as well as recent
dexamethasone use. She was discharged to complete 2-week
hydrocortisone taper
# AORTIC STENOSIS: Severe on ___ TTE. She appeared euvolemic
on discharge.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubated on ___, Extubated to Bipap on ___
History of Present Illness:
___ h/o missed MI (no intervention, ___, demand NSTEMI (___),
COPD, rectal cancer s/p chemoradiation and LAR, synchronous
breast cancer s/p lumpectomy, p/w dyspnea
Per the pt's son, prior to admission, the patient had frequent
non-productive cough and had caught a cold that was going around
the home. She had some R sided abdominal pain, but otherwise did
not complain of any symptoms. She did not mention chest pain or
palpitations, but per the son, would be unlikely to volunteer
that information. The son also noted that she had some leg
swelling, which has since resolved. She was satting 89% at home
up until the son returned home and found her in the bathroom
satting in the ___. She was taken to ___ for preliminary
work up and then transferred to ___.
In the ED, she was noted to have wide complex tachycardia to the
200's and she received amiodarone 150mg IV, and reverted to
sinus.
In the ED,
- Initial vitals were: HR 116, BP 116/83, RR 30, 93% NIV. Tmax
100.8
- Labs notable for: WBC 16.4, Na 133, Cr 1.5. Initial VBG 7.14,
CO2 93. Repeat 7.30, CO2 49 intubated.
- Studies notable for:
CXR:
1. Standard positioning of the endotracheal and enteric tubes.
2. Mild pulmonary vascular congestion and small right pleural
effusion.
3. Patchy opacification in the right mid lung field may reflect
pneumonia.
- Patient was given:
Lasix 40 IV
Zosyn
Amiodarone 150mg IV, started on drip at 1
Of note, the patient has had frequent ___
hospitalizations
for COPD exacerbation. She does not use any nebs or home O2. Her
medication compliance at home is reportedly rather poor.
On arrival to the CCU, the patient is intubated and sedated. She
had a brief run of tachycardia to the 150's, which self
resolved.
Full review of systems cannot be obtained due to mental status
and intubation
Past Medical History:
- Breast Cancer Stage I ER/PR positive HER2 negative (hormonal
therapy) s/p L needle localized ___
- Rectal Cancer Stage IIIB(neoadjuvant chemo and radiation
completed (___). Planned for ileostomy takedown soon.
- CAD s/p MI
- HTN
- HLD
- COPD
- Alcohol use (2 drinks per day)
- Sialadenitis
- Hemorrhoids
Social History:
___
Family History:
- mother died of lung cancer
- father had prostate cancer but died of MI
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: HR 95, BP 130/65, RR 25, saO2 100% Intubation
GENERAL: Intubated, sedated, lying in bed
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL.
NECK: Supple. JVP difficult to assess.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No adventitious breath
sounds.
ABDOMEN: Soft, non-distended. No palpable hepatomegaly or
splenomegaly. Ileostomy bag in place with gas.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: ___, intubated, sedated. not responding to commands.
DISCHARGE PHYSICAL EXAM
GENERAL: Elderly appearing woman in no acute distress.
Comfortable, non-toxic.
NEURO: AAOx3. Moving all four extremities with purpose.
HEENT: NCAT. EOMI. MMM.
CARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
PULMONARY: CTAB. Breathing comfortably on room air.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused, non-edematous.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS:
___ 01:59PM BLOOD WBC-16.4* RBC-4.50 Hgb-13.5 Hct-42.1
MCV-94 MCH-30.0 MCHC-32.1 RDW-17.8* RDWSD-61.4* Plt ___
___ 01:59PM BLOOD Neuts-90.1* Lymphs-1.5* Monos-6.6
Eos-0.0* Baso-0.2 Im ___ AbsNeut-14.82* AbsLymp-0.25*
AbsMono-1.08* AbsEos-0.00* AbsBaso-0.03
___ 01:59PM BLOOD ___ PTT-25.8 ___
___ 01:59PM BLOOD Glucose-198* UreaN-33* Creat-1.5* Na-133*
K-4.4 Cl-91* HCO3-26 AnGap-16
___ 01:59PM BLOOD ___
___ 01:59PM BLOOD cTropnT-0.13*
___ 05:49PM BLOOD CK-MB-3 cTropnT-0.11*
___ 05:49PM BLOOD TotProt-6.8 Calcium-9.9 Phos-3.3 Mg-1.7
Iron-20*
___ 05:49PM BLOOD calTIBC-339 Ferritn-76 TRF-261
___ 05:49PM BLOOD TSH-1.6
___ 05:49PM BLOOD PEP-NO SPECIFI IgG-1034 IgA-191 IgM-69
IFE-NO MONOCLO
___ 02:07PM BLOOD ___ pO2-46* pCO2-93* pH-7.12*
calTCO2-32* Base XS--2
___ 03:03PM BLOOD Type-ART ___ Tidal V-350 FiO2-40
pO2-116* pCO2-49* pH-7.30* calTCO2-25 Base XS--2
Intubat-INTUBATED Vent-CONTROLLED Comment-ETT
___ 02:07PM BLOOD Lactate-2.1*
___ 02:07PM BLOOD O2 Sat-66
MICRO
-----
___ 11:22 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.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
__________________________________________________________
___ 5:46 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:03 pm Rapid Respiratory Viral Screen & Culture
Source: Nasal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
__________________________________________________________
___ 2:03 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:00 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 2:39 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ 19:39 X ___
___.
__________________________________________________________
___ 1:59 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:59 pm URINE CATHETER.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING
=======
TTE ___
The left atrial volume index is normal. No thrombus/mass is seen
in the body of the left atrium (best excluded by TEE) There is
no evidence for an atrial septal defect by 2D/color Doppler. The
right atrial pressure could
not be estimated. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is SEVERE global
left ventricular hypokinesis and relative preservation of apical
and basal inferolateral systolic function. No thrombus or mass
is seen in the left ventricle. Quantitative biplane left
ventricular ejection fraction is 23 %. Left ventricular cardiac
index is normal (>2.5 L/min/m2). No ventricular septal defect is
seen. Normal right ventricular cavity size with moderate global
free wall hypokinesis. Tricuspid annular plane systolic
excursion (TAPSE) is depressed. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. There is a normal descending aorta diameter. The aortic
valve leaflets (3) appear structurally normal. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The pulmonary artery systolic pressure
could not be estimated. There is a trivial pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and severe
global hypokinesis consistent with diffuse process. Normal right
ventricular size with free wall hypokinesis. Mild mitral
regurgitation. Compared with the prior TTE ___ , the
biventricular systolic function is now less vigorous.
DISCHARGE LABS
===============
___ 05:20AM BLOOD WBC-10.7* RBC-3.93 Hgb-11.5 Hct-35.3
MCV-90 MCH-29.3 MCHC-32.6 RDW-18.4* RDWSD-60.5* Plt ___
___ 05:20AM BLOOD Neuts-82* Bands-2 Lymphs-9* Monos-4*
Eos-1 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-8.99*
AbsLymp-0.96* AbsMono-0.43 AbsEos-0.11 AbsBaso-0.00*
___ 05:20AM BLOOD Plt Smr-NORMAL Plt ___
___ 05:20AM BLOOD Glucose-81 UreaN-39* Creat-1.2* Na-136
K-5.1 Cl-98 HCO3-26 AnGap-12
___ 05:20AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Anastrozole 1 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
RX *albuterol sulfate [Ventolin HFA] 90 mcg ___ PUFF INH q4 hrs
Disp #*1 Inhaler Refills:*0
2. Amiodarone 200 mg PO BID
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
PUFF INH twice a day Disp #*1 Disk Refills:*0
5. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 mg/24 hour apply patch to arm q24 hrs Disp #*28
Patch Refills:*0
6. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
INH daily Disp #*1 Capsule Refills:*0
7. Anastrozole 1 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
HYPERCARBIC HYPOXIC RESPIRATORY FAILURE
COMMUNITY ACQUIRED PNEUMONIA
COPD EXACERBATION
CHF EXACERBATION
WIDE COMPLEX TACHYCARDIA
ACUTE KIDNEY INJURY
TYPE 2 NSTEMI
SECONDARY DIAGNOSIS
===================
CORONARY ARTERY DISEASE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with intubation// ?ETT placement
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Endotracheal tube terminates approximately 5.5 cm from the carina. Enteric
tube courses into the stomach with tip off of the inferior borders of the
film. Heart size is borderline enlarged. Minimal atherosclerotic
calcifications are seen at the aortic arch. Mediastinal and hilar contours
are unremarkable. Mild pulmonary vascular engorgement is present. Ill-defined
patchy opacification is seen in the right midlung field, concerning for
pneumonia. A small right pleural effusion is likely present. No
pneumothorax.
IMPRESSION:
1. Standard positioning of the endotracheal and enteric tubes.
2. Mild pulmonary vascular congestion and small right pleural effusion.
3. Patchy opacification in the right mid lung field may reflect pneumonia.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with intubation// ?interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs in CTs, most recently ___.
FINDINGS:
Unchanged position of ET esophageal feeding tubes.
No pleural effusions or pneumothorax.
Heart size is top normal.
Cardiomediastinal silhouette is unremarkable.
Mild vascular congestion with mild pulmonary edema.
IMPRESSION:
No interval change compared to prior study, showing mild vascular congestion
and pulmonary edema.
Radiology Report
INDICATION: ___ year old woman with COPD, respiratory failure, intubated with
increased pressures.// Please assess for ETT placement.
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with stable interstitial prominence. Cardiomediastinal
silhouette is stable. There is no pleural effusion. No pneumothorax is seen.
The ET and NG tube are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with COPD exacerbation and intubated// interval
change interval change
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Pulmonary edema present on ___ has resolved. Heart size is now
normal. Only a small region of consolidation may be present in the lingula,
or this could be the left nipple. There are no other findings to suggest
pneumonia. No pleural abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Respiratory distress
Diagnosed with Heart failure, unspecified
temperature: nan
heartrate: 116.0
resprate: 30.0
o2sat: 93.0
sbp: 116.0
dbp: 83.0
level of pain: UTA
level of acuity: 1.0 | ___ woman with a history of CAD with prior missed MI
___, no intervention), COPD, rectal cancer s/p chemoradiation
and low anterior resection, and breast cancer s/p lumpectomy who
was initially admitted to the CCU for multifactorial respiratory
failure requiring intubation in setting of acute pulmonary
edema, pneumonia, and COPD. Course further notable for new
wide-complex tachycardia, most likely to be atrial fibrillation
with aberrancy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y.o. M with alcoholic cirrhosis
(c/b
varices, ascites, SBP - currently listed for transplant as of
___ gout, HTN, GAD, avascular necrosis of hips bilaterally
s/p right hip arthroplasty, bilateral inguinal hernia repair,
SDH
___ admitted for hyponatremia (Na 127), Tbili 7.3 and MELD
30.
___ was recently admitted to ___ about 1 week prior
to this admission. ___ presented
because of severe fatigue and mild confusion after advisement
from his outpatient physician. ___ reports being treated there
for
3 days for "low sodium" and discharged with a sodium of 124.
They
were unable to perform a paracentesis at that point as ___ had
only very mild ascites. ___ reports that his fatigue and
generalized weakness improved significantly while at ___.
Since leaving the hospital, ___ reports ~10-lb weight gain. ___
reports that they changed the doses of his diuretics but is
unable to provide the updated dosages. Since discharge ___
reports
that ___ may have mixed up his diuretics and may have been taking
furosemide in addition to torsemide and spironolactone but is
unable to definitively say what ___ was taking.
___ presented to the hospital after advisement from outpatient
hepatologist for lab abnormalities. In terms of symptomatic
complaints, ___ notes some confusion and some fatigue but not as
severe as when ___ presented to ___ reports some bright
red
blood mixed in his stool and on paper for the past ___ days. ROS
negative for fevers chills or sweats. No SOB, no chest pain. No
urinary symptoms. No abdominal pain.
In the ED initial vitals: 98.2F, HR 79, BP 172/52, RR 19, SpO2
100% RA
- Exam notable for: +mild fluid wave, soft, distended, nt. b/l
___ swollen, erythematous c/w venous stasis.
- Labs notable for:
CBC: WBC 3.3/Hgb 8.5/Plt 35
Chem10: Na 129, K 3.7, Cl 95, HCO3 20, Cr 0.6 - Mg 1.5
LFTs: ALT 53, AST 113, AP 221, Tbili 5.8, Lipase 123, Alb 3.5.
Coags: INR 2.7
- Imaging notable for:
1) RUQUS: 1. Cirrhotic liver with a 1.8 cm hypoechoic lesion in
the right hepatic lobe, new since the prior CT from ___. Findings concerning for ___.Further evaluation with
dedicated CT or MRI liver recommended.2. Mild perihepatic
ascites. 3. Splenomegaly.
- Consults: Liver rec holding diuretics, lactulose 30cc until
clear, rifaximin, infx w/u: BCx, UCx, CXR, Dx para, albumin 50g.
- Patient was given:
Lactulose 30mL, Albumin 25% 50g.
- ED Course:
Pt had bedside US w/o ascites no paracentesis was performed.
Past Medical History:
Alcohol use disorder
Alcoholic cirrhosis c/b grade 1 varies, new onset ascites, SBP
Gout
GAD
HTN
Avascular necrosis of hips bilaterally s/p hip arthroplasty on R
Bilateral inguinal hernia report
MDD
SDH (___)
Social History:
___
Family History:
Heart disease/AD/HTN in father, ___ cancer in mother, heart
disease in brother
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM
=========================
VS: 98.3 PO 155 / 73 L Lying 82 18 98 Ra
GENERAL: Chronically ill appearing male sitting up in bed in NAD
HEENT: PERRL, EOMI, no facial droop, tongue midline, no
oropharyngeal lesions, sceral icterus present
NECK: JVP not elevated. No cervical LAD.
HEART: RRR, nl S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mildly distended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing. 2+ pitting edema to mid
thigh
bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. No
asterixis.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
===========================
DISCHARGE PHYSICAL EXAM
===========================
General: Overweight gentleman, pleasant, sitting up on edge of
bed
HEENT: sclera icteric, mucous membranes moist, poor
dentition/missing some teeth.
Lungs: vesicular breath sounds, no crackles or wheezing
CV: Regular rate and rhythm, soft systolic murmur best heard at
the left lower sternal border
Abdomen: obese, soft, non-tender to palpation. Reducible
umbilical hernia.
Ext: 1+ bilateral lower extremity edema. Erythema, scaling, and
pinpoint bleeding of the skin due to scratching/edema.
Neuro: Face grossly symmetric. Moving all limbs with purpose
against gravity. No asterixis.
Skin: jaundiced. Excoriations of upper/lower extremities.
Scaling
of the lower extremities.
Pertinent Results:
========================
ADMISSION LAB RESULTS
========================
___ 03:41PM BLOOD WBC-3.3* RBC-2.37* Hgb-8.5* Hct-25.0*
MCV-106* MCH-35.9* MCHC-34.0 RDW-14.3 RDWSD-54.8* Plt Ct-35*
___ 03:41PM BLOOD Neuts-65.8 Lymphs-13.6* Monos-13.6*
Eos-5.5 Baso-0.9 Im ___ AbsNeut-2.17 AbsLymp-0.45*
AbsMono-0.45 AbsEos-0.18 AbsBaso-0.03
___ 03:41PM BLOOD ___ PTT-37.4* ___
___ 03:41PM BLOOD Glucose-135* UreaN-11 Creat-0.6 Na-129*
K-3.7 Cl-95* HCO3-20* AnGap-14
___ 03:41PM BLOOD ALT-53* AST-113* AlkPhos-221*
TotBili-5.8*
___ 03:41PM BLOOD Albumin-3.5 Calcium-8.4 Phos-2.8 Mg-1.5*
___ 03:41PM BLOOD Osmolal-264*
___ 01:21AM BLOOD AFP-9.3*
==========================
DISCHARGE LAB RESULTS
==========================
___ 07:19AM BLOOD WBC-3.1* RBC-2.39* Hgb-8.3* Hct-25.1*
MCV-105* MCH-34.7* MCHC-33.1 RDW-13.9 RDWSD-53.9* Plt Ct-36*
___ 07:19AM BLOOD ___
___ 07:19AM BLOOD Glucose-83 UreaN-19 Creat-0.7 Na-132*
K-3.0* Cl-87* HCO3-30 AnGap-15
___ 07:19AM BLOOD ALT-32 AST-77* AlkPhos-162* TotBili-5.7*
___ 07:19AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8
==========================
IMAGING AND REPORTS
==========================
RUQ ULTRASOUND ___
IMPRESSION:
1. Cirrhotic liver with a 1.8 cm hypoechoic lesion in the right
hepatic lobe, new since the prior CT from ___,
noting that the CT did not included true arterial phase.
Findings raise possibility ___. Further evaluation with
dedicated CT or MRI liver recommended.
2. Mild perihepatic ascites.
3. Splenomegaly.
CHEST X-RAY ___
IMPRESSION:
Pulmonary vascular congestion without overt edema or focal
consolidation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. Sarna Lotion 1 Appl TP DAILY:PRN itching
6. Cholestyramine 4 gm PO BID
7. Lactulose 30 mL PO TID
8. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate
9. TraZODone 100-200 mg PO QHS:PRN insomnia
10. Acetaminophen 500 mg PO DAILY
11. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
12. Torsemide 40 mg PO DAILY
13. Spironolactone 100 mg PO DAILY
14. camphor-menthol 1 0.5% topical DAILY:PRN
Discharge Medications:
1. HydrOXYzine 25 mg PO Q6H:PRN itching
RX *hydroxyzine HCl 25 mg 1 tablet(s) by mouth Every six hours
as needed Disp #*120 Tablet Refills:*0
2. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q12H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ capsule(s) by mouth Twice daily as needed
Disp #*10 Capsule Refills:*0
4. Torsemide 80 mg PO BID
RX *torsemide 20 mg 4 tablet(s) by mouth twice a day Disp #*120
Tablet Refills:*0
5. Acetaminophen 500 mg PO DAILY
6. camphor-menthol 1 0.5% topical DAILY:PRN itching
7. Cholestyramine 4 gm PO BID
8. Ciprofloxacin HCl 500 mg PO DAILY
9. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
10. FoLIC Acid 1 mg PO DAILY
11. Lactulose 30 mL PO TID
12. Multivitamins 1 TAB PO DAILY
13. Sarna Lotion 1 Appl TP DAILY:PRN itching
14. Thiamine 100 mg PO DAILY
15. TraZODone 100-200 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Hypervolemic hyponatremia
SECONDARY:
-Alcoholic liver cirrhosis
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 abdominal distention, confusion, history of cirrhosis//
Portal vein thrombosis, ascites qualification
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is a 1.7 x 1.2 x 1.8 cm
hypoechoic lesion in the right hepatic lobe, not seen on the prior CT from ___. The main portal vein is patent with hepatopetal flow. There is
mild perihepatic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 6 mm
GALLBLADDER: The gallbladder wall is thickened likely secondary to liver
disease. The gallbladder is relatively collapsed. There is no evidence of
stones or gallbladder distension.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 16.4 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 12.8 cm
Left kidney: 13.2 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with a 1.8 cm hypoechoic lesion in the right hepatic lobe,
new since the prior CT from ___, noting that the CT did not
included true arterial phase. Findings raise possibility ___. Further
evaluation with dedicated CT or MRI liver recommended.
2. Mild perihepatic ascites.
3. Splenomegaly.
Radiology Report
INDICATION: ___ with worsening mental status, concern for fluid overload//
Pneumonia, effusion, fluid overload
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear. There is no consolidation perfusion. Cardiac silhouette
is stable. There is pulmonary vascular congestion though no overt edema. No
effusion. Osseous structures are unremarkable.
IMPRESSION:
Pulmonary vascular congestion without overt edema or focal consolidation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Abn lev hormones in specimens from female genital organs
temperature: 98.2
heartrate: 79.0
resprate: 19.0
o2sat: 100.0
sbp: 172.0
dbp: 52.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old man with history of alcoholic
cirrhosis MELD 30 listed for transplant with several recent
admissions for volume overload, gout, hypertension, GAD,
bilateral avascular hip necrosis, subdural hematoma who
presented to the ED for abnormal outpatient labs (hyponatremic
to 127). This was likely due to confusion over his diuretic
regimen after recent discharge from ___ on ___.
___ was given albumin and IV lasix and serum sodium improved. ___
was discharged on a regimen of torsemide 80g BID. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics) / prochlorperazine
/ Compazine
Attending: ___.
Chief Complaint:
Hypoxia, Tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with metastatic gallbladder carcinoma
status-post gemcitabine/cisplatin and ___ (last dose
___ and recent perforated duodenal ulcer/aspiration with
aspiration PNA and bowel obstruction who is admitted from home
off of hospice with pneumonia.
Recently hospitalized from ___ at ___ for ongoing
abdominal pain. She was found to have pneumoperitoneum and
diagnosed with a perforated duodenal ulcer. Underwent an
emergent ex-lap on ___ where the ulcer was repaired with a
___ patch. Her subsequent hospital course was complicated by
slow return of bowel function, poor oral intake (requiring
NGT/TF), aspiration pneumonia (treated with vancomycin,
cefepime, and flaygl) and recurrent bowel obstruction. Given
the patient's overall poor prognosis and long hospital course, a
goals of care meeting was held on ___ with the primary team
and palliative care. During that time she expressed a wish to
focus on feeling well and to "not have to come back to
hospital." For this reason, she was made DNR/DNI discharged home
with services on hospice. Family was in agreement for hospice in
order to make the patient comfortable. Hospice care and DNR/DNI
was confirmed with the patient's granddaughter, the primary HCP
on the day prior to discharge.
Since discharge, she felt progressively short of breath, and for
this reason EMS was called. The patient daughter states that the
patient's home oxygen machine was not working, however when EMS
arrived to her home and placed her on O2 she felt much better.
Patient reports ongoing SOB, abdominal pain and vomiting since
___. This initially occured after she drank a carnation
instant breakfast. Patient denies increased abdominal pain or
distention. She has not moved her bowels since she was
discharged from the hospital despite taking a bowel regimen. She
denies any chest pain. No fevers or chills. No cough. She has
an indwelling Foley catheter since discharge.
Given that ___ ICU was full, she was transferred
to ___ for further medical care.
ED COURSE:
- Initial vitals: 0 98.9 120 115/80 30 94% RA
- Exam notable for lungs with coarse breath sounds throughout
- Labs with VBG: 7.39 / 20 / HCO3 13
- No imaging performed, but OSH imaging with LLL PNA on CTA
- Given vanco, levaquin, flagyl, 3L NS at ___
- Given 1L NS at ___ ED
- BCx taken at ___, but no U/A
- Vitals prior to transfer: 0 99.0 122 120/73 30 97% RA
Past Medical History:
___ initially presented with abdominal pain in
___. She was found to have cholecystitis and underwent
cholecystectomy. Pathology, however, showed a stage II
gallbladder cancer. She was followed by a local oncologist, who
recommended surveillance. Imaging in ___ showed new ascites,
and she was hospitalized in ___ with abdominal distention and
pain. Peritoneal cytology from ___ showed atypical
glandular cells with a staining pattern consistent with
metastatic adenocarcinoma. She initiated palliative chemotherapy
with gemcitabine/cisplatin ___ and continued on this
through ___, having received 13 cycles. CT abdomen and
pelvis at ___ ___ performed for abdominal
pain showed interval development of large complex bilateral
adnexal cysts, likely representing drop metastases, numerous
hepatic hypodensities and increase in ascites. Ms. ___
transitioned to second line chemotherapy with FOLFOX ___.
Hospitalized ___ for FTT, had paracentesis 1L. She then
transitioned to ___ per modified de Gramont due to toxicity.
PAST MEDICAL HISTORY:
- Gallbladder cancer as above.
- COPD.
- Hyperlipidemia.
- Hypertension.
- GERD.
- Vertigo.
- History of coronary artery disease. The patient is not sure if
she has ever had a heart attack. She does not have any cardiac
stents.
- Recurrent UTIs.
Social History:
___
Family History:
Notable for mother who had a history of lung cancer. She was a
heavy smoker and granddaughter who has history of cervical
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: Reviewed in Metavision
GENERAL: Alert, oriented, rigoring
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear anteriorly
CV: Tachycardic, regular rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, 2+ pitting peripheral edema
SKIN: no rashes or lesions noted
NEURO: AOx2-3, CN ___ grossly intact, MAE purposefully
DISCHARGE PHYSICAL EXAM:
=======================
VS - 98.9 124 / 78 116 16 95 % RA
General: Alert, oriented, cachectic
HEENT: MMM, EOMI
Neck: no JVD, no LAD
CV: rrr, no m/r/g
Lungs: CTAB, poor inspiratory effort
Abdomen: mild TTP in epigastric region, mildly distended, +
bowel sounds, G tube site in LUQ w/o erythema, dressing c/d/i
GU: deferred
Ext: warm and well perfused, anasarca up to abdomen
Neuro: grossly normal
Pertinent Results:
ADMISSION LABS:
==============
___ 07:00AM URINE GRANULAR-4* HYALINE-21*
___ 07:00AM URINE RBC-7* WBC-8* BACTERIA-NONE YEAST-NONE
EPI-<1
___ 07:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:00AM URINE COLOR-Red APPEAR-Hazy SP ___
___ 07:00AM ALBUMIN-2.2*
___ 07:00AM ALT(SGPT)-7 AST(SGOT)-32 ALK PHOS-118* TOT
BILI-0.3
___ 07:00AM GLUCOSE-92 UREA N-19 CREAT-1.3* SODIUM-143
POTASSIUM-3.1* CHLORIDE-114* TOTAL CO2-13* ANION GAP-19
___ 07:17AM O2 SAT-54
___ 07:17AM ___ PO2-31* PCO2-20* PH-7.39 TOTAL
CO2-13* BASE XS--10 COMMENTS-NASAL ___
___ 07:27AM LACTATE-1.4
___ 09:47AM ___ PTT-32.5 ___
___ 09:47AM ___ PTT-32.5 ___
___ 09:47AM NEUTS-93.2* LYMPHS-3.1* MONOS-2.3* EOS-0.0*
BASOS-0.1 NUC RBCS-0.6* IM ___ AbsNeut-27.42*#
AbsLymp-0.90* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.03
___ 09:47AM WBC-29.4*# RBC-2.54* HGB-6.9* HCT-21.3*
MCV-84 MCH-27.2 MCHC-32.4 RDW-25.0* RDWSD-74.3*
___ 10:14AM ___ PTT-32.6 ___
___ 10:14AM PLT COUNT-172
___ 10:14AM NEUTS-93.7* LYMPHS-2.8* MONOS-2.2* EOS-0.0*
BASOS-0.1 NUC RBCS-0.5* IM ___ AbsNeut-27.41* AbsLymp-0.82*
AbsMono-0.64 AbsEos-0.00* AbsBaso-0.03
___ 10:14AM WBC-29.3* RBC-2.31* HGB-6.3* HCT-19.3* MCV-84
MCH-27.3 MCHC-32.6 RDW-25.0* RDWSD-74.1*
___ 10:14AM ALBUMIN-2.1* CALCIUM-7.0* PHOSPHATE-2.7
MAGNESIUM-1.4*
___ 10:14AM ALT(SGPT)-6 AST(SGOT)-31 LD(LDH)-749* ALK
PHOS-68 TOT BILI-0.3
DISCHARGE LABS:
===============
___ 06:44AM BLOOD WBC-13.1* RBC-2.89* Hgb-7.9* Hct-24.3*
MCV-84 MCH-27.3 MCHC-32.5 RDW-22.4* RDWSD-67.5* Plt ___
___ 06:44AM BLOOD Glucose-97 UreaN-19 Creat-1.5* Na-146*
K-2.9* Cl-118* HCO3-15* AnGap-16
___ 06:25AM BLOOD ALT-6 AST-16 LD(___)-752* AlkPhos-73
TotBili-0.2
___ 06:44AM BLOOD Calcium-7.3* Phos-2.5* Mg-2.1
STUDIES/IMAGING:
===============
___ CXR PORTABLE
Right chest Port-A-Cath tip extends to the right atrium. A
gastric tube
extends into the stomach. Focal consolidation in the medial left
lower lung zone likely corresponds to the previously described
left lower lobe pneumonia. New patchy opacities at the right
lung base may also reflect foci of infection. No pleural
effusion or pneumothorax identified. The size the
cardiomediastinal silhouette is within normal limits.
Calcification of the aortic arch is noted.
___ KUB
Dilated loop of small bowel in the left abdomen measuring up to
3.7 cm along with several air-fluid levels, likely reflecting a
degree of partial small bowel obstruction in the setting of
extensive multiloculated ascites and peritoneal metastatic
disease.
___ CXR
Previous bilateral lower lobe pneumonia continues to resolved.
Upper lungs clear. No pleural abnormality. Heart size normal.
Nasogastric feeding tube ends in the stomach. Right jugular
central venous infusion port ends just above the superior caval
atrial junction.
MICRO:
======
___ STOOL C. difficile NEGATIVE
___ URINE CULTURE NO GROWTH
___ BLOOD CULTURE PENDING
___ BLOOD CULTURE PENDING
___ URINE CULTURE NO GROWTH
Radiology Report
INDICATION: ___ year old woman with metastatic GB cancer admitted as OSH
transfer for LLL PNA on CT. No CT report here. // ?PNA LLL
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Right chest Port-A-Cath tip extends to the right atrium. A gastric tube
extends into the stomach.
Focal consolidation in the medial left lower lung zone likely corresponds to
the previously described left lower lobe pneumonia. New patchy opacities at
the right lung base may also reflect foci of infection. No pleural effusion
or pneumothorax identified.
The size the cardiomediastinal silhouette is within normal limits.
Calcification of the aortic arch is noted.
IMPRESSION:
New bibasilar opacities likely reflect the provided clinical history of left
lower lobe pneumonia.
Radiology Report
INDICATION: ___ F with PMHx metastatic gallbladder carcinoma s/p
gemcitabine/cisplatin and ___ (last dose ___ and recent
perforated duodenal ulcer/aspiration with aspiration PNA and bowel obstruction
who is admitted from home off of hospice transfer from ___ with LLL
pneumonia. // Eval for SBO, ileus
TECHNIQUE: Supine and left lateral decubitus views of the abdomen were
obtained
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
There is mild gaseous distension of the stomach. There is a generalized
paucity of bowel gas in the right abdomen. Dilated loop of small bowel in the
left abdomen measures up to 3.7 cm, likely similar to the recent CT
abdomen/pelvis performed on ___. Several air-fluid levels are
noted.
Left lateral decubitus view shows no evidence of pneumoperitoneum.
Osseous structures are unremarkable.
Atherosclerotic calcifications are noted in the iliac vessels bilaterally.
Cholecystectomy clips are noted. A central venous catheter is partially
imaged.
IMPRESSION:
Dilated loop of small bowel in the left abdomen measuring up to 3.7 cm along
with several air-fluid levels, likely reflecting a degree of partial small
bowel obstruction in the setting of extensive multiloculated ascites and
peritoneal metastatic disease.
Radiology Report
INDICATION: ___ year old woman with metastatic gallbladder cancer, bowel
obstruction, w/ NGT placement // eval for NGT position
TECHNIQUE: Portable abdominal radiograph
COMPARISON: Abdominal radiograph ___, CT torso ___
FINDINGS:
An enteric tube extends just beyond the gastroesophageal junction, likely
within the proximal fundus. Tip of the tube is slightly obscured by motion.
There is mild gaseous distension of the stomach. Dilated small bowel loops
measuring up to 3.3 cm are partially imaged on the left, likely similar to the
prior CT abdomen/pelvis performed ___.
Assessment for free intraperitoneal air is limited on supine radiographs.
However, there was no evidence of pneumoperitoneum on the prior left lateral
decubitus film performed 2 hours earlier.
Osseous structures are unremarkable.
Atherosclerotic calcifications are noted in the iliac vessels bilaterally.
IMPRESSION:
1. Enteric tube terminates just beyond the gastroesophageal junction, likely
in the proximal fundus.
2. Partially imaged small bowel dilation, likely reflecting a component of
partial small bowel obstruction in the setting of extensive multiloculated
ascites.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with recent NGT placement // eval for NGT
position eval for NGT position
IMPRESSION:
Compared to chest radiographs ___ through ___.
Previous bilateral lower lobe pneumonia continues to resolved. Upper lungs
clear. No pleural abnormality. Heart size normal. Nasogastric feeding tube
ends in the stomach. Right jugular central venous infusion port ends just
above the superior caval atrial junction.
Radiology Report
INDICATION: ___ year old woman with metastatic gallbladder carcinoma w/ SBO
and PNA. // Palliative venting G tube for malignant obstruction
COMPARISON: CT abdomen 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 not provided. 100 mcg of fentanyl was
administered. 1 % lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: 1 mg of intravenous glucagon. 100 mcg of fentanyl
CONTRAST: 30 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 10 min, 18 mGy
PROCEDURE: 1. Placement of a 14 ___ MIC gastrostomy tube 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 tube site was prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Permanent ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. A Amplatz wire was
introduced into the stomach. A small skin incision was made along the needle
and the needle was removed.
After sequential dilation using 10, 14, 16, and 18 ___ dilators, an 18
___ peel-away sheath was placed, and a MIC gastrostomy catheter was
advanced over the wire through the peel-away sheath into position. The
catheter was secured by instilling 5 ml of dilute contrast into the balloon in
the stomach after confirming the position of the catheter with a contrast
injection. The catheter was then flushed, capped and secured with 0-silk
sutures. Sterile dressings were applied. The patient tolerated the procedure
well and there were no immediate complications.
FINDINGS:
1. Successful placement of a ___ F MIC gastrostomy tube.
IMPRESSION:
Successful placement of a ___ F MIC gastrostomy tube. The catheter should not
be used for 24 hours for feeding but can be used for drainage..
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Pneumonia, Transfer, Elevated wbc
Diagnosed with Sepsis, unspecified organism
temperature: 98.9
heartrate: 120.0
resprate: 30.0
o2sat: 94.0
sbp: 115.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ with h/o metastatic GB adenoCA with peritoneal spread c/b
recent duodenal perforation s/p surgical repair, chronic bowel
obstruction with NGT, COPD, and CAD who presents from hospice
with SOB and persistent bowel obstruction, and inability to
manage symptoms at home.
Discharged home with home hospice.
# GOC: Patient has metastatic Gallbladder adenocarcinoma and
given limited functional status, is not a candidate for systemic
therapies. She is well known to palliative care service from
her recent admission and notably on last admission patient
expressed desire to be comfortable at home. Pt was recently
discharged tp home hospice as DNR/DNI/DNH. However, patient
became short of breath prior to admission, and EMS was called.
Her code status was reversed in ED and confirmed Full Code in
the ICU with HCP present. After speaking with daughter and HCP
on initial transfer to the floor, they stated they felt like
they were "forced" into DNR/DNI status. Palliative care was
reconsulted during admission. Had family meeting with Dr
___, patient and HCP on ___. Agreed on
DNR/DNI. A palliative venting G tube was placed by ___ ___.
Patient and family agreed on discharge to home with home
hospice.
# Sepsis ___ likely HCAP/Aspiration PNA: Patient admitted with
worsened SOB, tachycardia, leukocytosis and procalcitonin > 2.
Patinet with recent prolonged hospitalization with prior
HCAP/aspiration. Unfortunately, no micro data was obtained at
OSH prior to antibiosis. CXR here on admission consistent with
LLL PNA. She also has severe ileus / obstruction and bowel
translocation is possible.
She was initially given vancomycin, ceftazidime, flagyl
(___). Vancomycin was discontinued on ___. Antibiotics
were continued through ___. Blood cultures were negative.
# Bowel obstruction: Patient admitted with abdominal distension
in the setting of known malignancy, recurrent/chronic bowel
obstruction, and anasarca. On MICU transfer to floors, patient
reporting flatus and small BMs. Her NGT was to suction during
admission. Of note, patient came in with NGT from home hospice
for nausea and pain control. Her exlap stables were removed on
___. NGT was placed to low suction and patient remained NPO. A
venting G tube was placed by ___ ___. She was started on
octreotide.
# Tachycardia: Patient initially in ICU with HR110-120s which
persisted on initial floor transfer. The etiology of this
tachycardia was attributed to malnutrition / emaciation vs
metastatic cancer vs sepsis. HR on last DC summary was
documented as 106. Because patient is immobilized with cancer,
pulmonary embolism is on the differential, however ___ & ___
CTA was negative for PE. Patient was placed on telemetry
monitoring.
# Anemia of Chronic Disease: Hb on admission 6.2 and patient
received 1U PRBCs with greater than appropriate response.
# Non Gap Metabolic Acidosis: Patient admitted with metabolic
acidosis likely secondary to PPI usage, with also starvation
ketosis. Lactate normal, only trace ketonuria. Minimal uremia.
Significant respiratory compensation with pCO2 ~20. She was
continued on mIVF D51/2NS @75.
CHRONIC ISSUES
# Gallbladder Cancer: Widely metastatic. Last chemo (palliative)
___. She received oxycodone for pain control
# COPD: On nebs
# Hypertension: Held anti-hypertensives due to sepsis
TRANSITIONAL ISSUES:
====================
- Dr ___ be palliative care oncologist
- Home with ___' ___
- CODE: full at time of transfer home, but hospice intends to
discuss w patient
- CONTACT:
Name of health care proxy: ___
___: granddaughter
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Latex / Nickel / Bacitracin / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
leg pain and swelling
Major Surgical or Invasive Procedure:
___ thigh mass biopsy
___ ORIF and mass biopsy
History of Present Illness:
Mr. ___ is a ___ male with a history of DVT and MRI
showing the left thigh tumor presents with worsening lower
extremity pain and inability to stand. Patient is a poor
historian, unable to corroborate history with wife. He reports,
over the past 2 weeks has had worsening lower extremity edema
and pain with inability to stand on his feet this morning. He
denies any chest pain or shortness of breath.
Patient was scheduled for orthopedic oncology follow-up next
week however was seen in the emergency department. Per their
report he had an MRI done that revealed a 6 x 6 x 9 mass in the
neurovascular bundle concerning for sarcoma. Patient presented
to need that showed no improvement in the DVT. Orthopedics
oncology determined that there was no acute surgical need and
recommended admission to medicine for vascular consult. In the
emergency department his vital signs are within normal limits he
was started on a heparin drip.
Past Medical History:
Prostate cancer
Hypertension
CKD
Anemia
Hip replacement
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION:
=========
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK:LLE with 3+ edema to the mid thigh. sensation intact. 2+
pulses bilaterally.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented x 2 person and president, face symmetric,
gaze conjugate with EOMI, speech fluent
PSYCH: pleasant, appropriate affect
DISCHARGE:
=========
VITALS: Afebrile and vital signs stable
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: RRR, no m/r/g. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, ND, non-tender to palpation. Bowel sounds
present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: LLE with staples with mild serosanginous drainage
surrounding incision site. Able to lift LLE against gravity,
wiggle toes. sensation intact
NEURO: Alert, oriented x 2 person and president, face symmetric,
gaze conjugate with EOMI, speech fluent
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
========================
___ 03:45PM BLOOD WBC-11.1* RBC-2.80* Hgb-9.5* Hct-29.3*
MCV-105* MCH-33.9* MCHC-32.4 RDW-13.1 RDWSD-50.2* Plt ___
___ 03:45PM BLOOD Glucose-88 UreaN-78* Creat-2.0* Na-142
K-4.5 Cl-102 HCO3-23 AnGap-17
___ 06:55AM BLOOD calTIBC-263 VitB12-802 Ferritn-264
TRF-202
___ 06:55AM BLOOD PSA-0.07
___ 09:56AM BLOOD ALT-9 AST-19 LD(LDH)-197 AlkPhos-70
TotBili-0.2
IMAGING/OTHER STUDIES:
====================
CT Torso w/o contrast ___. Partially visualized lobulated, elongated mass along the
course of the left external iliac and femoral vascular
distributions measuring 13.5 x 5.0 x 4.1 cm where seen. This
likely correlates with the left thigh mass reportedly
evaluated per outside MRI on ___, and may represent
sarcoma, malignant nerve sheath tumor, or metastasis, including
metastatic left external iliac and inguinal lymphadenopathy.
2. Multiple bilateral pulmonary nodules measuring up to 1.7 cm
are concerning for metastatic disease.
3. Ill-defined soft tissue lesions about the bilateral
glenohumeral joints are incompletely characterized but suggest
complex chronic joint effusions. If these are a clinical
concern
MR imaging may be helpful.
4. Findings consistent with moderately severe interstitial lung
disease, probably best conforming to nonspecific interstitial
pneumonitis pattern.
Early usual interstitial pneumonitis is not excluded by this
study, however.
5. Severe diverticulosis without evidence of diverticulitis.
___ DOPPLERS ___
IMPRESSION: DVT in the mid to distal portion of the left SFV.
Probable occlusion of the mid to distal portion of the left
superficial femoral artery, with probable reconstitution at
the left popliteal artery, which shows most likely high-grade
stenosis
Extensive hypoechoic complex mass in the subcutaneous tissues
tracking down the left thigh, with no obvious internal
flow. Please correlate with findings of patient's recent MRI
that
was performed for this finding.
PET ___:
1. Large, markedly FDG avid conglomerate of lymph nodes or soft
tissue extending from the left external iliac nodal station down
the course of the left common femoral vein/artery through the
left thigh becoming contiguous with a large left thigh mass
above the knee as described above. The SUV max throughout this
region is approximately 38 and spans a craniocaudal distance of
approximately 38 cm. The left femur does not demonstrate
evidence
of increased FDG avidity.
2. Extensive FDG avidity at the site of the known left proximal
tibial fracture with internal soft tissue density and SUV max of
18.0.
3. Extensive FDG avid nodular opacities throughout both lung
fields highly concerning for metastatic disease within SUV max
of
17.6.
4. Focal area of increased FDG uptake in the posterior right
pelvis adjacent to loops of small bowel without definite
anatomic
correlate on the CT and possibly representing an abnormal lymph
node or an enteric lesion with an SUV max of 7.0
5. Focus of increased FDG avidity involving the spinous process
of T10 with an SUV max 6.4, concerning for metastasis.
LABS ON DISCHARGE:
================
___ WBC-11.3 Hgb-7.0, Hct-22.2, Plt ___
___ UreaN-36 Creat-1.3 Na-140 K-4.4 Cl-110* HCO3-21
___ Iron-17*
___ calTIBC-159* VitB12-1019* Folate-15 Hapto-302*
Ferritn-541* TRF-122*
___ Ret Aut-1.8 Abs Ret-0.04
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Levothyroxine Sodium 75 mcg PO DAILY
3. lisinopril-hydrochlorothiazide ___ mg oral Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Lidocaine 5% Ointment 1 Appl TP TID
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN
Breakthrough pain OR ___ minutes prior to planned ambulation
or LLE activity
7. OxyCODONE (Immediate Release) 5 mg PO Q6H
8. Polyethylene Glycol 17 g PO DAILY
9. Ramelteon 8 mg PO QPM
Should be given 30 minutes before bedtime
10. Senna 17.2 mg PO BID
11. Apixaban 2.5 mg PO BID
12. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Sarcoma, metastatic
# Malignancy-related DVT
# Pathologic left tibial plateau fracture
# Hyperkalemia
Discharge Condition:
stable. Continuing to work with ___. Currently, 2 person assist
to chair.
Followup Instructions:
___
Radiology Report
EXAMINATION: US INTERVENTIONAL PROCEDURE
INDICATION: ___ year old man with CKD and 2 months of LLE swelling and thigh
mass wrapped about superficial fem vessels// biopsy of soft tissue
masscurrently on heparin gtt for dvt
COMPARISON: No comparison available at the time of interpretation
TECHNIQUE: Following discussion of the risks, benefits, and alternatives to
the procedure informed written patient consent was obtained.
The patient was brought to the ultrasound suite and initial limited ultrasound
was performed.
A pre-procedure timeout confirmed three patient identifiers.
Under ultrasound guidance, an appropriate spot was marked. The area was
prepared and draped in standard sterile fashion.
3 cc 1% Lidocaine was used to achieve local anesthesia. Under direct
ultrasound visualization, a 16gauge Achieve device was advanced into the
lesion. 6 passes were made with 6 cores obtained. Specimens were placed in
formalin and taken to pathology by Dr. ___ the procedure.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in stable
condition. There were no immediate complications.
FINDINGS:
There is a hypoechoic, heterogeneous 5.4 x 3.1 x 5.7 cm mass with internal
vascularity centered about the superficial femoral artery in the anteromedial
left thigh. On limited assessment, no flow was seen in the femoral vessels at
this level. No additional suspicious lesion identified, again on limited
assessment.
IMPRESSION:
Technically successful ultrasound-guided left thigh biopsy.
Radiology Report
INDICATION: ___ year old man with thigh mass concerning for sarcoma.// staging
scan. no IV contrast due to CKD, but ok for PO if helpful to better eval the
abdomen.
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis without intravenous.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.9 s, 70.9 cm; CTDIvol = 9.1 mGy (Body) DLP = 638.6
mGy-cm.
Total DLP (Body) = 639 mGy-cm.; Acquisition sequence:
1) Spiral Acquisition 10.9 s, 70.9 cm; CTDIvol = 9.1 mGy (Body) DLP = 638.6
mGy-cm.
Total DLP (Body) = 639 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. There is
moderate atherosclerotic calcification about the aortic arch and descending
thoracic aorta. The heart is normal in size. No pericardial effusion. There
are mild scattered coronary artery calcifications. Mild aortic valvular and
moderate mitral annular calcifications.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is mild biapical pleuroparenchymal scarring. Subpleural
reticular opacities within the bilateral mid to lower lobes are bilateral,
mostly symmetric, and involve all lobes. These include peripheral small lung
cysts including partial single layer of small ones in the extreme lung bases.
There are multiple bilateral lower lobe predominant nodules measuring up to
1.7 cm on the right (4:226) and 1.3 cm on the left (4:180). No focal
consolidations are seen. The airways are patent to the level of the segmental
bronchi bilaterally. There is mild traction bronchiectasis in the right
middle lobe, lingula, and bilateral lower lobes, likely due to architectural
distortion from subpleural opacities.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion within the limitations of unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is contracted but otherwise within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
pancreatic ductal dilatation or focal lesions within the limitations of an
unenhanced scan. 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. A simple cyst
measuring 1.8 cm is seen within the interpolar region of the left kidney. No
concerning focal lesions are seen within the lower kidneys within the
limitations of unenhanced scan. There is no hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Evaluation of the small and
large bowel within the right lower quadrant and pelvis is limited due to right
hip arthroplasty associated streak artifact. Visualized small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout.
Severe diverticulosis of the sigmoid colon is noted, without evidence of wall
thickening and fat stranding. The appendix is normal.
There is no free fluid or free air in the abdomen.
PELVIS:
Bladder is not seen due to streak artifact from hip arthroplasty. There is no
definite free fluid in the pelvis.
REPRODUCTIVE ORGANS: Fiducial markers are seen within the prostate.
LYMPH NODES: In the left inguinal region, there is a lobulated, elongated mass
along the course of the left external iliac and proximal femoral arteries
which is partially visualized but measures at least 5.0 x 4.1 x 13.5 cm (AP by
___ by CC). This could represent confluent lymphadenopathy or mass obscuring
the lymph nodes. This multiloculated conglomerate mass extends as high is the
distal left external iliac chain. Elsewhere, there is no retroperitoneal or
mesenteric lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted.
BONES: Status post right total hip arthroplasty. Streak artifact from
arthroplasty hardware severely limits evaluation of the adjacent bone and
pelvic structures. There is mild dextroconvex curvature of the upper lumbar
spine. No acute fracture is seen. Subtle sclerosis of the left femoral head
and left humeral head is nonspecific, but could suggest avascular necrosis.
No associated osseous collapse.
SOFT TISSUES: About the bilateral glenohumeral joints, there are ill-defined
soft tissue lesions measuring 7.2 x 3.2 x 4.5 cm on the right (04:46) and 6.7
x 5.7 x 5.3 cm on the left (04:44).
IMPRESSION:
1. Partially visualized lobulated, elongated mass along the course of the left
external iliac and femoral vascular distributions measuring 13.5 x 5.0 x 4.1
cm where seen. This likely correlates with the left thigh mass reportedly
evaluated per outside MRI on ___, and may represent sarcoma, malignant
nerve sheath tumor, or metastasis, including metastatic left external iliac
and inguinal lymphadenopathy.
2. Multiple bilateral pulmonary nodules measuring up to 1.7 cm are concerning
for metastatic disease.
3. Ill-defined soft tissue lesions about the bilateral glenohumeral joints are
incompletely characterized but suggest complex chronic joint effusions. If
these are a clinical concern MR imaging may be helpful.
4. Findings consistent with moderately severe interstitial lung disease,
probably best conforming to nonspecific interstitial pneumonitis pattern.
Early usual interstitial pneumonitis is not excluded by this study, however.
5. Severe diverticulosis without evidence of diverticulitis.
Radiology Report
INDICATION: ___ year old man with thigh mass concerning for sarcoma.// staging
scan. no IV contrast due to CKD, but ok for PO if helpful to better eval the
abdomen.
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis without intravenous.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.9 s, 70.9 cm; CTDIvol = 9.1 mGy (Body) DLP = 638.6
mGy-cm.
Total DLP (Body) = 639 mGy-cm.; Acquisition sequence:
1) Spiral Acquisition 10.9 s, 70.9 cm; CTDIvol = 9.1 mGy (Body) DLP = 638.6
mGy-cm.
Total DLP (Body) = 639 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. There is
moderate atherosclerotic calcification about the aortic arch and descending
thoracic aorta. The heart is normal in size. No pericardial effusion. There
are mild scattered coronary artery calcifications. Mild aortic valvular and
moderate mitral annular calcifications.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is mild biapical pleuroparenchymal scarring. Subpleural
reticular opacities within the bilateral mid to lower lobes are bilateral,
mostly symmetric, and involve all lobes. These include peripheral small lung
cysts including partial single layer of small ones in the extreme lung bases.
There are multiple bilateral lower lobe predominant nodules measuring up to
1.7 cm on the right (4:226) and 1.3 cm on the left (4:180). No focal
consolidations are seen. The airways are patent to the level of the segmental
bronchi bilaterally. There is mild traction bronchiectasis in the right
middle lobe, lingula, and bilateral lower lobes, likely due to architectural
distortion from subpleural opacities.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion within the limitations of unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is contracted but otherwise within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
pancreatic ductal dilatation or focal lesions within the limitations of an
unenhanced scan. 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. A simple cyst
measuring 1.8 cm is seen within the interpolar region of the left kidney. No
concerning focal lesions are seen within the lower kidneys within the
limitations of unenhanced scan. There is no hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Evaluation of the small and
large bowel within the right lower quadrant and pelvis is limited due to right
hip arthroplasty associated streak artifact. Visualized small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout.
Severe diverticulosis of the sigmoid colon is noted, without evidence of wall
thickening and fat stranding. The appendix is normal.
There is no free fluid or free air in the abdomen.
PELVIS:
Bladder is not seen due to streak artifact from hip arthroplasty. There is no
definite free fluid in the pelvis.
REPRODUCTIVE ORGANS: Fiducial markers are seen within the prostate.
LYMPH NODES: In the left inguinal region, there is a lobulated, elongated mass
along the course of the left external iliac and proximal femoral arteries
which is partially visualized but measures at least 5.0 x 4.1 x 13.5 cm (AP by
___ by CC). This could represent confluent lymphadenopathy or mass obscuring
the lymph nodes. This multiloculated conglomerate mass extends as high is the
distal left external iliac chain. Elsewhere, there is no retroperitoneal or
mesenteric lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted.
BONES: Status post right total hip arthroplasty. Streak artifact from
arthroplasty hardware severely limits evaluation of the adjacent bone and
pelvic structures. There is mild dextroconvex curvature of the upper lumbar
spine. No acute fracture is seen. Subtle sclerosis of the left femoral head
and left humeral head is nonspecific, but could suggest avascular necrosis.
No associated osseous collapse.
SOFT TISSUES: About the bilateral glenohumeral joints, there are ill-defined
soft tissue lesions measuring 7.2 x 3.2 x 4.5 cm on the right (04:46) and 6.7
x 5.7 x 5.3 cm on the left (04:44).
IMPRESSION:
1. Partially visualized lobulated, elongated mass along the course of the left
external iliac and femoral vascular distributions measuring 13.5 x 5.0 x 4.1
cm where seen. This likely correlates with the left thigh mass reportedly
evaluated per outside MRI on ___, and may represent sarcoma, malignant
nerve sheath tumor, or metastasis, including metastatic left external iliac
and inguinal lymphadenopathy.
2. Multiple bilateral pulmonary nodules measuring up to 1.7 cm are concerning
for metastatic disease.
3. Ill-defined soft tissue lesions about the bilateral glenohumeral joints are
incompletely characterized but suggest complex chronic joint effusions. If
these are a clinical concern MR imaging may be helpful.
4. Findings consistent with moderately severe interstitial lung disease,
probably best conforming to nonspecific interstitial pneumonitis pattern.
Early usual interstitial pneumonitis is not excluded by this study, however.
5. Severe diverticulosis without evidence of diverticulitis.
Radiology Report
EXAMINATION: Ultrasound-guided biopsy
INDICATION: ___ year old man with large left thigh and left inguinal mass. DDx
includes sarcoma, neural sheath tumor, melanoma, other metastasis. Has
undergone core biopsy that revealed mostly necrotic tissue and was
non-diagnostic (final path report pending). Ortho-Oncology advising biopsy of
the left inguinal lymph node mass.// Please biopsy left inguinal lymph
node/mass? etiology of left thigh and left inguinal mass
COMPARISON: CT abdomen and pelvis dated ___.
PROCEDURE: Ultrasound-guided left inguinal mass 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 supine position on the US scan table. Limited
preprocedure ultrasound of the left groin 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. 10 cc of 1%
lidocaine were administered to the subcutaneous and deep tissues for local
anesthetic effect. Under continuous ultrasound guidance, an 16 gauge core
biopsy device with a 22 mm throw was used to obtain five core biopsy
specimens, which were sent per lymphoma protocol.
The procedure was tolerated well and there were no immediate post-procedural
complications.
SEDATION: None.
FINDINGS:
A heterogeneous, hypoechoic mass in the left groin was identified partially
encasing the femoral vessels, with dominant portion measuring approximately
3.3 x 4.9 x 2.6 cm, and was targeted for biopsy. There were no immediate
postprocedure complications.
IMPRESSION:
Technically successful ultrasound-guided left inguinal mass biopsy.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) LEFT; TIB/FIB (AP AND LAT) LEFT
INDICATION: ___ year old man with left thigh mass, associated DVT, here with
ongoing severe pain from the left knee down to the foot.// ? evidence for
bone/joint etiology of his pain
TECHNIQUE: Two radiographs of the left knee.
4 radiographs of the left tibia-fibula and ankle.
COMPARISON: None.
FINDINGS:
There is a transverse lucency in the proximal tibial diaphysis, concerning for
nondisplaced insufficiency fracture.There is a mildly permeative appearance in
that region on background osteopeniajoint spaces are grossly preserved. Ankle
mortise is symmetric and the talar dome is intact.Small plantar calcaneal
enthesophyte. Minimal vascular calcifications.
IMPRESSION:
Findings concerning for nondisplaced insufficiency or pathologic fracture of
the proximal tibial diaphysis. Underlying osseous lesion is not excluded,
given permeative appearance and MRI is recommended.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 4:14 pm, 10 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT
INDICATION: Intraoperative radiographs for left proximal tibia curettage and
internal fixation.
TECHNIQUE: Frontal and lateral view radiographs of left proximal tibia
COMPARISON: Knee radiographs from ___
FINDINGS:
Plate and screw fixation of the left proximal tibia with round radiodensity
projected within the left proximal tibia consistent with bone-cement.
Adjacent undisplaced pathologic fracture is again seen.
See operative note for further details.
Total fluoroscopic time: 14.7 s
IMPRESSION:
Intraoperative radiograph demonstrating bone-cement and internal-fixation of
the left proximal tibial pathologic fracture.
Radiology Report
INDICATION: ORIF left tibial fracture.
COMPARISON: ___
IMPRESSION:
There has been curettage and packing of a lesion within the left proximal
tibia. There has been placement of a medial fracture plate and associated
screws. The total intra service fluoroscopic time was 14.7 seconds. Please
refer to the operative note for additional details.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DVT, Transfer
Diagnosed with Acute embolism and thrombosis of left femoral vein
temperature: 97.6
heartrate: 82.0
resprate: 18.0
o2sat: 99.0
sbp: 140.0
dbp: 70.0
level of pain: 1
level of acuity: 2.0 | Mr. ___ is a ___ male with history of remote prostate
Ca, HTN, and CKD who presents with worsening LLE swelling in the
context of SFA DVT secondary to compressive left thigh mass that
failed to improve with outpatient apixaban.
# Left lower leg edema and pain, secondary to:
# Left SFA DVT
--Recently diagnosed with SFA DVT approximately two weeks
ago and started on apixaban. DVT likely secondary to local vein
compression by thigh mass (as detailed below). Repeat U/S
without essentially unchanged size of clot. Per heme, likely
does not represent clot failure, though preference for lovenox
at this time rather than resumption of apixaban. Patient started
on lovenox 60mg BID (slightly dose reduced for CKD). He then he
developed hyperkalemia, so decision was made by Heme to switch
back to apixaban, which he tolerated well. He was transitioned
to a heparin gtt in anticipation of surgery as below and then
restarted on apixaban 2.5 mg BID post-procedurally.
# Left tibial plateau fracture
--Continued to have severe left lower leg pain, worse with
bearing weight, despite therapeutic anticoagulation and
increasing multi-modal pain medication regimen, prompting
further imaging of the leg. X-rays of the leg showed a
non-displaced left tibial plateau fracture which most likely
pathologic and not traumatic. Knee immobilizer placed for
comfort. Given inability to bear weight due to pain and risk of
worsening fracture limiting quality of life, ortho-onc
recommended limited surgery to stabilize knee which was done on
___, which patient tolerated well. Intraoperative biopsies
taken were pending at time of discharge, but preliminary
pathology report suggestive of high grade sarcoma, as previously
suspected.
# Thigh mass:
# Metastatic sarcoma:
# Goals of care:
Recent MRI demonstrated large soft tissue mass in the left thigh
encircling the superficial femoral vessels with associated
femoral vein thrombosis (as above) with radiographic features
highly concerning for sarcoma. S/p biopsy on ___ and staging CT
on ___ that demonstrated lung nodules. First biopsy results
were non-diagnostic due to majority of cells being necrotic.
Another biopsy was performed, this time of the enlarged left
inguinal lymph node (rather than the thigh mass itself), and the
results showed likely sarcoma (final stains pending). PET-CT was
performed and revealed known disease in thigh/along vessels up
to iliac and pulmonary nodules as well as possible small focus
in spine. He was seen by oncology who recommended against
chemotherapy. He was evaluated by radiation oncology who said
they would continue to follow his course and consider palliative
radiation therapy depending upon the final pathology results,
with radiation commencing no sooner than 2 weeks following his
orthopedic surgery (i.e. no sooner than ___. After
discussion with palliative care, he was transitioned to DNR/DNI.
# Hyperkalemia: developed while on heparin/LMWH despite holding
his home lisinopril -HCTZ. Improved initially w/ stopping
heparin/LMWH, then worsened again, suspect from lack of bowel
movements. Improved after bowel regimen produced multiple BMs.
# Constipation: likely multifactorial from opioids, pain, and
lack of mobility from severe LLE pain. Improved with aggressive
bowel regimen.
I spent > 30 minutes of time on discharge planning and in face
to face encounter with patient and family
TRANSITIONAL ISSUES:
====================
[ ] Intraoperative biopsies from ___ suggestive of high grade
sarcoma. Finalized path expected ___. Pt will need hemonc
follow up and radiation oncology follow up for palliative
radiation therapy planning. Appointments pending at time of
discharge
[ ] Pt underwent ORIF on ___ with ortho oncology which he
tolerated well. He is scheduled for follow up in their clinic
for post operative check and staple removal
[ ] Post operative pain controlled with oxycodone 10 mg q6h at
first. Down titrated to 5 mg q6h on ___ as pain better
controlled. Continue to adjust pain meds as needed
[ ] Please continue apixaban 2.5 mg BID for recently diagnosed
LLE DVT
[ ] Patient found to be anemic to 7.1 on ___. Likely
multifactorial from iron deficiency anemia, anemia of chronic
disease, mild bleeding post operatively and dilutional from
fluid administration. Received IV iron on ___ and 1 unit pRBC on
day of discharge. Please continue PO iron supplementation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Urinary tract infection
Major Surgical or Invasive Procedure:
PCN placement
PCN repositioning ___
History of Present Illness:
___ pmhx schizoaffective disorder, BPH, presented with L flank
pain found on CT scan to have obstructinve L ureteropelvic
junction stone & severe hydronephrosis, c/f urosepsis, underwent
___ guided nephrostomy tube now admitted to ICU as pt remains
intubated post-procedurally owing to depressed mental status.
Presented to ED with 2 days of LLQ pain. Denied fever/chills.
Also reported chest pain and SOB. Per ED & consultant notes,
history was difficult to obtain from the patient.
In the ED,
- Initial Vitals:
97.1, 78, 95/75, 26, 93% RA
- Exam:
Diffuse abdominal TTP worst in LLQ
- Labs:
Leukocytois 25
BUN/Cr ___ (b/l Cr 0.7)
U/A grossly positive
- Imaging:
CT A/P:
-11 mm obstructing stone near the left ureteropelvic junction,
with resulting moderate hydronephrosis and delayed left
nephrogram. No focal areas of cortical hypoenhancement.
-Bladder wall thickening with stranding about the course of the
left ureter are concerning for urinary tract infection,
recommend
correlation with urinalysis.
-Prostatomegaly.
-Heavy stool burden throughout much of the colon.
- Consults:
Urology:
Recommended treatment for UTI and ___ for PCN
___:
Placed PCN
- Interventions:
- Vanc/ Cefepime
- IVF
- Broadened to meropenem
Patient went to ___ for perc nephrostomy which was otherwise
uncomplicated.
He was intubated due to depressed mental status.
Past Medical History:
Schizoaffective disorder
BPH
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: 122/57, HR 90, 93# RR 22
GEN: somnolent, awakes to sternal rub
HEENT: intubated
CV: RRR
PULM CTA
GI: Obese/S/ND/NT
EXT: WWP
DISCHARGE PHYSICAL EXAM:
======================
Pertinent Results:
ADMISSION LABS:
==============
___ 02:02PM VALPROATE-13*
___ 07:08AM GLUCOSE-116* UREA N-26* CREAT-1.4* SODIUM-139
POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-12
___ 07:08AM CALCIUM-7.9* PHOSPHATE-3.9 MAGNESIUM-2.5
___ 07:08AM WBC-15.6* RBC-3.66* HGB-10.8* HCT-36.5*
MCV-100* MCH-29.5 MCHC-29.6* RDW-14.7 RDWSD-54.3*
___ 07:08AM PLT COUNT-153
___ 05:25AM URINE COLOR-PINK* APPEAR-Cloudy* SP ___
___ 05:25AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-300*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG*
___ 05:25AM URINE RBC->182* WBC->182* BACTERIA-MANY*
YEAST-NONE EPI-0
___ 05:25AM URINE WBCCLUMP-MANY*
___ 09:23PM LACTATE-1.4
___ 06:56PM HGB-13.3* calcHCT-40
___ 06:45PM GLUCOSE-94 UREA N-26* CREAT-1.6* SODIUM-142
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-29 ANION GAP-11
___ 06:45PM estGFR-Using this
___ 06:45PM ALT(SGPT)-26 AST(SGOT)-37 ALK PHOS-72 TOT
BILI-0.4
___ 06:45PM LIPASE-18
___ 06:45PM cTropnT-<0.01
___ 06:45PM ALBUMIN-3.9
___ 06:45PM WBC-25.0* RBC-4.40* HGB-12.7* HCT-41.8 MCV-95
MCH-28.9 MCHC-30.4* RDW-14.5 RDWSD-50.4*
___ 06:45PM NEUTS-85.1* LYMPHS-6.9* MONOS-7.2 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-21.28* AbsLymp-1.73 AbsMono-1.79*
AbsEos-0.01* AbsBaso-0.03
___ 06:45PM PLT COUNT-237
INTERVAL LABS:
===============
DISCHARGE LABS:
===============
IMAGING:
========
___ (PORTABLE AP)
___ (PORTABLE AP)
IMPRESSION:
Heart size and mediastinum are overall stable appearance but
there are new
bibasal areas of atelectasis, extensive associated with small
bilateral
pleural effusion. There is no pneumothorax.
___ NEPHROSTO
FINDINGS:
1. Left nephrostogram showed dilated left renal pelvis with
stone at the
ureteropelvic junction.
2. Successful placement of left PCN tube. 5 cc of cloudy
urine was sent for
analysis.
IMPRESSION:
Successful placement of left 8 ___ nephrostomy tube.
RECOMMENDATION(S): Keep drain for bag drainage. Monitor
outputs.
___ ABD & PELVIS WITH CO
IMPRESSION:
1. An 11 mm obstructing stone near the left ureteropelvic
junction, with
resulting moderate hydronephrosis and delayed left nephrogram.
No focal areas
of cortical hypoenhancement.
2. Bladder wall thickening with stranding about the course of
the left ureter
are concerning for urinary tract infection, recommend
correlation with
urinalysis.
3. Prostatomegaly.
4. Heavy stool burden throughout much of the colon.
___ (PA & LAT)
IMPRESSION:
Limited study. Very low lung volumes. No definite acute
disease.
MICROBIOLOGY:
=============
__________________________________________________________
___ 2:02 pm BLOOD CULTURE Source: Venipuncture 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 2:20 pm BLOOD CULTURE Source: Venipuncture 1 OF 2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 5:25 am URINE,SUPRAPUBIC ASPIRATE Source:
Catheter.
FLUID CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >10,000 CFU/ML.
PROTEUS SPECIES. QUANTITATION NOT AVAILABLE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- =>32 R <=2 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R <=1 S
CEFTAZIDIME----------- =>64 R <=1 S
CEFTRIAXONE----------- =>64 R <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S 8 I
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S 2 S
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
KUB Abdomen ___
No radiographic evidence of bowel obstruction.
Discharge Labs:
___ 06:10AM BLOOD WBC-7.3 RBC-4.28* Hgb-12.3* Hct-39.1*
MCV-91 MCH-28.7 MCHC-31.5* RDW-14.2 RDWSD-47.6* Plt ___
___ 06:10AM BLOOD Glucose-104* UreaN-33* Na-144 K-4.4
Cl-105 HCO3-26 AnGap-13
___ 06:10AM BLOOD ALT-15 AST-12 AlkPhos-106 TotBili-0.4
___ 06:10AM BLOOD Phos-3.4 Mg-2.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 5 mg PO DAILY
2. Venlafaxine XR 37.5 mg PO DAILY
3. Venlafaxine XR 112.5 mg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Aspirin 81 mg PO DAILY
6. ClonazePAM 1 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. ClonazePAM 0.5 mg PO DAILY
9. ClonazePAM 0.5 mg PO DAILY
10. Clozapine 475 mg PO QHS
11. Polyethylene Glycol 17 g PO DAILY
12. LORazepam 1 mg PO QHS
13. melatonin 3 mg oral QHS
14. Divalproex (DELayed Release) 750 mg PO QHS
15. Atenolol 12.5 mg PO DAILY
16. Artificial Tears Preserv. Free 1 DROP BOTH EYES BID
17. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN GI
upset
18. ClonazePAM 0.5 mg PO QHS:PRN Anxiety
19. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
20. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
Discharge Medications:
1. Senna 8.6 mg PO BID
2. Simethicone 40-80 mg PO QID:PRN bloating
3. Clozapine 225 mg PO ONCE Duration: 1 Dose
4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
6. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN GI
upset
7. Artificial Tears Preserv. Free 1 DROP BOTH EYES BID
8. Aspirin 81 mg PO DAILY
9. Bisacodyl 5 mg PO DAILY
10. ClonazePAM 0.5 mg PO QHS:PRN Anxiety
11. Cyanocobalamin 500 mcg PO DAILY
12. Divalproex (DELayed Release) 750 mg PO QHS
13. melatonin 3 mg oral QHS
14. Polyethylene Glycol 17 g PO DAILY
15. Tamsulosin 0.4 mg PO QHS
16. Venlafaxine XR 112.5 mg PO DAILY
17. Venlafaxine XR 37.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Urosepsis
# Obstructive uropathy secondary to nephrolithiasis
# hypoactive delirium
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with obstructing stone and left hydronephrosis.
Concern for urosepsis // Left hydronephrosis
COMPARISON: CT on ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___ 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: This procedure was done under general anesthesia.
MEDICATIONS: 600 mg of clindamycin
CONTRAST: 15 ml of OPTIRAY contrast
FLUOROSCOPY TIME AND DOSE: 4 min, 52 mGy
PROCEDURE:
1. Left ultrasound guided renal collecting system access.
2. Left nephrostogram.
3. Left 8 ___ nephrostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
health care proxy. The patient was then brought to the angiography suite and
placed prone on the exam table. A pre-procedure time-out was performed per
___ protocol. The 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 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. 5 cc of cloudy
urine was aspirated and sent for analysis. A guidewire 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.
The patient tolerated the procedure well with no immediate post procedure
complication.
FINDINGS:
1. Left nephrostogram showed dilated left renal pelvis with stone at the
ureteropelvic junction.
2. Successful placement of left PCN tube. 5 cc of cloudy urine was sent for
analysis.
IMPRESSION:
Successful placement of left 8 ___ nephrostomy tube.
RECOMMENDATION(S): Keep drain for bag drainage. Monitor outputs.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with perc nephrostomy tubes now s/p intubation
// ETT placement ETT placement
IMPRESSION:
Heart size and mediastinum are overall stable appearance but there are new
bibasal areas of atelectasis, extensive associated with small bilateral
pleural effusion. There is no pneumothorax.
Radiology Report
INDICATION: ___ year old man with hypoxia-- eval for pneumonia // eval for
pneumonia
COMPARISON: ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. Bibasilar atelectatic
changes with small pleural effusions, predominantly unchanged from prior.
There are no pneumothoraces.
Radiology Report
INDICATION: ___ year old man s/p PCN tube and now decreased UOP concerning for
tube migration // PCN tube check
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Fluoroscopy images from percutaneous nephrostomy taken on ___ and abdominal CT from ___
FINDINGS:
The left percutaneous nephrostomy tube appears to be laterally displaced as
well as having lost its pigtail configuration, concerning for being dislodged
from the left renal collecting system. To assess function please correlate
clinically.
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
The left percutaneous nephrostomy tube appears to be laterally displaced as
well as having lost its pigtail configuration, concerning for being laterally
dislodged from the left renal collecting system. To assess function please
correlate clinically.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:04 pm, minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with urosepsis recently intubated and had been on
room air but now with worsening oxygen requirement. // please eval for
evidence of aspiration, new consolidation, edema, or atelectasis.
IMPRESSION:
In comparison with the study of ___, there again are low lung volumes.
Cardiomediastinal silhouette is stable. Bilateral small pleural effusions
with compressive atelectasis at the bases.
No evidence of acute focal pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with urosepsis and recent PCN placement that is
now markedly somnolent. // please eval for acute bleed, mass, or subacute
stroke within limits of CT.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.0 s, 20.5 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,068.6 mGy-cm.
Total DLP (Head) = 1,069 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of fracture, infarction,hemorrhage,edema, or mass. There
is prominence of the ventricles and sulci suggestive of involutional changes.
There is severe mucosal thickening in the ethmoid air cells and left maxillary
sinus. There is mild mucosal thickening in the right maxillary and bilateral
sphenoid sinuses. The visualized portion of the mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are normal.
IMPRESSION:
1. No acute intracranial abnormality or evidence of mass.
2. Severe paranasal sinus disease.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old man with urosepsis and obstructing kidney stone
status PCN that not appears to be displaced based on KUB. // please eval
position of PCN as requested by ___.
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 10.5 s, 55.7 cm; CTDIvol = 30.6 mGy (Body) DLP =
1,711.0 mGy-cm.
Total DLP (Body) = 1,711 mGy-cm.
COMPARISON: ___ CT abdomen/pelvis
FINDINGS:
LOWER CHEST: There is increased bibasilar atelectasis with persistent trace
bilateral pleural effusions.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no focal lesion within the limitations of an unenhanced scan. There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder contains gallstones without wall thickening or surrounding
inflammation.
PANCREAS: There is fatty atrophy of the pancreas. There is no evidence of
focal lesion, within the limitations of an unenhanced scan. There is a single
punctate calcification in the medial pancreatic tail. There is no pancreatic
ductal dilation or peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: Diffuse bilateral adrenal thickening is similar to the prior
examination.
URINARY: Patient is status-post left percutaneous nephrostomy tube. The tip
of the tube is located in a lower pole calyx, not the renal pelvis. The
previously seen nonobstructing left lower pole calculus has migrated, now
probably located adjacent to the pre-existing stone at the left ureteropelvic
junction, though it is not definitely separately identified from the
pre-existing UPJ stone. Hydronephrosis has resolved. Proximal left
periureteric fat stranding is improved. Distal left periureteric fat
stranding is similar. Distal right periureteric fat stranding is new (series
2, images 60-72). The urinary bladder is trabeculated with numerous bladder
wall diverticula.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness. The colon and rectum are within normal
limits. The appendix is not visualized.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Mild atherosclerotic disease is present. There is no abdominal
aortic aneurysm.
BONES: There is minimal retrolisthesis of L2 on L3. Endplate degenerative
changes are worst at L1-L2 and L2-L3.
SOFT TISSUES: There is mild diffuse body wall edema.
IMPRESSION:
1. A left percutaneous nephrostomy tube tip is located in a left lower pole
renal calyx rather than the renal pelvis. However, hydronephrosis has
resolved.
2. A pre-existing nonobstructive left lower pole calculus has migrated,
probably now located adjacent to the pre-existing left ureteropelvic junction
stone.
3. New right distal periureteric fat stranding. Consider infection.
Correlate with urinalysis.
4. Severe prostatomegaly with evidence of chronic bladder outlet obstruction.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 7:38 pm, approximately
15 minutes after discovery of the findings.
Radiology Report
INDICATION: ___ year old man with obstructing renal stone and urosepsis s/p
PCN now with concern for displaced PCN. // stat CT a/p ordered. consult for
replacement of tube. Discussed with Dr. ___.
COMPARISON: CT abdomen and pelvis ___.
TECHNIQUE:
OPERATORS: Dr. ___, attending Interventional Radiologist and
Dr. ___ fellow performed the procedure. The
attending(s) personally supervised the trainee during any key components of
the procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: General anesthesia monitored by anesthesia staff. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: See anesthesia report.
CONTRAST: 10 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 2 minutes 15 seconds, 16 mGy
PROCEDURE:
1. Left diagnostic antegrade nephrostogram.
2. Left 8 ___ nephrostomy exchange.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
healthcare proxy.The patient was then brought to the angiography suite and
general anesthesia was induced. The patient was 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.
A scout radiograph was performed.
Diluted contrast was injected into the left nephrostomy. The image was stored
on PACS.
A Glidewire was advanced through the existing left-sided nephrostomy tube into
the left renal collecting system and down the left ureter. The existing
left-sided nephrostomy tube was removed over the wire and a Kumpe catheter was
placed over the wire into the left renal collecting system. The wire was
removed and a small hand injection of contrast confirmed position within the
left ureter.
At that time, a Amplatz wire was advanced through the Kumpe catheter into the
distal left ureter. The Kumpe the was removed and a new 8 ___ APDL pigtail
catheter was advanced over the wire into the left renal pelvis. The wire and
metal inner stiffener of the pigtail drainage tube were removed and the
pigtail was formed in the left renal pelvis. A small hand injection of
contrast confirmed appropriate positioning. Final image was saved. The
catheter was then flushed. The catheter was secured with 0 silk suture and a
StatLock. The catheter was attached to gravity bag drainage.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Left antegrade nephrostogram shows improvement in the previously visualized
left UPJ obstruction with mild left hydronephrosis..
2. Appropriate final position of left 8 ___ nephrostomy tube.
IMPRESSION:
Technically successful left 8 ___ nephrostomy exchange.
Radiology Report
INDICATION: ___ year old man with cognitive decline and abdominal pain //
rule out obstruction
TECHNIQUE: Supine abdominal radiographs.
COMPARISON: CT abdomen pelvis and abdominal radiographs dated ___.
FINDINGS:
Mildly distended colon is noted in the left side abdomen. Otherwise no
abnormally dilated bowel loops. Supine position limits diagnostic evaluation
of pneumoperitoneum. Given the limitation, no large pneumoperitoneum
identified
Moderate degenerative changes of the lower lumbar spines and bilateral hips
are noted. There is a left percutaneous nephrostomy tube in place.
IMPRESSION:
No radiographic evidence of bowel obstruction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Hydronephrosis with renal and ureteral calculous obstruction
temperature: 97.1
heartrate: 78.0
resprate: 26.0
o2sat: 93.0
sbp: 95.0
dbp: 75.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ is a ___ male PMHx schizoaffective disorder
and BPH who was admitted with urosepsis in setting of
obstructing ureteral stone, s/p R. PCN by ___.
# Complicated UTI:
# Obstructing Nephrolithiasis:
# Acute kidney injury (resolved):
Presented with fever, leukocytosis, and flank pain all c/w
urosepsis. CT abdomen and pelvis noted 11 mm obstructing stone
near the left ureteropelvic junction. He underwent PCN
placement by ___ with resultant improvement in renal function to
baseline. Urine culture growing both MDR E.coli and Proteus,
both sensitive to meropenem. He completed total 10 day course of
antibiotics following his PCN repositioning on ___. With
regards to his PCN, this will remain in place until he has
definitive management of his obstructing kidney stone with
interventional radiology, in the ___ Building at ___
___ at 12:30p
# Toxic-metabolic encephalopathy:
# Schizoaffective disorder:
Hospital course complicated by both agitation and hypoactive
delirium secondary to acute infection and known schizoaffective
disorder. While markedly somnolent, all psychiatric medications
were initially held and the psychiatry team was consulted to
guide safe resumption of his regimen. Plan at discharge is to
hold scheduled benzodiazepines, continue Effexor/ valproate, and
continue uptitrating Clozaril by 50 mg daily. Dose on day of
discharge (___) should be 275 mg of Clozaril.
TRANSITIONAL ISSUES:
==================
[] Ensure that patient follows up with interventional radiology
after completion of antibiotics for replacement of perc
nephrostomy tube (___). Patient should follow up with
Urology upon discharge here at ___ for incomplete emptying
likely due to BPH- Dr. ___: office (___) ___ at 3:15 pm. ___ ___ floor.
[] Psychiatric regimen on discharge has changed; see med rec.
Plan at discharge is to hold scheduled benzodiazepines, continue
Effexor/ valproate, and continue uptitrating Clozaril by 50 mg
daily. Dose on day of discharge (___) should be 275 mg of
Clozaril.
>30 min spent on discharge planning |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Gold Salts / tape
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
___ upper endoscopy
___ embolization of left gastric artery
___ upper endoscopy with epi injection ___ embolization of left gastric artery
___ PICC line placed
History of Present Illness:
___ year old female with rheumatoid arthritis s/p bilateral knee
replacements and HTN who presents with hematemesis and
hypotension. She was recently d/c'ed from ___ (___) after
a prolonged admission for fever, severe sepsis, cellulitis and R
knee septic arthritis. At that time R knee arthrocentesis showed
WBC 25K and 93% PMNs and she was taken to the OR with Ortho for
parapatellar arthrotomy and synovectomy on ___. Synovial fluid
from the OR was cloudy, though gram stain and cultures were
negative. Ortho recommended Coumadin for DVT ppx, goal INR was
1.5-2.0. She was prescribed a course of Penicillin G for her
septic joint and her pan sensitive CONS bacteremia. She went to
rehab on the ___ and on the ___ she was found down and she
began vomiting blood. She was then sent to ___ for further
evaluation.
In the ED, initial vitals:
T 101.2 HR 88 BP 106/56 RR 20 O2 Sat 98% 2L
She triggered on arrival for hypotension with SBP in the ___.
NTG was placed and returned 600cc of dark red blood. She was
bolued 1L NS and her BP improved to the 100s. She then
desaturated to the ___ on RA and was placed on NRB with
improvement in her O2 sat to 100%. She was given Vanc/Zosyn.
Given reported fall, CT head/c-spine was negative. Labs were
notable for HCT 25 (28.3 at time of d/c), INR 1.7, Trop 0.05 and
lactate 1.0. GI was consulted; recommended transfusion, PPI gtt
and EGD.
On arrival to the MICU, initial VS were
T 98 BP 100/80 HR 70 RR 18 O2 Sat 98% 2L NC
She continued to have BRB from her NGT and was therefore given
vitamin K 5mg IV and transfused another unit of pRBCs. She then
became transiently hypotensive to the ___, which responded to 1L
NS bolus. GI was called and EGD was performed, which showed a
small GEJ ulcer that was not actively bleeding (cauterized) as
well as a large clot in the fundus
Review of systems:
(+) Per HPI
(-) Denies 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 dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
# Hypertension -- appears to be on four medications
# Rheumatoid Arthritis -- unclear diagnosis
-- exam more consistent with osteoarthritis
# Bilateral Knee Replacement
# Left Second Digit Distal Amputation
# Glaucoma
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Exam:
T 98 BP 100/80 HR 70 RR 18 O2 Sat 98% 2L NC
General- Pale, ill appearing woman in NAD
HEENT- EOMI, NCTA, MM dry, sclera pale
Neck- JVP flat
CV- RRR, normal S1/S2, no S3/S4, no m/r/g
Lungs- CTAB, no increased WOB, no w/r/r
Abdomen- Mild TTP in the epigastrium, otherwise NTND, NABS
Ext- R knee is warm without erythema. Surgical site is c/d/i
without pus. ___ with erythema and warmth below the knee.
Neuro- Alert and oriented to person and place. Non focal.
Discharge Exam:
Vitals: 98.4, 137/73, 96, 20 (___) 98% on 2.0L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, NTP, non-distended, no rebound tenderness
or guarding
Ext: significant pitting edema in legs bilaterally
Pertinent Results:
Admission Labs:
___ 05:22AM BLOOD WBC-6.3 RBC-2.99* Hgb-9.2* Hct-28.3*
MCV-95 MCH-30.9 MCHC-32.6 RDW-13.1 Plt ___
___ 02:37PM BLOOD Neuts-80.1* Lymphs-11.6* Monos-7.5
Eos-0.3 Baso-0.6
___ 05:22AM BLOOD ___ PTT-31.0 ___
___ 05:22AM BLOOD Glucose-95 UreaN-13 Creat-0.2* Na-138
K-4.8 Cl-97 HCO3-34* AnGap-12
___ 02:37PM BLOOD ALT-14 AST-22 AlkPhos-96 TotBili-0.3
___ 02:37PM BLOOD CK-MB-2 cTropnT-0.05*
___ 06:41PM BLOOD CK-MB-2 cTropnT-0.04*
___ 05:22AM BLOOD Calcium-7.6* Phos-3.3 Mg-1.9
___ 09:19AM BLOOD ___ pH-7.39
___ 09:19AM BLOOD freeCa-1.24
Interval Labs:
___ 02:37PM BLOOD WBC-10.2# RBC-2.77* Hgb-8.5* Hct-25.8*
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.4 Plt ___
___ 06:41PM BLOOD Hct-27.1*
___ 11:44PM BLOOD Hct-17.3*#
___ 02:50AM BLOOD WBC-10.8 RBC-3.10* Hgb-9.4* Hct-26.6*#
MCV-86# MCH-30.2 MCHC-35.1* RDW-15.7* Plt ___
___ 05:16AM BLOOD WBC-10.4 RBC-2.78* Hgb-8.3* Hct-24.3*
MCV-87 MCH-29.9 MCHC-34.4 RDW-15.9* Plt ___
___ 09:06AM BLOOD Hct-24.3*
___ 12:04PM BLOOD Hct-26.6*
___ 04:15PM BLOOD Hct-30.2*
___ 08:00PM BLOOD Hct-28.6*
___ 11:58PM BLOOD Hct-26.5*
___ 02:22AM BLOOD WBC-13.6* RBC-3.75*# Hgb-11.2*#
Hct-33.2*# MCV-89 MCH-30.0 MCHC-33.8 RDW-15.4 Plt ___
___ 06:33AM BLOOD Hct-30.6*
___ 09:51AM BLOOD Hct-28.1*
___ 03:05PM BLOOD Hct-27.8*
___ 06:45PM BLOOD Hct-28.9*
___ 11:22PM BLOOD Hct-28.7*
___ 12:37AM BLOOD WBC-9.2 RBC-3.10* Hgb-9.3* Hct-27.2*
MCV-88 MCH-30.0 MCHC-34.2 RDW-15.8* Plt ___
___ 04:06AM BLOOD Hct-27.2*
___ 08:08AM BLOOD Hct-28.1*
___ 12:37AM BLOOD ___ PTT-27.6 ___
___ 12:37AM BLOOD Glucose-100 UreaN-18 Creat-0.2* Na-135
K-3.5 Cl-102 HCO3-30 AnGap-7*
___ 12:37AM BLOOD Calcium-7.6* Phos-2.4* Mg-2.1
___ 12:47AM BLOOD ___ pH-7.41
___ 12:47AM BLOOD freeCa-1.12
___ 02:13PM BLOOD Lactate-1.1
Discharge labs:
___ 06:30AM BLOOD WBC-4.2 RBC-3.43* Hgb-10.3* Hct-30.5*
MCV-89 MCH-30.0 MCHC-33.6 RDW-15.1 Plt ___
___ 06:30AM BLOOD Glucose-93 UreaN-6 Creat-0.3* Na-137
K-4.1 Cl-98 HCO3-33* AnGap-10
Micro:
Blood Culture, Routine (Final ___: NO GROWTH
WOUND CULTURE PICC line (Final ___: No significant
growth.
.
CT Head (___):
Chronic changes described above. No evidence of hemorrhage,
contusion, infarction or fracture.
.
CT C-Spine (___):
No fracture of the cervical spine.
.
EGD (___):
Impression: Stricture of the gastroesophageal junction
Ulcer in the gastroesophageal junction (thermal therapy)
Blood in the fundus
After irrigation, clean bile was noted refluxing from the
pylorus
Otherwise normal EGD to third part of the duodenum
.
EGD (___):
Impression: Esophageal ulceration (injection, endoclip)
There was a 1 mm vascular bleb at the GE junction with no
evidence of active bleeding. This was injected with 1cc
Epinephrine ___, with no provocation of bleeding. Therefore,
it was not felt that this represented a visible vessel.
A large amount of organized clot was seen in the fundus, despite
having administered erythromycin prior to the procedure and
lavaging 2L of saline via Ewold. Other sources of GI bleeding
could not be ruled out given limited visualization.
Otherwise normal EGD to third part of the duodenum
EGD (___)
Ulcer in the gastroesophageal junction
3 large (2 very large) areas of ulceration with eschar/necrosis
(no visible vessels), consistent with post-embolization effect
Otherwise normal EGD to third part of the duodenum
.
___ Guided Embolization (___):
1. Right common femoral artery access.
2. Celiac digital subtraction angiogram.
3. Selective left gastric angiogram at the origin and in a more
distal
subselective branch.
4. Gelfoam treatment of the left gastric artery.
.
CXR (___):
1. Malpositioned endotracheal tube pointing towards the right
main stem
bronchus, proximal repositioning by ___ to 2 cm is
recommended.
2. Increasing pulmonary vascular congestion and mild edema.
.
CXR (___):
Standard position of support devices. New patchy basilar
opacities which may be due to atelectasis, pneumonia or
hemorrhage.
.
___ (___):
No evidence of deep vein thrombosis in the left leg.
.
___ Guided Embolization (___):
prophylactic completion embolization of the superior branches of
the left
gastric artery was performed with a combination of coils and
gelfoam with
complete cessation of flow to the treated arterial territory
.
CXR (___):
In comparison with the study of ___, the monitoring and support
devices are essentially unchanged. The patient has taken a
slightly better inspiration. The opacification at the right
base is less prominent, suggesting that much of it could have
represented crowding of vessels related to poor inspiration.
Nevertheless, the possibility of continued atelectasis or even
pneumonia or hemorrhage must be considered. Retrocardiac
opacification persists, with similar differential diagnosis.
Medications on Admission:
1. Atenolol 50 mg PO BID
2. Lisinopril 5 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Warfarin 2 mg PO DAILY16
6. Aspirin 81 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Penicillin G Potassium 3 Million Units IV Q4H
End date ___
Discharge Medications:
1. Docusate Sodium (Liquid) 100 mg PO BID
2. Hydrocortisone Cream 0.5% 1 Appl TP BID:PRN rash
3. Multivitamins 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Senna 1 TAB PO BID:PRN Constipation
6. Sucralfate 1 gm PO QID Duration: 2 Weeks
7. Vancomycin 1500 mg IV Q 12H, end date ___, then begin
penicillin G
8. Vitamin D 1000 UNIT PO DAILY
9. Hydroxychloroquine Sulfate 200 mg PO BID
10. Miconazole Powder 2% 1 Appl TP QID:PRN rash
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary: Upper GI bleed
Secondary: fluid overload, right knee septic arthritis
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
EXAM: Chest, single AP upright portable view.
CLINICAL INFORMATION: Hemetemesis.
___.
FINDINGS: Single AP upright portable view of the chest was obtained. A
right-sided PICC is again seen, terminating in the upper SVC. The cardiac
silhouette remains enlarged with a somewhat globular configuration and there
may be underlying pericardial effusion or cardiomyopathy. Left mid lung
opacity is again seen, which may be post-surgical. There is obscuration of
the left hemidiaphragm which may in part be due to overlying soft tissue;
however, left base consolidation or atelectasis may be present. Dedicated PA
and lateral views would be helpful for further evaluation. The aorta remains
calcified and tortuous.
IMPRESSION: Obscuration of the left hemidiaphragm may in part relate to
overlying soft tissue; however, underlying consolidation and/or atelectasis
may be present. Dedicated PA and lateral views would be helpful for further
evaluation. Enlargement of the cardiac silhouette, likely stable, but with a
somewhat globular configuration now, underlying pericardial effusion or
cardiomyopathy may be present.
Radiology Report
HISTORY: Hematemesis on coumadin and an unwitnessed fall yesterday. Evaluate
for acute injury.
TECHNIQUE: Contiguous axial sections were acquired through the brain without
administration intravenous contrast. Coronal and sagittal reformations were
provided and reviewed.
DLP: ___ mGy/cm.
CTDIvol: 59.625 mGy.
COMPARISON: None.
FINDINGS: There is no evidence of hemorrhage, edema or mass effect.
Prominence of the ventricles and sulci is compatible with age. Scattered and
confluent white matter hypodensities, while nonspecific, are thought to
reflect sequela of chronic small vessel ischemic disease. Dense
calcifications are seen within the carotid siphons.
The imaged paranasal sinuses and mastoid air cells are well aerated. The
imaged lens and globes are normal.
IMPRESSION: Chronic changes described above. No evidence of hemorrhage,
contusion, infarction or fracture.
Radiology Report
HISTORY: Unwitnessed fall yesterday. Evaluate for injury.
TECHNIQUE: MDCT axial images were acquired through cervical spine without
administration of intravenous contrast. Coronal sagittal reformations are
provided and reviewed.
DLP: 726.92 mGy/cm.
CTDIvol: 32.53 mGy.
COMPARISON: CT C-spine ___.
FINDINGS: There is mild reversal of the normal cervical lordosis at C5,
unchanged. There is no fracture. The presence of a nasogastric tube limits
detection of prevertebral soft tissue swelling. There are moderate
degenerative changes of the cervical spine with disc space loss and
osteophytosis. A well-circumscribed lucent lesion within the right pedicle of
C5 is certainly benign. The soft tissues of the neck are unremarkable. The
lung apices are normal. The thyroid is unremarkable. Intracranial contents
are better evaluated on the concurrent head CT.
IMPRESSION: No fracture of the cervical spine.
ATTENDING NOTE: The enlargement of right C5 foramen transversorium is likely
due to a vertebral artery loop due to tortuosity.
Radiology Report
INDICATION: ___ female of recent right knee septic arthritis and
cellulitis, which was placed on Coumadin for DVT prevention. Today, patient
presented with hematemesis and hypotension and an angiogram was requested.
Upper GI endoscopy demonstrated large clot in the fundus and ulcer in GE
junction.
ANESTHESIA: Moderate sedation was provided by administering divided doses for
a total of 0.5 mg of Versed and additionally 8mg of Zofran, during which
patient's hemodynamic parameters were continuously monitored. Additionally,
1% lidocaine 9mL was used for local anesthesia.
OPERATORS: Dr. ___, ___ fellow, and Dr. ___,
___ attending.
PROCEDURES:
1. Right common femoral artery access.
2. Celiac digital subtraction angiogram.
3. Selective left gastric angiogram at the origin and in a more distal
subselective branch.
4. Gelfoam treatment of the left gastric artery.
PROCEDURE DETAILS: Written informed consent was obtained from the patient's
healthcare proxy, the daughter, after explaining risks, benefits and
alternatives to the procedure. The patient was brought to the angiography
suite and placed supine on the imaging table. The right groin was prepped and
draped in the usual sterile fashion. A preprocedure timeout was performed as
per ___ protocol.
Under palpatory and fluoroscopic guidance and using a 19-gauge single-wall
needle, the right common femoral artery was punctured. ___
wire was advanced through the needle into the lower aorta. The needle was
exchanged for a short 5 ___ vascular sheath. The sidearm of the sheath was
attached to a heparinized saline sidearm. Following, an Omniflush catheter
was used to cross the iliac bifurcation into the contralateral side. The
catheter was subsequently removed and ___ catheter was reformed over
the bifurcation and navigated up into the aorta. Using the ___, the
celiac axis was selected. Small amount of contrast injection demonstrated
adequate positioning. Following, a digital subtraction angiogram was
performed. The digital subtraction angiogram demonstrated the origin of the
left gastric artery slightly distal to the ostium of the celiac and no area of
active extravasation was seen in this run. Based on the clinical findings,
decision was made to do a selective left gastric artery angiogram. Following,
using a Renegade ___ and a Transcend wire, further purchase was gained into
the left gastric. Digital subtraction angiogram was repeated, which
demonstrated a large area of contrast extravasation in the stomach fundus.
Based on these findings, decision was made to treat this region. Using a
Fathom wire, further purchase was gained into the inferior branch of the left
gastric artery, the area of bleeding. A repeat arteriogram confirmed active
contrast extavasation. Gelfoam embolization was performed to stasis. Digital
subtraction angiogram was again repeated through the microcatheter, which was
placed slightly more proximal. No further active extravasation was identified
in this run. Based on the concerns of the prior endoscopy which had shown a
lesion in the gastroesophageal junction, embolization of the rest of the left
gastric artery was still performed to stasis with gelfoam slurry. At the end,
small amount of contrast injection did not demonstrate any further flow into
the left gastric. Based on these findings, decision was made to terminate the
procedure. All catheters and wires were removed. The right common femoral
artery sheath was removed and 15 minutes of manual compression were used to
achieve hemostasis. Dry sterile dressing was applied. The patient tolerated
the procedure well without immediate complications.
IMPRESSION:
Successful treatment with Gelfoam embolization of a large area of active
extravasation of the left gastric artery (gastric fundus).
Radiology Report
INDICATION: ___ female with gastrointestinal bleed, now intubated.
Assess position of ET tube.
COMPARISON: Chest radiograph from ___ and ___.
PORTABLE FRONTAL CHEST RADIOGRAPH: The patient has been intubated in the
interval and the endotracheal tube is positioned low, at the level of the
carina. Proximal repositioning by ___ to 2 cm is recommended. A right
approach PICC terminates in the upper SVC, unchanged. There is mild vascular
congestion, which is increased from prior examination. Large pleural
effusions are evident. Moderate-to-severe cardiomegaly is stable.
IMPRESSION:
1. Malpositioned endotracheal tube pointing towards the right main stem
bronchus, proximal repositioning by ___ to 2 cm is recommended.
2. Increasing pulmonary vascular congestion and mild edema.
Dr ___ communicated the above results (#1) to Dr. ___ at 1:30
p.m. on ___ by telephone.
Radiology Report
INDICATION: ___ female admitted with GI bleed, now presenting with
hemoptysis.
COMPARISON: Chest radiographs dating back to ___, most recent from
___.
PORTABLE SEMI-ERECT FRONTAL CHEST RADIOGRAPH: An endotracheal tube is in
expected standard position. A right approach PICC terminates in the mid SVC,
unchanged from prior. There are worsening patchy bibasilar opacities, as
compared to most recent prior examination. There is possible small left
pleural effusion as well. Differential diagnosis for new basilar opacities
include atelectasis, pneumonia and hemorrhage given the clinical history of
hemoptysis. Upper lungs are clear. No overt interstitial edema is
identified. Lung volumes are low.
IMPRESSION: Standard position of support devices. New patchy basilar
opacities which may be due to atelectasis, pneumonia or hemorrhage.
Radiology Report
INDICATION:
___ female with recent right knee septic arthritis and cellulitis
which was placed on Coumadin for DVT prevention. Subsequently, patient
presented with large volume hematemesis and hypotension and the left gastric
artery was embolized on ___. After that, the patient continued to
bleed and repeat angiogram was requested.
ANESTHESIA:
Moderate sedation was provided by using fentanyl and Versed as per the ICU
nurse. 1% lidocaine was also used for local anesthesia.
OPERATORS:
Dr. ___, ___ fellow, and Dr. ___, ___ attending, who was
present and supervising.
PROCEDURES:
1. Right common femoral artery access.
2. Digital subtraction angiogram.
3. Superselective left gastric angiogram at the vessel origin.
4. Gelfoam and coil embolization of the remnant left gastric artery.
5. Digital subtraction angiogram of the GDA and branches.
PROCEDURE DETAILS:
Written informed consent was obtained from patient's healthcare proxy, after
explaining risks, benefits and alternatives to the procedure. The patient was
brought to the angiography suite and placed supine on the imaging table. The
right groin was prepped and draped in the usual sterile fashion. A
preprocedure timeout was performed as per ___ protocol.
Using palpatory and fluoroscopic guidance, and using a micropuncture needle,
the right common femoral artery was punctured athe level of the mid femoral
head. Following, a 0.018 nitinol wire was advanced under fluoroscopy. The
needle was exchanged for a micropuncture sheath and the wire upsized for a
___ wire. Following, a 5 ___ x 20 cm ___ vascular sheath was then
advanced under fluoroscopy over the ___ wire . The sidearm of the sheath
was then attached to a heparinized saline sidearm. A longer sheath was used
given significant tortuosity in the right common iliac artery. Following, a C2
catheter was used to catheterize the celiac origin. Subsequently, a digital
subtraction angiogram was performed, which some residual but reduced flow into
the left gastric artery, as well as an unremarkable splenic artery.
Based on these findings, decision was made to gain further purchase into the
left gastric for a superselective run. Following, using a Renegade ___ and
a Transcend wire, the left gastric artery was catheterized. Digital
subtraction angiograms were performed, which demonstrated no flow in the
inferior branches of previously embolized bleeding branches of the left
gastric artery. Ongoing residual flow was identified in some upper branches
supplying the gastric fundus. No active extravasation was see. Based on the
clinical scenario a decision was made to complete the embolization of this
artery. Following, Gelfoam was used to achieve stasis in the entire left
gastric artery. Subsequently, 11 coils measuring 5 mm x 1.5 cm length were
pushed into the main left gastric artery to achieve complete flow stasis. A
final small amount of contrast injection demonstrated no flow into this
artery. Following, the microcatheter was used to be navigated further down
back into the GDA with aid of the Fathom microwire. Digital subtraction
angiogram was performed, which demonstrated a normal appaering right
gastroepiploic artery supplying the greater curvature of the stomach; however,
no evidence of active extravasation was identified. Normal anatomy was noted.
Based on these findings the decision was made to terminate the procedure.
All catheters and wires were removed. The vascular sheath was removed and 15
minutes of manual compression were used to achieve hemostasis. The patient
tolerated the procedure well without immediate complications.
IMPRESSION:
The previously treated inferior branches of the left gastric, which previously
had active extravasation remained occluded in the current study. No evidence
of further bleeding or active extravasation was seen. The superior branches
of the left gastric artery which were priorly occluded were partially
recanalized in today's study, and further treatment was performed with coils
and Gelfoam. The gastroepiploic artery was also studied, with no evidence of
active extravasation of bleed.
In summary, even though no active extravasation or bleeding was identified,
prophylactic completion embolization of the superior branches of the left
gastric artery was performed with a combination of coils and gelfoam with
complete cessation of flow to the treated arterial territory.
Radiology Report
HISTORY: ___ female with GI bleed, asymmetric left lower extremity
swelling, evaluate for DVT.
COMPARISON: Left leg ultrasound ___.
FINDINGS:
Grayscale, color and Doppler images were obtained of the left common femoral,
femoral, popliteal and tibial veins. Normal flow, compression and
augmentation is seen in all of the vessels.
IMPRESSION:
No evidence of deep vein thrombosis in the left leg.
Radiology Report
HISTORY: GI bleed with massive transfusion, to assess for change.
FINDINGS: In comparison with the study of ___, the monitoring and support
devices are essentially unchanged. The patient has taken a slightly better
inspiration. The opacification at the right base is less prominent,
suggesting that much of it could have represented crowding of vessels related
to poor inspiration. Nevertheless, the possibility of continued atelectasis
or even pneumonia or hemorrhage must be considered. Retrocardiac
opacification persists, with similar differential diagnosis.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with large gastrointestinal
bleeding and new fever.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The patient was extubated in the meantime interval. The patient is currently
in substantial vascular engorgement/interstitial edema. Bibasilar
consolidations are unchanged with no interval increase in pleural effusion or
pneumothorax. The bibasilar consolidations most likely represent part of
pulmonary edema/vascular engorgement, but infectious process in particular in
the left lower lung cannot be excluded, further surveillance is recommended.
Radiology Report
INDICATION: ___ woman with new left PICC line.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: Frontal chest radiograph.
FINDINGS: As compared to prior chest radiograph from ___, there has
been interval placement of a left-sided PICC line with its tip terminating in
the mid SVC. There is no pneumothorax. The cardiac silhouette remains
enlarged. Vascular engorgement and interstitial edema have improved. No new
focal consolidations are identified.
IMPRESSION: Left-sided PICC line terminates in mid SVC.
These findings were discussed with ___, IV team nurse, ___
via telephone on ___ at 3:45 p.m., at time of discovery.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: HEMATEMESIS
Diagnosed with SEPTICEMIA NOS, GASTROINTEST HEMORR NOS, SEPSIS , ACCIDENT NOS
temperature: 101.2
heartrate: 88.0
resprate: 20.0
o2sat: 98.0
sbp: 106.0
dbp: 56.0
level of pain: 13
level of acuity: 1.0 | Primary Reason for Admission: ___ y/o woman with recent R knee
septic arthritis, cellulitis and severe sepsis on Coumadin
presenting with hematemesis and hypotension.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors / lisinopril
Attending: ___.
Chief Complaint:
chest discomfort; hyperkalemia
Major Surgical or Invasive Procedure:
HD x2 hours, incompleted
History of Present Illness:
___ hx ESRD on ___ HD, PE in ___, mechanical MVR on Coumadin,
CAD, HTN who presented from HD w/chest discomfort after R sided
fistula clotted, found to be hyperkalemic w/K>8. Patient reports
he was at HD and about one hour into treatment he began to feel
unwell. Describes feeling lightheaded, nauseous and fatigued. He
also developed chest pain/pressure with some associated mild
dyspnea which resolved on its own. Patient states symptoms not
similar to previous MI. He reports that he was feeling
frustrated because he was told the HD nurse put him on the wrong
K bath, so he asked to be de-accessed so he could go to the ED
to have his fistula evaluated.
Of note, patient had recent admission for subtherapeutic INR at
which time he was noted to be hyperkalemic. He was dialyzed
daily with little improvement in his potassium, so it was felt
that his fistula was malfunctioning. He was scheduled for
fistulogram inpatient but left AMA. Per ___ and patient he went
to scheduled fistula care appointment on ___, during which time
ultrasound revealed very poor flow through fistula. Patient
states that he is scheduled for intervention to "clean out"
fistula (presumably thrombectomy?) as outpatient on ___.
In the ED, initial vitals: 96.4, 85, 139/79, 16 100% RA
Labs were notable for potassium 8.7, trop 0.32 (baseline), Na
133, Cl 86, bicarb 24, BUN 87, Cr 15.2. EKG showed peaked T
waves, ST depression in II, III, AVF (ST changes similar to
prior on ___. CBC, LFT's wnl. ___ and renal were consulted in
ED. ___ declined to perform thrombectomy until patient received
HD. Renal recommended temporizing measures for hyperkalemia,
placement of temp HD line and urgent HD. Patient was given
10units regular insulin, 1g Calcium Gluconate, 25mg Dextrose x 2
and transferred to the MICU for monitoring and urgent HD.
On transfer, vitals were: afebrile, 86, 106/51, 18 99% RA.
On arrival to the MICU, patient well appearing with no acute
complaints. Denies chest pain, SOB, abdominal pain, nausea,
vomiting or diarrhea. He is requesting that HD be attempted
through R fistula before placing temp HD line.
Review of systems:
(+) Per HPI
Otherwise 10 point ROS negative.
Past Medical History:
-PE diagnosed ___
-ESRD ___ HTN on MWF hemodialysis since ___
-HTN diagnosed in ___ at age ___ while in jail, urgency episode
in ___ (c/b pulmonary edema requiring intubation)
-Substance abuse
-HLD
Past Surgical History:
-left upper extremity HeRO graft ___, ___)
-Left brachiocephalic AV fistula ___, ___
-Right brachiocephalic AV fistula ___, ___
-Placement of LUE HeRO graft ___, ___)
-Appendectomy complicated by postop ?leak/abscess requiring
emergent exploratory laparotomy
-? angioplasty of L brachiocephalic & SVC ___
Social History:
___
Family History:
Father - Died at age ___ from unknown cancer
Mother - Died at age ___ of MI, had HTN
Maternal grandmother - on hemodialysis for end-stage renal
disease.
Physical Exam:
ADMISSION EXAM:
VS: 86, 106/51, 18 99% RA.
GENERAL: laying in bed NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera,MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregular, mechanical valve with murmur, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, AVF with pulse,
some bruit/thrill
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
GENERAL: laying in bed NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera,MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregular, mechanical valve with murmur, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, AVF with pulse,
some bruit/thrill
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION/IMPORTANT LABS:
=========================
___ 04:15PM BLOOD WBC-6.1 RBC-5.21 Hgb-13.4* Hct-45.0
MCV-86 MCH-25.7* MCHC-29.8* RDW-20.4* RDWSD-61.5* Plt ___
___ 04:15PM BLOOD Neuts-79.2* Lymphs-9.3* Monos-9.0 Eos-1.5
Baso-0.5 Im ___ AbsNeut-4.86 AbsLymp-0.57* AbsMono-0.55
AbsEos-0.09 AbsBaso-0.03
___ 05:30PM BLOOD Glucose-85 UreaN-87* Creat-15.2*# Na-133
K-9.4* Cl-86* HCO3-24 AnGap-32*
___ 05:30PM BLOOD ALT-16 AST-36 CK(CPK)-249 AlkPhos-68
TotBili-0.4
Troponin trend:
--------------
___ 05:30PM BLOOD CK-MB-7 cTropnT-0.32*
___ 01:11AM BLOOD CK-MB-6 cTropnT-0.30*
___ 09:50PM BLOOD cTropnT-0.26*
Potassium trend:
---------------
___ 04:26PM BLOOD K-8.7*
___ 05:56PM BLOOD K-8.2*
___ 09:55PM BLOOD K-5.7*
___ 07:19AM BLOOD K-7.1*
___ 10:16PM BLOOD Lactate-2.5* K-6.0*
LABS AT DISCHARGE:
==================
___ 07:05AM BLOOD WBC-5.0 RBC-4.73 Hgb-12.3* Hct-40.3
MCV-85 MCH-26.0 MCHC-30.5* RDW-19.1* RDWSD-57.4* Plt ___
___ 07:05AM BLOOD Glucose-89 UreaN-84* Creat-15.2*# Na-132*
K-6.6* Cl-85* HCO3-21* AnGap-33*
MICRO:
=====
none.
IMAGING/OTHER STUDIES:
=====================
CXR ___
Patient is status post mitral valve replacement, with intact
median sternotomy wires and multiple mediastinal clips.The lungs
are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are unremarkable. Again seen is a large calcific lesion arising
from upper pole of the right kidney.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: Chest: Frontal and lateral views
INDICATION: ___ with chest pain // Eval for acute process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph on ___, CTA torso on ___.
FINDINGS:
Patient is status post mitral valve replacement, with intact median sternotomy
wires and multiple mediastinal clips.The lungs are clear without focal
consolidation. No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable. Again seen is a large calcific
lesion arising from upper pole of the right kidney.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified, Hypokalemia, End stage renal disease
temperature: 96.4
heartrate: 85.0
resprate: 16.0
o2sat: 100.0
sbp: 139.0
dbp: 79.0
level of pain: 8
level of acuity: 2.0 | ___ hx ESRD on ___ HD, PE in ___, mechanical MVR on Coumadin,
CAD, HTN who presented from HD w/chest discomfort after R sided
fistula clotted, found to be hyperkalemic w/K>8.
#Hyperkalemia:
Presented from HD w/chest discomfort after R sided fistula
clotted, found to be hyperkalemic w/K >8. Mr. ___ was
admitted to the ICU given hyperkalemia. It was felt that his K+
8.7 on admission was too high risk for immediate AVF clot
thrombectomy. He received 10units regular insulin, 1g Calcium
Gluconate, 25mg Dextrose x 2. He adamantly refused HD line
placement for urgent HD. Given this, HD was attempted via AVF
and he did undergo HD for 2 hours. This was unable to be
completed due to poor flow. K+ did improve to 5.7 but increased
to 7.1 on ___. This is concerning for recirculation with
ineffective removal of potassium. This potential issue was
brought up last week when patient admitted for subtherapeutic
INR, needing IV heparin (persistent high potassium values during
the admission). Patient otherwise denies this as being a problem
and insists this relates to our particular dialysis machines
and/or the way we access his fistula, denying problems with his
potassium outside of admissions to ___. Plan was to perform
urgent dialysis to lower K and then pursue thrombectomy with ___.
However, patient chose to leave AMA on morning of ___.
Patient repeatedly and very clearly told that there is high
concern for sudden death at home with current level of
potassium, particularly with inability to dialyze until ___.
He can clearly verbalize this concern, but wishes to go home
regardless. He is aware that lethal arrhythmia can develop at
home with absolutely no warning and no ability to have time to
call ___. We did discuss that compliance with medical
recommendations are important part of transplant evaluation and
selection.
# ESRD on HD MWF:
BUN 87, Creatinine 15.2 on admission. No evidence of volume
overload or uremia. As above, only tolerated HD for two hours
and adamantly refused temporarily HD line. Continued home
selevamer and calcium acetate.
#HFrEF:
TTE on ___ showed moderately-to-severely depressed systolic
function secondary to global contractile dysfunction and
dyssynchrony w/LVEF 30%. Continued metoprolol, atorvastatin,
aspirin.
# History of PE:
Diagnosed in ___. Therapeutic on Coumadin. continued
warfarin.
# Hypertension:
continued home metoprolol.
TRANSITIONAL ISSUES:
- patient requires K+ check as soon as possible. Last K+ 7.1 on
discharge
- patient requires AVF thrombectomy.
- full code
- HCP: ___ Relationship: Friend; Phone number:
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ciprofloxacin
Attending: ___.
Chief Complaint:
Right lower extremity pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female with a history of recent diagnosis
of AML NPM1+, FLT3, who presents with worsening right lower
extremity calf pain and ankle swelling. She is now d+15 after
7+3. She is being admitted for workup of her worsening right
calf pain.
Ms ___ first developed these symptoms 1.5 weeks ago
and they have progressed over the last week. She feels some
pain with weight-bearing and has begun favoring walking on her
left foot. She denies fevers, chills or erythema at the site
over the past four days. Dorsiflexion and plantar flexion
worsens the right calf pain which begins at the calf and runs
down to the foot along the back of the leg.
She had an ultrasound performed on ___ for these symptoms which
revealed a nodule measuring 2.7 x 1 x 1.7 cm in the distal,
medial portion of the calf.
Given her worsening pain over the last few days, she presented
to the ED for re-evaluation. In the ED, a repeat US was
performed which showed a nodule of 3.65 x 1.25 x 1.4 cm, which
is significantly larger than previous. The appearance is
vascular and heterogenous.
Review of systems is negative for chest pain, chest pressure,
shortness of breath, nausea, vomiting, diarrhea, anorexia,
jaundice, dysuria. No muscle or joint pain at any other sites
other than described above.
Past Medical History:
AML (NPM1+, FLT3) normal cytogenetics
Induction chemotherapy c/b typhlitis
Pulmonary nodules ___
SEASONAL ALLERGIES
s/p Breast Implants
ECZEMA
asthma
migraines
Social History:
___
Family History:
Her father has HTN. Brothers with HTN and HLD. Her mother has
hypertension and there is breast or any types of cancer in her
family.
Physical Exam:
VS: 97.8, 118/60, 67, 20, 98% RA
Gen: Pleasant, Caucasian female in no apparent distress
HEENT: Anicteric, oral mucosa clear
Cardiac: Nl s1/s2 RRR no murmurs appreciable
Pulm: clear bilaterally
Abd: soft, nontender and nondistended with normoactive bowel
sounds
Ext: right ankle 1+ edema at ankle and extending upward to the
right calf; no palpable mass on the right calf, no evidence of
erythema; left foot/ankle normal in appearance and on palpation
VSS
Heart, lungs, abd were all within normal limits
Right ankle 1+ edema at lateral malleolus and extending upward
to right calk. No palpable mass on right calf, no evidnece of
overlying skin changes or erythema
Pertinent Results:
ADMIT LABS:
___ 01:21AM BLOOD WBC-4.8 RBC-3.02* Hgb-9.3* Hct-25.6*
MCV-85 MCH-30.6 MCHC-36.1* RDW-15.6* Plt ___
___ 01:21AM BLOOD Neuts-36* Bands-1 ___ Monos-19*
Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-5* Promyel-1* Blasts-4*
NRBC-1*
___ 01:21AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Spheroc-2+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr-OCCASIONAL
___ 01:21AM BLOOD ___ PTT-36.6* ___
___ 01:21AM BLOOD Plt Smr-VERY HIGH Plt ___
___ 01:21AM BLOOD Glucose-90 UreaN-6 Creat-0.4 Na-144 K-4.1
Cl-105 HCO3-31 AnGap-12
___ 01:21AM BLOOD ALT-14 AST-19 LD(LDH)-307* AlkPhos-50
TotBili-0.2
___ 01:21AM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.2 Mg-2.2
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-6.7 RBC-3.35* Hgb-9.9* Hct-29.1*
MCV-87 MCH-29.6 MCHC-34.1 RDW-16.5* Plt ___
___ 07:45PM BLOOD Neuts-64 Bands-2 ___ Monos-7 Eos-0
Baso-0 Atyps-2* Metas-2* Myelos-2* Other-1*
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-87 UreaN-8 Creat-0.5 Na-142 K-4.2
Cl-104 HCO3-28 AnGap-14
___ 06:25AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.2
IMAGING:
US: ___:
There is normal compression and augmentation in the right common
femoral, superficial femoral and popliteal veins. There is
normal flow seen within the calf veins. Normal respiratory
phasicity is seen within the common femoral veins bilaterally.
Again, seen with in the distal medial portion of the calf is a
heterogeneous nodule which has increased in size, now measuring
3.65 x 1.25 x 1.4 cm and previously measuring 2.7 x 1 x 1.7 cm.
This nodule again demonstrates internal flow as demonstrated on
Power Doppler.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation prn wheezing
2. Multivitamins 1 TAB PO DAILY
3. Acyclovir 400 mg PO Q8H
4. Voriconazole 300 mg PO Q12H
5. Lorazepam 0.5 mg PO/IV Q6H:PRN nausea, insomnia, anxiety
please do not take this and drink alcohol or drive because it
causes drowsiness
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Lorazepam 0.5 mg PO/IV Q6H:PRN nausea, insomnia, anxiety
3. Multivitamins 1 TAB PO DAILY
4. Voriconazole 300 mg PO Q12H
5. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation prn wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
right lower extremity nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Right calf tenderness with recent induction chemotherapy for AML.
TECHNIQUE: Duplex Doppler examination was performed on the right lower
extremity.
COMPARISON: Right lower extremity ultrasound ___.
FINDINGS: There is normal compression and augmentation in the right common
femoral, superficial femoral and popliteal veins. There is normal flow seen
within the calf veins. Normal respiratory phasicity is seen within the common
femoral veins bilaterally.
Again, seen with in the distal medial portion of the calf is a heterogeneous
nodule which has increased in size, now measuring 3.65 x 1.25 x 1.4 cm and
previously measuring 2.7 x 1 x 1.7 cm. This nodule again demonstrates
internal flow as demonstrated on Power Doppler.
A small amount of fluid is seen superior to the calcaneus.
IMPRESSION:
1. No right lower extremity DVT.
2. Right lower extremity nodule with internal vascularity which has increased
in size from approximately 2 days prior. Again, this may represent a
hematoma, although, a another solid lesion is also a possibility. If this
doesn't resolve clinically, either followup ultrasound in 4 weeks or MRI is
recommended.
Radiology Report
HISTORY: ___ female with AML and new nodule on right lower extremity
ultrasound.
COMPARISON: Right lower extremity ultrasound of ___.
TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the right calf were
obtained on a 1.5 T magnet. Sequences were acquired before and after
administration of 6 cc of IV gadolinium contrast.
FINDINGS:
1.8 x 1.3 x 3.2 cm (transverse x AP x sagittal ___ lesion centered in
the mid-calf between the flexor hallucis longus and soleus muscles is faintly
T1-hyperintense to muscle, heterogeneously T2-hyperintense, and has a thick
rim of peripheral enhancement with small central nonenhancement. There is
moderate adjacent soft tissue edema. The muscular structures of the calf
otherwise have normal bulk and signal.
This examination is not tailored for evaluation of the ligamentous structures.
Within this limitation, the lateral ligamentous structures, deep and
superficial deltoid ligaments appear intact. The anterior extensor tendons,
medial flexor tendons, and peroneal brevis and longus tendons are intact. The
Achilles tendon is normal. The retrocalcaneal and superficial bursa are
unremarkable.
The cartilage of the tibiotalar and subtalar joints is maintained. The marrow
signal is within normal limits. No ankle joint effusion.
IMPRESSION:
3.2 x 1.8 x 1.3 x cm lesion centered between the flexor hallucis longus and
soleus muscles is faintly T1-hyperintense, heterogeneously T2-hyperintense,
and has a thick rim of peripheral enhancement with central nonenhancement.
This is of uncertain etiology and could represent a developing hematoma,
abscess, or a leukemic focus with central necrosis. This lesion should be
followed to resolution.
Dr. ___ was unable to be contacted via the paging system and
findings were entered into the critical results dashboard for direct
notification of the ordering provider.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RLE SWELLING
Diagnosed with LOCAL SUPRFICIAL SWELLNG, OTHER ACUTE PAIN , PAIN IN LIMB, ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
temperature: 98.4
heartrate: 78.0
resprate: 16.0
o2sat: 99.0
sbp: 141.0
dbp: 92.0
level of pain: 4
level of acuity: 2.0 | A/P:
___ year old female who is s/p 7+3 for NPM1+ FLT3+ AML presenting
with persistent right lower extremity pain and swelling.
# Right lower extremity pain: Pt presents with right lower
extremity pain, which is not a DVT. Based on US findings, may be
consistent with hematoma, given flow characteristics. ___ denies
any fevers, chills. While pt has pulm nodules, given lack of
other infectious sx, would not think that nodules in leg
represents fungal process. Also would consider whether this
represents leukemic involvement. Given recent neutropenia and
abnormal findings, will obtain MRI RLE to furhter characterize
the lesion. As pt is reliable and egaer to return home and does
not clinically appear to have evidence of significant leg
pain/tenderness or other evidnece pathology, that would be
worrisome for other emergent processes (e/g/ fasciitis), will DC
pt with MRI final read pending with plan to call pt and ask her
to return should MRI of RLE reveal issues that require urgent
intervention such as biopsy.
.
# AML with normal cytogenetics NPM1+, FLT3+: Day 14 BM negative.
BM from day ___ is pending.
.
# Pulm nodules: Was noted on prior CT which was suspected to be
possible infection (questionably fungal) - bronchoscopy was
considered on prior admission however was not performed because
patient decided against procedure. Pt will continue voriconazole
for treatment of presumed fungal infection with plan to check
B-glucan and galactomannan.
.
# Migraines: Pt may take tylenol prn, though advised not to take
standing adn to check temperature prior to taking tylenol.
.
# Anxiety: Patient is understandably very emotional and gets
easily worked up. Pt was continued on lorazepam 0.5mg PO q4h prn
.
#Asthma - albuterol nebs prn
TRANSITION ISSUES
# check beta d glucan and galactomannan from ___ and beta D
glucan on ___
# follow-up on pulm nodules with repeat CT in 2 weeks
# follow-up on RLE MRI results
# f/u BM biopsy to assess for CR1 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lisinopril / amitriptyline
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___: Laparascopic cholecystectomy
History of Present Illness:
___ PMHx for type I diabetes, depression, atrial fibrillation
not on anti-coagulation who presents to the ED with abdominal
pain, nausea with concerns for clinical cholecystitis. Of
significance, patient has a complicated PMH including type I
diabetes and depression. Patient states that for the past week
or so, she has had worsening abdominal pain, nausea, with some
inability to tolerate PO intake, albeit still passing gas and
having BMs.
Past Medical History:
Past Psychiatric History:
- Diagnoses: Depression
- SA/SIB: denies/denies
- Hospitalizations: denies/denies
- Psychiatrist: none
- Therapist: none
- Medication Trials: "I've been on everything"
Past Medical History:
- ___ esophagus
- CAD s/p NSTEMI in the setting of DKA
- HTN
- A-fib, rate controlled
- Type I DM
- Diabetic retinopathy
- Diabetic neuropathy
- Cerebral ataxia
- history of follicular lymphoma s/p rituximab
- Chronic anemia
- chornic diarrhea secondary to SIBO
Social History:
___
Family History:
Family History:
- Diagnoses: mother with ?bipolar disorder, not formerly
diagnosed
- Suicides: denies
- Addictions: Denies
Physical Exam:
Physical exam on Admission:
Vitals: Normal
General: AAOx3
Cardiac: Normal S1, S2
Respiratory: RA, equal breath sounds
Abdomen: Soft, tender, mid-epigastric region, no rebound or
guarding, tender RUQ, negative for ___ sign.
PHYSICAL EXAM ON DISCHARGE:
Physical exam:
Vitals: 24 HR Data (last updated ___ @ 2250)
Temp: 97.8 (Tm 98.1), BP: 126/66 (117-171/63-76), HR: 75
(72-86), RR: 16 (___), O2 sat: 96% (90-97), O2 delivery: 2l
nc,
Wt: 151.6 lb/68.77 kg
Gen: [x] NAD, [] AAOx3
CV: [x] RRR, [] murmur
Resp: [x] breaths unlabored, [] CTAB, [] wheezing, [] rales
Abdomen: [x] soft, [] distended, [x] tender, diffusely []
rebound/guarding
Wound: [] incisions clean, dry, intact
Ext: [x] warm, [] tender, [] edema
Pertinent Results:
CT ABD & PELVIS WITH CONTRAST Study Date of ___
1. No acute intra-abdominal or intrapelvic process.
Specifically, no evidence
of cholecystitis or colitis.
2. Diverticulosis without evidence of diverticulitis.
3. Cholelithiasis without evidence of acute cholecystitis.
US ABD LIMIT, SINGLE ORGAN Study Date of ___
Limited exam secondary to patient discomfort. Within these
limitations, there is cholelithiasis without ultrasound evidence
of acute cholecystitis.
CHEST (PA & LAT) Study Date of ___
No focal consolidations, pneumothorax, or pleural effusion.
ADMISSION LABS:
___ 12:50PM BLOOD WBC-10.8* RBC-3.91 Hgb-11.8 Hct-35.8
MCV-92 MCH-30.2 MCHC-33.0 RDW-12.4 RDWSD-41.2 Plt ___
___ 04:46AM BLOOD ___ PTT-24.8* ___
___ 01:55PM BLOOD Glucose-315* UreaN-24* Creat-1.3* Na-142
K-3.3* Cl-98 HCO3-25 AnGap-19*
___ 01:55PM BLOOD ALT-11 AST-13 AlkPhos-100 TotBili-0.4
___ 01:55PM BLOOD Lipase-29
___ 01:55PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:55PM BLOOD Albumin-4.3
___ 12:55PM BLOOD %HbA1c-6.9* eAG-151*
___ 11:23PM BLOOD ___ pO2-30* pCO2-49* pH-7.38
calTCO2-30 Base XS-1
___ 12:58PM BLOOD Lactate-1.4
___ 11:23PM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 04:49AM BLOOD WBC-12.8* RBC-2.98* Hgb-9.3* Hct-28.4*
MCV-95 MCH-31.2 MCHC-32.7 RDW-12.1 RDWSD-42.1 Plt ___
___ 04:49AM BLOOD Glucose-151* UreaN-23* Creat-1.4* Na-145
K-3.3* Cl-104 HCO3-27 AnGap-14
___ 04:49AM BLOOD ALT-18 AST-24 AlkPhos-70 TotBili-0.4
___ 04:49AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.5*
MICRO:
___ 7:08 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 10:17 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 11:20 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Apixaban 5 mg PO BID
2. Atorvastatin 40 mg PO QPM
3. BuPROPion (Sustained Release) 150 mg PO BID
4. ClonazePAM 0.25 mg PO QHS
5. DULoxetine ___ 80 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Succinate XL 150 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Sertraline 200 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Vitamin B Complex 1 CAP PO DAILY
14. Glargine 18 Units Breakfast
Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Glucose Gel 15 g PO PRN hypoglycemia protocol
3. Glargine 8 Units Breakfast
Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. BuPROPion (Sustained Release) 150 mg PO BID
8. ClonazePAM 0.25 mg PO QHS
9. Docusate Sodium 100 mg PO BID
10. DULoxetine ___ 80 mg PO DAILY
11. Losartan Potassium 100 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
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: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ with DMI, CAD, HTN presents with 7 days N/V and 2 days of RUQ
pain, evaluate for cholelithiasis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
The exam was aborted early due to patient discomfort.
LIVER: Limited views of the liver demonstrate normal appearance of the hepatic
parenchyma. The contour of the liver is smooth.
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
IMPRESSION:
Limited exam secondary to patient discomfort. Within these limitations, there
is cholelithiasis without ultrasound evidence of acute cholecystitis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with N/V with each PO intake x 1 week with ___ days of RUQ
pain, evaluate for cholecystitis or colitis.
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 6.0 s, 47.6 cm; CTDIvol = 15.7 mGy (Body) DLP = 746.1
mGy-cm.
Total DLP (Body) = 758 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___ and ultrasound abdomen
dated ___..
FINDINGS:
LOWER CHEST: There is minimal bibasilar atelectasis. Otherwise, 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 contains gallstones without
wall thickening or surrounding inflammation, similar in appearance compared to
prior study dated ___.
PANCREAS: There is redemonstration of moderate atrophy of the pancreatic body
and tail, without evidence of focal lesions or pancreatic ductal dilatation.
There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape. The left
adrenal gland is thickened without evidence of a discrete nodule.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There are subcentimeter hypodensities in the upper pole of the right kidney,
too small to characterize. There is no evidence of hydronephrosis. Bilateral
renal vascular calcifications are noted. There is no perinephric abnormality.
GASTROINTESTINAL: Hiatal hernia is noted. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is colonic
diverticulosis without evidence of wall thickening or pericolonic stranding.
Otherwise, 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. Surgical clips are again noted in the right
inguinal region.
REPRODUCTIVE ORGANS: The uterus is retroverted. There are no adnexal
abnormalities.
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 moderate multilevel degenerative changes of the thoracolumbar
spine, most prominent at L4-L5. Chronic appearing right posterior eleventh
and twelfth rib fractures are again noted. There is no evidence of worrisome
osseous lesions or acute fracture.
SOFT TISSUES: Hyperdense material is again seen within the umbilicus,
unchanged. The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intra-abdominal or intrapelvic process. Specifically, no evidence
of cholecystitis or colitis.
2. Diverticulosis without evidence of diverticulitis.
3. Cholelithiasis without evidence of acute cholecystitis.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with fever. Evaluate for infection.
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
The lungs are clear without evidence of focal consolidations. There is no
pleural effusion or pneumothorax. The cardiomediastinal silhouette is within
normal limits. The visualized upper abdomen is unremarkable. Mild right
basilar atelectasis. Mild perihilar bronchial wall thickening bilaterally
IMPRESSION:
No focal consolidations, pneumothorax, or pleural effusion.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V, RUQ abdominal pain
Diagnosed with Unspecified abdominal pain
temperature: 95.9
heartrate: 112.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 74.0
level of pain: 5
level of acuity: 3.0 | Patient is a ___ year old female with past medical history of
type I diabetes, depression, and atrial fibrillation not on
anti-coagulation who presents to the ED with complaints of
abdominal pain, nausea with concerns for clinical cholecystitis.
Imaging was completed following arrival which demonstrated
cholelithiasis without ultrasound evidence of acute
cholecystitis. Therefore acute care surgery was consulted for
evaluation and management.
She was then taken to the operating room and underwent
laparoscopic cholecystectomy on ___. (Please see operative
report for details of this procedure). She tolerated the
procedure well, was extubated upon completion, and was
subsequently taken to the PACU for recovery.
Once pain was well controlled, and the patient experienced a
return of bowel function, her diet was advanced as tolerated.
During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient
became hypoglycemic and the ___ Diabetes inpatient service
adjusted her insulin regimen which she tolerated well. An
appointment was made for her on ___ at 1:00PM at the
___ Diabetes ___ to re-evaluate the new insulin regimen.
The patient 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. She was
afebrile and her vital signs were stable. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and her pain was well controlled. The patient was
discharged home without services. Discharge teaching was
completed and follow-up instructions were reviewed with reported
understanding and agreement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lidocaine
Attending: ___
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with ___ stage IV (brain met s/p resection and
cyberknife) C1D8 carboplatin gemcitabine (first round last
___ who presented to ___ clinic today with persistent,
severe fatigue and found to have HCT 17%. Pt reported dark BMs
for a week. He was sent to the ED for eval. Heme/onc recommended
CT torso to assess for hemorrrhagic pleural effusion from his
cancer, and also for intraabdominal mass. In ED, patient had one
episode of guaiac positive stool, NG lavage attempted but pt did
not tolerate placement. Patient complaining of ongoing shortness
of breath and had one episode of lightheadedness with standing
up in ED, but denies chest pain, n/v, abdominal pain, BRBPR,
hemotypsis or hematemesis.
.
In the ED inital vitals were, T 99.2 126 119/74 16 98% RA. Got 2
L NS in ED and ordered for 2 units blood. Started on protonix
gtt. Given cefepime for T 99.2. GI consulted, they will not
scope emergently unless he decompensates. Non-con CT of
abdomen/pelvis done to evaluate for RP bleed. CXR unchanged from
prior. Access is 20-gauge x 2.
.
On arrival to the ICU, patient reports stable shortness of
breath, denies lightheadedness, chest pain, abdominal pain, n/v
or other problems. He also reports feeling warm this morning,
but no chills.
.
Review of systems:
(+) Per HPI
(-) Denies chills. Denies headache, rhinorrhea or congestion.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, abdominal pain. Denies
dysuria, frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
Past Medical History:
Pertinent Oncologic history (include past therapies, surgeries,
etc):
___ squamous cell carcinoma stage IV
- ___ Presented with constipation, R side weakness
- ___ Presented to OSH, found to have L brain met, R lung
mass, malignant hypercalcemia, transferred to ___
- ___ CT and MRI head showed L hemispheric cortical
enhancing lesion with extensive surrounding edema and necrosis
- ___ Bronchoscopy biopsy showed ___ SCC
- ___ Underwent resection of L brain met
- ___ MRI showed possible residual tumor
- ___ Presented for initial outpatient oncology visit and
found to be hypoxic and tachycardic. Send to ED. Felt to be due
to COPD.
- ___ Cyberknife to his residual brain met
- ___ Zoledronic acid for Ca ___ and 2 unit RBCs
- ___ cycle 1 of carboplatin and gemcitabine
.
Other Past Medical History:
- Diverticulitis ___ s/p partial colectomy
- Ventral hernia from partial colectomy
- s/p L3-4 fusion and laminectomy ___
- s/p fall down stairs with head trauma
- Polyp on past colonoscopy ___ years ago per patient)
Social History:
___
Family History:
- Mother: ___ dementia
- Father: ___ cancer
Physical Exam:
ADMISSION EXAM:
.
General: Chronically ill appearing male, gray appearing. Alert,
no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, decreased breath
sounds RLL, no wheezes, rales, rhonchi
CV: tachycardic, normal S1/S2, no murmurs, rubs, gallops
Abdomen: well healed midline surgical scar, +ventral hernia that
reduces on its own. Soft, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, some peripheral edema, LLE
> RLE. no clubbing, cyanosis.
.
DISCHARGE EXAM:
98.2 102/64 -118/69 107-122 22 98% RA
GENERAL: NAD
SKIN: warm and well perfused
HEENT: NCAT,anicteric sclera, pale conjunctiva, MMM
CARDIAC: tachycardic, S1/S2, no mrg
LUNG: Decreased breath sounds at right base
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding. ventral hernia noted
M/S: moving all extremities, however unable to lift left arm
against gravity, otherwise strength ___. trace ___ edema
bilaterally. no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: awake, A&Ox3. CN II-XII intact
.
Pertinent Results:
ADMISSION LABS:
___ 11:45AM BLOOD WBC-9.8 RBC-2.36*# Hgb-5.1*# Hct-17.0*#
MCV-72* MCH-21.5* MCHC-29.9* RDW-20.2* Plt ___
___ 11:45AM BLOOD Neuts-72.8* Bands-0 ___ Monos-7.9
Eos-0.8 Baso-0.2
___ 03:12PM BLOOD ___ PTT-32.7 ___
___ 03:12PM BLOOD ___
___ 11:45AM BLOOD ___ ___
___ 11:45AM BLOOD UreaN-12 Creat-0.5 Na-134 K-4.0 Cl-101
HCO3-25 AnGap-12
___ 11:45AM BLOOD ALT-92* AST-53* LD(LDH)-1246* AlkPhos-129
TotBili-0.1
___ 11:45AM BLOOD Albumin-2.5* Calcium-10.6*
.
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-8.5 RBC-3.16* Hgb-8.2* Hct-24.2*
MCV-77* MCH-25.8* MCHC-33.7 RDW-19.2* Plt ___
___ 06:05AM BLOOD ___ PTT-29.7 ___
___ 06:05AM BLOOD Glucose-107* UreaN-7 Creat-0.5 Na-132*
K-3.8 Cl-100 HCO3-26 AnGap-10
___ 06:05AM BLOOD ALT-81* AST-54* LD(LDH)-1112* AlkPhos-121
TotBili-0.4
___ 06:05AM BLOOD Calcium-9.4 Phos-1.7* Mg-2.0
.
MICROBIOLOGIC DATA:
___ Blood culture (x 2) - pending
___ MRSA screen - pending
___ urine culture - ___ organisms
.
IMAGING STUDIES:
___ CHEST (PORTABLE AP) - Two portable AP views of the chest
are compared to previous exam from ___. There is
stable right basilar opacity compatible with patient's known
lung mass. Elsewhere, the lungs are grossly clear.
Cardiomediastinal silhouette is again notable for thickening of
the right paratracheal stripe compatible with known mediastinal
adenopathy. Osseous and soft tissue structures are grossly
unremarkable.
.
___ CT ABD & PELVIS W/O CON - No evidence of a
retroperitoneal hematoma. Markedly increased retrocrural,
retroperitoneal, and mesenteric lymphadenopathy, as described
above. Incompletely evaluated large right lower lobe pulmonary
mass, not significantly changed in size compared to CT from
___. Richter-type ventral abdominal wall hernia,
involving the transverse colon. No evidence of obstruction or
strangulation. Non-specific lucency within the left iliac bone,
not significantly changed in appearance.
.
LENIS ___: IMPRESSION: No bilateral lower extremity DVT.
Medications on Admission:
Oxycontin 20 mg BID
Oxycodone 10 mg q4hrs prn for pain
Keppra 750 mg BID
Albuterol neb q6 hrs prn for shortness of breath
Nystatin swish/swallow 5 cc QID
Ondansetron 8 mg TID prn nausea
Prochlorperazine 10 mg q6hr prn nausea
Quetiapine 25 mg ___ tab qHS prn anxiety/insomnia
Ranitidine 150 mg BID
Ibuprofen 500 mg BID prn pain
Discharge Medications:
1. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours.
Disp:*90 Tablet(s)* Refills:*0*
3. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) cc PO four
times a day: swish and swallow.
6. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia/anxiety.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnoses: anemia, lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST X-RAY: ___
HISTORY: ___ male with cancer, anemia, and dyspnea. Question
pneumonia or effusion.
FINDINGS: Two portable AP views of the chest are compared to previous exam
from ___. There is stable right basilar opacity compatible with
patient's known lung mass. Elsewhere, the lungs are grossly clear.
Cardiomediastinal silhouette is again notable for thickening of the right
paratracheal stripe compatible with known mediastinal adenopathy. Osseous and
soft tissue structures are grossly unremarkable.
IMPRESSION: No acute cardiopulmonary process. Large right basilar mass and
mediastinal adenopathy.
Radiology Report
INDICATION: Hematocrit drop, evaluate for retroperitoneal bleed.
TECHNIQUE: MDCT axial images were acquired from the lung bases through the
lesser trochanters without the administration of oral or intravenous contrast
material. Multiplanar reformations were performed.
COMPARISON: CT abdomen and pelvis from ___.
ABDOMEN CT: Within the right lower lobe, there is a large mass, measuring up
to 12.5 x 10.5 cm in its greatest axial ___, not significantly changed
in size compared to ___, but incompletely evaluated on this
non-contrast study. As mentioned on the previous CT report, this mass encases
the right inferior pulmonary vein. The remainder of the visualized portions
of lung bases are clear. Relative hypodensity of blood within the ventricles
compared to the myocardium is consistent with anemia. There is a trace
pericardial effusion, as before.
Lack of intravenous contrast material limits assessment of the abdominal
organs. The liver is within normal limits. Mild gallbladder wall thickening
likely relates to the gallbladder's contracted state. The spleen, pancreas,
adrenal glands, and kidneys are within normal limits. A small right renal
hypodensity seen on prior CT from ___ is not well assessed on the
current study given the lack of intravenous contrast material. The stomach is
unremarkable. The small bowel is within normal limits. There is a
Richter-type hernia involving the transverse colon along the mid ventral
abdominal wall (2:34), unchanged in appearance. There is evidence of prior
partial colectomy (2:66). There is no bowel wall thickening or obstruction.
There is no free fluid or free air in the abdomen. Extensive retrocrural,
retroperitoneal, and mesenteric lymphadenopathy is increased compared to CT
from ___. For example, a previously seen tiny left paraaortic
node now measures 2.7 x 1.3 cm (2:47) and a previously 11 x 9 mm aortocaval
node now measures 16 x 13 mm (2:38). The abdominal aorta is normal in
caliber. Scattered aortic and biiliac artery calcifications are seen. There
is no retroperitoneal hematoma.
PELVIS CT: The bladder is unremarkable. Coarse prostatic calcifications are
seen. There is no free fluid in the pelvis. No pathologically enlarged
pelvic lymph nodes are seen.
BONE WINDOW: Within the left iliac bone, there is a small lucency (2:58),
nonspecific in nature, but not significantly changed in appearance compared to
CT from ___. No suspicious blastic lesions are seen. Multilevel
degenerative changes of the thoracolumbar spine are most severe at L4-5 and
L5-S1 where there is marked endplate sclerosis and disc vacuum phenomenon. As
before, the patient is status post bilateral L4 and L5 laminectomies. An old
posterior left tenth rib fracture is again seen.
IMPRESSION:
1. No evidence of a retroperitoneal hematoma.
2. Markedly increased retrocrural, retroperitoneal, and mesenteric
lymphadenopathy, as described above.
3. Incompletely evaluated large right lower lobe pulmonary mass, not
significantly changed in size compared to CT from ___.
4. Richter-type ventral abdominal wall hernia, involving the transverse
colon. No evidence of obstruction or strangulation.
5. Nonspecific lucency within the left iliac bone, not significantly changed
in appearance.
Radiology Report
INDICATION: ___ male with metastatic non-small cell lung carcinoma,
asymmetric leg swelling.
No prior examinations for comparison.
BILATERAL LOWER EXTREMITY ULTRASOUND: There is normal compressibility, flow,
and augmentation in the bilateral common femoral, greater saphenous,
superficial and deep femoral, and popliteal veins. Color flow is also noted
in the posterior tibial and peroneal veins. There is moderate subcutaneous
edema.
IMPRESSION: No bilateral lower extremity DVT.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVER/HCT DROP
Diagnosed with ANEMIA NOS, TACHYCARDIA NOS, GASTROINTEST HEMORR NOS
temperature: 99.2
heartrate: 126.0
resprate: 16.0
o2sat: 98.0
sbp: 119.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ with ___ stage IV (brain met s/p resection and
cyberknife) s/p C1 of carboplatin gemcitabine on ___ who
presented to clinic with fatigue found to have a HCT of 17 now
s/p ICU stay with 5 units PRBCs.
.
# GASTROINTESTINAL BLEEDING - Patient had guaiac positive stool
in the ED (confirmed by ___ physician) with an unsuccessful
nasogastric lavage. There was initial concern for upper
gastrointestinal bleeding given his hematocrit of 17% (10% drop
since ___ - though that was after transfusion for a
hematocrit of 23% on ___. Patient has been taking Ibuprofen
for headache while on steroids, which could predispose the
patient to gastritis among other issues. Patient does report
history of polyps on colonoscopy ___ prior and has known
diverticular disease, which could be a source for lower GI
bleeding. We initiated a Protonix infusion following a bolus and
consulted the GI specialists. He was maintained NPO with plans
for endoscopy, however HCT stabilized and he remained
hemodynamically stable without evidence of frank melana or
hematochezia. He received 5 units of packed red cells on
admission for his hematocrit of 17%. His HCT stabilized between
24 and 25. Given risks associated with intervention and the lack
of evidence for acute bleeding the decision was made to
empirically treat with PPI without endoscopy. The protonix gtt
was changed to IV BID and then omeprazole 40 mg po BID. His INR
was elevated likely in the setting malnutrition and he was given
1 unit of PRBC and vitamin K. Patient was monitored overnight
and continued to remain stable. He was discharged with plans to
avoid NSAIDS and with a prescription for a PPI.
.
# SEVERE MICROCYTIC ANEMIA - Patient has unclear hematocrit
baseline and has known anemia with recent hematocrit of 23%
following recent transfusion in ___ clinic.
Chronic GI bleeding, marrow suppression given his underlying
malignancy vs. marrow suppressive therapy could be contributing.
We monitored his hematocrit serially and transfused as needed.
.
# METASTATIC NON-SMALL CELL LUNG CANCER - The patient is
status-post resection and cyberknife of brain metastatsis and
first cycle of chemotherapy. He was continued on his Keppra
dosing for seizure prophylaxis and oxycontin and oxycodone for
pain. The patient was evaluated by the palliative care team.
Patient decided at this time he is interested in full aggressive
care including CPR and intubation but not prolonged intubation.
Once he feels that he is declining and nearing death, he says
that he will likely choose to die without resuscitation but is
not at that point now. Patient was discharged with plans for
home visiting care (minimal services at this time) and potential
bridge to hospice should that be decided as the next step.
Patient has plans to follow up with his outpatient oncologist
next week and issues of goals of care will be discussed during
that visit.
.
# SINUS TACHYCARDIA - On reviewing his record, patient's
baseline heart rate has been in the 110-120s (lowest HR recorded
in clinic was 112), except for a single EKG from ___
documenting a rate of 80 bpm. Unclear etiology likely ___
anemia. Patient continued to have sinus tachycardia despite
blood tranfusions and IVF making hypovolemia less likely. Had
CTA chest on ___ which was negative for PE and patient
remained in no respiratory distress, without pleuritic chest
pain, and maintained oxygen saturations in the ___ on room air.
LENIs were negative for DVT. Also, likely component of
overlying anxiety.
.
# ASTHMA, COPD - Patient denies history of COPD, however given
his smoking history, this was likely. Patient did not appear to
be in exacerbation during admission. He was treated with
albuterol nebulizer treatments as needed.
.
# FEVERS - Patient had reported temperature of 99.2F in the ED,
and was given Cefepime for unclear source. The patient does have
stable and chronic non-productive cough, but his CXR did not
appear to demonstrate pneumonia. An infectious work-up was
performed with reassuring blood and urine cultures.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone
Attending: ___.
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
NGT placement and removal
History of Present Illness:
___ with stage IIIC possible fallopian tube primary
adenocarcinoma, intestinal type s/p ex-lap, radical
hysterectomy, BSO, small bowel resection, rectosigmoid
resection, omentectomy, pelvic LND, end colostomy, cysto on
___ currently in cycle 4 of chemotherapy (FOLFOX) s/p
recent high grade SBO managed
conservatively with NGT ___.
Today she reports onset of abdominal pain coinciding with
absence of ostomy output (stool nor flatus) since the morning,
similar to previous presentation. She began to experience nausea
and emesis x2 over the course of the day prompting her
presentation for care. Still with no ostomy output s/p NGT
placement for 400cc. Denies fevers, chills, chest pain,
shortness of breath, dysuria, leg swelling, rash.
Past Medical History:
ONCOLOGIC HISTORY:
- ___: had constipation, abdominal pain, CT scan that showed
a complex multiloculated predominantly cystic 11.5 x 9 x 8.7 cm
pelvic mass w/ intracystic mural solid subcomponents that was
highly suspicious for ovarian neoplasm. No pelvic ascites was
visualized. The liver had several variably sized lesions that
appeared most consistent radiographically with cysts.
- ___: negative endometrial biopsy
- ___: CA125 of 58, a CEA of 10.2 and a ___ of 16,480.
- ___: diagnostic laparoscopy that was converted to
laparotomy with type 2 radical oophorectomy inclusive of an en
bloc radical hysterectomy, bilateral salpingo-oophorectomy,
rectosigmoid resection with an omentectomy, bilateral pelvic
lymph node dissection, small bowel resection, end colostomy, and
cystoscopy. Pathology of her tumor tissue returned as metastatic
adenocarcinoma,intestinal type. Adenocarcinoma was present in
the
bilateral ovaries, bilateral fallopian tubes and omentum. The
tumor showed transmural mesorectal infiltration without a
mucosal
lesion. Metastatic mesenteric implants were present on the small
bowel mesentery and cecum without mucosal lesions. The umbiical
nodule was positive for disease. Six of 30 pericolonic lymph
nodes and 1 of 5 pelvic lymph nodes were positive for disease.
Washings were also positive. While a fallopian tube primary was
favored, evaluation for an intestinal or pancreaticobiliary
primary was recommended.
- ___: negative colonsocopy
- ___: port placed
- ___ - ___: admitted for partial SBO (conservative
management)
- ___: C1D1 FOLFOX
- ___: C1D15 FOLFOX
- ___ - ___: ED for abdominal pain, nausea, given antibx
for
colitis
- ___ - ___: admitted for SBO (conservative management with
NGT)
- ___: C2D1 FOLFOX
- ___: C3D1 FOLFOX
- ___: C3D15: held FOLFOX fro neutropenia, received neulasta
- ___: NGT placement for high grade SBO with resolution,
discharged ___
- ___ C4D1: FOLFOX
Social History:
___
Family History:
denies bleeding/clotting disorders, gyn/GI malignancies, breast
cancer
Physical Exam:
Admission exam:
Gen: NAD
HEENT: NGT in place with 400cc brown/green output
CV: RRR
Pulm: CTAB, normal work of breathing
Abd: soft, mildly distended, tympanic with hyperactive bowel
sounds. Ostomy bag without air or stool, last changed this
morning, ostomy pink.
Pelvic: deferred
Ext: no edema
Discharge exam:
Gen - NAD
CV - RRR
Lungs - CTAB
Abd - soft, NT, ND, no r/g, +bowel sounds, + gas and brown stool
in ostomy bag, osotmy pink
Ext - nontender, no edema
Pertinent Results:
___ 05:27AM BLOOD WBC-4.9 RBC-3.04* Hgb-8.9* Hct-27.6*
MCV-91 MCH-29.3 MCHC-32.2 RDW-17.5* RDWSD-58.2* Plt ___
___ 05:00AM BLOOD WBC-5.4# RBC-3.39* Hgb-9.9* Hct-29.7*
MCV-88 MCH-29.2 MCHC-33.3 RDW-17.8* RDWSD-57.1* Plt ___
___ 07:41PM BLOOD WBC-17.9*# RBC-3.92 Hgb-11.5 Hct-35.0
MCV-89 MCH-29.3 MCHC-32.9 RDW-18.1* RDWSD-59.1* Plt ___
___ 05:00AM BLOOD Neuts-64.2 ___ Monos-4.3*
Eos-0.2* Baso-0.6 Im ___ AbsNeut-3.44# AbsLymp-1.61
AbsMono-0.23 AbsEos-0.01* AbsBaso-0.03
___ 07:41PM BLOOD Neuts-92.0* Lymphs-4.9* Monos-2.3*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-16.48*# AbsLymp-0.87*
AbsMono-0.42 AbsEos-0.00* AbsBaso-0.03
___ 07:41PM BLOOD ALT-29 AST-28 AlkPhos-133* TotBili-0.8
___ 05:27AM BLOOD Glucose-100 UreaN-9 Creat-0.6 Na-140
K-3.7 Cl-107 HCO3-25 AnGap-12
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
HYDROMORPHONE - hydromorphone 2 mg tablet. ___ tablet(s) by
mouth
every ___ hours as needed for pain
LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth three
times a day as needed for nausea, anxiety
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth once a day
ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by
mouth every eight (8) hours as needed for nausea ICD 10
Code:C57.00 Malignant neoplasm of unspecified fallopian tube
PRENATAL VITS-IRON FUM-FOLIC [M-VIT] - M-Vit 27 mg-1 mg tablet.
1
tablet(s) by mouth once a day - (Prescribed by Other Provider)
PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg
tablet.
1 tablet(s) by mouth every six (6) hours as needed for nausea
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by
mouth
every six (6) hours as needed for pain - (Prescribed by Other
Provider)
CALCIUM-VITAMIN D3-VITAMIN K [CALCIUM SOFT CHEW] - Calcium Soft
Chew 500 mg-1,000 unit-40 mcg tablet. 1 tablet(s) by mouth once
a
day - (Prescribed by Other Provider)
CETIRIZINE [ALL DAY ALLERGY (CETIRIZINE)] - All Day Allergy
(cetirizine) 10 mg tablet. 1 tablet(s) by mouth once a day -
(Prescribed by Other Provider; ___)
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by
mouth twice a day - (Prescribed by Other Provider)
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with likely sbo, NGT placed// confirm NGT
placement
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Enteric tube tip seen within the stomach, side-port just past the GE junction.
Right chest wall port is seen with catheter tip projecting over the lower SVC.
The lungs are clear without consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits. No free intraperitoneal
air.
IMPRESSION:
Enteric tube tip in the stomach.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified intestinal obstruction
temperature: 98.0
heartrate: 99.0
resprate: 16.0
o2sat: 100.0
sbp: 114.0
dbp: 82.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ was admitted to the gyn/onc service with an SBO.
Given her symptoms were similar to prior recent presentations
and she had no peritoneal signs on examination, imaging was
referred. An NGT was placed for bowel rest/decompression in the
ED. Her white blood cell count was noted to be elevated, but
there was no clinical evidence of infection (normal exam,
normal lactate). A repeat CBC on hospital day 1 showed a normal
WBC
She was managed conservatively during her admission with an NG
tube.
On hospital day 3, she began noticing more stool and gas in her
ostomy. She had minimal residual on an NGT clamp trial. Her NGT
was removed and her diet was
advanced without issue. On hospital day #3 she was tolerating a
regular
diet. She was discharged home in stable condition with
outpatient follow-up planned. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Speech disturbance; right face, arm, and leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an ___ year old right handed woman with past medical
history of atrial fibrillation not on anticoagulation whom
presents as transfer from ___ with suspected left MCA
syndrome and consideration of possible thrombectomy.
Patient's history was obtained after speaking to her neighbor
whom is her health care proxy on the phone.
Patient's neighbor reports that she had a conversation with
patient on the phone at about 5:00 ___ and patient was in normal
state of health and without dysarthria.
Patient at about 9:30 ___ arrived at neighbor's door and was
signaling for help. Patient could not speak and had a right
facial droop. Patient could walk on her own and did not look
unsteady.
EMS was immediately called and neighbor noticed that the patient
could not reliably follow any directions on both sides of body.
Patient was taken to ___. Patient's initial images were
of poor quality and it could not be determined if there was
proximal major vessel cutoff. Patient was transferred to ___
for escalation of care by ground transportation.
Per neighbor, patient is very independent at baseline and
requires no assistance with activities of daily living.
Patient's
neighbor had patient's home medications and they are:
Aspirin 81 mg daily
Metoprolol 25 mg BID
Torsemide 20 mg daily
Dorzolamide eye drops, 1 drop in right eye twice daily
Latanoprost eye drop, 1 drop in right eye twice daily
Patient's neighbor knew that patient had atrial fibrillation,
but
did not know why she was not on anticoagulation.
Past Medical History:
Atrial fibrillation not on anticoagulation, reason unknown
Chronic swelling of her legs
Right eye problems, neighbor did not know issue
Social History:
Patient lives alone in a home. Patient's husband lives in a
nursing home and has severe alzheimer's disease. Patient has no
children and no other family.
Modified Rankin Scale:
[x] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Neighbor does not know, not pertinent to this admission.
Physical Exam:
ADMISSION EXAMINATION
=====================
Vitals:
Temperature: 97.8
Blood pressure: 149/98
Heart rate: 67
Oxygen saturation: 95%
General physical examination:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic:
Mental status:
Patient alert, crying, appears very frustrated and confused.
Patient is trying to communicate, but examiner cannot understand
what she is trying to say (broken words).
Cranial nerves:
Patient with post surgical fixed right ovoid pupil, left pupil
briskly reactive to light. EOMI grossly normal, but cannot
formally test. Facial sensation intact. Right lower quadrant
facial droop. Hearing intact. Patient will not open mouth.
Shoulders sit symmetrically.
Motor examination:
Patient will not comply for formal examination. Patient's left
side of the body is strongly antigravity. Patient's right arm
when lifted at the shoulder quickly falls back the bed. Patient
with antigravity ability to flex at elbow. Patient with right
wrist drop and her fingers are held in flexion. Of note, the
movement of the right upper extremity is greatly improved from
initial presentation when it appeared densely plegic. Patient's
right lower extremity is strongly antigravity.
Sensation:
Patient signals that she appreciates sensation of crude touch in
upper and lower extremities. Patient without tactile neglect.
Coordination:
Could not assess
Reflexes:
Patient would not relax for examination. No pectoral or cross
abductor reflexes. Ankle reflexes symmetric. Strong withdrawal
to plantar reflexes.
Gait:
Deferred.
DISCHARGE EXAMINATION
=====================
Vitals: Temp: 98.2 (Tm 98.5), BP: 103/59 (93-120/42-72), HR: 73
(72-88), RR: 18 (___), O2 sat: 96% (92-100), O2 delivery: RA
General: awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Alert, cooperative. Non-fluent aphasia with
impaired comprehension, though able to follow some midline and
appendicular commands, and somewhat improved compared to prior.
-Cranial Nerves: No BTT in right field OD, though with limited
visual acuity per patient. Face largely symmetric with
activation. Hearing intact to conversation.
-Motor: No pronator drift, able to maintain BUE and BLE against
gravity.
-Sensory: Deferred.
-DTRs: ___.
-Coordination: Deferred.
Pertinent Results:
___ 06:25AM BLOOD WBC-6.1 RBC-3.82* Hgb-11.4 Hct-35.7
MCV-94 MCH-29.8 MCHC-31.9* RDW-16.0* RDWSD-54.9* Plt ___
___ 09:45AM BLOOD ___ PTT-30.0 ___
___ 06:25AM BLOOD Glucose-81 UreaN-11 Creat-0.9 Na-146
K-4.2 Cl-111* HCO3-20* AnGap-15
___ 09:45AM BLOOD ALT-25 AST-32 LD(LDH)-215 CK(CPK)-64
AlkPhos-45 TotBili-1.2
___ 04:10AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.4
___ 09:45AM BLOOD GGT-28
___ 09:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:45AM BLOOD %HbA1c-5.4 eAG-108
___ 09:45AM BLOOD Triglyc-97 HDL-49 CHOL/HD-3.1 LDLcalc-85
___ 09:45AM BLOOD TSH-3.6
___ 09:45AM BLOOD CRP-2.4
___ 02:18AM URINE Color-Straw Appear-Clear Sp ___
___ 02:18AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 02:18AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 2:18 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 1:28 AM CTA HEAD AND CTA NECK; CT BRAIN PERFUSION
1. Study is degraded by motion and dental amalgam streak
artifact, especially limiting evaluation of the posterior fossa.
2. Within limits of study, no definite acute intracranial
hemorrhage. Please note MRI of the brain is more sensitive for
the detection of acute infarct.
3. CT perfusion demonstrates increased mean transit time with
areas of mildly decreased cerebral blood flow within the left
parietal temporal lobe. If
clinically indicated, consider brain MRI for further evaluation.
4. Decreased distal arborization of the left M3/M4 branches,
which may
correlate with the area of decreased cerebral perfusion.
5. Punctate left expected P1 origin probable infundibulum versus
approximately 1 mm aneurysm.
6. Otherwise grossly patent intracranial and cervical carotid
and vertebral arteries.
7. 1.5 cm partially calcified inferior left thyroid nodule.
Please see
recommendation below.
8. Nonspecific cervical lymphadenopathy as described, image may
be reactive, however neoplastic or inflammatory etiologies are
not excluded on the basis of this examination. Recommend
correlation with oncologic history.
9. Limited imaging lungs demonstrate moderate to severe
centrilobular
emphysematous changes with air trapping. If clinically
indicated, consider dedicated chest imaging for further
evaluation.
___ 6:36 ___ CHEST (PORTABLE AP)
There is no opacity projecting along the periphery of the right
mid lung which may reflect atelectasis and/or consolidation.
Patchy retrocardiac opacities likely also reflect atelectasis.
There is no pneumothorax or large pleural effusion. The size of
the cardiac silhouette is mildly enlarged and there is a
tortuous
thoracic aorta. No radiodense foreign object is seen within the
visualized thorax.
___ 6:36 ___ PORTABLE ABDOMEN
No radiopaque foreign object is identified within the abdomen or
pelvis.
Portable TTE ___ at 11:04:10 AM
Mild symmetric left ventricular hypertrophy with preserved
global
and regional biventricular systolic function. Suggestion of
elevated LV filling pressure and significant diastolic
dysfunction. Mild aortic regurgitation. Moderate to severe
mitral
regurgitation. Moderate pulmonary hypertension. Possible ASD
with
left to right flow, a focused study with saline contrast may be
considered for further evaluation if clinically indicated.
___ 9:41 AM VIDEO OROPHARYNGEAL SWALLOW
1. Trace penetration of nectar thick liquids.
2. Trace silent aspiration with thin liquids.
___ 8:50 AM MR HEAD W/O CONTRAST
1. Multiple foci of acute to subacute left MCA territory
infarct,
likely thromboembolic given distribution pattern.
2. Sequelae of probable chronic small vessel ischemic disease.
Medications on Admission:
1. Aspirin EC 81 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Torsemide 20 mg PO DAILY
4. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE BID
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 (One) tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
2. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 (One) tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
4. Latanoprost 0.005% Ophth. ___. 1 DROP RIGHT EYE BID
5. Metoprolol Tartrate 25 mg PO BID
6. Torsemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Left middle cerebral artery ischemic infarct
2. Atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD.
INDICATION: ___ year old woman with atrial fibrillation not on anticoagulation
whom presents with aphasia, dysarthria, right face and arm weakness.// Stroke,
suspect left cortical.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Prior CTA head from ___.
FINDINGS:
Limited examination due to patient motion, within this limitation, there are
multiple foci of restricted diffusion in the left MCA territory with
associated increased T2/FLAIR signal compatible with acute to subacute
infarct, likely thromboembolic given distribution pattern. Additional small
foci of high T2/FLAIR signal in the subcortical, deep, and periventricular
white matter of the cerebral hemispheres, which are nonspecific but may be
related to sequela of chronic small vessel ischemic disease in a patient of
this age. There is no evidence of intracranial hemorrhage, mass, or midline
shift. The ventricles and sulci are normal in caliber and configuration.
There major arterial flow voids are grossly preserved. The visualized
paranasal sinuses mastoid air cells are clear. The orbits are unremarkable.
IMPRESSION:
1. Multiple foci of acute to subacute left MCA territory infarct, likely
thromboembolic given distribution pattern.
2. Sequelae of probable chronic small vessel ischemic disease.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:37 am.
Radiology Report
EXAMINATION: Fluoroscopic video oropharyngeal swallow
INDICATION: ___ year old woman with L MCA stroke c/b dysphagia// Assess for
dysphagia
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 2 minutes 4 seconds.
COMPARISON: None
FINDINGS:
Trace penetration was seen with nectar thick liquids. Trace silent aspiration
was noted with thin liquids when taking larger sips.
IMPRESSION:
1. Trace penetration of nectar thick liquids.
2. Trace silent aspiration with thin liquids.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
INDICATION: ___ year old woman with stroke, needs MRI.// Eval for metallic
foreign body prior to MRI.
TECHNIQUE: AP portable chest radiograph
COMPARISON: None
IMPRESSION:
There is no opacity projecting along the periphery of the right mid lung which
may reflect atelectasis and/or consolidation. Patchy retrocardiac opacities
likely also reflect atelectasis. There is no pneumothorax or large pleural
effusion. The size of the cardiac silhouette is mildly enlarged and there is
a tortuous thoracic aorta. No radiodense foreign object is seen within the
visualized thorax.
Radiology Report
INDICATION: ___ year old woman with stroke, needs MRI.// Eval for metallic
foreign body prior to MRI.
TECHNIQUE: 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 unremarkable. No radiopaque foreign object is
identified. Contrast material opacifies the bladder.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No radiopaque foreign object is identified within the abdomen or pelvis.
Radiology Report
EXAMINATION: CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK
INDICATION: History: ___ with weakness// stroke
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 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) Sequenced Acquisition 8.0 s, 8.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
401.4 mGy-cm.
3) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP =
2,513.8 mGy-cm.
4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
5) Spiral Acquisition 4.7 s, 37.0 cm; CTDIvol = 31.8 mGy (Head) DLP =
1,177.7 mGy-cm.
Total DLP (Head) = 5,026 mGy-cm.
COMPARISON: None.
FINDINGS:
Study is degraded by motion and dental amalgam streak artifact, especially
limiting evaluation of the posterior fossa..
CT HEAD:
Within these limitations, there is no evidence for acute hemorrhage, mass
effect, or edema.
The ventricles and sulci are moderately prominent compatible global
parenchymal volume loss. Periventricular and subcortical white matter FLAIR
hyperintensities are noted, a nonspecific finding that most likely represents
the sequelae of chronic small vessel ischemic disease.
The paranasal sinuses, middle ear cavities, and mastoid air cells are clear.
The patient is status post bilateral lens replacement..
CTA HEAD AND NECK:
There is a normal 3 vessel aortic arch identified. The vertebral arteries are
patent without high-grade stenosis or occlusion.
The bilateral common carotid arteries are patent. Minimal calcifications are
seen at the bilateral carotid bulbs. Mild partially calcified atherosclerotic
disease within the proximal internal carotid arteries resulting approximately
20% stenosis by NASCET criteria on the right, without definite stenosis on the
left.
Mild-to-moderate calcifications are seen at the bilateral cavernous internal
carotid arteries. Although no discrete vessel occlusion is identified, there
appears to be mildly decreased asymmetric arborization of the distal left
M3/M4 branches (for example, 601:26).
Question left P1 origin infundibulum versus approximately 1 mm aneurysm (see
658:17). Otherwise, no additional sites of high-grade stenosis, occlusion, or
aneurysm. There is a fetal origin of the left posterior communicating artery.
The dural venous sinuses are patent.
CT PERFUSION:
There is a moderate sized area of increased mean transit time with mildly
decreased cerebral blood flow seen within the left parietal temporal lobe.
This correlates with a mismatch volume of 42 mm, per the RAPID software.
OTHER:
The lung apices demonstrate moderate to severe centrilobular emphysematous
changes, subpleural reticulations, and evidence of mild air-trapping.
The thyroid gland is diffusely heterogeneous and demonstrates 1.5 cm irregular
nodule with mild peripheral calcification seen extending from the posterior
inferior left thyroid lobe.
Multiple prominent cervical and mediastinal lymph nodes are identified, none
of which are pathologically enlarged by CT size criteria.
IMPRESSION:
1. Study is degraded by motion and dental amalgam streak artifact, especially
limiting evaluation of the posterior fossa.
2. Within limits of study, no definite acute intracranial hemorrhage. Please
note MRI of the brain is more sensitive for the detection of acute infarct.
3. CT perfusion demonstrates increased mean transit time with areas of mildly
decreased cerebral blood flow within the left parietal temporal lobe. If
clinically indicated, consider brain MRI for further evaluation.
4. Decreased distal arborization of the left M3/M4 branches, which may
correlate with the area of decreased cerebral perfusion.
5. Punctate left expected P1 origin probable infundibulum versus approximately
1 mm aneurysm.
6. Otherwise grossly patent intracranial and cervical carotid and vertebral
arteries.
7. 1.5 cm partially calcified inferior left thyroid nodule. Please see
recommendation below.
8. Nonspecific cervical lymphadenopathy as described, image may be reactive,
however neoplastic or inflammatory etiologies are not excluded on the basis of
this examination. Recommend correlation with oncologic history.
9. Limited imaging lungs demonstrate moderate to severe centrilobular
emphysematous changes with air trapping. If clinically indicated, consider
dedicated chest imaging for further evaluation.
RECOMMENDATION(S):
1. Nonspecific cervical lymphadenopathy as described, image may be reactive,
however neoplastic or inflammatory etiologies are not excluded on the basis of
this examination. Recommend correlation with oncologic history.
2. Thyroid nodule. Ultrasound follow up recommended if not already performed.
___ College of Radiology guidelines recommend further evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5
cm in patients age ___ or older, or with suspicious findings.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 21:58 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Aphasia, Transfer
Diagnosed with Weakness
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 2.0 | Ms. ___ is an ___ woman with history notable for
atrial fibrillation (not on anticoagulation), HFpEF, and
___ transferred from ___ after presenting with
aphasia and right face, arm, and leg weakness, found to have
multifocal L MCA ischemic infarcts. Thrombolytics not
administered due to presentation outside the tPA window, and CT
imaging of the head and neck otherwise negative for large vessel
occlusion amenable to thrombectomy. Mechanism of infarction
accordingly most likely atrial fibrillation not on
anticoagulation, which, per discussion with Ms. ___ PCP,
was due to patient preference. Accordingly, anticoagulation
initiated with apixaban to reduce risk of future strokes, along
with low-intensity atorvastatin therapy given likely
cardioembolic mechanism and low atherosclerotic burden on
imaging.
Hospital course complicated by non-fluent aphasia and
dysarthria, for which SLP evaluation recommended modified diet.
TRANSITIONAL ISSUES
1. Continued SLP evaluation and advancement of diet as
indicated.
2. Thyroid ultrasound to evaluate incidentally-noted left
thyroid nodule.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 85) - () No
5. Intensive statin therapy administered? () Yes - (x) No [Low
atherosclerotic burden and cardioembolic mechanism of stroke]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (x) No [Low
atherosclerotic burden and cardioembolic mechanism of stroke]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
35 minutes were spent on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy on ___
History of Present Illness:
___ w/lymphoma, C. diff presents with abdominal pain. Pain
started yesterday morning. It is constant and located in the
right upper quadrant. Associated with nausea and emesis. The
pain is very similar to her prior diverticulitis. She is not on
chemotherapy. No fever no chills. She is currently being treated
for Cdiff and continues to have diarrhea.
In ED pt given morphine, Zofran, 1Lns, Maalox, cipro, donnatol
and viscous lidocaine. Pt went directly to ERCP when she was
found to have a stenotic papilla and biliary sludge.
On arrival to the floor pt
ROS: +as above, otherwise reviewed and negative
Past Medical History:
IBS
COPD
Obesity
T2DM
MALT Lymphoma
- s/p 2 cycles of Rituxan/Bendamustine
Diverticulitis
Social History:
___
Family History:
Maternal aunt had breast cancer at age ___. She has 3 sisters
and 1
half brother. One sister had lymphoma at age ___, another sister
had brain cancer at age ___. A half brother had brain cancer at
age ___.
Physical Exam:
ADMISSION EXAM:
Vitals: T:98.1 BP:119/75 P:75 R:16 O2:97%ra
PAIN: 0
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
.
.
DISCHARGE EXAM:
Gen: Comfortable sitting up in bed
HEENT: EOMI, sclera anicteric, MMM
Cards: RR, no m/r/g
Chest: CTAB
Abd: soft, not distended, very mild tenderness in epigastrium
and RUQ, otherwise non-tender throughout, BS+, no rigidity or
rebound tenderness
Ext: WWP
Neuro: AAOx3, clear speech
Psych: calm, cooperative
Pertinent Results:
ADMISSION LABS:
___ 04:30AM GLUCOSE-161* UREA N-10 CREAT-0.7 SODIUM-142
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17
___ 04:46AM LACTATE-1.7
___ 04:30AM ALT(SGPT)-390* AST(SGOT)-775* ALK PHOS-185*
TOT BILI-2.3* DIR BILI-1.8* INDIR BIL-0.5
___ 04:30AM LIPASE-54
___ 04:30AM ALBUMIN-4.2 CALCIUM-9.8 PHOSPHATE-3.5
MAGNESIUM-1.9
___ 04:30AM WBC-5.5# RBC-3.95 HGB-11.9 HCT-35.7 MCV-90
MCH-30.1 MCHC-33.3 RDW-16.0* RDWSD-53.2*
___ 04:30AM NEUTS-85.4* LYMPHS-3.1* MONOS-9.5 EOS-1.1
BASOS-0.5 IM ___ AbsNeut-4.70# AbsLymp-0.17* AbsMono-0.52
AbsEos-0.06 AbsBaso-0.03
___ 04:30AM PLT COUNT-207
___ 04:30AM ___ PTT-28.0 ___
___ 08:20AM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 08:20AM URINE RBC-7* WBC-148* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
___ 08:20AM URINE COLOR-Yellow APPEAR-Hazy SP ___
NOTABLE LABS WHILE INPATIENT:
.
LFTS -
___ 04:30AM BLOOD ALT-390* AST-775* AlkPhos-185*
TotBili-2.3* DirBili-1.8* IndBili-0.5
___ 07:00AM BLOOD ALT-259* AST-207* AlkPhos-201*
TotBili-0.7
___ 05:22AM BLOOD ALT-163* AST-77* AlkPhos-169* TotBili-0.7
___ 05:32AM BLOOD ALT-107* AST-34 AlkPhos-141* TotBili-0.6
.
Lipase -
___ 04:30AM BLOOD Lipase-54
___ 07:00AM BLOOD Lipase-2469*
___ 05:22AM BLOOD Lipase-269*
___ 05:32AM BLOOD Lipase-46
IMAGING/PROCEDURES:
ERCP
Impression: Initial cannulation of the biliary duct with the
sphincterotome and a cannulation was not successful due to an
extremely stenotic papilla.
Because the papilla was stenotic, a small pre-cut needle knife
sphincterotomy was made.
A small amount of bile flow was then seen. Following the
pre-cut sphincterotomy, deep cannulation was ultimately
successful with a sphincterotome
No evidence post sphincterotomy bleeding was noted
The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles and cystic duct were filled with
contrast and well visualized.
The course and caliber of the structures are normal with no
evidence of extrinsic compression, no ductal abnormalities, and
no filling defects,
8 mm balloon was used to sweep the CBD, initial sweep showed
small amount of sludge. Sweeps were repeated until no further
sludge was noted.
There was excellent flow of bile at the end of the procedure
Otherwise normal ercp to third part of the duodenum
.
.
DISCHARGE LABS:
___ 05:32AM BLOOD WBC-4.3 RBC-3.48* Hgb-10.6* Hct-30.8*
MCV-89 MCH-30.5 MCHC-34.4 RDW-15.0 RDWSD-48.3* Plt ___
___ 05:32AM BLOOD Glucose-98 UreaN-5* Creat-0.6 Na-142
K-3.2* Cl-104 HCO3-29 AnGap-12
___ 05:32AM BLOOD ALT-107* AST-34 AlkPhos-141* TotBili-0.6
___ 05:32AM BLOOD Lipase-46
___ 05:32AM BLOOD Calcium-9.1 Phos-2.7 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. colestipol 5 gm oral BID
2. Vancomycin Oral Liquid ___ mg PO Q6H
3. Omeprazole 20 mg PO DAILY
4. Acyclovir 400 mg PO Q12H
5. Citalopram 20 mg PO DAILY
6. LORazepam 0.5 mg PO Q6H:PRN nausea, anxiety and insomnia
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Simvastatin 20 mg PO QPM
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Citalopram 20 mg PO DAILY
3. colestipol 5 gm oral BID
4. Omeprazole 20 mg PO DAILY
5. Vancomycin Oral Liquid ___ mg PO Q6H
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Doses
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*3 Tablet Refills:*0
7. LORazepam 0.5 mg PO Q6H:PRN nausea, anxiety and insomnia
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
# Biliary Obstruction: ___ choledocholithiasis s/p ERCP on
___
# Post-ERCP pancreatitis
Secondary:
# C. diff
# Lymphoma
# Type II DM - diet controlled
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Gen: Comfortable sitting up in bed
HEENT: EOMI, sclera anicteric, MMM
Cards: RR, no m/r/g
Chest: CTAB
Abd: soft, not distended, very mild tenderness in epigastrium
and RUQ, otherwise non-tender throughout, BS+, no rigidity or
rebound tenderness
Ext: WWP
Neuro: AAOx3, clear speech
Psych: calm, cooperative
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ woman presenting with RUQ abdominal pain. Evaluate
for pneumonia.
TECHNIQUE: PA and lateral radiograph views of the chest.
COMPARISON: Fluoroscopic chest, ___. Limited reference is made to
FDG PET-CT dated ___.
FINDINGS:
A right Port-A-Cath tip ends in the lower SVC. Right perifissural opacity
corresponds to known FDG avid lesion, better appreciated on the PET-CT from
___. No focal consolidation to suggest pneumonia. No pleural effusion,
edema, or pneumothorax. The cardiomediastinal silhouette is normal. The
descending thoracic aorta is mildly tortuous. No acute osseous abnormality.
IMPRESSION:
1. No focal pneumonia.
2. Right perifissural opacity appears to correspond to known FDG avid lesion
on PET-CT from ___.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ woman presenting with right upper quadrant abdominal
pain. Evaluate for cholecystitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis dated ___ ; FDG PET-CT 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. The CHD measures 9 mm,
appears to measured up to 8 mm on CT from ___.
GALLBLADDER: There is cholelithiasis. Echogenic foci a with ring down
artifact suggests adenomyomatosis. No gallbladder wall thickening or
pericholecystic fluid. No sonographic ___ sign.
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 9.9 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cholelithiasis.
2. Gallbladder adenomyomatosis.
3. Ectatic CBD, measuring 9 mm, measuring 8 mm on a recent CT. No ductal
stones detected. No intrahepatic bile duct dilation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Calculus of bile duct w/o cholangitis or cholecyst w/o obst
temperature: 96.1
heartrate: 105.0
resprate: 16.0
o2sat: 96.0
sbp: 181.0
dbp: 87.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ is a ___ y/o F w/lymphoma, C. diff presents with
abdominal pain due to biliary obstruction now s/p ERCP with
sphincterotomy on ___, but with recurrent abdominal pain with
improving LFTs but newly elevated lipase most likely due to
post-ERCP pancreatitis, which subsequently resolved with
conservative measures (NPO, IVF, pain control). On the day of
discharge, her lipase had normalized and she was tolerating a
normal diet with no abdominal pain. Regarding her biliary
obstrcution ___ choledocholithiasis, the patient will follow-up
with surgery as an outpatient to discuss possible
cholecystectomy, as she did not want to pursue any surgical
intervention during this hospitalization. She will complete 5
days of oral ciprofloxacin for ppx per ERCP team recs. She was
advised to avoid aspirin, plavix, NSAIDs, coumadin and other
anticoagulant medications for 5 days following her procedure.
She was otherwise continued on her home medications during
hospitalization.
Time in care: 45 minutes in patient care, patient counseling,
care coordination and other discharge-related activities on the
day of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
PEG ___
IVC filter ___
History of Present Illness:
Ms. ___ is an ___ woman with history of hypertension,
hyperlipidemia, and hypothyroidism who presents as a transfer
from ___ with a complaint of altered mental status in the
context of one day of epigastric pain followed by 3 episodes of
vomiting. Per outside reports, the patient was complaining of
abdominal pain at home with her son. She got up to go to the
bathroom, vomited with retching, and walked over to the couch to
sit, and her son noted that she "looked off". She was taken to
an outside hospital where she was noted to have depressed mental
status, aphasic, and progressively became more unresponsive and
seemed to have a left gaze preference, right sided facial droop,
and was without movement of the right upper or lower
extremities. A non-contrast Head CT was obtained, and notable
for left frontal IPH. The patient was given Zofran, Ativan in
order to obtain the CT scan prior to transfer here. She was
given 1 g of Keppra prior to arrival.
In ED initial VS: HR:93; 157/66; RR: 20; POx:100% NRB
Exam notable for: Somnolent, not responding to questioning but
does move intermittently to command. Withdrawing bilateral lower
extremities to painful stimuli, squeezes left hand on command
but not seen moving the right upper extremity. Left gaze
preference.
Labs significant for: WBC 10.8, HGB: 10.5, PLT: 178, Creatinine
1.2, BUN: 26, Bicarb 20, K 3.6, Na: 138, Cl: 104, AST: 674, ALT:
443, TBili: 1.6, Albumin 3.8.
Serum tox negative for ASA, EtOH, APAP, Tricyclic.
Urine tox negative.
Patient was intubated with propofol, etomidate, and succ, and
given 1L NS.
Imaging notable for: RUQUS without cholelithiasis or
cholecystitis, and mild left hydronephrosis. CXR Confirmed ET
tube placement
Consults: Neurology: recommended MICU admission for further work
up of transaminitis. Recommended blood pressure management for
IPH.
VS prior to transfer: HR:83 BP:122/69 RR:16 POx:100% Intubated
On arrival to the MICU, the patient is intubated and sedated.
Past Medical History:
Left carotid stenosis, reportedly 85%
Hypertension
Hyperlipidemia
Hypothyroidism
Arthritis
Social History:
___
Family History:
Siblings with hypertension, heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T:99.3, P:68, RR: 16, Pox: 100%
GENERAL: Intubated, sedated, not arousable to voice
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No jaundice or rashes
NEURO: Right sided facial droop. Unable to assess further as
patient sedated.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: ___ 1208 Temp: 98.1 PO BP: 126/74 HR: 89 RR: 16 O2
sat: 99% O2 delivery: Ra
General: Minimally verbal. No acute distress
Cardiac: Well perfused.
Lungs: Breathing comfortably on room air.
Abdomen: nondistended nontender
Ext: no edema, trigger finger left hand ___ digit
Neuro: ___ speaking only
MS- Awake, alert, follows simple commands in ___, able to
say
short phrases mostly in ___ (name, "good morning"),
___.
CN- PERRL ___ bilat, left gaze preference, slight right facial
droop with poor activation
Sensory/Motor-
LUE antigravity
LLE antigravity
RUE moves in plane of bed
RLE moves in plane of bed
Pertinent Results:
ADMISSION LABS:
===============
___ 02:00AM BLOOD WBC-10.8* RBC-3.48* Hgb-10.5* Hct-32.3*
MCV-93 MCH-30.2 MCHC-32.5 RDW-13.6 RDWSD-46.0 Plt ___
___ 02:00AM BLOOD Neuts-95.4* Lymphs-2.0* Monos-1.9*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-10.27* AbsLymp-0.21*
AbsMono-0.20 AbsEos-0.00* AbsBaso-0.01
___ 02:00AM BLOOD ___ PTT-23.0* ___
___ 02:00AM BLOOD Glucose-152* UreaN-26* Creat-1.2* Na-138
K-3.6 Cl-104 HCO3-20* AnGap-14
___ 02:00AM BLOOD ALT-443* AST-674* AlkPhos-85 TotBili-1.6*
___ 08:15AM BLOOD Lipase-1811*
___ 02:00AM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.3 Mg-1.7
___ 08:15AM BLOOD Free T4-1.3
___ 08:15AM BLOOD TSH-1.2
___ 02:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 02:08AM BLOOD ___ pO2-31* pCO2-45 pH-7.34*
calTCO2-25 Base XS--2
___ 02:08AM BLOOD Lactate-1.4
___ 02:08AM BLOOD O2 Sat-53
IMAGING:
========
___ CT H:
1. Interval increase in size of the left frontotemporal
intraparenchymal
hemorrhage, with underlying subarachnoid hemorrhage and left
parietal
involving. Mild interval increase in mass effect with midline
shift up to 5 mm.
RUQUS:
No cholelithiasis or cholecystitis.
TTE: no thrombus
___ CT Torso
1. No evidence of malignancy within the abdomen or pelvis.
2. Asymmetric enlargement of the right common femoral vein,
compared to the left. Recommend further evaluation with
ultrasound to assess for possible AV shunt or thrombus.
3. Slight interval improvement in mild peripancreatic fat
stranding,
compatible with the patient's known acute pancreatitis. No
adjacent fluid
collections or vascular complications.
4. No significant change in gallbladder wall edema, possibly due
to hepatic dysfunction or third spacing.
5. Please refer to the separate report of the chest CT performed
on the same day for thoracic characterization.
___ MRI/MRA
1. In comparison with initial head CT from an outside
institution dated ___ at 22:50 7 hours, there is a
larger left frontotemporal
intraparenchymal hemorrhage with underlying subarachnoid
hemorrhage extending towards the left frontoparietal regions as
described detail above as well as the left sylvian fissure.
There is no evidence of abnormal enhancement surrounding the
hematoma or increased vascularity, however underlying conditions
cannot be completely excluded, long-term followup until complete
resolution of the hematoma is advised.
2. Approximately 4 mm of midline shifting towards the right is
identified
with adjacent vasogenic edema surrounding the left
frontoparietal hematoma.
3. Grossly unchanged oval-shaped T1 hypointense, T2 and FLAIR
hyperintense lesion in the right temporal lobe, with partial
enhancement and incomplete halo susceptibility suggestive of a
second hemorrhagic lesion, measuring approximately 2 x 1.5 cm
in transverse dimension, with no significant mass effect.
TTE: No intracardiac source of thromboembolism identified.
Preserved biventricular systolic function. Mild mitral
regurgitation. Mild pulmonary hypertension
___ DVT US: Nonocclusive deep vein thrombosis of the right
popliteal vein, and occlusive deep vein thrombosis of the right
peroneal veins.
MRCP ___:
FINDINGS:
Patient terminated the study earlier. Not all pre contrast
sequences were
performed, and gadolinium was accordingly not administered.
Dedicated MRCP sequences are nondiagnostic due to motion
artifact. However, no evidence for pancreatic mass is found on
limited imaging. There is no biliary or pancreatic ductal
dilatation. No gallstones are found. No inflammatory changes
are found. No focal liver lesions are identified. Limited
imaging sequences show no abnormalities involving spleen,
adrenals or kidneys. Visualized stomach and bowel are
unremarkable. No enlarged lymph nodes are found. No ascites is
noted. Limited visualization of the lungs is unremarkable.
Narrowing increased signal on T2 weighted imaging within the
L2-L3 and L3-L4 interspaces is probably degenerative.
IMPRESSION:
Incomplete imaging showing no evidence of significant
abnormality. Completion of MRCP imaging could be considered or
alternatively, if it may be difficult to complete the imaging
using MR, multiphasic CT could be considered as an alternative.
DISCHARGE LABS:
================
___ 04:45AM BLOOD WBC-3.4* RBC-3.51* Hgb-10.8* Hct-33.6*
MCV-96 MCH-30.8 MCHC-32.1 RDW-16.0* RDWSD-55.8* Plt ___
___ 04:45AM BLOOD Plt ___
___ 04:45AM BLOOD Glucose-104* UreaN-15 Creat-1.1 Na-134*
K-4.7 Cl-101 HCO3-21* AnGap-12
___ 04:45AM BLOOD Calcium-9.8 Phos-4.3 Mg-2.1
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Cyclobenzaprine 10 mg PO TID:PRN pain
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Acetaminophen 500 mg PO Q8H
6. Lidocaine 5% Patch 1 PTCH TD Q12H
7. Sucralfate 1 gm PO TID
8. Rosuvastatin Calcium 10 mg PO QPM
9. Pantoprazole 40 mg PO Q24H
10. Baclofen 10 mg PO TID
11. Zolpidem Tartrate 5 mg PO QHS:PRN Insomnia
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
2. Heparin 5000 UNIT SC BID
3. Miconazole Powder 2% 1 Appl TP BID:PRN vaginal irritation
4. Multivitamins W/minerals Chewable 1 TAB PO DAILY
5. Senna 8.6 mg PO BID
6. Acetaminophen 500 mg PO Q8H
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Rosuvastatin Calcium 10 mg PO QPM
10. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until told to resume by your doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Non traumatic intraparenchymal hemorrhage
Pulmonary edema
Pancreatitis
Dysphagia s/p PEG
UTI
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI of the head and MRA of the head.
INDICATION: ___ woman with new intraparenchymal hemorrhage, rule out
amyloid angiopathy.
TECHNIQUE: Precontrast axial sagittal T1 weighted images were obtained, axial
FLAIR, axial T2, axial magnetic susceptibility and axial diffusion-weighted
images. The T1 weighted images were repeated after the intravenous
administration of 7 mL of Gadavist contrast agent.
MRA of the head. 3D time-of-flight arteriography of the head was obtained,
axial source images and maximum intensity projection images were reviewed.
COMPARISON: Head CT dated ___ at 10:40 hours, prior head CT dated ___.
FINDINGS:
MRI of the brain. In comparison with the initial head CT there is a slightly
larger left frontotemporal intraparenchymal hemorrhage, with underlying
subarachnoid hemorrhage, which is extending towards the left frontoparietal
regions as well as the left sylvian fissure.. The hematoma measures
approximately 6.8 x 4.4 cm in transverse dimension, and on the initial head CT
measures 3.4 x 2.7 cm in transverse dimension, currently the hematoma is
producing effacement of the sulci and approximately 4 mm are fitting of the
normally midline structures towards the right (image 14, series 6). There is
no evidence of intraventricular hemorrhage. The perimesencephalic cisterns
are preserved. There is an unchanged oval-shaped T1 hypointense, T2 and FLAIR
hyperintense lesion in right temporal lobe with an incompletely halo of
susceptibility suggestive of a second hemorrhagic lesion measuring
approximately 2.1 x 1.5 cm in transverse dimension (image 8, series 6),
approximately 2 by 0. 7 cm in coronal projection, please note that this lesion
demonstrates few areas of abnormal enhancement (image 8, series 10) and
probably is consistent with a resolving hematoma.
The major vascular flow voids are present and demonstrate normal distribution.
The orbits are unremarkable, the paranasal sinuses are clear, patchy mucosal
thickening is identified in the mastoid air cells bilaterally.
IMPRESSION:
1. In comparison with initial head CT from an outside institution dated ___ at 22:50 7 hours, there is a larger left frontotemporal
intraparenchymal hemorrhage with underlying subarachnoid hemorrhage extending
towards the left frontoparietal regions as described detail above as well as
the left sylvian fissure. There is no evidence of abnormal enhancement
surrounding the hematoma or increased vascularity, however underlying
conditions cannot be completely excluded, long-term followup until complete
resolution of the hematoma is advised.
2. Approximately 4 mm of midline shifting towards the right is identified
with adjacent vasogenic edema surrounding the left frontoparietal hematoma.
3. Grossly unchanged oval-shaped T1 hypointense, T2 and FLAIR hyperintense
lesion in the right temporal lobe, with partial enhancement and incomplete
halo susceptibility suggestive of a second hemorrhagic lesion, measuring
approximately 2 x 1.5 cm in transverse dimension, with no significant mass
effect.
Radiology Report
EXAMINATION: CT chest with contrast
INDICATION: ___ female with intraparenchymal hemorrhage and concern
for malignancy.
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: None available.
FINDINGS:
ABDOMEN: Included portion of the unenhanced upper abdomen is unremarkable.
No supraclavicular lymphadenopathy is identified.
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. Mild
coronary artery calcifications are visualized otherwise the heart,
pericardium, and great vessels are within normal limits based on an unenhanced
scan. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. NG tube is in place coursing below the diaphragm
terminating within the stomach.
PLEURAL SPACES: Small bilateral pleural effusions are visualized with adjacent
atelectasis.
LUNGS/AIRWAYS: An endotracheal tube is in place. 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.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No intrathoracic findings identified to suggest malignancy.
2. Small bilateral pleural effusions.
Radiology Report
EXAMINATION: CT abdomen and pelvis.
INDICATION: ___ year old woman with IPH and concern for malignancy, repeat
scan. Evaluate for malignancy. Repeat scan with and without IV and PO
contrast
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,378 mGy-cm.
COMPARISON: CT abdomen ___. CT chest ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: A subcentimeter focal hypodensity of the left hepatic lobe is
too small to characterize (02:42). The liver demonstrates homogenous
attenuation throughout. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. Mild gallbladder
wall edema appears similar to the prior study, while small volume
pericholecystic fluid has slightly decreased. No cholelithiasis. The common
bile duct measures approximately 7 mm.
PANCREAS: Mild peripancreatic fat stranding, most evident around the
pancreatic tail and head, appears slightly improved from the prior study. No
adjacent fluid collections, mass, or ductal dilatation.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Bilateral extrarenal pelvises are redemonstrated. The kidneys are of
normal and symmetric size with normal nephrogram. There is no evidence of
focal renal lesions or hydronephrosis.
GASTROINTESTINAL: An enteric tube terminates within the stomach. Small hiatal
hernia. Otherwise, the stomach is unremarkable. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
previously seen omental fat stranding adjacent to the distal transverse colon
appears mildly improved. Mild right lateral conal fascial thickening inferior
to the liver appears unchanged from prior. Sigmoid diverticulosis, without
evidence of acute diverticulitis. Otherwise, the colon and rectum are within
normal limits. The appendix is not definitively identified, but there are no
secondary signs of acute appendicitis.
PELVIS: The bladder is decompressed about a Foley catheter. There is trace
pelvic free fluid.
REPRODUCTIVE ORGANS: The uterus and 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. Mild atherosclerotic disease
is noted. The splenic vein is patent. No evidence of splenic artery
aneurysm. The right common femoral vein appears asymmetrically enlarged
compared to the left (2:110).
BONES: A sclerotic focus of the sacrum (2:87) is likely a bone island. Mild
retrolisthesis of L2 on L3 and L3 on L4 is likely degenerative in etiology.
Multilevel degenerative changes of the thoracolumbar spine are most prominent
within the lumbar spine. There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: Small, fat containing left inguinal hernia. Focal
calcifications overlie the bilateral gluteus muscles. Otherwise, the
abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of malignancy within the abdomen or pelvis.
2. Asymmetric enlargement of the right common femoral vein, compared to the
left. Recommend further evaluation with ultrasound to assess for possible AV
shunt or thrombus.
3. Slight interval improvement in mild peripancreatic fat stranding,
compatible with the patient's known acute pancreatitis. No adjacent fluid
collections or vascular complications.
4. No significant change in gallbladder wall edema, possibly due to hepatic
dysfunction or third spacing.
5. Please refer to the separate report of the chest CT performed on the same
day for thoracic characterization.
RECOMMENDATION(S): Recommend further evaluation with ultrasound of asymmetric
enlargement of the right common femoral vein, for possible AV shunt or
thrombus.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ p/w confusion, epigastric pain, vomiting- tx simple
pancreatitis, intubated, now w/ increased size of IPH concern for underlying
lesion vs. ischemic infarct w/ transformation// assess IPH to start ___
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: CT head ___. MRI brain ___.
FINDINGS:
Mild increase in size of the left frontoparietal and frontotemporal
intraparenchymal hemorrhage with a subarachnoid component, measuring up to 6.7
x 5.2 cm, previously 6.7 x 4.6 cm. A previously identified midline shift is
stable-mildly increased, measuring up to 5 mm. There is effacement of the
left lateral ventricle, with blood seen near the tentorium, which appears
similar to prior. Areas of hyperdensity near the parietal bone suggest some
continued bleeding.
Hypodensity with some hyperdense streaking in the right temporal lobe thought
to be consistent with a second hemorrhagic lesion on prior MRI from ___ appears overall unchanged from prior.
No evidence of large territorial infarct.
There is no evidence of acute 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. Mildly increased size of a left frontoparietal and frontotemporal
intraparenchymal hemorrhage with a subarachnoid component. Stable to mild
increase in midline shift measuring up to 5 mm. No change in effacement the
left lateral ventricle or blood tracking near the tentorium. Hyperdense
material near the parietal bone suggests continued bleeding.
2. Hypodense foci with some hyperdense streaking over the right temporal lobe
is consistent with area of likely second hemorrhagic lesion seen on prior MRI
from ___, and appears overall unchanged.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with IPH and ?dilated common femoral on CT
torso. radiology recommending U/s for evaluation of thrombus.// thrombus in
femoral?
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,
specifically the right common femoral vein is patent.
Radiology Report
INDICATION: ___ year old woman with IPH// consolidation?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The ET tube and NG tube have been removed. Lungs are low volume with
bibasilar atelectasis. Cardiomediastinal silhouette is stable. Small
bilateral effusions have slightly increased in volume. Pulmonary edema is
slightly worsened. No pneumothorax is seen
Radiology Report
INDICATION: ___ year old woman with IPH.
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Radiograph from ___.
FINDINGS:
Mild cardiomegaly persists. An enteric tube extends below the diaphragm with
the tube out of view of this film. Small left pleural effusion with adjacent
atelectasis is seen. There is mild pulmonary vascular congestion. No
definite evidence of pneumothorax.
IMPRESSION:
Small left pleural effusion with adjacent atelectasis. No definite evidence
of pneumothorax. Mild pulmonary vascular congestion.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with L IPH, ? pain in legs in setting of being
bedbound// 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 left popliteal veins. Normal color flow and
compressibility are demonstrated in the left posterior tibial and peroneal
veins. Normal color flow and compressibility is demonstrated within the right
posterior tibial veins. There is noncompressibility of the right popliteal
vein which contains internal echogenic debris and incomplete flow on color
Doppler imaging, consistent with nonocclusive deep vein thrombosis. The right
peroneal veins are noncompressible, contain internal echogenic debris, and do
not demonstrate flow on color Doppler, consistent with occlusive deep vein
thrombosis.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Nonocclusive deep vein thrombosis of the right popliteal vein, and
occlusive deep vein thrombosis of the right peroneal veins.
2. No evidence of deep venous thrombosis in the leftlower extremity veins.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, RDMS on the telephone on ___ at 10:36 am, 2 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with right frontal parietal IPH with residual
right hemiplegia, global aphasia with hospital course now c/b DVT. Right pop
vein non-occlusive DVT and right peroneal vein occlusive in calf on ___ from
___// IVC filter placement iso non-occlusive proximal DVT in patient with
IPH 1 month ago
COMPARISON: CT scan from ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
25mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service
time of 11 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: None
CONTRAST: 15 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 2.0, 64 mGy
PROCEDURE:
1. IVC venogram.
2. Infrarenal Denali IVC filter deployment.
3. Post-filter placement venogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. Both groins were prepped and draped in the usual sterile fashion.
Under ultrasound and fluoroscopic guidance, the patent and compressible Right
common femoral vein was punctured using a 21G micropuncture needle. Ultrasound
images of the access was stored on PACS. A Amplatz wire was advanced through
the micropuncture sheath into the inferior vena cava. The sheath of the IVC
filter was then placed into the iliac vein.
A iliac and inferior vena cava venogram was performed. Based on the results of
the venogram, detailed below, a decision was made to place a infrarenal
filter. The filter sheath was advanced over the wire into the IVC past the
take-off of the renal vessels. An inferior vena cava filter was advanced over
the wire until the cranial tip was at the level of the inferior margin of the
lower renal vein. The sheath was then withdrawn until the filter was deployed.
The wire and loading device were then removed through the sheath and a repeat
contrast injection was performed, confirming appropriate filter positioning.
The final image was stored on PACS.
The sheath was removed and pressure was held for 10 minutes,at which point
hemostasis was achieved. A sterile dressing was applied.
The patient tolerated the procedure well and there were no immediate post
procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with single bilateral renal veins
and no evidence of a clot.
2. Successful deployment of an infra-renal Denali IVC filter.
IMPRESSION:
Successful deployment of Denali retrievable IVC filter.
Radiology Report
EXAMINATION: VIDEO SWALLOW
INDICATION: ___ year old woman with IPH// video swallow study
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 03:21 min.
COMPARISON: None.
FINDINGS:
There was trace penetration with thin liquids, with cough response. No gross
aspiration was seen.
IMPRESSION:
Trace penetration with thin liquids. No gross aspiration.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with concern for pancreatic mass// eval for
mass as per GI
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
Patient terminated the study earlier. Not all pre contrast sequences were
performed, and gadolinium was accordingly not administered. Dedicated MRCP
sequences are nondiagnostic due to motion artifact. However, no evidence for
pancreatic mass is found on limited imaging. There is no biliary or
pancreatic ductal dilatation. No gallstones are found. No inflammatory
changes are found. No focal liver lesions are identified. Limited imaging
sequences show no abnormalities involving spleen, adrenals or kidneys.
Visualized stomach and bowel are unremarkable. No enlarged lymph nodes are
found. No ascites is noted. Limited visualization of the lungs is
unremarkable. Narrowing increased signal on T2 weighted imaging within the
L2-L3 and L3-L4 interspaces is probably degenerative.
IMPRESSION:
Incomplete imaging showing no evidence of significant abnormality. Completion
of MRCP imaging could be considered or alternatively, if it may be difficult
to complete the imaging using MR, multiphasic CT could be considered as an
alternative.
Radiology Report
EXAMINATION: Portable AP chest
INDICATION: History: ___ with intubation and OGT placement// eval for ET and
OG tube placement
TECHNIQUE: Portable AP chest
COMPARISON: None.
FINDINGS:
An endotracheal tube tip projects 3.0 cm above the carina. An enteric tube
courses below the diaphragm, with tip outside the field of view.
Lung volumes are low. There are no focal consolidations. The
cardiomediastinal and hilar silhouettes are within normal limits. No pleural
effusions. No pneumothorax.
IMPRESSION:
1. Status post placement of endotracheal tube, with tip projecting 3.0 cm
above the carina.
2. Status post placement of enteric tube, which courses below the diaphragm,
with tip projecting outside the field of view.
3. No evidence of complications.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with elevated transaminites// eval for cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 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: Not well-visualized.
KIDNEYS: Limited views of the kidneys show left pelviectasis.No
hydronephrosis. There is trace fluid adjacent to the right kidney.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
No cholelithiasis or cholecystitis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with new parenchymal hemorrhage, obtaining
serial CT to evaluate for rate of bleed or change// interval change in
hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head without contrast ___
FINDINGS:
There has been interval increase in size and extent of the left
frontotemporal, intraparenchymal hemorrhage with a subarachnoid component,
now with left parietal involvement, measuring up to 6.8 x 4.4 cm, previously
3.4 x 2.7 cm. Hyperdensity in the left temporal lobe appears increased from
prior, representing subarachnoid hemorrhage within the sylvian fissure. Blood
is seen near the tentorium. The surrounding edema is more conspicuous with
increased left hemispheric sulcal effacement. Interval increase in midline
shift now measuring to 5 mm, previously approximately 3 mm when measured in a
similar plane, with interval development of mild left lateral ventricular
effacement and left parietal involvement. No large territorial infarct is
demonstrated.
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. Interval increase in size of the left frontotemporal intraparenchymal
hemorrhage, with underlying subarachnoid hemorrhage and left parietal
involving. Mild interval increase in mass effect with midline shift up to 5
mm.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:55 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT abdomen.
INDICATION: ___ year old woman with unclear history of abdominal pain and
elevated lipase to 1800. Evaluate for pancreatitis.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,412 mGy-cm.
COMPARISON: Liver ultrasound ___.
FINDINGS:
LOWER CHEST: Mild, bibasilar atelectasis. Otherwise, the visualized lungs are
within normal limits. There is no evidence of pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder wall is mildly edematous,
which appears new from the prior ultrasound, with the development of small
volume pericholecystic fluid. No cholelithiasis. The common bile duct
measures approximately 8 mm, top normal for age.
PANCREAS: There appears to be slight edema insinuating within portions of the
pancreas within the head and mild peripancreatic stranding, most evident
around the pancreatic tail and head. No adjacent fluid collections. No mass
or duct dilation.
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 extrarenal pelvises are demonstrated. 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: An enteric tube terminates within the stomach. The stomach
is unremarkable. The imaged small bowel loops demonstrate normal caliber,
wall thickness, and enhancement throughout. A portion of the distal
transverse colon has equivocal wall thickening, but the colon appears
collapsed. There is mild omental fat stranding adjacent to this portion of
colon. Otherwise, the imaged colon is within normal limits. Mild right
lateral conal fascial thickening inferior to the liver.
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 splenic vein is patent. No evidence of splenic artery
aneurysm.
BONES: Mild retrolisthesis of L2 on L3 and L3 on L4, likely degenerative in
etiology. There is no evidence of worrisome osseous lesions or acute
fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Mild peripancreatic fat stranding of bilateral anterior pararenal spaces,
right lateral conal fascia, and omentum of the transverse colon, most
compatible with acute pancreatitis. No evidence of adjacent fluid collections
or vascular complications.
2. Interval new gallbladder wall edema, without cholelithiasis or ductal
dilatation, which may be due to interval progression of hepatic dysfunction or
fluid resuscitation.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: CVA, R Facial droop
Diagnosed with Nontraumatic intracerebral hemorrhage, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 2.0 | Ms. ___ is an ___ year old woman with history of hypertension
who presented with abdominal pain, vomiting, confusion, aphasia
and right sided weakness found to have left fronto-temporal ICH
complicated by hematoma expansion and respiratory failure.
#Left IPH
#Right anterior temporal ischemia with hemorrhagic conversion
vs. mass
She developed acute onset confusion, aphasia and right sided
weakness. Her exam was notable for left gaze deviation, right
facial droop, RUE w/d in plane of bed and RLE with dense plegia.
She had a NCHCT with left fronto-temporal IPH and right anterior
temporal hypodensity. She was intubated in the emergency
department given increasing somnolence. She had LFTs which were
elevated (~400) with elevated lipase (~1800) and was admitted to
the medicine ICU. She had increasing somnolence and serial NCHCT
with expansion of her hematoma without increased midline shift.
She was transferred to neuro ICU. SBP goal <150 and did not
require standing antihypertensives. Her 48 hour NCHCT showed
overall stable hemorrhage and subq heparin was resumed. In terms
of etiology, given her preceding months of abdominal symptoms,
weight loss and an area of hemorrhage and area of hypodensity,
suspicion for malignancy was high. She underwent MRI/MRA which
showed left fronto-temporal IPH without evidence of contrast
enhancement or abnormal vascularity as well as an area in right
temporal anterior lobe with contrast enhancement suspicious of
underlying malignancy. She had a CT Torso with and without
contrast which showed no evidence of malignancy but did show
pancreatitis. GI was consulted who recommended MRCP in ___ weeks
to assess for underlying malignancy after inflammation has
resolved. Alternative etiologies for her IPH were ischemic
hemorrhagic conversion, but TTE negative for thrombus and LENIs
negative as well. CAA vs. hypertensive etiologies were also
considered, but she had no persistent hypertension and no other
findings suggestive of CAA on MRI. In the neuro ICU, her mental
status improved and she was alert, but not following commands
with global aphasia. She was subsequently extubated on ___. She
was transferred to the neurology ward service where she
continued to improve. She had PEG placed ___. She remained
stable from neuro perspective. On discharge, she was alert with
improving aphasia, able to speak short phrases softly in ___
and able to follow simple commands in ___. She will have
follow-up with neurology and repeat MRI with and without
contrast of brain to assess left IPH and possible right anterior
temporal mass, amyloid.
#Acute on Chronic Abdominal Pain
#Pancreatitis
Family reported weeks to months of abdominal complaints. She was
scheduled for endoscopy as outpatient. Prior to presentation she
had acute worsening of her abdominal pain and vomiting. LFTs
were elevated (400-600s), lipase was elevated to 1800sand tbili
to 1.6. She had CT Torso which showed pancreatitis. She was
treated with aggressive fluids for 48 hrs and her liver enzymes
normalized. She had no evidence of gallstones, no history of
etoh, normal ANCA, triglycerides and calcium. She does however
take statin, celocoxib and supplements, all of which have been
linked to pancreatitis. These medications were stopped. There
was also suspicion for pancreatic malignancy given her history
of chronic abdominal issues and 20 lb weight loss. Given
inflammation in the setting of pancreatitis, GI recommended MRCP
which was performed but not completed due to chest pain (EKG
unremarkable) and anxiety. No pancreatic abnormality detected on
this limited study. Given the study limitations, she was
scheduled for an outpatient EUS and GI follow-up prior to
discharge.
#Hypoxic respiratory failure
She arrived to ED on NRB and was intubated in the setting of
somnolence and inability to protect her airway. She was
extubated on ___ and required face tent. She had rhonchorous
breath sounds and evidence of pulmonary edema on CXR. She was
treated with duonebs, albuterol, chest ___ and suctioning. She
was given Lasix 10 mg x1 on ___ with improvement in her
respiratory status. She was redosed with Lasix 20 mg x1 on ___
and subsequently was sating well on RA. She did not require
further dieresis throughout her course.
#UTI
Had fever to 103 on ___, UCx revealed pan sensitive E. coli. She
was treated with CTX for ___. She then had foul
smelling urine on ___ and UA was obtained which had many WBC
and leuk esterase. UCx showed E. coli sensitive to CTX. She was
started on CTX with 7 day course (___).
#Dysphagia
She had PEG placement ___ without complication. TFs resumed
1200 on ___. Nepro used given hyperkalemia and ___.
#Urinary retention
She had urinary retention requires Q6H straight caths throughout
her hospital course. Given some vaginal irritation and skin
breakdown, foley was replaced. Please do void trial at rehab.
#Hyponatremia
She developed Na from 128-130. Urine lytes suggestive of SIADH.
FWF were decreased and she was started on salt tabs 1 g TID. Her
Na normalized. Then on ___ she again developed hyponatremia.
Repeat urine lytes on ___ still suggestive of SIADH. TSH was
rechecked day prior and was 18. Endocrine recommended increasing
levothyroxine. FWF was decreased and Na trended upward. Na 134
at time of discharge.
#Hypothyroidism
She missed 3 days of levothyroxine on admission given patient
aphasia and family obtaining med list. TSH 12 on ___, 8 on
___, 18 on ___. Levothyroxine 100 mcg daily increased to 125
mcg on ___ and 150 mcg on ___. She should have repeat TFTs ___
weeks after discharge.
#DVT
She was grabbing at left leg at times and therefore a lower
extremity ultrasound was done on ___ which showed non occlusive
right popliteal thrombus and occlusive peroneal vein thrombus.
She was hemodynamically stable and sating well on RA. She was
felt to be too high risk given her IPH for high dose IV heparin
or systemic anticoagulation. ___ was consulted who recommend IVC
filter placement which was done on ___ without complications. |
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:
This patient is a ___ year old female who complains of
ABDOMINAL PAIN. gradual onset RLQ pain with radiation to
back since ___. + nausea. Small amount of diarrhea. Denies
hematuria
HPI: rapid onset RLQ pain, h/o stones, some n/v
Timing: Sudden Onset
Quality: Sharp
Severity: Moderate
Duration: Hours
Location: RLQ
Context/Circumstances: feels similar to renal colic
Mod.Factors: ___.
Associated Signs/Symptoms: none
Past Medical History:
Knee surgery and one episode of nephrolithiasis
Social History:
___
Family History:
Non-contributory.
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 99.2 HR: 80 BP: 122/81 Resp: 14 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, TTP mcburney's point
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
Physcial examination upon discharge: ___:
vital signs: t=98.2, hr=55, bp=118/80, rr 18, oxygen sat 98%
CV: ns1, s2, -s3, -s4, + grade 3 systolic murmur, ___ ICS,
RRSB, LSB
LUNGS: clear
ABDOMEN: soft, tender, port site without erythema, DSD
ExT: no calf tenderenss bil., + dp bil
NEURO: alert and oriened x 3, speech clear
Pertinent Results:
___ 12:45AM BLOOD WBC-18.5*# RBC-5.00 Hgb-16.1* Hct-46.7
MCV-93 MCH-32.3* MCHC-34.6 RDW-12.9 Plt ___
___ 12:45AM BLOOD Neuts-88.0* Lymphs-6.5* Monos-4.5 Eos-0.6
Baso-0.4
___ 12:45AM BLOOD Plt ___
___ 12:45AM BLOOD Glucose-149* UreaN-17 Creat-0.9 Na-138
K-4.8 Cl-101 HCO3-24 AnGap-18
___ 12:52AM BLOOD Lactate-2.2*
___: cat scan of abdomen and pelvis:
Preliminary Report1. Acute appendicitis.
Preliminary Report2. Right adrenal nodule, new from ___ is
incompletely characterized.
Preliminary ReportFurther evaluation is recommended with adrenal
protocol CT, or MRI.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
hold for loose stool
2. Senna 1 TAB PO BID:PRN constipation
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
may cause drowsiness, avoid driving while on this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H pain
Discharge Disposition:
Home
Discharge Diagnosis:
appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL INFORMATION: ___ female with periumbilical pain radiating to
the right lower quadrant. Question appendicitis.
COMPARISON: CT performed ___.
TECHNIQUE: Helical CT images were acquired of the abdomen and pelvis
following the uneventful administration of 130 cc of Omnipaque intravenously,
and oral contrast. These were reformatted into coronal and sagittal planes.
FINDINGS: The lung bases are clear, with minimal bibasilar atelectasis.
There is no pleural or pericardial effusion.
ABDOMEN: The liver is normal in appearance. A hypodensity is present in the
anterior portion of segment 4a/b, which is unchanged from ___ and likely to
represent a cyst. The spleen is normal in appearance. The pancreas is
unremarkable. The gallbladder is normal. There is no intra- or extra-hepatic
biliary ductal dilatation. There is a 1.6 x 1.6 x 2.0-cm nodule within the
medial limb of the right adrenal gland, which is new from ___. The
left adrenal is normal. The kidneys demonstrate symmetric contrast
enhancement and brisk bilateral excretion without hydronephrosis.
The stomach is filled with positive contrast and normal in appearance. Loops
of small bowel are normal in caliber and enhancement. Small bowel mesentery
is normal appearing.
PELVIS: The appendix is dilated measuring up to 1.4 cm and fluid filled, with
surrounding inflammatory change. An appendicolith is seen lodged within the
base. There is no evidence of perforation. The bladder is normal in
appearance. The uterus and adnexa are unremarkable. The colon is normal in
appearance. There is no pelvic sidewall lymph node enlargement.
Bone windows demonstrate no concerning lytic or blastic osseous lesion.
IMPRESSION:
1. Acute appendicitis.
2. 2cm right adrenal nodule, new from ___ is incompletely characterized, but
likely represents an adenoma. Further evaluation with adrenal protocol CT, or
MRI could be considered
Findings were discussed with Dr. ___ at 3:45 a.m.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 99.2
heartrate: 80.0
resprate: 14.0
o2sat: 100.0
sbp: 122.0
dbp: 81.0
level of pain: 7
level of acuity: 3.0 | The patient was admitted to the acute care service with
abdominal pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent imaging. On cat scan of the
abdomen she was reported to have a dilated, fluid filled
appendix suggestive of appendicitis. Because of these findings,
she was taken to the operating room for a laparoscopic
appendectomy.
The operative course was stable with minimal blood loss. She
was extubated after the procedure and monitored in the recovery
room. During the post-operative course, she reported a headache
which resolved with fioricet and toradol. She was started on
clear liquids and advanced to a regular diet.
She was discharged on POD #1 with stable vital signs.
Appointments were made for follow-up with the acute care service
and with her primary care provider;
******
Of note: finding on cat scan of abdomen:
2cm right adrenal nodule, new from ___ is incompletely
characterized, but
likely represents an adenoma. Further evaluation with adrenal
protocol CT, or
MRI could be considered;
Patient was informed of these findings and recommendation made
for follow-up with primary care provider. Copy of report given
to patient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Left knee pain
Major Surgical or Invasive Procedure:
Left knee I&D, liner exchange ___, ___
History of Present Illness:
___ male with history of hepatitis C status post Harvoni
treatment and prior left TKA ___, ___, Dr.
___, who now presents with left knee pain concerning for a
prosthetic joint infection.
Symptoms started 1 day prior. Patient started noticing
worsening pain, inability to ambulate. He also spiked a fever
up to 101 °F. He went to ___, where
the emergency room aspirated his left knee with visualization of
frank pus. This was sent off for labs, including Gram stain
with positive GPC's. Cell count 360k, no crystals. The patient
was then transferred over to the ___ campus for
further
evaluation and treatment.
Past Medical History:
Hep c
Cirrhosis
Decompensated liver failure
Portal hypertension
Ascites
Hepatic encephalopathy
L TKA ___, ___)
HTN
Thrombocytopenia
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
T current: 36.5 °C (97.7 °F) HR: 99 BP 116/53 RR: 20 SPO2: 95%
General: generally well-appearing, obese male
HEENT: Normocephalic, atraumatic
Neck: Supple
CV: Normal sinus rhythm, no murmur
Lungs: CTA
Abdomen: Soft, nontender, mild ascites
GU: deferred
Ext: warm, well perfused
Skin: no evidence jaundice, dry, intact
DISCHARGE PHYSICAL EXAM:
=====================
___ 0717 Temp: 98.2 PO BP: 154/73 L Lying HR: 104 RR: 18
O2
sat: 94% O2 delivery: Ra
___ Total Intake: 1389ml
___ Total Output: 1410ml
GENERAL: obese man, pleasant, in no acute distress
HEENT: mildly icteric sclerae, MMM, NC/AT
CV: RRR, early systolic murmur heard best at the ___, no rubs
or
gallops, normal s1/s2
LUNGS: CTAB, no wheezes or rhonchi, normal work of breathing
ABDOMEN: soft, obese, non-distended, non-tender
EXTREMITIES: left knee covered with dressing; drain in place
with
serosanguinous material, iscteric; trace edema of the
R leg, 1+ edema of the L leg; distal pulse palpable bilaterally
NEURO: AOx3, moving all 4 extremities with purpose, + tremor,
but
no asterixis
Pertinent Results:
ADMISSION LABS:
___ 04:03AM BLOOD WBC-4.8 RBC-3.56* Hgb-9.5* Hct-32.9*
MCV-92 MCH-26.7 MCHC-28.9* RDW-22.1* RDWSD-72.5* Plt Ct-23*
___ 04:03AM BLOOD ___ PTT-37.6* ___
___ 04:03AM BLOOD Glucose-127* UreaN-35* Creat-1.8* Na-138
K-5.1 Cl-108 HCO3-14* AnGap-16
___ 05:07AM BLOOD ALT-27 AST-67* LD(LDH)-316* AlkPhos-77
TotBili-4.2* DirBili-1.9* IndBili-2.3
___ 06:07PM BLOOD Calcium-8.6 Phos-6.4* Mg-1.6
___ 04:03AM BLOOD CRP-72.5*
___ 04:17AM BLOOD Lactate-6.7*
MICROBIOLOGY:
___ 3:50 pm SWAB LEFT KNEE SWAB.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
Susceptibility testing performed on culture # ___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 4:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 2:10 pm PERITONEAL FLUID PERITONEAL FLUID.
**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.
___ 3:57 pm JOINT FLUID Source: Knee.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
IMAGING:
Knee XR ___: Small to moderate joint effusion without
evidence of acute fracture or dislocation.
GALLBLADDER ULTRASOUND ___:
IMPRESSION:
1. Cirrhotic liver morphology with splenomegaly and moderate
volume ascites.
No evidence of concerning focal hepatic lesions.
2. Patent hepatic vasculature.
3. No hydronephrosis.
ECHO ___:
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with a normal
cavity size. There is normal regional left ventricular systolic
function. Overall left ventricular systolic function is
hyperdynamic. Quantitative biplane left ventricular ejection
fraction is 77 %. 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. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on
the aortic valve. There is no aortic valve stenosis. The
increased velocity is due to high stroke volume. There
is no aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve. There is
trivial mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. No mass/vegetation are seen
on the tricuspid valve. There is mild [1+]
tricuspid regurgitation. There is moderate pulmonary artery
systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. No vegetations or
clinically-significant valvular disease
seen. Hyperdynamic left ventricular systolic function.
CTA ___
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
6 mm nodule in the middle lobe, follow-up recommendations as
below.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk
patient, and
an optional CT in ___ months is recommended in a high-risk
patient.
DUPLEX UPPER EXTREMITY: ___
IMPRESSION:
1. Small amount of nonocclusive thrombus in the right basilic
vein adjacent to
the intraluminal catheter.
2. Otherwise, no evidence of deep vein thrombosis in the
bilateral upper
extremity veins.
CT ABDOMEN ___
1. 5 mm obstructing stone in the right mid ureter with moderate
upstream
hydroureteronephrosis. Multiple additional punctate
nonobstructing stones in
the right kidney.
2. Cirrhotic liver with no focal hepatic lesions identified.
3. Sequela of portal hypertension including small volume
intra-abdominal
ascites, extensive upper abdominal collateral vessels,
paraesophageal varices,
and splenomegaly.
4. Cholelithiasis without evidence of cholecystitis.
5. Please refer to separate report of CT chest performed the
same day for
description of the thoracic findings.
DISCHARGE LABS:
___ 04:48AM BLOOD WBC-3.7* RBC-2.70* Hgb-7.9* Hct-26.0*
MCV-96 MCH-29.3 MCHC-30.4* RDW-21.3* RDWSD-74.8* Plt Ct-31*
___ 04:48AM BLOOD ___ PTT-41.7* ___
___ 04:48AM BLOOD Glucose-121* UreaN-12 Creat-1.2 Na-136
K-3.9 Cl-96 HCO3-31 AnGap-9*
___ 04:48AM BLOOD ALT-13 AST-33 LD(LDH)-227 AlkPhos-96
TotBili-3.3*
___ 04:48AM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.9 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Propranolol 20 mg PO BID
4. aMILoride 15 mg PO BID
5. Rifaximin 550 mg PO BID
6. Furosemide 60 mg PO DAILY
7. Ferrous Sulfate 325 mg PO BID
8. One Daily For Men (multivit with min-FA-lycopene) 1 TAB oral
DAILY
9. Lactulose 15 mL PO TID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 1 tablet(s) by mouth four times per day
Disp #*120 Tablet Refills:*0
2. CefTRIAXone 2 gm IV Q24H
3. Miconazole Powder 2% 1 Appl TP TID:PRN groin rash
RX *miconazole nitrate 2 % please apply to groin rash three
times per day Disp #*1 Spray Refills:*0
4. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
5. Vitamin D ___ UNIT PO 1X/WEEK (WE) Duration: 8 Weeks
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth on ___ Disp #*6 Capsule Refills:*0
6. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
7. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth three times per day
Disp #*2700 Milliliter Refills:*0
8. Levothyroxine Sodium 75 mcg PO DAILY
9. One Daily For Men (multivit with min-FA-lycopene) 1 TAB oral
DAILY
10. Pantoprazole 40 mg PO Q24H
11. Propranolol 20 mg PO BID
12. Rifaximin 550 mg PO BID
13. HELD- aMILoride 15 mg PO BID This medication was held. Do
not restart aMILoride until you speak to your liver doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Left knee prosthetic joint infection
Hepatitis C cirrhosis
Group B strep bacteremia
Secondary:
PICC associated non-occlusive thrombus
Nephrolithiasis
Acute kidney injury
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with need for operative intervention// ?pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
Lung volumes are well expanded. The lungs are clear. The cardiomediastinal
silhouette and hilar silhouette are normal. Pleural surfaces are normal.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: History: ___ with purulent knee effusion// ?knee fracture or
effusion
TECHNIQUE: Frontal, lateral, and sunrise view radiographs of the left knee.
COMPARISON: None
FINDINGS:
No acute fracture or dislocation. Patient status post left knee arthroplasty.
There is a small to moderate joint effusion. No suspicious lytic or sclerotic
lesions are identified.
IMPRESSION:
Small to moderate joint effusion without evidence of acute fracture or
dislocation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with central line placement// Central Line placement
TECHNIQUE: Frontal chest radiograph
COMPARISON: Chest radiograph from ___ at 05:43
FINDINGS:
Right IJ central venous catheter tip projects over the upper SVC.
Compared to prior exam, pulmonary edema has improved, minimal residual. There
is no focal consolidation, though retrocardiac streaky opacity may represent
mild atelectasis or trace aspiration. There is no pleural effusion or
pneumothorax. The heart remains mildly enlarged. The mediastinal contours
are overall similar to prior exam and the pulmonary vasculature remains mildly
engorged.
IMPRESSION:
Right IJ central venous catheter tip projecting over the upper SVC. No
pneumothorax or pleural effusion.
Improved pulmonary vascular congestion, now minimal. Retrocardiac opacity,
likely atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ male with history of hepatitis C status post Harvoni treatment
and prior left TKA ___, ___ Hospital, Dr. ___ and HTN, who now
presents with L knee prosthetic joint infection c/b septic shock now s/p left
knee I D and liner exchange w/ orthopedics.// ?PNA, interval change ?PNA,
interval change
IMPRESSION:
Comparison to ___. The lung volumes are stable. Moderate
cardiomegaly persists. Mild retrocardiac atelectasis. No pulmonary edema.
No pleural effusions. No pneumonia. Stable correct position of the right
internal jugular vein catheter.
Radiology Report
EXAMINATION: Knee radiograph
INDICATION: ___ male with history of hepatitis C status post Harvoni treatment
and prior left TKA ___, ___ Hospital, Dr. ___ and HTN, who now
presents with L knee prosthetic joint infection c/b septic shock now s/p left
knee I D and liner exchange w/ orthopedics.// please obtain portable
TECHNIQUE: Two views of the left knee
COMPARISON: Radiograph ___
FINDINGS:
Interval liner exchange. Moderate knee effusion with drain in place. No
periprosthetic fracture. Moderate soft tissue edema.
IMPRESSION:
Postsurgical changes of an T and liner exchange. Moderate effusion with drain
in place. Moderate soft tissue edema about the knee and distal thigh.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
INDICATION: please obtain w/ dopplars to r/o PVT, eval for ascities
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: None.
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular.. No focal liver
lesions are identified. There is moderate volume ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation.
CHD: 3 mm
Gallbladder: The gallbladder appears within normal limits, without stones,
abnormal wall thickening, or edema.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture.
Spleen length: 18.4 cm
Kidneys: No stones, masses, or hydronephrosis are identified in either kidney.
Right kidney: 12.4 cm
Left kidney: 11.1 cm
Doppler evaluation: Examination velocities is slightly limited due to
patient's inability to follow Respiratory commands and overlap of vasculature
waveforms. However, within these limitations:
The main portal vein is patent, with flow in the appropriate direction.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
IMPRESSION:
1. Cirrhotic liver morphology with splenomegaly and moderate volume ascites.
No evidence of concerning focal hepatic lesions.
2. Patent hepatic vasculature.
3. No hydronephrosis.
Radiology Report
INDICATION: ___ year old man with cirrhosis, septic arthritis (unclear nidus)
and pancytopenia. Transferred from ICU to floor.// diagnostic paracentesis; pt
is coagulopathic
TECHNIQUE: Ultrasound-guided diagnostic paracentesis.
COMPARISON: Abdominal ultrasound ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of ascites. A suitable target in the deepest pocket in the right upper
quadrant was selected for paracentesis.
PROCEDURE: Ultrasound guided diagnostic paracentesis
Location: Right upper quadrant
Fluid: 0.8 L of serosanguinous fluid
Samples: Fluid samples were submitted to the laboratory the requested analysis
(chemistry, hematology, microbiology and cytology).
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ personally supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic paracentesis.
Insufficient fluid for a therapeutic paracentesis. No immediate complications
noted.
2. 0.8 L of fluid were removed and sent for requested analysis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cirrhosis/ascites and significant dyspnea.//
fluid, PNA, e/o COPD
IMPRESSION:
In comparison with study of ___, the cardiomediastinal silhouette is
stable. No definite vascular congestion or pleural effusion. Probable
atelectatic changes at the right base. However, there is mild asymmetry in
opacification on the right, which in the appropriate clinical setting could be
consistent with superimposed aspiration/pneumonia.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man with left knee septic joint now with left hip
pain// R/O DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the left
common femoral, femoral, and popliteal veins. Normal color flow demonstrated
in the posterior tibial and peroneal veins. Grayscale visualization of the
calf veins is limited due to soft tissue edema.
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
INDICATION: ___ year old man with hx of hep C cirrhosis and SBP// Repeat
diagnostic para
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of ascites. A suitable target in the deepest pocket in the left lower
quadrant was selected for paracentesis.
PROCEDURE: Ultrasound guided diagnostic paracentesis
Location: left lower quadrant
Fluid: 0.97 L of serosanguinous fluid
Samples: Fluid samples were submitted to the laboratory the requested analysis
(chemistry, hematology, microbiology).
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of
the procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic paracentesis.
2. 0.97 L of fluid were removed and sent for requested analysis.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new R PICC// R DL Power PICC 52cm ___
___ Contact name: ___: ___
IMPRESSION:
In comparison with the study of ___, there is an placement of right
subclavian PICC line that extends to the mid to lower SVC.
Otherwise, little overall change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with septic joint and cirrhosis// Any acute
intrapulmonary process (penumonia) Any acute intrapulmonary process
(penumonia)
IMPRESSION:
Right PICC line tip is at the level of cavoatrial junction. Heart size and
mediastinum are stable. Lungs overall clear except for minimal bibasal
atelectasis. No appreciable pleural effusion or pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with Hep C cirrhosis and septic joint on abx. Now
with new fever// Any new pneumonia/pulmonary edema?
TECHNIQUE: Chest PA and lateral
COMPARISON: Radiograph of the chest performed on ___.
FINDINGS:
Heart size is normal. Hilar and mediastinal contours are normal. Right-sided
PICC line is seen terminating at the lower SVC. No focal consolidations
concerning for pneumonia identified. There is no pleural effusion or
pneumothorax. The visualized osseous structures are unremarkable.
IMPRESSION:
No focal consolidations concerning for pneumonia identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with liver cirrhosis now with fever// Evidence of
pneumonia?
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right PICC line projects over the cavoatrial junction.
Right infrahilar opacities are more conspicuous than prior and could reflect
hilar vasculature or developing pneumonia. There is no pleural effusion or
pneumothorax identified. The size of the cardiac silhouette is unchanged.
IMPRESSION:
New right infrahilar opacities could reflect hilar vasculature or developing
pneumonia.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with fever despite broad spectrum and negative
infectious work up, also tachycardia, and left lower extremity swelling
compared to right. Please perform bilateral lower extremity ultrasounds to
r/o 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 veins bilaterally.
The right peroneal veins demonstrate normal compressibility and color flow.
The left peroneal veins are not visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
The left peroneal veins are not visualized. No evidence of deep venous
thrombosis in the right or left lower extremity veins.
Radiology Report
EXAMINATION: BILAT UP EXT VEINS US
INDICATION: ___ year old man with fever despite broad spectrum and negative
infectious work up, also tachycardia, all started following placement of a
PICC line. He is diffusely swollen and has bilateral upper extremity swelling.
Please obtain bilateral upper extremity U/S to r/o DVT.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins. Patient is status post right-sided PICC line placement.
The bilateral internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility.
The left cephalic vein is patent, compressible and shows normal color flow.
There is a small amount of nonocclusive thrombus in the right basilic vein
adjacent to the intraluminal catheter.
IMPRESSION:
1. Small amount of nonocclusive thrombus in the right basilic vein adjacent to
the intraluminal catheter.
2. Otherwise, no evidence of deep vein thrombosis in the bilateral upper
extremity veins.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with cirrhosis, coagulopathy, sinus tachycardia
and recurrent fevers despite broad spectrum ABX and no infectious source.
Right upper extremity// r/o PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 33.7 cm; CTDIvol = 14.9 mGy (Body) DLP = 502.7
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 4.8 s, 0.5 cm; CTDIvol = 26.4 mGy (Body) DLP =
13.2 mGy-cm.
Total DLP (Body) = 518 mGy-cm.
COMPARISON: None available.
FINDINGS:
Suboptimal contrast bolus impairs evaluation of the more distal subsegmental
branches of the pulmonary arteries.
HEART AND VASCULATURE:
The heart is normal size and shape. No pericardial effusion. Severe
atherosclerotic calcifications in the coronary arteries, mild in the aorta and
none in the cardiac valves. The pulmonary arteries and aorta are normal in
caliber throughout. There is no evidence of dissection, penetrating
atherosclerotic ulcers or aneurysmal dilations. No filling defects are noted
in the main pulmonary artery throughout its segmental branches. No evidence
of right heart strain.
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in either axilla or
thoracic inlet. Mild bilateral gynecomastia. Mild atherosclerotic
calcifications in the head and neck arteries.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Small mediastinal lymph nodes, none
pathologically enlarged by CT size criteria. No hilar lymphadenopathy.
PLEURA:
No pleural effusions. No apical scarring bilaterally.
LUNGS:
Respiratory motion artifacts impair optimal parenchymal evaluation. The
airways are patent to the subsegmental levels. No bronchial wall thickening,
bronchiectasis or mucus plugging. Suggestion of a 6 mm nodule in the middle
lobe (301:115). Small scattered calcified granulomas, for example in the
right lung base (301:149). No consolidations or atelectasis.
CHEST CAGE:
Old healed fracture in the left lateral sixth through eighth ribs. No acute
fractures. Mild dorsal spondylosis. No suspicious lytic or sclerotic
lesions.
UPPER ABDOMEN:
The limited sections of the upper abdomen show evidence of hepatic cirrhosis
with associated splenomegaly, numerous collateral vessels throughout the upper
abdomen and moderate ascites. Calcified gallstones with no associated acute
inflammatory signs.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
6 mm nodule in the middle lobe, follow-up recommendations as below.
RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis.
INDICATION: ___ year old man with HCV cirrhosis and fever of unclear origin//
Diagnostic and therapeutic paracentesis in setting of fever of unclear source,
concern for infection/SBP
TECHNIQUE: Ultrasound-guided paracentesis.
COMPARISON: Ultrasound on ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of ascites with tiny pockets in the right upper quadrant and left lower
quadrant.
PROCEDURE: The patient declined the procedure due to small amount of ascites
and unlikely significant therapeutic benefit.
IMPRESSION:
Paracentesis was not performed due to patient preference and unlikely
significant therapeutic benefit given small amount of ascites present.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old man with HCV cirrhosis. Evaluate for ascites prior to
___ tap.// Evaluate for ascites
TECHNIQUE: Grayscale ultrasound images were obtained of the 4 quadrants of
the abdomen.
COMPARISON: ___
FINDINGS:
Targeted grayscale ultrasound images were obtained of the 4 quadrants of the
abdomen, revealing a small amount of ascites, the largest pocket in the right
upper quadrant.
IMPRESSION:
Small amount of ascites, the largest pocket in the right upper quadrant.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HCV cirrhosis and continued fevers with new
hypoxia// Evaluate for cardiopulmonary process
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT dated ___
FINDINGS:
The tip of a right PICC line projects over the mid SVC. There is left basilar
atelectasis, otherwise no focal consolidation, pleural effusion or
pneumothorax. The size of the cardiac silhouette is mildly enlarged but
unchanged.
IMPRESSION:
Left basilar atelectasis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with HCV cirrhosis and recurrent fevers, unclear
source.// Evaluate for infectious source
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 70.7 cm; CTDIvol = 22.4 mGy (Body) DLP =
1,583.2 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
4) Stationary Acquisition 10.8 s, 0.5 cm; CTDIvol = 60.4 mGy (Body) DLP =
30.2 mGy-cm.
Total DLP (Body) = 1,617 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There are bibasilar opacities, suggestive of atelectasis. Please
refer to separate report of CT chest performed the same day for description of
the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation with a nodular
contour consistent with known cirrhosis. 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. There is mild volume intra-abdominal ascites.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is enlarged measuring 18.4 cm, 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 a 5
mm obstructing stone in the right mid ureter causing upstream moderate
hydroureteronephrosis. There are 2 nonobstructing stones in the right kidney
measuring up to 3 mm (2:65 and 2:73). 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: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is a 9 mm porta hepatis lymph node, not pathologically
enlarged based on CT size criteria (02:57). 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. Extensive collateral vessels are seen in the upper abdomen.
Paraesophageal and esophageal varices are seen.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are sclerotic foci in the posterior L3 vertebral body (602:46) and in
the left ilium (2:94). Moderate degenerative changes are seen in the
thoracolumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. 5 mm obstructing stone in the right mid ureter with moderate upstream
hydroureteronephrosis. Multiple additional punctate nonobstructing stones in
the right kidney.
2. Cirrhotic liver with no focal hepatic lesions identified.
3. Sequela of portal hypertension including small volume intra-abdominal
ascites, extensive upper abdominal collateral vessels, paraesophageal varices,
and splenomegaly.
4. Cholelithiasis without evidence of cholecystitis.
5. Please refer to separate report of CT chest performed the same day for
description of the thoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with HCV cirrhosis and recurrent fevers, unclear
source.// Evaluate for infectious source
TECHNIQUE: Multidetector scanning of the chest was performed in coordination
with IV contrast administration and reconstructed as contiguous 5- and 1.25-mm
thick axial, 5-mm thick coronal and sagittal, and 8x8 MIP images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 70.7 cm; CTDIvol = 22.4 mGy (Body) DLP =
1,583.2 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
4) Stationary Acquisition 10.8 s, 0.5 cm; CTDIvol = 60.4 mGy (Body) DLP =
30.2 mGy-cm.
Total DLP (Body) = 1,617 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: ___ CT chest
FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in either axilla or
thoracic inlet. No abnormalities on the chest wall. No atherosclerotic
calcifications in the head and neck arteries. Mild bilateral gynecomastia is
unchanged.
HEART AND VASCULATURE:
The heart is normal in size and shape. No pericardial effusion. Severe
atherosclerotic calcifications in the coronary arteries, mild in the aorta,
none in the cardiac valves. The aorta and pulmonary arteries are normal in
caliber throughout. Right upper extremity PICC line terminates in the mid
superior vena cava.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Small mediastinal lymph nodes, none
pathologically enlarged by CT size criteria. No hilar lymphadenopathy.
PLEURA:
No pleural effusions. Mild bilateral apical scarring.
LUNGS:
The airways are patent to the subsegmental levels. No bronchial wall
thickening, bronchiectasis or mucus plugging. A 6 mm nodule in the right
middle lobe is stable. Interval increase of linear opacities at the lung
bases bilaterally likely represents atelectasis. No definite consolidation.
CHEST CAGE:
No acute fractures. Old healed fractures of the left lateral sixth through
eighth ribs. Mild dorsal spondylosis. No suspicious lytic or sclerotic
lesions.
UPPER ABDOMEN:
Please see separately dictated report for findings within the abdomen and
pelvis.
IMPRESSION:
1. No focal consolidation. Interval worsening of bibasilar atelectasis.
2. 6 mm nodule in the right middle lobe. Please see recommendations below.
3. Please see separately dictated report for findings within the abdomen and
pelvis.
RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Knee pain, Transfer
Diagnosed with Sepsis, unspecified organism, Pyogenic arthritis, unspecified, Thrombocytopenia, unspecified
temperature: 99.0
heartrate: 93.0
resprate: 18.0
o2sat: 99.0
sbp: 97.0
dbp: 59.0
level of pain: 6
level of acuity: 2.0 | SUMMARY
========
Mr. ___ is a ___ male with history of hep C (Harvoni
with SVR ___ cirrhosis complicated by varices, ascities and
hepatic encephalopathy, who presented to an outside hospital on
___ with worsening left knee pain, was found to have septic
knee arthritis complicated by septic shock s/p I&D and drain on
___ with repeat washout on ___, with course complicated by
volume overload and ___, now improving.
ACTIVE ISSUES
==============
# Septic arthritis
# Group B Strep Bacteremia (blood stream infection)
Patient presented with knee pain found to have septic knee
arthritis complicated by septic shock and group B strep
bacteremia status post I&D and liner exchange on ___ with
improvement in his blood pressures and lactate. Drain removed on
___. Blood cultures grew group B strep and bacillus species,
per ID bacillus species is thought to be a contaminant.
Initially placed on vancomycin/cefepime/Flagyl for concern of
polymicrobial infection then narrowed to ceftriaxone 2g daily
for 6 weeks. He underwent repeat L knee washout on ___ in
the setting of recurrent fevers. TTE was without evidence of
endocarditis. The infection is thought to be due to potentially
gut translocation in the setting of cirrhosis. ___ assessed the
patient and recommended home with ___.
# Intermittent fevers
# Tachycardia
Onset ___ while on Ceftriaxone, added vancomycin, broadened to
cefepime on ___. Pt continued to spike through broad spectrum
ABX despite negative work up and the absence of localizing
infectious symptoms. PICC line inserted on ___. UA is
negative and blood cultures remained negative. CXR was negative
for pneumonia. Repeat arthrocentesis demonstrated neutrophilic
predominance concerning for ongoing infection of joint. Patient
underwent repeat washout with ortho on ___. Patient
defervesced and has been afebrile for >48 hours at time of
discharge. He will continue ceftriaxone 2gm daily for 6 weeks
(last day ___.
# Volume overload
# Shortness of breath
Dyspneic at baseline following ?VATS procedure ___ years ago.
Baseline weight per patient 233 pounds, presented at standing
weight of 268. Ongoing volume issues due to need for transfusion
of blood products for anemia. Diuresed with Lasix drip, to
weight 235 pounds. He will be discharged on torsemide 40mg.
# Hep C cirrhosis (Childs C, MELD 24 on admission)
Complicated by ascites, varices, hepatic encephalopathy and GI
bleed in the past due to gastric ulcers. Not currently listed
for transplant.
- HE: history of frequent hospitalizations due to hepatic
encephalopathy. Patient has been AOx3 without asterixis.
Continued home rifaxamin & lactulose TID
- Ascites: discharged on torsemide 40mg PO daily
- SBP: Will require cipro ppx for life after rx with ceftriaxone
- Esophageal varices - last EGD reportedly in ___
though report unavailable. Discharged on home propranolol
- Thrombocytopenia: In the setting of infection and liver
disease/splenomegaly. Patient received multiple transfusions of
platelets in perioperative period.
- HCV - treated in ___ with SVR
# PICC Associated Nonocclusive thrombus
Duplex ultrasound obtained to evaluate for blood clot as cause
of ongoing fevers. Non occlusive thrombus identified in right
basilic vein adjacent to the intraluminal catheter. PICC
continued to be functional. Thrombus not felt to be source of
fevers. Elected against anticoagulation of thrombus given size,
provocation of PICC and underlying coagulopathy and cirrhosis.
#Nephrolithiasis
During fever workup, a CT abdomen with contrast was performed on
___ which demonstrated a 5 mm obstructing stone in the right
mid ureter with moderate upstream
hydroureteronephrosis. Patient denying urinary symptoms or pain.
Felt to be an incidental finding and not the source of fevers.
# Anemia:
Hgb 9.5 on presentation, downtrended to 6.6 while in hospital in
setting of multiple procedures. No other source of bleeding.
Felt in part to be related to polyphlebotomy. Patient received 3
units of pRBC over hospital course. Hgb on discharge 7.9.
#Leukopenia
As low as 2.9 during hospitalization. Patient on multiple
antibiotics that were felt to be potential culprits (Cipro,
vancomycin). Improving with transition back to ceftriaxone, was
3.7 on discharge.
# ___
Baseline creatinine 0.9-1.1, initially presenting to ___
___
with a creatinine of 2.5. Creatinine then trended down to 1.1.
Had second insult in setting of supratherapuetic vancomycin.
Improved to 1.2 at time of discharge.
CHRONIC ISSUES
# Hypertension: Held home propranolol while in house due to
sepsis.
# Hypothyroidism: Continued home levothyroxine. |
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 bloating
Major Surgical or Invasive Procedure:
paracentesis ___
History of Present Illness:
Mr. ___ is a ___ year old male with a history of HCV, EtOH
cirrhosis complicated by ___ on chemotherapy who presented to
the ED for abdominal discomfort after discussing symptoms with
his PCP.
The symptoms started on ___ as epigastric discomfort with
bloating after eating a large meal. He noticed increased
distension afterwards and had the sensation of bloating. He has
not had frank pain, no fevers or chills. No diarrhea. No change
in urinary or stool habits. He has experienced this discomfort
with each of his meals since ___. He did not have a BM or
pass gas on ___, but has since had a large BM and has
been passing gas.
He presented to the ED thinking he was going to be admitted for
chemotherapy since he has missed his last few treatments.
In the ED:
Initial vitals: 98.1 114 125/78 18 96%
Transfer vitals: 99.1 98 113/74 16 100% RA
Meds: None
Fluids: None
Access: 20g PIV
Studies: abd xray and abd ultrasound
He was evaluated in the ED by transplant surgery who will follow
along.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, melena, hematemesis,
hematochezia. Denies dysuria, stool or urine incontinence.
Denies arthralgias or myalgias. Denies rashes or skin breakdown.
No numbness/tingling in extremities. All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Oncologic history: (please see OMR for full details)
Onc Dx: HCC, well-to-moderately differentiated on bx ___
Onc Tx: RFA ___, TACE ___ and repeated
___ Started sorafenib in ___ with some decline
in AFP. Progression ___ and started xeloda - no response
by AFP or imaging. Progressed in ___ and started
doxil/gem with excellent decrease in AFP.
--as of ___: C1 Day 8 of doxil/gem held for
thrombocytopenia
--day 8 chemo planned for ___, patient missed appt due to
confusion ___ nursing note: "Reviewed that his plt-
54,000 therefore he would be unable to receive D8 Gemzar
today.")
--Missed 2 most recent appointments for chemotherapy.
PMH/PSH:
- Chronic hepatitis C. Hx interferon tx
- Former IV drug abuse history, including heroin.
- Hx alcohol dependence and abuse
- s/p stab wound to right abdomen requiring emergency laparotomy
- COPD
- HTN
Social History:
___
Family History:
FAMILY HISTORY:
Sister with colon cancer
Physical Exam:
PHYSICAL EXAM:
Vitals: 99 110/74 90 16 97%RA
GENERAL: NAD, awake, alert
HEENT: AT/NC, MMM
NECK: nontender and supple, no LAD, no JVD
CARDIAC: RRR, nl S1 S2, II/VI SEM
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, nontender, distended, no rebound or guarding
EXT: warm and well-perfused, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO:strength ___ throughout, sensation grossly normal, no
asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
==================================
Labs
==================================
___ 12:00PM BLOOD WBC-7.8 RBC-3.52* Hgb-11.3* Hct-37.0*
MCV-105* MCH-32.0 MCHC-30.5* RDW-15.7* Plt ___
___ 07:20AM BLOOD WBC-6.6 RBC-3.03* Hgb-9.8* Hct-32.3*
MCV-107* MCH-32.2* MCHC-30.3* RDW-15.8* Plt ___
___ 08:00AM BLOOD WBC-6.8 RBC-2.94* Hgb-9.7* Hct-31.4*
MCV-107* MCH-32.9* MCHC-30.8* RDW-15.8* Plt Ct-87*
___ 02:18PM BLOOD ___ PTT-37.8* ___
___ 07:20AM BLOOD ___ PTT-41.0* ___
___ 07:55AM BLOOD ___ PTT-35.3 ___
___ 08:00AM BLOOD ___ PTT-37.3* ___
___ 12:00PM BLOOD Glucose-78 UreaN-11 Creat-1.2 Na-135
K-3.6 Cl-101 HCO3-25 AnGap-13
___ 07:20AM BLOOD Glucose-88 UreaN-10 Creat-1.1 Na-133
K-3.8 Cl-104 HCO3-24 AnGap-9
___ 08:00AM BLOOD Glucose-94 UreaN-10 Creat-1.0 Na-132*
K-3.7 Cl-103 HCO3-23 AnGap-10
___ 12:00PM BLOOD ALT-43* AST-125* AlkPhos-507*
TotBili-5.5*
___ 07:35AM BLOOD ALT-37 AST-114* AlkPhos-433* TotBili-4.9*
___ 07:20AM BLOOD ALT-34 AST-105* LD(LDH)-204 AlkPhos-385*
Amylase-58 TotBili-4.8*
___ 07:55AM BLOOD ALT-43* AST-126* LD(LDH)-255*
AlkPhos-424* TotBili-5.1*
___ 07:35AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.9
___ 07:20AM BLOOD Calcium-7.6* Phos-2.1* Mg-1.9
___ 07:55AM BLOOD TotProt-8.5* Albumin-2.6* Globuln-5.9*
Calcium-7.8* Phos-3.1 Mg-1.8
==================================
Radiology
==================================
___
IMPRESSION:
1. Moderately distended gallbladder with mobile shadowing
gallstones.
Pericholecystic fluid and minimal gallbladder wall thickening is
non-specific
and can be seen in chronic liver disease.
2. Nodular and heterogeneous liver compatible with cirrhosis
with multiple
lesions consistent with HCC, better seen on MR from ___.
Multiple enlarged portahepatic lymph nodes and moderate ascites.
___ KUB
FINDINGS: As compared to the previous radiograph, there is
unchanged evidence
of air-fluid levels in several small bowel loops. The overall
diameter and
mild distention of the previous radiograph are no longer
present. However,
there is increasing distention of bowel loops noted in the
middle abdomen.
The concern for ascites persists. There is no evidence of free
intra-abdominal air. Presence of a coil projecting over the
right upper
quadrant is unchanged.
___ CT abd/pelvis
Final Report
INDICATION: End-stage liver disease with hepatocellular
carcinoma and five
days of abdominal bloating and pain. Evaluate for small bowel
obstruction.
COMPARISONS: CT of the abdomen and pelvis without contrast from
___. MRI of abdomen with and without contrast from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through
the abdomen and
pelvis after the administration of IV and oral contrast.
Sagittal and coronal
reformatted images were obtained and reviewed.
TOTAL DLP: 388.9 mGy-cm.
FINDINGS:
LUNG BASES: There is minimal bibasilar atelectasis and
reticulation. No
focal consolidation or discrete nodule is identified. The base
of the heart
is normal in size. There is no pericardial effusion.
ABDOMEN: The liver is shrunken and nodular, consistent with
cirrhosis. In
the inferior left lobe, there is a 42 x 30 x 28 mm hypodensity
(2, 27 and 8B,
12) at the site of a prior radiofrequency ablation. The
contours are slightly
irregular. There is a small amount of air within the
hypodensity (2, 24). A
tiny of locule of air present more anteriorly also appears to be
within the
hypodensity (9b, 37). The size of this hypodensity has
increased from the
prior MRI in ___, at which time it measured 30 x 23
mm. The
multiple known hepatocellular carcinomas are not well evaluated
on this
single-phase contrast CT. Subtle irregular hypodensities
throughout the
bilateral lobes of the liver, more prominent on the left than
the right,
represents the hepatocellular carcinoma. Exact measurements are
difficult to
determine. The largest is in the mid left lobe and is partially
exophytic.
It measures about 82 x 53 mm (6, 19). In comparison to the
prior MRI, the
exophytic portion appears larger, suggesting that the
hepatocellular
carcinomas are progressing.
The portal vein, SMV, and the splenic vein are patent. A
metallic focus in
the mid liver is unchanged. The gallbladder is distended,
though there is no
wall thickening to suggest cholecystitis. Stones are layering
in the
gallbladder. There is no intra or extra-hepatic biliary duct
dilation.
In the hepatic hilum, there is a soft tissue mass which measures
52 x 44 mm
(6, 29). It previously measured 40 x 34 mm. In the left upper
quadrant,
there is a second soft tissue mass which measures 56 x 42 mm.
It previously
measured 47 x 35 mm. This increasing size is consistent with
progression of
metastatic disease. Other smaller lymph nodes are present
around the celiac
axis and in the hepatic hilum. There are borderline enlarged.
Small lymph
nodes are also noted in the retroperitoneum, and do not meet
criteria for
pathologic enlargement. No new lymphadenopathy or mesenteric
masses are
identified.
There is a moderate amount of ascites, increased from the prior
MRI in
___.
The pancreas is normal without focal masses or inflammatory
changes. The duct
is not dilated. The bilateral adrenal glands are normal. The
kidneys are
normal without hydronephrosis, renal masses, or pyelonephritis.
The kidneys
enhance and excrete contrast symmetrically.
The stomach is not distended. The loops of small bowel are
normal in caliber
and filled with oral contrast. The distal and terminal ileum
are slightly
prominent (6, 50), but oral contrast passes freely into the
large bowel,
suggesting there is no obstruction. The large bowel is normal
in caliber.
There are no surrounding inflammatory changes or evidence of a
mass.
The abdominal vasculature is normal in caliber without evidence
of aneurysm.
Mild atherosclerotic calcifications are identified.
PELVIS: The bladder and prostate are unremarkable. There is no
pelvic or
inguinal lymphadenopathy. Small bilateral fat-containing
inguinal hernias are
noted. There is a moderate amount of free fluid in the pelvis,
consistent
with ascites.
OSSEOUS STRUCTURES: In the right iliac bone, there is a
sclerotic focus (6,
55), which is most likely a bone island. Additionally in the
right ilium,
there are several small lucencies (6, 60). There are other
smaller scattered
lucencies throughout the bones of the pelvis and in the left
femur. These
were not previously imaged, as the pelvis has not been imaged in
the past. No
fracture is identified. Minimal degenerative changes are noted
in the lower
lumbar spine.
IMPRESSION:
1. Interval enlargement of the hypodensity in the left lobe of
the liver at
the site of the prior ablation site. Locules of air are of
uncertain
significance and superimposed infection is not excluded.
2. Interval enlargement of the known hepatocellular carcinomas
and the
hepatic hilar and left mesenteric metastases. No new discrete
metastases are
identified.
3. New moderate ascites.
4. No evidence of a small bowel obstruction.
5. New scattered small lucencies in the pelvis, of uncertain
etiology. These
would be atypical for hepatocellular carcinoma metastases. If
further workup
is required, could correlate with an SPEP/UPEP.
6. Cholelithiasis without cholecystitis.
___ paracentesis
PROCEDURE: Ultrasound-guided diagnostic and therapeutic
paracentesis.
PROCEDURE IN DETAIL: After the risks, benefits and alternatives
of the
procedure were explained to the patient, written informed
consent was
obtained. A preprocedure timeout was performed using three
patient
identifiers and the procedure to be performed as per standard
___ protocol.
An initial four-quadrant ultrasound of the abdomen demonstrated
small to
moderate volume ascites, predominantly within the right lower
quadrant. A
suitable spot was marked in the right lower quadrant under
ultrasound
guidance. The skin was prepped and draped in the usual sterile
fashion. 1%
lidocaine was used to anesthetize the skin and subcutaneous
tissues. A 5
___ ___ catheter was then advanced into the abdominal
cavity.
Approximately 1.2 liters of clear yellow fluid was drained. As
requested,
samples were sent for microbiology and chemistry.
The patient tolerated the procedure well and no immediate
post-procedure
complications were observed.
The attending radiologist, Dr. ___ was present throughout the
procedure.
ULTRASOUND OF THE LIVER: Limited ultrasound evaluation of a left
lobe
radiofrequency ablation bed shows a lesion that is centrally
isoechoic to
liver parenchyma with a hypoechoic border. The lesion measures
3.2 x 2.8 x 3.8
cm and demonstrates a lack of through transmission which
suggests a lack of
fluid component. The lesion contains a locule of gas.
IMPRESSION:
1. Successful ultrasound-guided paracentesis yielding 1.2
liters of clear
yellow fluid. Samples sent for microbiology and chemistry as
requested.
2. Radiofrequency ablation bed in the left lobe of the liver is
predominately
solid with a single locule of gas. The lesion is better seen on
the recent CT
scan of ___.
RUQ US ___
Final Report
HISTORY: End-stage liver disease and hepatocellular carcinoma.
Evaluate
ascites for possible peritoneal Pleurx catheter placement.
COMPARISON: Paracentesis performed ___.
FINDINGS: Limited ultrasound review of the 4 quadrants of the
abdomen showed
a small volume ascites within the right upper and lower
quadrants with the
deepest pocket measuring 5.5 cm in depth. Minimal fluid is seen
within the
left upper and lower quadrants.
IMPRESSION:
Ascites with a small amount in the right upper and lower
quadrants and no
significant amount of fluid in the left upper and lower
quadrants.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. Amlodipine 5 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Oxazepam 10 mg PO HS:PRN insomnia
6. Tiotropium Bromide 1 CAP IH DAILY
7. TraZODone 50 mg PO HS:PRN insomnia
8. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
9. Multivitamins 1 TAB PO DAILY
10. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. Amlodipine 5 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. TraZODone 50 mg PO HS:PRN insomnia
5. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Simethicone 40-80 mg PO QID:PRN gas or bloating
8. Spironolactone 25 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
9. FoLIC Acid 1 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Oxazepam 10 mg PO HS:PRN insomnia
13. Thiamine 100 mg PO DAILY
14. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
symptomatic abdominal ascites
liver cancer
hepatitis C cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Right upper quadrant pain, evaluate for biliary obstruction.
TECHNIQUE: Grayscale and Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___ and MR from ___.
FINDINGS: The liver has a nodular, heterogeneous, and coarsened echotexture
consistent with clinical history of cirrhosis. Multiple hepatic lesions are
seen, consistent with previously described HCC and better seen on the MR from
___. There is no intrahepatic or extrahepatic biliary
dilatation, and the common bile duct measures 4 mm. The main portal vein is
patent and has normal hepatopetal flow. The gallbladder is moderately
distended with mobile shadowing gallstones. There is perihepatic ascites and
pericholecystic fluid. The gallbladder wall is minimally thickened, which is
nonspecific and can be seen with chronic liver disease. Sonographic ___
sign was negative. Multiple enlarged portahepatic lymph nodes are seen, the
largest measuring 2.2 x 2.5 x 2.1 cm, and was present on the prior MRI. The
spleen is homogeneous in echotexture and measures 11.2 cm. There is a
moderate amount of ascites seen.
IMPRESSION:
1. Moderately distended gallbladder with mobile shadowing gallstones.
Pericholecystic fluid and minimal gallbladder wall thickening is non-specific
and can be seen in chronic liver disease.
2. Nodular and heterogeneous liver compatible with cirrhosis with multiple
lesions consistent with HCC, better seen on MR from ___.
Multiple enlarged portahepatic lymph nodes and moderate ascites.
Radiology Report
HISTORY: Abdominal distention.
COMPARISON: MRI abdomen ___, CT abdomen ___, chest
radiograph ___
TECHNIQUE: Upright and supine AP views of the abdomen.
FINDINGS:
Dilatation of small bowel loops to 3.3 cm are demonstrated with at least 2
air-fluid levels noted on the upright view. Findings are concerning for
either an early or partial small-bowel obstruction, with air seen distally in
colonic loops of bowel. Bowel loops are centrally located, indicative of
underlying ascites. Embolization coil is noted in the right upper quadrant of
the abdomen. Sclerotic focus overlying the right iliac wing is presumably a
bone island. There is no free intraperitoneal air or pneumatosis. Coarse
interstitial abnormalities are noted at the lung bases, as seen on the prior
chest radiograph from ___, and likely reflective of chronic
interstitial lung disease.
IMPRESSION:
Dilated loops of small bowel may reflect an early or partial small bowel
obstruction. Central location of bowel loops indicative of underlying
ascites. No free intraperitoneal air.
Radiology Report
ABDOMEN
Questionable obstruction.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of air-fluid levels in several small bowel loops. The overall diameter and
mild distention of the previous radiograph are no longer present. However,
there is increasing distention of bowel loops noted in the middle abdomen.
The concern for ascites persists. There is no evidence of free
intra-abdominal air. Presence of a coil projecting over the right upper
quadrant is unchanged.
Radiology Report
INDICATION: End-stage liver disease with hepatocellular carcinoma and five
days of abdominal bloating and pain. Evaluate for small bowel obstruction.
COMPARISONS: CT of the abdomen and pelvis without contrast from ___. MRI of abdomen with and without contrast from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and
pelvis after the administration of IV and oral contrast. Sagittal and coronal
reformatted images were obtained and reviewed.
TOTAL DLP: 388.9 mGy-cm.
FINDINGS:
LUNG BASES: There is minimal bibasilar atelectasis and reticulation. No
focal consolidation or discrete nodule is identified. The base of the heart
is normal in size. There is no pericardial effusion.
ABDOMEN: The liver is shrunken and nodular, consistent with cirrhosis. In
the inferior left lobe, there is a 42 x 30 x 28 mm hypodensity (2, 27 and 8B,
12) at the site of a prior radiofrequency ablation. The contours are slightly
irregular. There is a small amount of air within the hypodensity (2, 24). A
tiny of locule of air present more anteriorly also appears to be within the
hypodensity (9b, 37). The size of this hypodensity has increased from the
prior MRI in ___, at which time it measured 30 x 23 mm. The
multiple known hepatocellular carcinomas are not well evaluated on this
single-phase contrast CT. Subtle irregular hypodensities throughout the
bilateral lobes of the liver, more prominent on the left than the right,
represents the hepatocellular carcinoma. Exact measurements are difficult to
determine. The largest is in the mid left lobe and is partially exophytic.
It measures about 82 x 53 mm (6, 19). In comparison to the prior MRI, the
exophytic portion appears larger, suggesting that the hepatocellular
carcinomas are progressing.
The portal vein, SMV, and the splenic vein are patent. A metallic focus in
the mid liver is unchanged. The gallbladder is distended, though there is no
wall thickening to suggest cholecystitis. Stones are layering in the
gallbladder. There is no intra or extra-hepatic biliary duct dilation.
In the hepatic hilum, there is a soft tissue mass which measures 52 x 44 mm
(6, 29). It previously measured 40 x 34 mm. In the left upper quadrant,
there is a second soft tissue mass which measures 56 x 42 mm. It previously
measured 47 x 35 mm. This increasing size is consistent with progression of
metastatic disease. Other smaller lymph nodes are present around the celiac
axis and in the hepatic hilum. There are borderline enlarged. Small lymph
nodes are also noted in the retroperitoneum, and do not meet criteria for
pathologic enlargement. No new lymphadenopathy or mesenteric masses are
identified.
There is a moderate amount of ascites, increased from the prior MRI in
___.
The pancreas is normal without focal masses or inflammatory changes. The duct
is not dilated. The bilateral adrenal glands are normal. The kidneys are
normal without hydronephrosis, renal masses, or pyelonephritis. The kidneys
enhance and excrete contrast symmetrically.
The stomach is not distended. The loops of small bowel are normal in caliber
and filled with oral contrast. The distal and terminal ileum are slightly
prominent (6, 50), but oral contrast passes freely into the large bowel,
suggesting there is no obstruction. The large bowel is normal in caliber.
There are no surrounding inflammatory changes or evidence of a mass.
The abdominal vasculature is normal in caliber without evidence of aneurysm.
Mild atherosclerotic calcifications are identified.
PELVIS: The bladder and prostate are unremarkable. There is no pelvic or
inguinal lymphadenopathy. Small bilateral fat-containing inguinal hernias are
noted. There is a moderate amount of free fluid in the pelvis, consistent
with ascites.
OSSEOUS STRUCTURES: In the right iliac bone, there is a sclerotic focus (6,
55), which is most likely a bone island. Additionally in the right ilium,
there are several small lucencies (6, 60). There are other smaller scattered
lucencies throughout the bones of the pelvis and in the left femur. These
were not previously imaged, as the pelvis has not been imaged in the past. No
fracture is identified. Minimal degenerative changes are noted in the lower
lumbar spine.
IMPRESSION:
1. Interval enlargement of the hypodensity in the left lobe of the liver at
the site of the prior ablation site. Locules of air are of uncertain
significance and superimposed infection is not excluded.
2. Interval enlargement of the known hepatocellular carcinomas and the
hepatic hilar and left mesenteric metastases. No new discrete metastases are
identified.
3. New moderate ascites.
4. No evidence of a small bowel obstruction.
5. New scattered small lucencies in the pelvis, of uncertain etiology. These
would be atypical for hepatocellular carcinoma metastases. If further workup
is required, could correlate with an SPEP/UPEP.
6. Cholelithiasis without cholecystitis.
Results were discussed with Dr. ___ at 3:15 p.m. on ___ via telephone
by Dr. ___ minutes after the findings were discovered.
Radiology Report
CLINICAL INDICATION: End-stage liver disease and hepatocellular carcinoma
complicated by ascites and abdominal pain. He presents for diagnostic and
therapeutic paracentesis.
COMPARISON: CT abdomen and pelvis performed ___.
RADIOLOGISTS: Dr. ___ (radiology resident) and Dr. ___
(radiology attending).
PROCEDURE: Ultrasound-guided diagnostic and therapeutic paracentesis.
PROCEDURE IN DETAIL: After the risks, benefits and alternatives of the
procedure were explained to the patient, written informed consent was
obtained. A preprocedure timeout was performed using three patient
identifiers and the procedure to be performed as per standard ___ protocol.
An initial four-quadrant ultrasound of the abdomen demonstrated small to
moderate volume ascites, predominantly within the right lower quadrant. A
suitable spot was marked in the right lower quadrant under ultrasound
guidance. The skin was prepped and draped in the usual sterile fashion. 1%
lidocaine was used to anesthetize the skin and subcutaneous tissues. A 5
___ ___ catheter was then advanced into the abdominal cavity.
Approximately 1.2 liters of clear yellow fluid was drained. As requested,
samples were sent for microbiology and chemistry.
The patient tolerated the procedure well and no immediate post-procedure
complications were observed.
The attending radiologist, Dr. ___ was present throughout the procedure.
ULTRASOUND OF THE LIVER: Limited ultrasound evaluation of a left lobe
radiofrequency ablation bed shows a lesion that is centrally isoechoic to
liver parenchyma with a hypoechoic border. The lesion measures 3.2 x 2.8 x 3.8
cm and demonstrates a lack of through transmission which suggests a lack of
fluid component. The lesion contains a locule of gas.
IMPRESSION:
1. Successful ultrasound-guided paracentesis yielding 1.2 liters of clear
yellow fluid. Samples sent for microbiology and chemistry as requested.
2. Radiofrequency ablation bed in the left lobe of the liver is predominately
solid with a single locule of gas. The lesion is better seen on the recent CT
scan of ___.
Radiology Report
HISTORY: End-stage liver disease and hepatocellular carcinoma. Evaluate
ascites for possible peritoneal Pleurx catheter placement.
COMPARISON: Paracentesis performed ___.
FINDINGS: Limited ultrasound review of the 4 quadrants of the abdomen showed
a small volume ascites within the right upper and lower quadrants with the
deepest pocket measuring 5.5 cm in depth. Minimal fluid is seen within the
left upper and lower quadrants.
IMPRESSION:
Ascites with a small amount in the right upper and lower quadrants and no
significant amount of fluid in the left upper and lower quadrants.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ABDOMINAL DISTENTION
Diagnosed with INTESTINAL OBSTRUCT NOS, MAL NEO LIVER, PRIMARY
temperature: 98.1
heartrate: 114.0
resprate: 18.0
o2sat: 96.0
sbp: 125.0
dbp: 78.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ year old male with a history of HCV, EtOH
cirrhosis complicated by ___ on chemotherapy who presented to
the ED for abdominal discomfort with possible SBO, worsening
metastatic disease, worsening ascites, severe constipation.
Abdominal Bloating associated with mild pain with low grade
fever. no SBO on CT scan. improved with paracentesis ___ but
symptoms returned the following day. discussed indwelling
catheter to allow frequent drainage of ascites. this would
normally be done in a hospice setting, but Mr. ___ now
indicates that he is not ready for hospice and wants to get a
second opinion. as such, plan for catheter cancelled. he has
some small fluid pockets on US but no urgent indication for
paracentesis at this time.
# HCV and EtOH cirrhosis complicated by HCC. MELD 22. Missed
recent chemo x2 out of difficulty getting to clinic. No clear
evidence of hepatic encephalopathy. Not on diuretics or
lactulose. did not tolerate taking lactulose in the past due to
diarrhea even at small doses. He was seen by the liver service
with recommendation to start rifaximin. He was also started on
aldactone to help with ascites management. His primary
oncologist Dr. ___ spoke with the patient ___ regarding his
poor prognosis (months) and that further chemotherapy will not
help him. He is upset but understands. He plans to seek another
opinion from Cancer Treatment Centers of ___.
# coagulopathy - likely from liver disease. He received vitamin
K 5mg PO x 3 days with little benefit, suggesting coagulopathy
due to liver synthetic function
# Dispo:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
____________________________________
___, MD, pager ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman with PMH of seizure disorder,
hypothyroidism who presents after being found down in pool and
unresponsive. Per report, the patient was in a hot tub and told
the people around she felt unwell, and then was witnessed
falling into a pool. She was in the pool for several minutes
while bystanders attempted to rescue her. The police arrived on
the scene first and initiated CPR after not finding a pulse, and
water came out her mouth. When EMS arrived she had a pulse and
was breathing spontaneously but unresponsive. At ___
___ she was intubated and sedated with propofol.
Reportedly a chest x-ray and head CT without contrast were
unremarkable. She was transported to ___ via med flight.
In ED initial VS were T 98.5 HR 96 BP 128/92 RR 18 O2 100% on
CMV FiO2 50% TV 400 RR 20 PEEP 5. Exam was notable for an
intubated a sedated patient with warm extremities and focal
myoclonic movements and hyperreflexia. ABG showed 7.25/57/30,
lactate 3.8; serum tox screen negative. Neurology was consulted
who noted the hyperreflexia and myoclonus and recommended tox
consult for possible serotonin syndrome as patient is on
citalopram. At this time the fentanyl and propofol were stopped
and midazolam drip was started. She was also given lorazepam IV
x1. A repeat CT head at ___ ED showed cerebral edema, stable
from the study at ___.
On arrival to the MICU, she is following all commands.
Past Medical History:
Seizure disorder
Hypothyroidism
Insomnia
GERD
Anxiety
Social History:
___
Family History:
Mother ESOPHAGEAL CANCER
Father SCLERODERMA
Brother ASTHMA
Physical Exam:
ADMISSION:
VITALS: 36.7, 91, 156/72, 20, 100% on pressure support ___
General: intubated, EEG leads in place
HEENT: ET tube in place
CV: RRR, no m/r/g
PULM: CTAB without wheezes or rales, mechanical breath sounds
heard
ABD: soft, NT, ND
EXT: WWP, no ___ edema
Neuro: Easily awakened to voice, follows all commands, PERRL,
will close eyes when not stimulated
Discharge Physical Exam:
- Mental status: Awake, alert, oriented x self, place, date.
She is able to relay history fully. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria.
Normal prosody. Able to follow both midline and appendicular
commands.
- Cranial Nerves: PERRL 5->3 and brisk bilaterally. EOMI with
no
nystagmus, buries sclera fully. V1-V3 without deficits to light
touch bilaterally. No facial movement asymmetry. Smile
symmetric. Hearing intact to conversation. Palate
elevationsymmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor: Normal bulk and tone. No drift. Slight bl fine
tremor, worsened with intention.
[___]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 3 3 3 3
R 3 3 3 3 3
Hyperreflexic with pec jerks bl
___ negative
Crossed adductors present bl
2 beats of clonus on the right, 3 beats on the left
- Coordination - FTN intact bilaterally
- Gait - good initiation, normal stride and arm swing
Pertinent Results:
ADMISSION:
___ 04:35PM BLOOD WBC-8.1 RBC-3.61* Hgb-10.7* Hct-30.8*
MCV-85 MCH-29.6 MCHC-34.7 RDW-14.0 RDWSD-43.7 Plt ___
___ 04:35PM BLOOD Neuts-78.8* Lymphs-14.5* Monos-6.1
Eos-0.0* Baso-0.2 Im ___ AbsNeut-6.34* AbsLymp-1.17*
AbsMono-0.49 AbsEos-0.00* AbsBaso-0.02
___ 04:35PM BLOOD ___ PTT-23.8* ___
___ 04:35PM BLOOD Glucose-120* UreaN-11 Creat-0.9 Na-144
K-4.4 Cl-107 HCO3-20* AnGap-17
___ 04:35PM BLOOD ALT-73* AST-102* AlkPhos-102 TotBili-<0.2
___ 04:35PM BLOOD cTropnT-<0.01
___ 08:50PM BLOOD CK-MB-7 cTropnT-<0.01
___ 08:50PM BLOOD Calcium-8.5 Phos-3.1 Mg-1.8
___ 08:50PM BLOOD TSH-1.5
___ 01:01AM BLOOD Prolact-15
___ 04:35PM BLOOD Phenyto-20.1*
___ 04:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:01AM BLOOD Ethanol-NEG
___ 04:48PM BLOOD Type-ART Rates-20/ Tidal V-400 PEEP-5
FiO2-50 pO2-143* pCO2-53* pH-7.28* calTCO2-26 Base XS--2
As/Ctrl-ASSIST/CON Intubat-INTUBATED
___ 04:51PM BLOOD Lactate-3.8*
___ 09:01PM BLOOD Lactate-3.2*
___ 12:31AM BLOOD freeCa-1.14
IMAGING/STUDIES:
___ Imaging CT HEAD W/O CONTRAST
There is no evidence of acute territorial infarction,hemorrhage,
or mass. The
ventricles and sulci are again smaller than expected for
patient's age raising
suggesting persistent global cerebral edema. The basilar
cisterns remain
patent.
There is no evidence of fracture. There is persistent mild
mucosal thickening
throughout the paranasal sinuses and mild partial opacification
of the
bilateral mastoid air cells likely secondary to prolonged supine
positioning
or recent intubated status. The middle ear cavities are clear.
The
visualized portion of the orbits are unremarkable.
IMPRESSION:
Persistent, essentially unchanged cerebral edema.
___ Cardiovascular ECHO
The left atrial volume index is normal. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). 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. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No clinically-significant valvular disease seen.
___ Imaging MR HEAD W & W/O CONTRAS
1. Please note that prior head CT mentioned in history is not
submitted for
direct comparison.
2. Study is mildly degraded by motion.
3. No evidence of acute infarct.
4. No evidence of dural venous sinus thrombosis.
5. Small enhancing dural-based lesion overlying the right
temporal lobe
measures up to 6 mm. Allowing for difference technique, finding
is grossly
similar to ___ prior exam, suggestive of meningioma.
6. Paranasal sinus disease, as described.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Baclofen 10 mg PO TID
3. Citalopram 40 mg PO DAILY
4. LORazepam 2 mg PO QHS
5. Acyclovir 200 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Phenytoin Sodium Extended 300 mg PO DAILY
8. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
9. Vitamin D 1000 UNIT PO DAILY
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*8 Tablet Refills:*0
2. Zonisamide 200 mg PO DAILY
RX *zonisamide [Zonegran] 100 mg 2 capsule(s) by mouth daily
Disp #*60 Capsule Refills:*2
3. Baclofen 10 mg PO TID
4. Citalopram 40 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Levothyroxine Sodium 88 mcg PO DAILY
7. LORazepam 2 mg PO QHS
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Phenytoin Sodium Extended 300 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. HELD- Acyclovir 200 mg PO DAILY This medication was held.
Do not restart Acyclovir until you follow up with your PCP
13. HELD- Calcium Carbonate Dose is Unknown PO Frequency is
Unknown This medication was held. Do not restart Calcium
Carbonate until you follow up with your PCP
___:
Home
Discharge Diagnosis:
Cardiac arrest
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Trauma.
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
Endotracheal tube tip is 1.8 cm from the carina. Enteric tube tip projects
over left upper quadrant, side-port past GE junction. Lungs are grossly clear
besides mild left basilar atelectasis. No displaced fractures.
IMPRESSION:
ET tube tip 1.8 cm from the carina. Enteric tube appropriately positioned.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with repeat chest after tube movement during equipment
adjusrment repeat chest after tube movement during equipment adjusrment
TECHNIQUE: Portable supine view of the chest
COMPARISON: Chest radiograph from ___ at 16:06
FINDINGS:
The tip of an ETT is seen approximately 1.5 cm above the carina and should be
retracted for optimal positioning. Enteric tube is seen terminating in the
stomach. Lung volumes are low without focal consolidation. There is no
pulmonary edema, pneumothorax, or large pleural effusion. The
cardiomediastinal silhouette and hilar contours appear unchanged.
IMPRESSION:
The tip of an ETT seen approximately 1.5 cm above the carina and should be
retracted for optimal positioning.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with Repeat head CT to evaluate for evolution of cerebral
edema
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, 16.8 cm; CTDIvol = 47.7 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 4.0 s, 4.2 cm; CTDIvol = 47.7 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: Noncontrast head CT ___ at 14:52.
FINDINGS:
There is no evidence of acute territorial infarction,hemorrhage, or mass. The
ventricles and sulci are again smaller than expected for patient's age raising
suggesting persistent global cerebral edema. The basilar cisterns remain
patent.
There is no evidence of fracture. There is persistent mild mucosal thickening
throughout the paranasal sinuses and mild partial opacification of the
bilateral mastoid air cells likely secondary to prolonged supine positioning
or recent intubated status. The middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
Persistent, essentially unchanged cerebral edema.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with seizure disorder status post cardiac
arrest, with cerebral edema seen on noncontrast head CT. Evaluate for
intracranial mass, infarct, and venous sinus thrombosis.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 7 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: ___ noncontrast brain MRI.
___ noncontrast head CT.
FINDINGS:
Study is mildly degraded by motion. There is a small enhancing dural-based
lesion overlying the right temporal lobe measuring up to 6 mm(series 101,
image 62). Allowing for difference technique, finding is grossly unchanged
compared to ___ prior exam (see 5:149; 10:53 on our.
Grossly stable right basal ganglia probable Virchow ___ space is again noted
(see 02:16; 14:134; 100:68 on current study and 5:119 on prior exam).
A grossly stable 5 mm pineal cyst is again noted (see 14:104).
There is no evidence of hemorrhage, edema, mass effect, midline shift or
infarction. There is a prominent perivascular space within the right temporal
lobe. The major intracranial vascular flow voids are maintained. The
ventricles and sulci are stable in caliber and configuration.
There is mild-to-moderate mucosal thickening of the ethmoid air cells,
maxillary sinuses, left sphenoid sinus and frontal sinuses. The mastoid air
cells and orbits are normal. Grossly stable left frontal calvarium probable
bone island is again noted (see 101:19; 100:91 on current study and 03:23 on
prior head CT).
IMPRESSION:
1. Please note that prior head CT mentioned in history is not submitted for
direct comparison.
2. Study is mildly degraded by motion.
3. No evidence of acute infarct.
4. No evidence of dural venous sinus thrombosis.
5. Small enhancing dural-based lesion overlying the right temporal lobe
measures up to 6 mm. Allowing for difference technique, finding is grossly
similar to ___ prior exam, suggestive of meningioma.
6. Paranasal sinus disease, as described.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:33 am, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p cardiac arrest, now extubated// Interval
change assessment Interval change assessment
IMPRESSION:
Compared to chest radiographs ___.
Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes
and pleural surfaces are normal.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by UNKNOWN
Chief complaint: Transfer
Diagnosed with Cardiac arrest, cause unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UTA
level of acuity: 1.0 | ___ is a ___ year old woman with PMH of seizure disorder
with witnessed fall into pool, face down in water for several
minutes, found to be without pulse with CPR initiated followed
by coughing up water, with ROSC, intubated at ___ transferred to
___ for further care.
# S/p cardiac arrest:
# Respiratory failure:
On arrival to the MICU was following all commands, though when
weaned to pressure support took increasingly smaller tidal
volumes and eventually apneic so kept intubated overnight on
CMV. Extubated in the AM ___. without complications. Since
mental status intact on arrival, was not cooled but kept
normothermic at 36 C. Etiology of arrest thought to be hypoxemia
from being down in pool. Initiating event causing fall into pool
thought to be seizure. TTE WNL. Repeat chest imaging on ___
demonstrated a possible RLL infiltrate. This in the setting of
increased green sputum production and rising leukocytosis
prompted the initiation of Zosyn on ___ for PNA.
Anti-pseudomonal coverage was chosen given history of water
ingestion. Her leukocytosis resolved, and she had no fevers, and
CXR showed no pneumonia, and clinically she did not have
symptoms. Prior to discharge, ___ was switched to Augmentin
875mg BID for 4 more days to complete a ___erebral edema seen on non-contrast head CT:
Seen on 2 serial CTs, though not seen significantly on
subsequent MRI. Per neurology consult, level of edema did not
correlate with intact mental status exam. MRI performed to
evaluate venous sinus thrombosis as etiology, which was not
seen. Small meningioma was noted incidentally.
# Seizures
___ did not have any missed doses of medications, so she was
continued on her home Dilantin. The night before her seizure and
cardiac arrest she had not taken her ativan and hadn't slept
well, so it was thought that sleep deprivation may have been a
provoking factor. Zonisamide 100mg daily was added, with plan to
increase to 200mg daily after 2 weeks. She was continued on
cvEEG, and had no seizures captured. She was continued on Ativan
QHS for sleep, which she should continue until follow up. She
has follow up with Dr. ___ outpatient epileptologist.
#Hypothyroidism
She was continued on her home levothyroxine 88mcg daily
#Depression, anxiety
She was continued on her home citalopram 40mg daily, baclofen
10mg TID, and lorazepam 1mg PO QHS PRN insomnia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Penicillins / latex / lidocaine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ guided drainage of infected abdominal wall seroma, ___
History of Present Illness:
___ PMHx morbid obesity s/p gastric bypass with significant
weight loss s/p abdominoplasty with panniculectomy at ___
___ (___) p/w abdominal abscess. She relates
increased abomdinal pain and girth since the abomdinal drain was
accidentally dislodged and discontinued several weeks ago. Over
the last several weeks and most strikingly over the last ___
days, she had increased pain and fever and presented to ___
___ where a CT abdomen/pelvis showed a possible abscess at
her surgical site. She also notes that a new opening ___ her
skin appeared at ___. Given concern for sepsis,
she was transferred to ___ from ___. She
received zosyn prior to transfer to ___. En route to ___,
she was hypotensive and received 1 L IVF.
___ the ED, initial vitals: 98 115 95/54 20 100% Nasal Cannula
Exam was notable for: Palpable fluid collection at the lower
abdomen under the surgical incision, breakage of surgical
incision at the right lateral aspect which is actively draining
serosanguineous fluid.
Plastic surgery saw the pt ___ the ED and felt that she had a
likely infected seroma that would be best managed with
intravenous antibiotics and drainage by interventional
radiology.
Labs were notable for: WBC 16.6 (96% PMN) INR 1.3 Lactate 1.6
On transfer, vitals were: 97.4 85 102/52 20 100% Nasal Cannula
On arrival to the MICU, pt endorses diffuse abdominal pain.
Past Medical History:
Morbid Obesity s/p bypass surgery s/p abdominoplasty with
panniculectomy
MEN1
Social History:
___
Family History:
MEN 1 ___ several siblings, mother, maternal aunts, maternal
uncles.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.0 BP: ___ P: 97 R: 24 O2: 100% RA
WEIGHT: 70.4 kg
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: No JVD
LUNGS: CTAB anteriorly
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, diffusely tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Right flank with erythema and two round skin ulcers. The
superior ulcer is draining serosanguinous material. Left flank
with large palpable fluid collection that is tender to
palpation.
EXT: WWP, no ___ edema
SKIN: Right flank erythema with two incisions, superior
incision draining serosanguinous fluid
NEURO: Grossly intact, moving all extremities
Pertinent Results:
==ADMISSION LABS==
___ 09:10PM BLOOD WBC-16.6* RBC-3.67* Hgb-8.0* Hct-27.2*
MCV-74* MCH-21.8* MCHC-29.4* RDW-15.9* RDWSD-42.3 Plt ___
___ 09:10PM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-15.94*
AbsLymp-0.50* AbsMono-0.17* AbsEos-0.00* AbsBaso-0.00*
___ 09:10PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL
___ 09:10PM BLOOD ___ PTT-26.6 ___
___ 09:01PM BLOOD Lactate-1.6
Imaging:
US-guided drainage of seroma ___
IMPRESSION:
Successful US-guided placement of an ___ pigtail catheter
into the
collection. Samples was sent for microbiology evaluation.
Removal of 100 cc purulent fluid.
CXR ___:
IMPRESSION:
No acute cardiopulmonary process.
MICRO:
___ 12:43 pm ABSCESS Source: abscess.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
FLUID CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Preliminary):
ACID FAST CULTURE (Preliminary):
__________________________________________________________
___ 9:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:39 pm SWAB Source: R abd wall.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
__________________________________________________________
___ 8:55 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO TID W/MEALS
2. Vitamin B-12 (cyanocobalamin (vitamin B-12)) 1,000 mcg
sublingual DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Calcitriol 0.25 mcg PO DAILY
2. Calcium Carbonate 500 mg PO TID W/MEALS
3. Multivitamins 1 TAB PO DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drink alcohol or drive while taking this medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H: PRN Disp #*30
Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Vitamin B-12 (cyanocobalamin (vitamin B-12)) 1,000 mcg
sublingual DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 500 mg 2 vials IV every twelve (12) hours Disp
#*28 Vial Refills:*0
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
to start after vancomycin is complete
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
infected seroma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Ultrasound-guided drainage.
INDICATION: ___ year old woman with bilateral flank collections // drainage
of collections
After discussion with plastic surgery and the ICU team, the decision was made
to drain the left lower quadrant collection only given that the right lower
quadrant collection is small, thin with flat configuration, and spontaneously
decompressed itself through the skin.
COMPARISON: Outside CT abdomen ___.
PROCEDURE: Ultrasound-guided drainage of left lower quadrant abdominal wall
collection.
OPERATORS: Dr. ___ radiology fellow and Dr. ___,
___ radiologist, who personally supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the 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 in the left lower quadrant. The site was marked. Local anesthesia
was administered with diluted diphenhydramine givens the patient's allergy to
lidocaine.
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 100 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: 0.5 mg IV Dilaudid.
FINDINGS:
1. Left lower quadrant abdominal wall fluid collection measures about 9 x 2
cm.
2. Removal of 100 cc purulent fluid.
3. Decompressed fluid cavity post drainage.
IMPRESSION:
Successful US-guided placement of an ___ pigtail catheter into the
collection. Samples was sent for microbiology evaluation.
Removal of 100 cc purulent fluid.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with picc // r dl picc 43cm iv ping ___
Contact name: ping, ___: ___ r dl picc 43cm iv ping ___
IMPRESSION:
In comparison with the study of ___, there has been placement of right
subclavian PICC line that extends to the lower SVC just above the cavoatrial
junction.
No evidence of acute cardiopulmonary disease.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abscess, Abd pain, Transfer
Diagnosed with Sepsis, unspecified organism
temperature: 98.0
heartrate: 115.0
resprate: 20.0
o2sat: 100.0
sbp: 95.0
dbp: 54.0
level of pain: 7
level of acuity: 3.0 | ___ PMHx morbid obesity s/p gastric bypass with significant
weight loss s/p abdominoplasty with panniculectomy at ___
___ (___) p/w abdominal abscess.
# Sepsis: On admission, pt meets ___ SIRS criteria (leukocytosis
and tachycardia). She also has a presumed source (abdominal
wound). She also had hypotension that was fluid responsive.
# Infected Seroma: Pt s/p recent abdominal surgery. She has had
increased abdominal pain and girth over the last several days.
She now has a leukocytosis, tachycardia, and mild hypotension.
Imaging from ___ is suggestive of an infectious
intraabdominal collection. Plastic surgery saw the pt ___ the ED
and recommended medical management with IV antibiotics and ___
drainage of collection. ___ drained 100 cc's of pus from her
left-sided collection, wound swab growing MRSA, pigtail left ___
place. Her antibiotics were narrowed to vancomycin alone, PICC
was placed given difficult access. She received Oxycodone 2.5 mg
PO Q4H PRN pain. She was called out to the plastic surgery
service. Given that she continued to have pain ___ her RLQ, a
bedside I&D was performed. She tolerated this procedure well and
her exam continued to improve. ID recommended 1 week of IV
vancomycin followed by 1 week of Bactrim PO which was ordered.
# S/p Gastric Bypass: Continued tums, B12, MVI, calcitriol
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled. She
was discharged home with ___ services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Hydrochlorothiazide / lisinopril
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - Emergent resection of ascending aortic
aneurysm rupture and ascending aortic replacement with a 28 mm
Gelweave tube graft and coronary artery bypass grafting x 1
with reverse saphenous vein graft to the right coronary
artery.
History of Present Illness:
Ms. ___ is a ___ year old woman with ahistory of ascending
aortic aneurysm, hyperlipidemia, hypertension, lymphoma, and
osteoarthritis. She presented with chest pain that began at 4
am. She was in the bathroom when she began to experience ___
centralized chest pain. She denied radiation, nausea, vomiting,
diaphoresis, dizziness, or syncope. However on exam, she has a
right black eye she cannot explain. Upon arrival to the
emergency department she was hemodynamically stable, and given
Tylenol for pain. Chest CT revealed ascending aortic aneurysm
rupture with active extravasation. Her last echocardiogram in
___ revealed a tricuspid aortic valve. Cardiac surgery was
consulted and she was taken to the emergently to the operating
room.
Past Medical History:
Aortic Insufficiency
Ascending Aortic Aneurysm
Chronic Fatigue Syndrome
Follicular Lymphoma of the neck s/p RT
Hemorrhoids
Hyperlipidemia
Hypertension
Intertrigo
Obesity status post left thigh panniculectomy in ___
S/p Appendectomy ___
Bowel Obstruction ___ adhesions ___
S/p Uterine Myomectomy for benign polyp in the ___
Social History:
___
Family History:
Father with rheumatic heart disease.
Mother with polycythemia ___.
Children all healthy.
Physical Exam:
Pulse: 63/SR Resp: 18 O2 sat: 96 RA
B/P ___ (74)
Height: 62" Weight: 270 lbs 122 kg
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade I/VI
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+[X] Severely obese
Extremities: Warm [X], well-perfused [X] Edema [X] 1+ edema
bilateral lower extremities.
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
___ Right: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit: None
.
DISCHARGE EXAM:
Physical Examination:
General/Neuro: NAD [x] A/O x3 [x] non-focal [x]
Cardiac: RRR [x] Irregular [] Nl S1 S2 []
Lungs: CTA [x] No resp distress []
Abd: NBS [x]Soft x[] ND [x] NT [x]
Extremities: no CCE[] Pulses doppler [] palpable [x]
1+ ___ edema
Wounds: Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x] Prevena []
right groin wound- c/d/I with staples
Pertinent Results:
CTA Torso ___
Ascending aortic aneurysm rupture with active extravasation of
contrast near the level of the sino-tubular junction, above the
coronary sinuses, resulting in hemomediastinum and
hemopericardium with a small amount of mass effect on the right
atrium. Blood products also extend along the proximal aortic
arch, some of which may be intramural, and along the course of
the pulmonary arteries to the subsegmental level on the right
and the lobar level on the left, resulting in a decrease in
caliber of the affected vasculature. No hemothorax.
Transesophageal Echocardiogram ___
Pre Bypass: Image quality is marginal with almost absent
transgatric windows. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is severely dilated. There are complex (>4mm) atheroma in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is a moderate sized pericardial effusion. There is sustained
right atrial collapse, consistent with low filling pressures or
early tamponade.
Post Bypass: Pateint is A paced on phenylepherine. Image quality
is poor with difficuilt transgastric windows. There is a
prosthetic graft in the ascending aorta. There is now moderate
eccentric aortic insufficency. Aortic regurgitation pressure
half time is 338 with a jet width ___ 3-6 mm. Mitral
regurgitation is now mild. Left ventricular function is
preserved. There is mild global right ventricular hypokiensis.
Remaining aortic contours unchanged. Remaining exam is
unchanged. All findings discussed with surgeon at the time of
the exam.
___ 09:30AM BLOOD WBC-12.4* RBC-3.69* Hgb-11.0* Hct-34.5
MCV-94 MCH-29.8 MCHC-31.9* RDW-15.5 RDWSD-52.7* Plt ___
___ 04:45AM BLOOD WBC-12.8* RBC-3.40* Hgb-10.2* Hct-32.0*
MCV-94 MCH-30.0 MCHC-31.9* RDW-15.3 RDWSD-52.1* Plt ___
___ 06:11AM BLOOD WBC-13.9* RBC-3.29* Hgb-9.8* Hct-31.2*
MCV-95 MCH-29.8 MCHC-31.4* RDW-15.4 RDWSD-52.5* Plt ___
___ 09:30AM BLOOD Glucose-221* UreaN-55* Creat-1.5* Na-142
K-4.4 Cl-93* HCO3-32 AnGap-17
___ 04:45AM BLOOD Glucose-156* UreaN-58* Creat-1.4* Na-144
K-4.4 Cl-99 HCO3-35* AnGap-10
___ 06:11AM BLOOD Glucose-222* UreaN-62* Creat-1.5* Na-145
K-4.0 Cl-98 HCO3-32 AnGap-15
___ 05:59AM BLOOD Glucose-230* UreaN-56* Creat-1.5* Na-142
K-4.6 Cl-98 HCO3-32 AnGap-12
___ 06:11AM BLOOD WBC-11.0* RBC-3.43* Hgb-10.4* Hct-32.3*
MCV-94 MCH-30.3 MCHC-32.2 RDW-15.7* RDWSD-53.1* Plt ___
___ 06:11AM BLOOD Glucose-150* UreaN-55* Creat-1.5* Na-149*
K-4.5 Cl-100 HCO3-34* AnGap-15
Medications on Admission:
AMLODIPINE-ATORVASTATIN 1 Tablet(s) by mouth once a day -
(Prescribed by Other Provider)
ATENOLOL 1 Tablet(s) by mouth once a day - (Prescribed by Other
Provider)
FOLIC ACID-VIT 2.2 mg-25 mg-0.5 mgtablet. 1 (One) Tablet(s) by
mouth once a day - (Prescribed by
Other Provider)
OMEPRAZOLE 20 mg capsule,delayed release. 1
capsule(s) by mouth twice a day - (Prescribed by Other
Provider)
ONDANSETRON HCL 4 mg tablet. 1 tablet(s) by
mouth three times a day as needed for nausea
Medications - OTC
ASPIRIN Adult Low Dose Aspirin 81 mg
tablet,delayed release. 1 (One) tablet(s) by mouth daily -
(Prescribed by Other Provider; ___)
CHOLECALCIFEROL (vitamin D3) 1,000
unit capsule. One capsule(s) by mouth Daily - (OTC)
GLUCOSAMINE-CHONDROITIN - 500 mg-400 mg
capsule. 2 (Two) Capsule(s) by mouth once a day - (Prescribed
by
Other Provider)
MULTIVIT-MIN-FA-LYCOPEN-LUTEIN [CENTRUM SILVER] - Centrum Silver
0.4 mg-300 mcg-250 mcg tablet. one tablet(s) by mouth -
(Prescribed by Other Provider; ___)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Calcium Carbonate 500 mg PO QID:PRN heartburn
6. Docusate Sodium 100 mg PO BID
7. Furosemide 60 mg IV TID
8. Heparin 5000 UNIT SC TID
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
10. Levofloxacin 750 mg IV Q48H Citrobacter in BAL
last dose: ___
11. Metoprolol Tartrate 25 mg PO TID
12. Multivitamins W/minerals Liquid 15 mL PO DAILY
13. Omeprazole 20 mg PO BID
14. Polyethylene Glycol 17 g PO DAILY
15. Potassium Chloride 20 mEq PO TID
16. Folic Acid-Vit B6-Vit B12 (Ca) (calcium-vitamins B6-B12-FA)
1 oral DAILY
17. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. HELD- glucosamine-chondroitin 500-400 mg oral DAILY This
medication was held. Do not restart glucosamine-chondroitin
until directed by PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Type A Aortic Dissection
Aortic Insufficiency
Ascending Aortic Aneurysm
Chronic Fatigue Syndrome
Follicular Lymphoma of the neck s/p RT
Hemorrhoids
Hyperlipidemia
Hypertension
Intertrigo
Obesity status post left thigh panniculectomy in ___
Discharge Condition:
Alert and oriented x3 non-focal
Max assist, lift to chair
Sternal pain managed with Tylenol
Sternal Incision - healing well, no erythema or drainage
right groin- healing well with staples
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with CP// r/o PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
There is increased right inferior perihilar opacity, concerning for pneumonia.
No pleural effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are moderately enlarged, progressed since ___. Central
vascular engorgement is also new, though without overt pulmonary edema.
IMPRESSION:
Right inferior perihilar opacity, concerning for pneumonia.
Progressed moderate cardiomegaly and new central vascular engorgement.
Radiology Report
EXAMINATION: CTA TORSO
INDICATION: ___ year old woman with hx of aortic aneurysm here w/ chest pain
worse with deep inspiration// r/o aneurysm. eval for PE. more concerned about
aneurysm.
TECHNIQUE: Chest/abdomen/pelvis CTA: Non-contrast and multiphasic
post-contrast images were acquired through the chest, abdomen, and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP =
6.1 mGy-cm.
2) Spiral Acquisition 8.1 s, 63.8 cm; CTDIvol = 15.0 mGy (Body) DLP = 957.7
mGy-cm.
Total DLP (Body) = 964 mGy-cm.
COMPARISON: ___ CT abdomen/pelvis, ___ CT torso, ___ CT torso, ___ CT torso
FINDINGS:
HEART/VASCULATURE: There is ascending aortic aneurysm rupture with active
extravasation of contrast near the level of the sino-tubular junction, above
the coronary sinuses, resulting in hemomediastinum and hemopericardium. There
is a small amount of mass effect on the right atrium. Blood products extend
along the proximal aortic arch, some of which may be intramural, overall
narrowing the lumen from the previous 4.9 cm diameter to a diameter of
approximately 4.2 cm. Blood products also extend along the course of the
pulmonary arteries to the subsegmental level on the right and the lobar level
on the left, also resulting in mass effect on the overall caliber of the
pulmonary arteries with the main pulmonary artery measuring up to 2.7 cm,
previously 4.1 cm. The pulmonary arteries appear patent to the subsegmental
level. The great vessel origins demonstrate mild atherosclerosis, but are
patent. The descending thoracic aorta is unchanged compared to prior
examinations with mild calcified atherosclerosis, but no penetrating
atherosclerotic ulcer formation or evidence of dissection.
The abdominal aorta is patent and normal in caliber, without dissection.
There is a slight focal ectasia of the infrarenal abdominal aorta without
aneurysm, measuring up to 2.3 cm (series 2, image 139). The iliac branches
are patent and normal in caliber. There is slight aneurysmal dilatation of
the proximal right common hepatic artery, which branches early off of the
common hepatic artery (series 2, image 108, 110), measuring up to 7 mm. The
SMA and renal arteries are patent and normal in caliber.
MEDIASTINUM/HILA/AXILLA: No mediastinal, hilar, or axillary lymphadenopathy
appreciable.
LUNGS/PLEURA: No pleural effusion or pneumothorax. There is thickening of the
central pulmonary interstitium, compatible with extension of blood products
along the bronchovascular structures. No significant pulmonary nodule or
consolidation.
LOWER NECK: The visualized portion of the base of the neck is unremarkable.
ABDOMEN:
HEPATOBILIARY: A hypoattenuating lesion in segment II/segment IV is too small
to completely characterize, but unchanged compared to prior examinations,
likely reflecting a cyst or biliary hamartoma. The remainder of the hepatic
parenchyma enhances homogeneously. Since ___, there has been
interval removal of a common bile duct stent. There is mild intrahepatic
pneumobilia, but no significant intrahepatic or extrahepatic biliary ductal
dilatation-pneumobilia likely the result of prior ERCP with sphincterotomy.
The gallbladder is also contains few locules of air without wall thickening or
adjacent fat stranding.
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: A 3 cm exophytic lesion arising from the upper pole of the left
kidney is unchanged in size, now intermediate attenuation, but previously
characterized as a simple cyst on ___ CT abdomen/pelvis. A bilobed
cyst in the interpolar right kidney measuring up to 3.8 cm is unchanged. No
suspicious renal lesion identified. No hydronephrosis or perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is diverticulosis without focal wall
thickening or adjacent fat stranding. Appendix is not visualized. There is
no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The uterus is anteverted. Multiple adnexal
calcifications are again seen.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild bilateral hip and thoracolumbar spine degenerative changes are noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Ascending aortic aneurysm rupture with active extravasation of contrast near
the level of the sino-tubular junction, above the coronary sinuses, resulting
in hemomediastinum and hemopericardium with a small amount of mass effect on
the right atrium. Blood products also extend along the proximal aortic arch,
some of which may be intramural, and along the course of the pulmonary
arteries to the subsegmental level on the right and the lobar level on the
left, resulting in a decrease in caliber of the affected vasculature. No
hemothorax.
NOTIFICATION: The findings and recommendation for cardiac surgery
consultation were discussed with ___, M.D. by ___, M.D.
on the telephone on ___ at approximately 09:05 am, less than 5 minutes
after discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with S/P Repair of rupture aorta// fast track
extubation, effusion, pneumothx Contact name: ___, Phone: 1
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT scan of the chest from earlier today, preop
IMPRESSION:
The patient is post median sternotomy with repair of a ruptured ascending
aortic aneurysm. The tip of the endotracheal tube projects over the mid
thoracic trachea. On the initial radiograph, the tip of a right internal
jugular Swan-Ganz catheter is looped in the pulmonary artery and the tip
projects over the left hilum likely within a branch of the left lower lobe
pulmonary artery. This positioning is subsequently corrected on the
subsequent radiographs. On the final radiograph the tip projects over the main
pulmonary artery, in satisfactory position. Multiple mediastinal drains and
chest tubes are present.
Patchy opacities at both lung bases likely reflect atelectasis. The size of
the cardiomediastinal silhouette is enlarged, likely reflecting a hematoma and
postoperative change. No pneumothorax is identified.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman s/p asc aortic dissection// eval for pulm edema
TECHNIQUE: Portable AP chest
COMPARISON: Comparison is made to ___.
FINDINGS:
Endotracheal tube terminates approximately 3.2 cm from the carina. A right
internal jugular Swan-Ganz catheter tip projects over the main pulmonary
artery. There has been interval removal of a left chest tube. No
pneumothorax. The right hemithorax appears better aerated compared to most
recent prior. Vascular congestion and edema appear slightly improved compared
to ___. Small bilateral pleural effusions. Stable
postoperative appearance of the cardiomediastinal silhouette.
IMPRESSION:
1. Interval improvement of pulmonary vascular congestion and edema compared to
___.
2. All support and monitoring devices are in standard position.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman s/p Asc. Ao replacement, CABG- CTs d/c'd// eval
for pneumothorax
TECHNIQUE: Portable AP chest
COMPARISON: Comparison is made to chest radiograph performed 2 hours prior
FINDINGS:
Endotracheal tube terminates 4.0 cm from the carina. A nasoenteric tube is
visualized projecting below the left hemidiaphragm in the expected region of
the stomach. Right internal jugular Swan-Ganz catheter tip terminates in the
pulmonary outflow tract. Interval removal of a mediastinal chest tube without
evidence of pneumothorax. Small pleural effusions, left lower lobe collapse,
and moderate right basal atelectasis are unchanged. The cardiomediastinal
silhouette is unremarkable and unchanged compared to most recent prior.
IMPRESSION:
All support and monitoring devices are in standard positions. No pneumothorax
or mediastinal widening.
Radiology Report
INDICATION: ___ year old woman s/p dissection repair// eval for infiltrate
eval tube position
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The ET tube, NG tube and the Swan-Ganz catheter are unchanged. Pulmonary
edema is slightly worsened. Bilateral effusions are stable.
Cardiomediastinal silhouette is unchanged. No pneumothorax is seen.
Radiology Report
INDICATION: ___ year old woman with s/p ascending aorta replacement, CABG x
1// evaluate new dob hoff tube
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph performed 5 hours prior and dated ___ and ___.
FINDINGS:
The Dobbhoff tube terminates in the stomach. The remaining during the support
devices are in unchanged position. Right lower lobe atelectasis. No
pulmonary edema. Bilateral pleural effusions are unchanged no pneumothorax.
The cardiomediastinal silhouette is unchanged.
IMPRESSION:
The Dobbhoff tube terminates in the stomach. Otherwise stable exam.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p aortic dissection repair// eval for
infiltrate eval for infiltrate
IMPRESSION:
Swan-Ganz catheter tip is at the level of the right ventricular outflow tract.
Type of tube passes below the diaphragm terminating in the stomach. ET tube
tip is 5 cm above the carinal. There is minimal improvement in the right
basal consolidation. The patient is still in mild pulmonary edema. No
pneumothorax.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with emergent AAA repair// DHT location
TECHNIQUE: Portable AP chest
COMPARISON: Comparison is made to ___.
FINDINGS:
Successive radiographs demonstrating insertion of a Dobhoff feeding tube which
ultimately projects over the right mainstem bronchus. Right central venous
catheter sheath in the mid SVC. Bilateral low lung volumes. No pneumothorax.
Bilateral pleural effusions are likely increased compared to most recent
prior. Probable left lower lobe collapse is unchanged. Enlarged cardiac
silhouette is partially obscured. Mild pulmonary vascular congestion and
edema appears worse compared to prior.
IMPRESSION:
1. Interval insertion of a Dobhoff feeding tube projecting over the right
mainstem bronchus. The primary team is aware and the tube has since been
removed.
2. Pulmonary edema and bilateral effusions appear slightly worse compared to
prior.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 1:35 pm, 5 minutes
after discovery of the findings.
Radiology Report
INDICATION: ___ year old woman s/p DHT placement// ___ year old woman s/p DHT
placement
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: Scout of CT ___.
FINDINGS:
There is paucity of gas in the abdomen limited evaluation of the bowel gas
pattern. An enteric tube ends in the stomach. There is a right IJ central
line sheath in the distal superior vena cava. Changes of CABG are noted.
Radiology Report
INDICATION: ___ year old woman eval dht, perform at 1430// ___ year old woman
eval dht, perform at 1430
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: A scout of CT ___.
FINDINGS:
No findings of bowel obstruction. The enteric tube ends in the proximal
stomach. No free air on supine. A sternal wires noted.
IMPRESSION:
No findings of bowel obstruction
Radiology Report
INDICATION: ___ year old woman s/p DHT adjustment// ___ year old woman s/p DHT
adjustment
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph ___.
FINDINGS:
Paucity of gas in the abdomen without definite findings of bowel obstruction.
The enteric tube ends in the proximal stomach. Sternal wires noted. Small
left pleural effusion and left airspace disease again noted.
IMPRESSION:
No definite findings of bowel obstruction. Left lower airspace disease and
pleural effusion.
Radiology Report
INDICATION: ___ year old woman s/p DHT adjustment// ___ year old woman s/p DHT
adjustment
TECHNIQUE: Single supine abdomen
COMPARISON: ___ at 07:29.
FINDINGS:
There is paucity of gas in the upper abdomen. The enteric tube now appears to
be post pyloric. Sternal wires are again noted. The sheath of a right IJ
catheter is unchanged.
Bibasilar atelectasis, greater on the left and small left pleural effusion are
again noted.
IMPRESSION:
The enteric tube now appears to be post pyloric.
Radiology Report
INDICATION: ___ year old woman s/p DHT placement// ___ year old woman s/p DHT
placement
TECHNIQUE: Portable frontal view of the chest/abdomen.
COMPARISON: ___ 12:07.
IMPRESSION:
Compared to the earlier same day examination, the Dobhoff tube has been
repositioned with the tip projecting over the expected location of the
pylorus, satisfactory. There is a nonspecific bowel gas pattern with relative
paucity of visualized bowel gas. The lung apices are excluded from view.
Right IJ central venous catheter appears grossly unchanged. This study is not
tailored for examination of the lung parenchyma, with left-sided effusion and
bibasilar opacities appearing grossly similar.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new L PICC and existing R IJ central
line// 54 cm L basilic DL PICC- ___ ___ Contact name: ___:
___ cm L basilic DL PICC- ___ ___
IMPRESSION:
Comparison to ___. The patient has received a new left-sided
PICC line. The course of the line is unremarkable, the tip of the line
projects over the mid SVC. No complications, notably no pneumothorax.
Otherwise unchanged radiograph, including the right jugular introduction sheet
and the feeding tube.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p CABG, AAA repair// follow up effusions
follow up effusions
IMPRESSION:
Comparison to ___. Bilaterally, the extent of the pre-existing
pleural effusions has minimally decreased. Areas of substantial atelectasis
are still visualized at the left and right lung bases. Moderate cardiomegaly
persists. No new focal parenchymal changes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with sob// eval for effusion
IMPRESSION:
In comparison with study of ___, there again is substantial
enlargement of the cardiac silhouette with moderate pulmonary edema.
Retrocardiac opacification is consistent with substantial volume loss in the
left lower lobe and probable small effusion. Less prominent changes are seen
at the right base.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with s/p Asc. Aorta and CABG- worsening
tachypnea// evaluate effusions, atx, pna or acute process evaluate
effusions, atx, pna or acute process
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Edema has resolved. Left lower lobe remains densely consolidated accompanied
by an indeterminate volume pleural effusion. Moderate enlargement of cardiac
silhouette is unchanged.
No pneumothorax.
Feeding tube passes into the stomach and out of view. Left PIC line ends in
the mid SVC.
Radiology Report
INDICATION: ___ year old woman with s/p cardiac surgery- ?migration of DHT//
evaluate Dob Hoff position
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the Dobhoff projects over the stomach. A left PICC line tip is
noted at the cavoatrial junction.
Unchanged cardiopulmonary findings since the radiograph performed yesterday
including a left lower lobe consolidation and pleural fluid. The appearance
of the cardiac silhouette is unchanged.
IMPRESSION:
The tip of the Dobhoff projects over the stomach.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with s/p Asc.AO. replacement/CABG// eval
pneumonia/ pleural effusion
IMPRESSION:
In comparison with the study of ___, the Dobhoff tube has been
removed. Left subclavian catheter is unchanged.
Continued enlargement the cardiac silhouette with mild vascular congestion.
Opacification at the left base is consistent with substantial volume loss in
left lower lobe and pleural fluid.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 97.2
heartrate: 75.0
resprate: 16.0
o2sat: 98.0
sbp: 130.0
dbp: 83.0
level of pain: 7
level of acuity: 2.0 | She was admitted on ___ and was taken emergently to the
operating room. She underwent emergent Ascending Aorta
replacement with CABG x 1 with Dr. ___. Please see operative
note for full details. She tolerated the procedure well and was
transferred to the ___ in stable condition for recovery and
invasive monitoring.
She weaned from sedation on POD#1 but she was slow to wake. She
was arrousable but she required aggressive diuresis with a Lasix
drip and was extubated on POD#4. She had tube feeds through a
dobhoff tube which was very difficult to place and required ___.
Her chest tubes and wires were discontinued in the first few
days postop. She was weaned from inotropic and vasopressor
support. Beta blocker was initiated and she was diuresed toward
his preoperative weight. She had an elevated WBC and grew
Citerobacter on a BAL. She was treated with Ceftazadime and
Levofloxacin. Levofloxacin is to continue until ___ to complete
course of antibiotics for PNA. She remained hemodynamically
stable and was transferred to the telemetry floor for further
recovery. As PO intake increased, TFs and DHT discontinued.
Encourage oral intake/free water with rising Na. She received SC
Heparin for DVT prophylaxis. Wound care consult evaluated
sternal and right groin wounds. Initially draining serous -
which resolved. Softsorb applied to sternal wound to minimize
irritation with good effect. She was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 17 she required maximum assistance
for mobility, the wound was healing, and pain was controlled
with Tylenol only. She was discharged to ___
___ in good condition with appropriate follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF THE PRESENTING ILLNESS: Mr. ___ is a ___ with
history of R ankle fracture s/p hardware placement and no
history
of diabetes presenting with persistent RLE cellulitis.
Patient was hospitalized in ___ for RLE cellulitis at
___. Labs at that time notable for an ESR of 99 and CRP
of 19.7. CT of the right lower extremity was completed given
history of ankle fracture with hardware with no evidence of deep
tissue infection. Initially treated with vancomycin then
transitioned to ceftriaxone/azithromycin then to oral Keflex and
then finally recommended discharge to rehab on doxycycline for
planned course through ___.
Patient presented to his PCP for ___ after discharge from
rehab on ___. At this time the erythema was improving but not
yet resolved and he was restarted on doxycycline with plan for a
7-day course. ___ on ___ with his PCP was notable for
continued slow improvement and plan to extend doxycycline for
another week. On ___ his cellulitis was not improving so his
course on doxy was extended and Keflex was added. At this time
patient felt that the cellulitis was about 90% improved.
He was at a follow up appointment with his orthopedist ___ for
evaluation of R ankle hardware placed in ___. Ortho felt
hardware was not compromised but that patient should come to ED
to have cellulitis re-evaluated. Patient denies fever or
chills.
He says at baseline his ankle is swollen but looks more swollen
now than usual. Also has tenderness of his lateral ankle at
baseline which is not changed. He denies any pain of the right
lower extremity. Overall, he is eager to leave the hospital
saying that he has plans for the weekend and would like to be
home for that.
Notably, on ROS patient patient complaining of urinary
frequemcy.
Denies dysuria, hesitancy or suprapubic pain.
In the ED, initial vitals were:
T 96.4, HR 84, BP 94/57 to 110/74, RR 18, 100% RA
- Exam notable for:
2+ pitting edema bilateral lower extremities, RLE with large
area
of erythema with bandage in place over small wound on shin,
second area of erythema over dorsum/medial aspect of foot with
second bandage in place over wound on dorsal aspect of foot.
- Labs notable for:
- Hb 7.9 (hemoglobin 10.6 on ___
- WBC normal without left shift
- UA cloudy with large leuk, small blood, 30 protein, many
bacteria and >182 WBC
- Patient was given: Ceftriaxone 1g
Past Medical History:
-Diverticulosis
-Abnormal liver function tests
-Nocturia
-s/P cardiac pacemaker for sick sinus syndrome (pt reports about
___ years ago)
-Spinal stenosis
-Intracranial meningioma s/p resection
-DJD
-Chronic low back pain
-Urinary retention
-Normocytic reasonable to get any anemia
-Hyponatremia (notable at admission in ___ for cellulitis)
-Dizziness
-R Ankle fracture s/p ORIF
Social History:
___
Family History:
Not-pertinent to the current admission.
Physical Exam:
AMDISSION PHYSICAL EXAM:
VITALS: ___ 1704 Temp: 97.8 PO BP: 105/68 HR: 79 RR: 18 O2
sat: 99% O2 delivery: Ra
GENERAL: Lying in bed, wearing a R eye patch, no acute distress
HEENT: EOMI. Sclera anicteric and without injection. MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Grade
2
systolic murmur best heard at the left upper sternal border.
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. No organomegaly.
EXTREMITIES: 2+ nonpitting edema bilaterally.
RLE skin: Large area of erythema extending from the ankle to two
___ of the way up the shin. Mildly warm, no tenderness, no area
of fluctuance, or purulence. Mild scaling. On the right shin
there is a well-healed ulcer covered with a bandage. There is a
second area of erythema on the dorsum of the right foot with a 1
x 1 cm ulcer with surrounding granulation tissue. The lateral
malleolus does not have erythema but is tender to palpation and
appears larger than the left lateral malleolus. Ankle range of
motion on the right is moderately limited (baseline per
patient).
DISCHARGE PHYSICAL EXAM
GENERAL: Lying in bed, wearing a R eye patch, no acute distress
HEENT: Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic murmur best heard at the RUSB
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.
EXTREMITIES: Trace edema bilaterally. Left leg with more muscle
bulk than right, with scar from old left TKA.
RLE skin: Large area of erythema extending from the ankle to two
___ of the way up the shin. Not warm. Nickel-sized wound on
dorsum of right foot with surrounding erythema and granulation
tissue +mild tenderness to palpation. No fluctuance or
purulence.
+Scaling.
NEUROLOGIC: Alert, conversant. Shoulders ___. Otherwise, no
gross focal deficits.
Pertinent Results:
ADMISSION
___ 02:00PM BLOOD WBC-4.9 RBC-2.74* Hgb-7.9* Hct-25.3*
MCV-92 MCH-28.8 MCHC-31.2* RDW-15.2 RDWSD-51.1* Plt ___
___ 02:00PM BLOOD Neuts-34.2 Lymphs-53.5* Monos-8.2 Eos-3.3
Baso-0.6 Im ___ AbsNeut-1.67 AbsLymp-2.61 AbsMono-0.40
AbsEos-0.16 AbsBaso-0.03
___ 02:00PM BLOOD Glucose-71 UreaN-29* Creat-0.8 Na-139
K-4.3 Cl-104 HCO3-22 AnGap-13
___ 02:00PM BLOOD Calcium-8.6 Phos-3.6 Mg-1.9
___ 07:41AM BLOOD calTIBC-189* Ferritn-306 TRF-145*
___ 07:41AM BLOOD CRP-10.9*
DISCHARGE
___ 06:05AM BLOOD WBC-4.3 RBC-2.79* Hgb-8.2* Hct-25.6*
MCV-92 MCH-29.4 MCHC-32.0 RDW-15.0 RDWSD-50.3* Plt ___
___ 06:05AM BLOOD Glucose-77 UreaN-15 Creat-0.9 Na-143
K-4.3 Cl-107 HCO3-24 AnGap-12
___ 06:05AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.8
***MICRO***
___ 1:45 pm URINE
URINE CULTURE (Preliminary):
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 2 I
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cephalexin 500 mg PO Q8H
2. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth four times daily
Disp #*16 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PIMARY
======
Cellulitis
Mixed arterial and venous vascular insufficiency
SECONDARY
=========
Right Ankle fracture s/p open reduction internal fixation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old man with left lower extremity swelling.// ?DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial vein. Only 1 of the peroneal veins
could be visualized, which was patent.
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.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Ankle pain, R Ankle swelling
Diagnosed with Cellulitis of right lower limb, Urinary tract infection, site not specified
temperature: 96.4
heartrate: 84.0
resprate: 18.0
o2sat: 100.0
sbp: 94.0
dbp: 57.0
level of pain: 1
level of acuity: 3.0 | Mr. ___ is a ___ with history of sick sinus syndrome s/p
pacemaker, R ankle fracture s/p ORIF with hardware placement,
presenting with persistent RLE cellulitis x2 months.
ACTIVE ISSUES
=============
#Non-purulent RLE Cellulitis
Patient presented to ___ in early ___ for a
pneumonia, and was found to have RLE cellulitis, which was
treated
initially with IV vancomycin, CTX, and azithromycin, and he was
discharged on PO doxycycline. Course was extended due to
insufficient response, and cephalexin was added on ___.
Presenting here due to persistent cellulitis, due to concern
from
orthopedics given ongoing infection and plan for possible
further
surgical intervention to right ankle. Patient was afebrile, and
hemodynamically stable, and there is no evidence of involvement
of the underlying joint or hardware. However, given the
persistence of the infection and the possibility for seeding the
ankle hardware or cardiac pacemaker, pt was treated initially
with IV
antibiotics. Patient was seen by infectious disease, felt that
some of his skin changes were more consistent with peripheral
vascular disease (likely mixed arterial and venous), and
therefore recommended discontinuing IV antibiotics and
completing a course of cephalexin (end ___. Blood cultures
were pending. CRP elevated at 10.9/ESR 46. Recommended
outpatient vascular surgery evaluation, which was discussed with
pt and his wife prior to discharge home.
#Normocytic anemia
Most recent hemoglobin in ___ was 10.6. Hemoglobin on admission
7.9. Iron studies consistent with anemia of chronic
inflammation.
#Complicated UTI
Urinalysis in the ED was significant for pyuria and bacteria.
Patient also reports increased frequency of urination. Urine
cultures grew KLEBSIELLA PNEUMONIAE >100,000 CFU/mL;
sensitivities reported after discharge revealed highly resistant
(carbapenem resistant, sensitive only to amikacin). Discussed
with ID, RNs, and environmental services for appropriate room
cleaning. Pt and his wife notified by phone; given lack of
dysuria, reasonable to defer further treatment of UTI vs
asymptomatic bacteruria. Received one dose of CTX in the ED, and
initially treated with PO Ciprofloxacin 500 mg BID, neither of
which were active against highly resistant Klebsiella.
Chronic Issues
==============
# Chronic low back pain
Tylenol ___ mg every 8 hours as needed
# SSS s/p cardiac pacemaker (per patient, about ___ years ago)
# CODE: full (presumed)
# CONTACT: ___ H: ___ c: ___
TRANSITIONAL ISSUES
===================
- On course of cephalexin 500 mg four times a day through ___
for cellulitis. It is unclear how much of his current findings
are due to infection vs peripheral vascular disease.
- Will need follow up with vascular surgery for question of
peripheral vascular disease
- Urine sensitivities for Klebsiella resulted after patient was
already discharged. Resistant to nearly all antibiotics
(intermediate sensitivity to meropenem, and sensitive to
amkikacin). Patient was only having very minor urinary symptoms
(just frequency) so the risks of treating outweigh the benefits.
However, should he develop more significant urinary symptoms or
become septic, this will be a very difficult organism to treat.
[x ] The patient is safe to discharge today, and I spent [ ]
<30min; [x ] >30min in discharge day management services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
SOB
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
This is a ___ with history of Hodgkin's disease in the ___
treated with chemo RT and autologous bone marrow transplant,
also complicated by radiation pneumonitis and hypothyroidism on
levothyroxine who now presentes with productive cough, chills,
and shortness of breath for 1 week. She reports low grade
fevers over the past week, and the sensation of a upper
respiratory bronchitis which has moved into her chest. She
normally has at least one episode of bronchitis each year in the
setting of her known pneumonitis but this episode has persisted
longer. The cough is productive of green sputum. She has been
using her flovent and albuterol without much effect. No chills
or night sweats. She has had some post tussive emesis but
otherwise no nausea/vomitting. She works as a ___ grade ___
and notes multiple kids have been sick in school
She went to her PCP today where she was noted to by tachycardic
and wheezy, so was subsequently referred to the ED. In the ED,
Pt received vanc/ceftriaxone/azithromycin and 40mg PO
prednisone. CXR showed stable paramediastinal radiation
fibrosis but no acute process. She was noted to have a
leukocytosis to 15.6 and lactate was 3.2 on admission and
climbed to 4.5 despite 3L IV fluid. EKG showed sinus tach but
no other acute changes. She also received
albuterol/ipratroptium nebs. Pt was noted to be persistently
tachycardic to the 120s despite IVF. Bedside u/s showed no
pericardial effusion, good EF, dilated IVC/RV. UA was clean.
Given her rising lactate and tachycardia she was admitted to ICU
for further monitoring. VS on transfer ___ 100%RA
On arrival to the MICU, VS were 98.2 117 113/69 98% ra. She
feels much better from a respiratory status after the nebs and
just has a slight residual cough. Pt notes that after
vancomycin she developed a rash over the back of her ears
bilaterally.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias.
Past Medical History:
-Hodkin's lymphoma: nodular sclerosing Stage IIa Hodgkin's
disease dx in ___. Treated initially with combined modality
therapy with ABVD chemotherapy followed by mantle and
para-aortic radiation. She did have several doses of her
Bleomycin held due to decrements in her DCLO. She replapsed in
___ and underwent the SPICE protocol. She underwent a bone
marrow transplant on LAMP protocol in ___ at BID.-
-Hypothyroidism
-Hysteroscopic myomectomy
-adenoidectomy
-eye surgery
Social History:
___
Family History:
HTN, GM with stomach cancer, GF with brain cancer, multiple
breast cancers
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.2 117 113/69 98% ra.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur ___ left upper sternal border
Lungs: Mild end-expiratory wheezing, no crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all extremities, a/o
.
DISCHARGE PHYSICAL EXAM:
VS afebrile, BP 120s/80s, HR 100s-110s, saturations > 98% RA
exam unchanged except resolution of wheezes
Pertinent Results:
IMPORTANT TRENDS:
___ 12:20PM BLOOD WBC-15.6*# RBC-4.19* Hgb-13.9 Hct-39.8
MCV-95 MCH-33.2* MCHC-34.9 RDW-11.9 Plt ___
___ 05:12AM BLOOD WBC-10.4 RBC-3.32* Hgb-11.1* Hct-32.9*
MCV-99* MCH-33.5* MCHC-33.9 RDW-12.0 Plt ___
___ 12:20PM BLOOD Neuts-80.7* Lymphs-13.4* Monos-5.1
Eos-0.3 Baso-0.5
___ 12:20PM BLOOD Glucose-89 UreaN-10 Creat-0.8 Na-142
K-4.4 Cl-102 HCO3-25 AnGap-19
___ 12:20PM BLOOD ALT-18 AST-27 AlkPhos-89 TotBili-0.7
___ 12:20PM BLOOD cTropnT-<0.01
___ 12:20PM BLOOD Albumin-4.9
___ 05:12AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.0
___ 12:20PM BLOOD D-Dimer-232
___ 12:20PM BLOOD TSH-1.5
___ 12:35PM BLOOD Lactate-3.2*
___ 03:28PM BLOOD Lactate-3.8*
___ 04:20PM BLOOD Lactate-4.5*
___ 10:25PM BLOOD Lactate-2.4*
___ 05:27AM BLOOD Lactate-0.8
MICRO:
___ URINE CULTURE NEGATIVE FINAL
___ BLOOD CULTURE X 2 PENDING
IMAGING:
___ CXR: FINDINGS: The heart is of normal size with stable
cardiomediastinal contours. Interstitial changes of
paramediastinal upper lung zones are similar to prior and
compatible with fibrosis from prior radiation for lymphoma. The
lungs are otherwise clear. No focal consolidation, pleural
effusion, or pneumothorax.
No radiopaque foreign body.
IMPRESSION: No evidence for acute cardiopulmonary process.
Stable
paramediastinal radiation fibrosis.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q4hr wheezing
___ puffs as needed
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
rinse mouth after use
4. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 6 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
2. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin [Adult Tussin Chest Congestion] 100 mg/5 mL ___
ml Syrup(s) by mouth every 6 hours Disp ___ Milliliter
Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
INHALATION Q4HR wheezing
___ puffs as needed
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
community acquired pneumonia
Secondary:
history of lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Cough and fever.
COMPARISON: ___ chest radiograph. CT chest of ___.
TECHNIQUE: Frontal and lateral views of the chest.
FINDINGS: The heart is of normal size with stable cardiomediastinal contours.
Interstitial changes of paramediastinal upper lung zones are similar to prior
and compatible with fibrosis from prior radiation for lymphoma. The lungs are
otherwise clear. No focal consolidation, pleural effusion, or pneumothorax.
No radiopaque foreign body.
IMPRESSION: No evidence for acute cardiopulmonary process. Stable
paramediastinal radiation fibrosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB/COUGH
Diagnosed with TACHYCARDIA NOS
temperature: 100.2
heartrate: 116.0
resprate: 18.0
o2sat: 100.0
sbp: 108.0
dbp: 73.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old female with history of Hodgkin's
Lymphoma, status post chemo and SCT in ___, residual radiation
pneumonitis who presents with cough and shortness of breath x1
week, noted to be tachycardic with lactic acidosis in the ED.
She was admitted to the MICU and her lactate resolved and
symptoms improved with IV fluids and treatment for community
acquired pneumonia.
# Community acquired pneumonia: She did have WBC to 15 with
mild fevers and productive cough/sputum production. We decided
to treat with levofloxcain 750 mg daily x 7 days because of her
history of radiation damage and bronchiectasis. Other likely
etiologies are a viral URI/bronchitis in the setting of her sick
contacts at school with associated reactive airway disease,
especially given her normal CXR. She was continued on her home
fluticasone inhaler and albuterol inhaler. She did recieve 40
mg of prednisone in the ED but this was not continued.
# Tachycardia: Could be in setting of infection, though pt
reports very good PO fluid intake. She says she has been
running a "high" heart rate in the ___ over recent months
at baseline and this is confirmed in prior clinic notes.
Pulmonary embolus was considered but her Ddimer in the 200s
makes this less likely. No evidence of effusion/tamponade on ED
bedside echo. No recent levothryoxine dose changes. We sent an
email to her outpatient PCP making them aware that this was an
ongoing issue and they may want to pursue cardiac work-up
including echo and stress since she has potential for
radiation-induced CAD or heart failure.
# Lactic acidosis: Unclear why her lactate persisted greater
than 4 despite 3L NS in the absence of a significant infectious
process. BP is normal on the floor. No abdominal pain or other
localizing symptoms. It did resolve the following morning.
# Hypothyroidism: Continued home levothyroxine 75 mcg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Found down, likely secondary to alcohol intoxications
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ man with a h/o alcohol abuse complicated
by withdrawal seizing episodes in the past, cirrhosis ___ EtOH
and HCV with varices (last admitted in ___ for GI bleed
secondary to varices at which time he required intubation, and
again in ___ for EtoH intoxication and hematemesis), who
was initially admitted for complicated alcohol withdrawal.
He had initially been found down in the street around ___,
and taken by EMS to the ___ ED. He reports drinking that
evening but does not recall other details. In the ED he was
afebrile, not tachycardic (heart rate ___, and otherwise
stable. He was unresponsive and only withdrew to pain. His EtOH
level was
433, lactate was 2.4. Labs were also notable for LFT elevation
with AST>ALT pattern. In the ED, he received 2mg of lorazepam
that resulted in somnolence. He was given Naloxone but did not
demonstrate a response to it. CT Spine/CT Head imaging was clear
for any abnormalities. Tox screen positive for EtOH,
amphetamines, negative for opiates.
He then had an evolving oxygen requirement from 2 L up to 4L NC
in the ED, and thus had a chest CTA that was negative for PE or
other acute processes. His oxygen requirement spontaneously
resolved, but due to an increase in his heart rate to the 120s,
he was admitted to the MICU for further care. He had a fever
with
TMax 101.6F that resolved spontaneously.
In the MICU, he was originally not given Phenobarbital, but he
later ultimately received one loading dose of this at 0200 ___
(300 mg IV). He also had a repeat lactate which was 3.5, after
which he received 1L LR, with improvement to 1.5. His INR was
1.8 on admission and he was given a Vit K challenge, as well as
thiamine and folate. It is unclear whether he has been taking
his other home medications (Nadalol and Lactulose).
In terms of past medical history, he reports a diagnosis of
cirrhosis secondary to Hep C and alcohol use, he is not followed
by any hepatologist. He has a prescription for Adderall but
denies filling this or using this medication. He reports
contracting Hep C due to IVDU ___ years ago. He denies IVDU at
this time as well as opiates, cocaine, MJ,
or other substances.
During his last hospitalization, he was placed under Section 35.
He reports going to ___ for a detox program and being
discharged after 3 weeks. He states he did not find it helpful
and does not want to return to that program or any other
program.
Past Medical History:
ETOH abuse with pt reported history of withdrawal seizures
PTSD
ADHD
Multiple ED admissions for alcohol intoxication/assaults
IVDA
HCV
Inderterminate Quant Gold
asthma
ETOH abuse with pt reported history of withdrawal seizures
PTSD
ADHD
Multiple ED admissions for alcohol intoxication/assaults
IVDA
HCV
Inderterminate Quant Gold
asthma
Social History:
___
Family History:
Unknown, adopted at age ___
Physical Exam:
ADMISSION EXAM:
VS: T 100.4F HR 115 BP 121/58 RR 21 O2Sat 94%RA
GENERAL: Intermittently responsive to questions, easily falls
asleep, no acute distress
HEENT: PERRLA. Sclera anicteric, MMM, oropharynx clear
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No asterixis
SKIN: Not jaundiced, tattoo that says "libra" on the left side
of his neck
NEURO: Moves extremities with purpose, able to wiggle toes
DISCHARGE EXAM:
0730: Temp: 98.4 PO BP: 96/60 R Lying HR: 71 RR: 18 O2 sat: 97%
O2 delivery: RA
1130: Temp 98.5, 111/64
General: Nontoxic appearing. Disheveled appearing.
HEENT: Head normocephalic, hair disheveled. MMM, oropharynx
clear. Has scar across upper lip and above right eyebrow.
Resp: Clear to auscultation bilaterally anteriorly, no wheezes
CV: regular rate and rhythm
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding. Liver span ~12 cm, 6-8 cm below
costal margin
MSK: warm, well perfused, no edema
Neuro: CNs grossly intact. Face symmetric, motor function
grossly
normal, moving and bending all four extremities.
Pertinent Results:
ADMISSION RESULTS:
___ 11:45PM BLOOD WBC-10.2* RBC-3.29* Hgb-8.9* Hct-28.3*
MCV-86 MCH-27.1 MCHC-31.4* RDW-17.2* RDWSD-52.9* Plt ___
___ 11:45PM BLOOD Plt ___
___ 11:45PM BLOOD Glucose-140* UreaN-5* Creat-0.6 Na-146
K-3.3 Cl-109* HCO3-22 AnGap-15
___ 11:45PM BLOOD ALT-19 AST-47* AlkPhos-156* TotBili-0.5
___ 11:45PM BLOOD Albumin-3.2*
___ 11:00PM BLOOD ___ PTT-45.6* ___
___ 11:45PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:16PM BLOOD Lactate-2.4*
IMAGING
========
CXR (___): Streaky opacities overlying the bilateral lower
lobes could represent atelectasis given low lung volumes,
however infection cannot be excluded.
Slight vascular prominence may be exaggerated by low lung
volumes.
CT C-SPINE (___): 1. No fracture or malalignment.
2. The palatine tonsils are prominent, slightly greater in the
expected for the patient's age, but overall unchanged from prior
exam. This could be reactive in nature. Clinical correlation
is recommended.
CT HEAD WITHOUT CONTRAST (___): 1. No acute intracranial
abnormality on noncontrast head CT. Specifically no large
territory infarct or intracranial hemorrhage. Suggestion of
bilateral orbital frontal encephalomalacia.
2. Mild left frontal scalp soft tissue swelling without evidence
of acute
displaced calvarial fracture.
3. Additional findings as described above.
CTA CHEST (___): 1. Evaluation of the subsegmental pulmonary
arterial levels within the lung bases is limited by respiratory
motion. Allowing for this, no pulmonary embolism to the
segmental level is demonstrated. No acute thoracic aortic
pathology is seen.
2. Re-demonstration of nodular contour of the liver compatible
with underlying cirrhosis with esophageal varices and bilateral
gynecomastia.
MICROBIOLOGY
=============
Blood cultures NO GROWTH at the time of discharge
DISCHARGE LABS
==============
___ 02:30AM BLOOD WBC-10.7*# RBC-3.41* Hgb-9.0* Hct-28.2*
MCV-83 MCH-26.4 MCHC-31.9* RDW-16.6* RDWSD-50.0* Plt ___
___ 02:30AM BLOOD Glucose-90 UreaN-4* Creat-0.7 Na-131*
K-3.7 Cl-96 HCO3-25 AnGap-10
___ 02:30AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.4*
Medications on Admission:
The patient denies taking any home medications
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath or
wheeze
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled
every 4 hours Disp #*1 Inhaler Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
#Alcohol intoxication
#Acute hypoxic respiratory failure
#Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Surgery area
INDICATION: History: ___ with ams, hypoxic// plz evaluate for evidence of
consolidation
TECHNIQUE: Frontal view radiograph the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
Lung volumes are low. Streaky opacities overlying the bilateral lower lobes
favor atelectasis. Slight vascular prominence may be exaggerated by low lung
volumes. Prominent cardiomediastinal silhouette is likely accentuated by low
lung volumes and technique. There is no definite pleural effusion or
pneumothorax.
IMPRESSION:
Streaky opacities overlying the bilateral lower lobes could represent
atelectasis given low lung volumes, however infection cannot be excluded.
Slight vascular prominence may be exaggerated by low lung volumes.
RECOMMENDATION(S): Consider dedicated PA and lateral view radiographs when
tolerated by patient.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ obtunded// plz evaluate for evidence of injury
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. This was repeated due to motion degradation.
Coronal and sagittal reformats were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.8 cm; CTDIvol = 47.7 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 8.0 s, 16.8 cm; CTDIvol = 47.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Prominent ventricles and sulci are advanced given the patient's
age. Suggestion of bilateral orbitofrontal encephalomalacia.
There is partial opacification of the right anterior ethmoid air cells..
Mastoid air cells and middle ear cavities are well aerated. Mild left frontal
scalp soft tissue swelling without evidence of acute displaced calvarial
fracture.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT. Specifically no
large territory infarct or intracranial hemorrhage. Suggestion of bilateral
orbital frontal encephalomalacia.
2. Mild left frontal scalp soft tissue swelling without evidence of acute
displaced calvarial fracture.
3. Additional findings as described above.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ obtunded// plz evaluate for evidence of injury
plz evaluate for evidence of injury
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.6 s, 22.0 cm; CTDIvol = 22.7 mGy (Body) DLP = 499.6
mGy-cm.
Total DLP (Body) = 500 mGy-cm.
COMPARISON: CT cervical spine of ___.
FINDINGS:
Alignment is anatomic.No fractures are identified. There is no evidence of
spinal canal or neural foraminal stenosis. Multilevel degenerative changes
are present most severe at C3-C4. There is no prevertebral soft tissue
swelling.Thyroid is unremarkable. Bilateral lung apices are clear. There is
no cervical lymphadenopathy by size criteria. The palatine tonsils are
prominent, slightly greater expected for the patient's age but unchanged from
prior examination. Clinical correlation is recommended.
IMPRESSION:
1. No fracture or malalignment.
2. The palatine tonsils are prominent, slightly greater in the expected for
the patient's age, but overall unchanged from prior exam. This could be
reactive in nature. Clinical correlation is recommended.
Radiology Report
INDICATION: History: ___ with hypoxia// PE? pneumonia?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP =
6.1 mGy-cm.
2) Spiral Acquisition 3.0 s, 23.6 cm; CTDIvol = 12.0 mGy (Body) DLP = 283.9
mGy-cm.
Total DLP (Body) = 290 mGy-cm.
COMPARISON: CT torso ___
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 segmental level, with no
evidence of filling defect within the main, right, left, lobar, or segmental
pulmonary arteries. Assessment of the subsegmental pulmonary arterial levels
within the lung bases is somewhat limited due to respiratory motion. The main
and right pulmonary arteries are normal in caliber, and there is no evidence
of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
4 mm hypodense nodule in the left thyroid gland does not warrant follow-up per
ACR criteria.
There is no evidence of pericardial effusion. There is no pleural effusion.
Mild dependent atelectasis is noted in the lung bases. A cyst measuring 15 mm
is seen within the lingula. There is mild diffuse airway wall thickening.
Airways are otherwise patent centrally.
Limited images of the upper abdomen demonstrate esophageal varices, as seen
previously and a mildly nodular contour of the liver compatible with
underlying cirrhosis.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Bilateral gynecomastia is re-demonstrated.
IMPRESSION:
1. Evaluation of the subsegmental pulmonary arterial levels within the lung
bases is limited by respiratory motion. Allowing for this, no pulmonary
embolism to the segmental level is demonstrated. No acute thoracic aortic
pathology is seen.
2. Re-demonstration of nodular contour of the liver compatible with underlying
cirrhosis with esophageal varices and bilateral gynecomastia.
Radiology Report
INDICATION: ___ year old man with fever, cough// Evaluate for infection
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lung volumes have improved. There are no new consolidations. Heart size is
normal. There is no pleural effusion. No pneumothorax is seen
Gender: M
Race: HISPANIC/LATINO - HONDURAN
Arrive by AMBULANCE
Chief complaint: ETOH, Unresponsive
Diagnosed with Alcohol dependence with intoxication, unspecified
temperature: 96.6
heartrate: 91.0
resprate: 16.0
o2sat: 96.0
sbp: 107.0
dbp: 78.0
level of pain: UTA
level of acuity: 2.0 | ___ man with a h/o alcohol abuse complicated by withdrawal
seizing episodes in the past, cirrhosis ___ EtOH and HCV with
varices, who was brought in by EMS after being found down. On
arrival, patient was minimally responsive and noted to have an
EtOH level of 433. He initially received 2 mg IV Ativan, but due
to persistent tachycardia with minimal responsiveness, he was
admitted to the MICU. On arrival to the MICU, he was arousable,
but generally refused to engage in conversation. He received a
phenobarbital loading dose, but was not continued on maintenance
dosing due to his cirrhosis and stabilization of his symptoms.
He had a transient fever, which was felt to be due to aspiration
pneumonitis vs ETOH withdrawal, which resolved without
antibiotics. He was transferred to the floor on ___, where
he remained without signs of alcohol withdrawal. He was seen by
SW; at discharge plan for made for the patient to follow-up at
the ___ where he could be set up with a
case manager. He also expressed interest in following up with
his PCP in order to be connected to Behavioral Health Services.
#ETOH withdrawal.
#Tachycardia.
Prior discharge summary notes history of withdrawal seizures
which patient denies. On arrival in MICU, patient was
tachycardic, tremulous, and nauseous concerning for onset of
withdrawal. Serum ETOH 433 on arrival to ED, with elevated
lactate to 2.4 (suspect type B lactic acidosis). Received 2 mg
Ativan in ED and was reportedly somnolent. Mental status
improved on assessment in MICU and patient received reduced
phenobarbital load to 5 mg/kg which he tolerated to good effect.
He received high dose Thiamine, folate, and multivitamin.
The patient was transferred to the floor on ___ and
remained clinically stable. He did not exhibit any signs or
symptoms of acute alcohol withdrawal and did not require any
additional lorazepam (written for 1 mg q4 PRN per ___
protocol). He was continued on Thiamine, multivitamin, folate.
He was seen by ___ and expressed interest in programs for
Behavioral Health and substance use recovery and was provided
with relevant resources. At discharge, a plan was made for the
patient to follow-up at ___ where he can
be set up with a case manager, as well as with his primary care
provider, who was informed about his admission.
#Acute Hypoxemic Respiratory Failure
Patient noted to desaturate and had oxygen requirement in the
MICU. This was likely due to sedation. It resolved prior to
discharge.
#Fever.
Temperature to 101.6F in ED. Mild leukocytosis on admission,
which normalized later. CXR with b/l lower lobe opacities
favoring atelectasis rather than infection. UA negative for
infection. Antibiotics were deferred given hemodynamic stability
and low suspicion for infection.
On the floor, the patient spiked a fever again to 101.7 the
night of ___. UCx was clear and repeat CXR did not demonstrate
pulmonary process suggestive of pneumonia. The etiology was
thought to be most likely temperature fluctuations in setting of
withdrawal. The patient remained afebrile throughout the morning
on the day of discharge. He was given return precautions to
re-present to care if he developed more concerning respiratory
symptoms
#Hyponatremia: Na 131 on ___, drop from 139, together with
lower blood pressures (systolics <100) was noted. This was
thought to be most likely hypovolemic hyponatremia. The patient
was treated with IVF and increased PO intake and his blood
pressures increased to systolics >110 prior to d/c.
#Cirrhosis
#Esophageal varices.
#Hx ___ tear.
Received Nadolol and Lactulose on prior admissions, though does
not take these medications as an outpatient. In ___ EGD
showed 2 cords of grade II varices seen in the lower esophagus.
He was restarted on Pantoprazole, Lactulose, and Nadolol while
inpatient.
#Coagulopathy: Presented with an admission INR of 1.8. This did
not respond to Vitamin K challenge, so likely primarily due to
liver disease.
#Anemia of chronic disease: His hemoglobin was low on admission
but similar to prior values in our system. Likely due to marrow
dysfunction from alcohol and cirrhosis, and there was no
evidence of active blood loss.
====================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
MS ___
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old with history of UC s/p total proctocolectomy and
ileoanal pouch, ankylosing spondylitis, type 2 DM, DVT, and
recent admission ___ to ___ where he was found to have BPPV and
a LLL PE started on Coumadin now presenting with dizziness and
chest pressure for one day.
Pt was admitted ___ to ___ with complaint of gross hematuria,
chest tightness and suicidal ideation in the setting of a
steroid taper. He was found to have a LLL PE on CTA chest and
was started on Coumadin. Workup, including CTU, was
unremarkable, and pt was was planned for urology follow up after
discharge. Pt's course was complicated by episodes of dizziness
and gait instability. A CT head was negative for an acute
process. Pt was ultimately diagnosed with BPPV and planned for
outpatient vestibular ___.
Pt states that since discharge he continued to have dizziness.
He describes the dizziness as constant and states that he feels
like the works is "moving back and forth," but denies spinning.
He states that it does not stop and start suddenly, rather is
persistent. Furthermore, he reports a sensation of falling to
both his right and left rather than just his right side during
his last admission. He also states that today he developed chest
pressure with associated shortness of breath. He states that it
feels as though he cannot take in a full breath. The chest
pressure was also associated with tingling in his hands and feet
which caused a great deal of anxiety. He denies fevers, dysuria,
frank hematuria, new joint pain, worsened diarrhea (baseline),
abdominal pain, nausea or vomiting. Pt states that he has had
some chills recently. Pt states that he back pain and AS
symptoms are currently at baseline, but he does not some hand
and feet swelling that resolved a few days ago.
In the ED, initial vital signs were: 98.4 115 123/75 18 100% RA
- Exam was notable for: unsteady gait
- Labs were notable for: WBC 9.9, H/H 11.1/38.3, plts 394, Na
136, K 3.5, BUN/Cr ___, INR 3.2, troponin <0.01 x 2, proBNP
16, lactate 3.6 x 2
- UA with >182 RBCs, large blood, 2 WBC
- Imaging: CT head did not demonstrate an acute process and CTA
chest did not demonstrate an interval PE and known is less
distinct
- The patient was given: 2L NS, Dilaudid 1mg IV x 2, Oxycodone
5mg PO x 1
- Consults: None
Vitals prior to transfer were: 98.2 99 118/54 18 100% RA
Upon arrival to the floor,pt states that he continues to have
subtle chest pressure, but states that he is overall
comfortable. He also has some mild dizziness.
Past Medical History:
PAST MEDICAL HISTORY:
UC
Ankylosing spondylitis,
OSA
Depression
HTN
Low testosterone,
DVT (upper extremity and lower extremity)
PE
NARCOTIC ABUSE
Prior suicide attempt
DIABETES (HBA1C 6.6 ___
BPPV
PAST SURGICAL HISTORY:
Lap total proctocolectomy
Ileoanal J pouch
Diverting loop ileostomy ___ w/ Dr ___
Ileostomy takedown (___)
___ abscess.
Social History:
___
Family History:
Confirmed on admission ___
Father: ___ for renal CA
Mother: ___ CA, RA
No IBD in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS - 98.6 108 135/87 18 97% on RA, WT 129.3 kg
GENERAL - pleasant, in no distress, sitting in a chair
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA
NECK - supple, no LAD, no thyromegaly, JVP flat
CARDIAC - Tachycardic, normal S1/S2, no murmurs rubs or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - ___, CN II-XII grossly normal, lateral nystagmus
on upward but not downward gaze, normal sensation, with strength
___ throughout. Loss of pain, temperature, and vibratory
sensation on his lower extremities, persistent decreased touch
on feet over anterior plantar aspect and heel; instability on
tandem gait and Romberg test.
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE PHYSICAL EXAM
VITALS - 99.0 121/86 93 19 99RA
GENERAL - pleasant, in no distress, sitting in a chair
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA
NECK - supple, no LAD, no thyromegaly, JVP flat
CARDIAC - RRR, normal S1/S2, no murmurs rubs or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - ___, CN II-XII grossly normal, no nystagmus on
lateral or downward gaze, some lateral nystagmus with upward
gaze, strength ___ throughout. Loss of pain, temperature, and
vibratory sensation on his lower extremities, persistent
decreased touch on feet over anterior plantar aspect and heel;
instability on tandem gait and Romberg test.
PSYCHIATRIC - listen & responds to questions appropriately, but
anxious appearing
Pertinent Results:
ADMISSION
=========
___ 01:15PM BLOOD WBC-9.9 RBC-5.30 Hgb-11.1* Hct-38.3*
MCV-72* MCH-20.9* MCHC-29.0* RDW-18.6* RDWSD-45.3 Plt ___
___ 01:15PM BLOOD Neuts-44.6 ___ Monos-9.9 Eos-1.1
Baso-1.2* NRBC-0.3* Im ___ AbsNeut-4.38 AbsLymp-4.11*
AbsMono-0.98* AbsEos-0.11 AbsBaso-0.12*
___ 02:05PM BLOOD ___ PTT-46.4* ___
___ 01:03PM BLOOD Glucose-135* UreaN-6 Creat-0.6 Na-136
K-3.5 Cl-102 HCO3-22 AnGap-16
___ 07:30PM BLOOD ALT-46* AST-29 AlkPhos-112 TotBili-0.2
___ 09:20AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.8
___ 01:07PM BLOOD Lactate-3.6*
___ 03:57PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:57PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 03:57PM URINE RBC->182* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
PERTINENT
=========
___ 01:03PM BLOOD cTropnT-<0.01 proBNP-16
___ 07:30PM BLOOD cTropnT-<0.01
___ 09:20AM BLOOD VitB12-503
___ 08:40AM BLOOD %HbA1c-6.8* eAG-148*
___ 08:40AM BLOOD ___
___ 08:40AM BLOOD RheuFac-<3
___ 09:20AM BLOOD CRP-2.5
___ 08:10AM BLOOD antiDGP-12
___ 12:22AM BLOOD Lactate-1.8
DISCHARGE
=========
___ 08:20AM BLOOD WBC-11.8* RBC-4.84 Hgb-9.9* Hct-34.1*
MCV-71* MCH-20.5* MCHC-29.0* RDW-17.4* RDWSD-43.6 Plt ___
___ 08:20AM BLOOD ___ PTT-30.2 ___
___ 08:20AM BLOOD Glucose-109* UreaN-9 Creat-0.6 Na-138
K-4.2 Cl-99 HCO3-28 AnGap-15
___ 08:20AM BLOOD Calcium-9.7 Phos-5.2* Mg-2.0
IMAGING
=======
- MRI MRA head ___:
1. No acute intracranial abnormality without infarct,
hemorrhage, or mass.
2. Small right mastoid air cell effusion.
3. Patent intracranial vasculature without occlusion,
dissection, significant stenosis, or aneurysm. No evidence of
vascular malformation.
-Stress EKG/Echo:
Poor functional exercise capacity. No ECG or 2D
echocardiographic evidence of inducible ischemia to achieved
workload. Normal hemodynamic response to exercise. No anginal
type symptoms or significant EKG changes.
-Nuclear pharm stress perfusion:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
-CT Head ___
IMPRESSION:
No acute intracranial process.
-CTA Chest ___
IMPRESSION:
1. No interval pulmonary embolism. Previously seen pulmonary
emboli are less distinct on the present study.
2. No other acute process is detected.
-TTE ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with borderline normal free
wall function (no overt RV strain). 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 structurally normal. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
-EKG ___: NSR at 96, T wave inversions in lateral leads
(similar pattern compared to ___, however more pronounced)
MICRO
=====
___ URINE URINE CULTURE-MIXED BACTERIAL FLORA (
>= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-
NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO DAILY
2. Gabapentin 600 mg PO NOON
3. Gabapentin 900 mg PO QHS
4. Methylprednisolone 5 mg PO DAILY
5. Metoprolol Succinate XL 150 mg PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
7. Tizanidine 4 mg PO QHS Spasm
8. Venlafaxine XR 150 mg PO DAILY
9. Warfarin 5 mg PO DAILY16
10. Humira (adalimumab) 40 mg/0.8 mL subcutaneous weekly
11. LOPERamide 2 mg PO TID:PRN loose stool
12. Testosterone Cypionate 100 mg IM 1X/WEEK (___) Low
testosterone
Discharge Medications:
1. Enoxaparin Sodium 120 mg SC Q12H Duration: 7 Days
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 120 mg/0.8 mL 120 mg SubQ every 12 hours Disp
#*14 Syringe Refills:*3
2. Gabapentin 600 mg PO DAILY
3. Gabapentin 600 mg PO NOON
4. Gabapentin 900 mg PO QHS
5. Methylprednisolone 5 mg PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
7. Tizanidine 4 mg PO QHS Spasm
8. Venlafaxine XR 150 mg PO DAILY
9. Warfarin 5 mg PO DAILY16
10. ClonazePAM 0.25 mg PO BID
RX *clonazepam 0.25 mg 1 tablet(s) by mouth twice a day Disp #*6
Tablet Refills:*0
11. Vitamin E 400 UNIT PO DAILY
RX *vitamin E 400 unit 1 capsule by mouth daily Disp #*30
Capsule Refills:*0
12. Humira (adalimumab) 40 mg/0.8 mL subcutaneous weekly
13. LOPERamide 2 mg PO TID:PRN loose stool
14. Metoprolol Succinate XL 150 mg PO DAILY
15. Testosterone Cypionate 100 mg IM 1X/WEEK (___) Low
testosterone
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
Anxiety
Panic disorder
Rule out ACS
SECONDARY
Pulmonary embolism
Hematuria
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with dizziness, anticoagulated, recent fall, evaluate for
bleed or other acute intracranial process.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: Prior head CT dated ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
There is no evidence of fracture.
Mild mucosal thickening is noted within bilateral maxillary sinuses with more
moderate mucosal thickening noted within the anterior ethmoidal air cells.
The visualized portion of the mastoid air cells and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with PE being treated with Coumadin, now presents with
dizziness, pleurisy, and tachycardia, evaluate for worsening pulmonary
embolism or other acute process.
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) = 801 mGy-cm.
COMPARISON: Prior chest CT dated ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental level. Subsegmental branches are not well opacified due to motion
and timing of contrast. The previously seen left lower lobe pulmonary
embolism is less well demonstrated on the present study, likely due to a
combination of bolus timing and embolus evolution. Similar right lower lobe
subsegmental filling defect (3:145) is again noted. No new filling defects
are seen to suggest interval embolism. Main, right, and left pulmonary
arterial caliber is normal. There is no evidence of right heart strain. 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. 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 again notable for centrally
fatty lesion in the left upper quadrant.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No interval pulmonary embolism. Previously seen pulmonary emboli are less
distinct on the present study.
2. No other acute process is detected.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ male with ankylosing spondylitis experiencing chest
pressure and dizziness with pulsatile sensation. Evaluate for intracranial
mass for lesion.
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
Multiplanar, sagittal T1, axial T1, axial GRE, axial FLAIR, axial T2 imaging
of the brain was performed. After the uneventful intravenous administration
of 9 cc Gadavist, gadolinium base contrast, axial T1 and sagittal MPRAGE
imaging was obtained. Multiplanar reformatted images of the MPRAGE images
were then produced.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
Study is mildly degraded by motion.
MRI BRAIN:
There is motion artifact on the postcontrast MPRAGE sequence which degrades
spatial resolution. There is with linear enhancement at the right cerebellar
hemisphere and mild gradient hypointensity, without signal abnormality on T2
or FLAIR imaging, likely representing a capillary telangiectasia versus
atypical developmental venous anomaly. Otherwise the parenchymal signal is
unremarkable without acute infarct, hemorrhage, mass, or mass effect. The
ventricles and cortical sulci are normal caliber configuration. The vascular
flow voids are preserved. The cortical veins and dural venous sinuses enhance
normally. There is suggestion of small right cerebellar developmental venous
anomaly (see 1300:40-41).
The orbits, calvarium, and soft tissues are unremarkable. There is a small
right mastoid air cell effusion. There is no fluid signal within the
paranasal sinuses.
MRA BRAIN:
The bilateral intracranial internal carotid arteries are patent. The anterior
bilateral posterior communicating arteries are visualized. There are
codominant vertebral arteries. The anterior and posterior arterial
circulations are patent without occlusion, dissection, significant stenosis,
or aneurysm. There is no evidence of vascular malformation.
IMPRESSION:
1. No acute intracranial abnormality without infarct, hemorrhage, or mass.
2. Small right mastoid air cell effusion.
3. Patent intracranial vasculature without occlusion, dissection, significant
stenosis, or aneurysm. No evidence of vascular malformation.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Dizziness, Dyspnea
Diagnosed with Dizziness and giddiness, Dehydration, Abnormal electrocardiogram [ECG] [EKG]
temperature: 98.4
heartrate: 115.0
resprate: 18.0
o2sat: 100.0
sbp: 123.0
dbp: 75.0
level of pain: 6
level of acuity: 2.0 | ___ year old with history of UC s/p total proctocolectomy and
ileoanal pouch, ankylosing spondylitis, type 2 DM, DVT, and
recent admission ___ to ___ where he was found to have BPPV and
a LLL PE started on Coumadin now presenting with dizziness since
discharge and chest pressure for one day, found to be
tachycardic with an elevated lactate.
# Dizziness:
Patient reporting new onset dizziness, described as feeling his
pulse in his head and his vision beating side to side. Pt was
given a diagnosis of BPPV at last admission, however his
symptoms are not consistent with this finding. On exam, e/o
decreased proprioception on exam w/ nystagmus laterally on
prolonged upward gaze. Workup for seropositive autoimmune
disorder negative so far: RF<3, ___ neg. CRP 2.5, sed rate 6.
B12 503. Cu nl. Vit E low. RPR nl. CT head did not demonstrate
an acute process. MRI head with no gross abnormalities. Thought
most likely to be a multifactorial peripheral cause (planter
neuropathy), with additional strong component of anxiety.
Improved with Ativan. Started on Vit E 400u/day and citalopram
0.25mg BID. Should follow up with remaining labs sent by neuro
at f/u appointment with Dr. ___ should also be referred
to psychiatry from PCP ___ (per psychiatry recommendations,
as they think this is the fastest mechanism for him) for ongoing
treatment of anxiety. Also has f/u appointment w/ ENT ___
at ___.
# Chest pressure, shortness of breath:
Pt presents with chest pain/discomfort on deep inspiration. EKG
demonstrated non-specific T-wave inversions, but troponin was
negative x 2 so ACS ruled out. TTE ___ demonstrated normal LV
function, slightly dilated RV, PASP unable to be estimated. BNP
low (unreliable given his adiposity); overall, CHF exacerbation
unlikely. New tachycardia and pleuritic nature of pain c/f
repeat PE, but CTA negative and patient on coumadin. Trial of
naproxen ineffective at controlling pain, suggesting
pericarditis less likely. Nitro effective at pain control,
suggesting angina; However, exercise stress test without
inducible ischemia, angina, or echo abnormalities and nuclear
stress test without any abnormalities. Seen by psychiatry, who
think symptoms may be ___ anxiety attacks. Patient was on
longstanding metoprolol, which was held this admission for
dizziness and may be exacerbating anxiety and tachycardia.
Restarted metoprolol, and started Clonazepam 0.25mg BID, with
some improvement in symptoms. Instructed in relaxation
techniques as well.
# Pulmonary embolism: Pt presents with INR 3.3 and known PE
diminished in size without evidence of new PE. Subsequently
became subtherapeutic after holding for supratherapeutic INR.
Transitioned from coumadin to apixiban 10mg BID, but had
hematuria so converted back to Coumadin. Started on heparin GTT.
Patient triggered ___ for tachycardia, c/f possible repeat PE
in the setting of subtherapeutic Coumadin and heparin, but no HD
instability so decision was made not to pursue CT angio and to
continue treatment with lovenox as a bridge to heparin moving
forward.
# Hematuria: Pt presents with UA demonstrating large amounts of
blood. He was noted to have gross hematuria during his recent
admission with negative initial workup. He had a repeat episode
of hematuria after starting apixiban. Urology was consulted
during last admission and plan was for urology follow up as
outpatient cystoscopy. Outpatient follow up planned on ___.
# Ankylosing spondylitis: Pt denies worsening symptoms, however
states that he did notice some hand and feet swelling a few days
ago that resolved. Continued home gabapentin,
methylprednisolone, oxycodone PRN. ESR and CRP WNL.
# Hypertension: Restarted metoprolol as above
# Depression, recent SI: Pt denies SI/HI. Continued home
venlafaxine.
# UC: Pt reports some blood in stool following apixiban, but no
other abdominal pain or active symptoms. Deferred humira to
outpatient.
# Diabetes, likely steroid induced: HISS in house, not on any
medications at home.
# Low testosterone: Held home testosterone in house
TRANSITIONAL ISSUES
===================
-Should get close psychiatry follow-up for ongoing management of
anxiety (both pharmacologic and non-pharmacologic).
-f/u pending labs, including anti-GAD and anti-gliaden
-recheck INR ___, adjust warfarin dosing accordingly;
should instruct patient to stop lovenox. PCP to coordinate with
___.
- Patient with hematuria currently in the process of workup;
needs outpatient cystoscopy
# CONTACT: ___ (sister) ___
# CODE STATUS: Full code |