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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ yo F with recurrent left knee dislocations, now presenting
for definitive surgical management
Major Surgical or Invasive Procedure:
___: L TKA revision
___: L knee exchange of antibiotic spacer
___: L knee gastroc flap
History of Present Illness:
___ yo F s/p L TKA ___, s/p revision L TKA ___, now
presenting with recurrent L knee dislocations, has failed
conservative measures and now elects to undergo definitive
surgical management
Past Medical History:
HLD, HTN, s/p L TKA ___, s/p revision TKA ___.
Social History:
___
Family History:
non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Dressing clean, dry and intact
* JP drain x1 in place
* Thigh full but soft
* Capable of DF/PF, ___
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 06:48AM BLOOD WBC-9.3 RBC-2.86* Hgb-7.5* Hct-24.8*
MCV-87 MCH-26.2 MCHC-30.2* RDW-15.8* RDWSD-50.1* Plt ___
___ 06:48AM BLOOD Glucose-91 UreaN-12 Creat-0.4 Na-141
K-3.5 Cl-100 HCO3-28 AnGap-13
___ 06:48AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.5 Mg-1.9
___ 05:33AM BLOOD WBC-10.6* RBC-2.74* Hgb-7.4* Hct-24.0*
MCV-88 MCH-27.0 MCHC-30.8* RDW-15.9* RDWSD-51.2* Plt ___
___ 05:23AM BLOOD WBC-15.4* RBC-2.83* Hgb-7.6* Hct-24.9*
MCV-88 MCH-26.9 MCHC-30.5* RDW-16.0* RDWSD-52.2* Plt ___
___ 01:14PM BLOOD WBC-15.8* RBC-2.80* Hgb-7.5* Hct-24.4*
MCV-87 MCH-26.8 MCHC-30.7* RDW-16.2* RDWSD-52.2* Plt ___
___ 06:00AM BLOOD WBC-11.6* RBC-3.36* Hgb-9.1* Hct-28.9*
MCV-86 MCH-27.1 MCHC-31.5* RDW-15.5 RDWSD-48.6* Plt ___
___ 06:41AM BLOOD WBC-8.2 RBC-3.03* Hgb-8.2* Hct-26.2*
MCV-87 MCH-27.1 MCHC-31.3* RDW-15.5 RDWSD-48.6* Plt ___
___ 07:10AM BLOOD WBC-9.3 RBC-3.06*# Hgb-8.3*# Hct-25.8*#
MCV-84 MCH-27.1 MCHC-32.2 RDW-15.2 RDWSD-46.2 Plt ___
___ 06:18AM BLOOD WBC-7.4 RBC-2.42* Hgb-6.3* Hct-20.2*
MCV-84 MCH-26.0 MCHC-31.2* RDW-15.4 RDWSD-46.1 Plt ___
___ 03:45PM BLOOD WBC-8.5 RBC-2.62* Hgb-7.0* Hct-22.1*
MCV-84 MCH-26.7 MCHC-31.7* RDW-15.1 RDWSD-46.1 Plt ___
___ 07:08AM BLOOD WBC-7.0 RBC-2.69* Hgb-6.7* Hct-22.5*
MCV-84 MCH-24.9* MCHC-29.8* RDW-15.2 RDWSD-46.5* Plt ___
___ 07:05AM BLOOD WBC-8.1 RBC-2.68* Hgb-6.9* Hct-22.4*
MCV-84 MCH-25.7* MCHC-30.8* RDW-15.1 RDWSD-45.5 Plt ___
___ 08:00PM BLOOD WBC-10.3* RBC-2.66* Hgb-6.8* Hct-22.1*
MCV-83 MCH-25.6* MCHC-30.8* RDW-15.3 RDWSD-46.0 Plt ___
___ 09:11AM BLOOD WBC-9.1 RBC-3.26* Hgb-8.2* Hct-26.7*
MCV-82 MCH-25.2* MCHC-30.7* RDW-15.2 RDWSD-45.1 Plt ___
___ 07:10AM BLOOD Neuts-68 Bands-1 Lymphs-13* Monos-9 Eos-6
Baso-2* ___ Metas-1* Myelos-0 NRBC-1* AbsNeut-6.42*
AbsLymp-1.21 AbsMono-0.84* AbsEos-0.56* AbsBaso-0.19*
___ 09:11AM BLOOD Neuts-74.8* Lymphs-12.3* Monos-8.3
Eos-3.0 Baso-0.2 NRBC-0.2* Im ___ AbsNeut-6.79*
AbsLymp-1.12* AbsMono-0.75 AbsEos-0.27 AbsBaso-0.02
___ 07:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL
Polychr-OCCASIONAL Ovalocy-1+* Burr-OCCASIONAL
___ 06:00AM BLOOD Plt ___
___ 06:41AM BLOOD Plt ___
___ 07:10AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:18AM BLOOD Plt ___
___ 03:45PM BLOOD Plt ___
___ 07:08AM BLOOD Plt ___
___ 07:05AM BLOOD Plt ___
___ 08:00PM BLOOD Plt ___
___ 09:11AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-105* UreaN-12 Creat-0.4 Na-140
K-4.6 Cl-98 HCO3-28 AnGap-14
___ 06:18AM BLOOD Glucose-95 UreaN-14 Creat-0.6 Na-138
K-4.3 Cl-100 HCO3-27 AnGap-11
___ 03:45PM BLOOD Glucose-135* UreaN-18 Creat-0.7 Na-141
K-4.4 Cl-104 HCO3-28 AnGap-9*
___ 07:08AM BLOOD Glucose-91 UreaN-15 Creat-0.8 Na-140
K-4.3 Cl-102 HCO3-26 AnGap-12
___ 07:05AM BLOOD Glucose-118* UreaN-11 Creat-0.6 Na-141
K-4.5 Cl-104 HCO3-26 AnGap-11
___ 09:11AM BLOOD Glucose-110* UreaN-14 Creat-0.7 Na-142
K-4.9 Cl-101 HCO3-24 AnGap-17
___ 09:30AM BLOOD CK(CPK)-41
___ 06:00AM BLOOD Calcium-8.6 Phos-4.5 Mg-1.9
___ 03:45PM BLOOD Calcium-8.0* Phos-2.7 Mg-1.8
___ 07:08AM BLOOD Calcium-8.2* Phos-4.3 Mg-1.8
___ 07:05AM BLOOD Calcium-8.0* Phos-4.5 Mg-1.9
___ 09:29AM BLOOD Lactate-1.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. ALPRAZolam 0.5 mg PO Q6H; PRN anxiety
3. Metoprolol Tartrate 25 mg PO BID
4. lovastatin 20 mg oral qd
5. Aspirin 81 mg PO DAILY
6. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Ciprofloxacin HCl 500 mg PO Q12H
Stop on ___
3. Collagenase Ointment 1 Appl TP DAILY
4. Daptomycin 750 mg IV Q24H Duration: 6 Weeks
Proposed End date: ___
RX *daptomycin 500 mg 1.5 vials IV q24H Disp #*63 Vial
Refills:*0
5. Docusate Sodium 100 mg PO BID
stop taking if having loose stools
6. Enoxaparin Sodium 60 mg SC Q12H
Continue for 4 weeks
7. Gabapentin 300 mg PO TID
8. 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
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID
stop taking if having loose stools
11. Vitamin D 5000 UNIT PO DAILY
12. Lisinopril 30 mg PO DAILY
13. ALPRAZolam 0.5 mg PO Q6H; PRN anxiety
14. lovastatin 20 mg oral qd
15. Metoprolol Tartrate 25 mg PO BID
16. TraZODone 100 mg PO QHS:PRN insomnia
17. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you complete your course of Lovenox x
28 days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L knee dislocation, s/p L TKA reivsion; s/p left knee antibiotic
spacer exchange and gastro flap of left knee
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((SINGLE VIEW) LEFT
INDICATION: CLOSED REDUCTION LT KNEE
TECHNIQUE: Intraoperative fluoroscopic images of the left knee.
COMPARISON: None.
FINDINGS:
2 intraoperative fluoroscopic images of the left knee were obtained without a
radiologist present.
Images demonstrate a left total knee arthroplasty. Alignment is difficult to
ascertain given the projections.
IMPRESSION:
Intraoperative images obtained during closed reduction of the left knee.
Please refer to operative report for further details.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) LEFT
INDICATION: ___ year old woman with above stated// s/p revision TKA, left, abx
spacer placement s/p revision TKA, left, abx spacer placement
TECHNIQUE: Frontal and cross-table lateral portable view radiographs of the
left knee were obtained
COMPARISON: Intraoperative images dated ___
IMPRESSION:
There has been interval removal of the left knee total arthroplasty with
placement of an antibiotics spacer. A drain is present and postoperative
changes including swelling and subcutaneous emphysema are noted.
Radiology Report
INDICATION: ___ year old woman with 52cm right arm DL power PICC. ___
___// 52cm right arm DL power PICC Contact name: ___: ___
TECHNIQUE: Frontal radiograph of the chest.
COMPARISON: None
IMPRESSION:
Right-sided PICC is seen with tip terminating at the low SVC. No
pneumothorax, pleural effusion, pulmonary edema, or infiltrative opacity.
Mild cardiomegaly. Mild degenerative change of the thoracic spine.
Radiology Report
INDICATION: ___ year old woman s/p knee revision surgery with ab pain,
distention and no bowel movement// question of obstruction
TECHNIQUE: Supine and left lateral decubitus abdominal x-rays.
COMPARISON: Final prior abdominal x-rays.
FINDINGS:
There is moderate air the large colon, the largest dimension is 5.9 cm. There
is a small amount of air in the small bowel, however there is no distension.
In the left upper quadrant there are peripherally calcified,
well-circumscribed densities which could represent splenic aneurysms.
There is no free intraperitoneal air.
There are degenerative changes of the thoracic and lumbar spine.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
There is a nonspecific air pattern in the small and large colon.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with leukocytosis, low grade fevers s/p L knee
antibiotic spacer exchange with L knee gastroc flap closure// r/o
cardiopulmonary process r/o cardiopulmonary process
IMPRESSION:
No prior chest radiographs available.
Lungs grossly clear. Heart size top-normal. No pulmonary edema pleural
effusion.
Right PIC line is most readily visible on the lateral view passing to the low
right atrium.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Headache, R Knee injury, Transfer
Diagnosed with Instability of internal left knee prosthesis, init encntr, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 98.2
heartrate: 76.0
resprate: 18.0
o2sat: 95.0
sbp: 151.0
dbp: 59.0
level of pain: 3
level of acuity: 2.0 | The patient was admitted to the Orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending: ___.
Chief Complaint:
pain and swelling at graft site
Major Surgical or Invasive Procedure:
interventional radiology: fistulogram and thrombectomy with
balloon dilation and stent placement
History of Present Illness:
HPI: ___ year old male with history of end stage renal disease
status post failed kidney transplant now on hemodialysis
(___), diabetes, and hypertension presenting
with pain and swelling at graft site. He was reinitiated on
hemodialysis in ___ after receiving a transplant in ___. He
still urinates a small amount. Two weeks ago, he went to AV care
where they wanted to examine the graft as he had not used it in
___ years. They noticed a narrowing within the graft and
performed a balloon dilatation. He had pain afterwards with a
hematoma that has now resolved. He underwent successful dialysis
session on ___. On ___ morning, he woke with increased
pain in graft site. He went to dialysis where they were unable
to auscultate or feel bruit/thrill at dialysis or bedside
ultrasound. Denies trauma to left arm. He denies fevers,
chills, chest pain, shortness of breath, nausea, vomiting, and
diarrhea.
Review of systems:
+Per HPI.
-fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, bright red blood per rectum, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
- ESRD secondary to DM s/p deceased donor renal transplant ___
course complicated by delayed graft function and well as
resolved
BK nephropathy
- Type II Diabetes complicated by peripheral neuropathy,
retinopathy, and nephropathy
- Hypertension
- Hyperlipidemia
- Chronic anemia
- Legally blind L eye s/p 3 vitrectomies
Social History:
___
Family History:
Father with DM2. Sister with gestational diabetes.
Physical Exam:
Admission exam:
VS - 97.7 172/83 63 16 98% on RA 172.7lbs
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, trace b/l ___ edema, 2+ peripheral pulses
(radials, DPs), left upper ext AV graft without palpable thrill
or bruit
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge exam:
VS 98 156/65 74 16
GENERAL - well-appearing man in NAD, comfortable, appropriate,
non-toxic, non-diaphoretic
HEENT - NC/AT, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no RG, soft ___ systolic murmur at right second
intercostal space, nl S1-S2
ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, trace b/l ___ edema, left upper ext AV graft
unable to be assessed in detail as pt receiving HD
NEURO - awake, alert, fluent, appropriate
Pertinent Results:
___ 06:30AM BLOOD WBC-6.0 RBC-3.39* Hgb-10.1* Hct-30.3*
MCV-89 MCH-29.6 MCHC-33.2 RDW-16.6* Plt ___
___ 08:55AM BLOOD WBC-5.9 RBC-3.58* Hgb-10.4* Hct-31.7*
MCV-88 MCH-28.9 MCHC-32.7 RDW-16.2* Plt ___
___ 06:51PM BLOOD WBC-6.5# RBC-3.62* Hgb-10.4* Hct-32.4*
MCV-89 MCH-28.6 MCHC-32.0 RDW-16.4* Plt ___
___ 06:51PM BLOOD Neuts-67.9 ___ Monos-7.0 Eos-2.7
Baso-0.9
___ 11:31PM BLOOD ___ PTT-29.3 ___
___ 08:55AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-151* UreaN-96* Creat-7.5* Na-131*
K-4.8 Cl-92* HCO3-27 AnGap-17
___ 06:30AM BLOOD Calcium-8.7 Phos-6.3* Mg-2.0
___ 06:30AM BLOOD tacroFK-4.0*
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Torsemide 100 mg PO DAILY
2. Losartan Potassium 25 mg PO BID
3. leflunomide *NF* 20 mg Oral daily
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Glargine 13 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
6. Tacrolimus 3 mg PO QAM
6AM
7. Tacrolimus 2 mg PO QPM
6PM
8. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral qPM
9. Vitamin D 50,000 UNIT PO QMONTH
10. Labetalol 300 mg PO TID
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Medications:
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. Labetalol 300 mg PO TID
3. leflunomide *NF* 20 mg Oral daily
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
5. Tacrolimus 3 mg PO QAM
6AM
6. Tacrolimus 2 mg PO QPM
6PM
7. Torsemide 100 mg PO DAILY
8. Rosuvastatin Calcium 5 mg PO DAILY hyperlipidemia
Hold if proximal muscle weakness, elevated CK
9. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral qPM
10. Vitamin D 50,000 UNIT PO QMONTH
11. Glargine 13 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
12. Nephrocaps 1 CAP PO DAILY HD
RX *Nephrocaps 1 mg 1 Capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
13. Losartan Potassium 100 mg PO DAILY HTN
Hold for SBP<100.
RX *losartan 100 mg 1 Tablet(s) by mouth one time per day Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: graft thrombosis
secondary diagnosis: ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
LEFT UPPER EXTREMITY AV GRAFT AND OUTFLOW TRACT THROMBECTOMY, VENOGRAPHY,
ANGIOPLASTY AND VENOUS JUXTA-ANASTOMOSIS STENT PLACEMENT
INDICATION: ___ man with clotted left upper extremity AV graft.
OPERATORS: Drs. ___ (fellow) and ___ (attending
physician). Dr. ___ was present throughout the procedure.
CONTRAST: Sterile 90 mL Optiray 320.
PROCEDURE:
1. Two accesses, one each in the arterial and venous limbs of the left upper
extremity graft.
2. Pullback venogram in the venous outflow tract.
3. AngioJet mechanical thrombectomy extending from the venous outflow tract
through the AV graft.
4. Arterial anastomosis embolectomy with over-the-wire ___ balloon.
5. AV graft, venous outflow tract and central venography.
6. Dilatation with a 7 x 20 mm balloon extending from the venous outflow
tract through the AV graft.
7. Post-dilatation venography, and evaluation of arterial anastomosis.
8. Dilatation with 8 x 40 mm balloon at venous anastomosis and along 2 sites
of the AV graft.
9. Post-dilatation venoraphy.
10. Placement of an 8 x 40 mm Fluency stent at the venous anastomosis of the
graft followed by dilatation with 8 x 40 mm balloon.
11. Post-stent placement venography.
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.
Initial grayscale and color sonogram of the left upper extremity did not
demonstrate flow within the AV graft. Under aseptic conditions, sonographic
guidance and after infiltrating the skin with 1% lidocaine, a micropuncture
needle was placed in the arterial limb of the graft with its tip pointing
towards the venous outflow tract. A 0.018 wire was carefully advanced into
the graft. Needle was exchanged for a 4.5 ___ microsheath. After removing
the inner cannula and wire, a 0.035 angled Glidewire was advanced through the
microsheath and eventually into the venous outflow tract. After removing the
microsheath, a 6 ___ short ___ sheath was placed. After removing the
inner cannula, a 5 ___ Kumpe catheter was used over the wire to negotiate
the wire centrally. Glidewire was then exchanged for a 0.035 ___ wire,
with its tip left in the upper SVC. A similar procedure was utilized for
placing a 6 ___ short sheath in the venous limb of the graft with its tip
pointing towards the arterial anastomosis. A 0.035 Glidewire was advanced
through the venous limb sheath and with the help of the 5 ___ Kumpe
catheter, eventually advanced into the arterial inflow. Glidewire wire was
then exchanged for a 0.035 ___ wire. Kumpe catheter was used to perform
pullback venography to the point of thrombus in the venous outflow tract
(brachial vein). A 6 ___ AngioJet catheter was used within the sheaths to
perform mechanical thrombectomy extending from the venous outflow tract (from
the level of left brachial vein) through the AV graft (to within 2 cm of the
arterial anastomosis). A ___ embolectomy balloon was placed within the
venous limb sheath and over the wire to perform arterial anastomotic
embolectomy. Small amount of sterile contrast material was injected through
the sidearm of the arterial limb sheath, following which DSA venography was
performed in the AV graft, venous outflow tract and central veins. Dilatation
was performed with a 7 x 20 mm balloon extending from the venous outflow tract
through the entire AV graft. Post-balloon dilatation venography was
performed. Further dilatation with 8 x 40 mm balloon was performed at the
venous anastomosis and along 2 sites on the venous limb of the graft.
Post-balloon dilatation venography was performed. Arterial anastomosis was
evaluated by injected contrast with the balloon inflated in the graft. The
arterial limb 6 ___ sheath was then exchanged for a 9 ___ sheath over
the wire. Subsequently, an 8 x 40 mm Fluency covered metallic stent was
placed across the venous anastomosis. Stent was then dilated with 8 x 40 mm
balloon. Post stenting/plasty venography was performed. Access sheaths and
wires were removed. Gentle pressure was applied to the access sites to
achieve complete hemostasis. Sites were dressed in a sterile fashion.
Patient tolerated the procedure well. No immediate post-procedure
complication was seen.
At the end of the procedure, good thrill was felt along the graft.
FINDINGS:
1. Pullback venography along the venous outflow tract demonstrated thrombus
extending to the level of left brachial vein.
2. Post-mechanical thrombectomy and ___ arterial anastomotic embolectomy
venogram demonstrated some flow within the graft and outflow tract, but with
about 80% venous juxta-anastomotic stenosis, in addition to moderate amount of
thrombus in the mid graft. No central stenosis was seen.
3. Post balloon dilatation (7 x 20 mm) venography demonstrated some
improvement in the flow and venous juxta-anastomotic stenosis. There was also
some improvement in the mid graft thrombosis.
4. No stenosis seen at the arterial anastomosis.
5. Post balloon dilatation (8 x 40 mm) venography demonstrated improvement in
the flow but with about 40% residual stenosis at the venous anastomosis.
There was also improvement in the arterial limb thrombus, with minimal
residue.
6. Post venous juxta-anastomotic stenting/plasty venography demonstrated
significant improvement in the flow with no residual stenosis at the venous
anastomosis. At the end of the procedure, good thrill was felt through the
graft.
IMPRESSION: Uncomplicated left upper extremity AV graft, venous outflow tract
and central venography, mechanical thrombectomy, arterial anastomosis
embolectomy, angioplasty (7 and 8mm) and venous anastomotic Fluency 8 x 40 mm
stent placement.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: AV FISTULA EVAL
Diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ABN REACT-RENAL DIALYSIS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA
temperature: 98.1
heartrate: 71.0
resprate: 16.0
o2sat: 100.0
sbp: 199.0
dbp: 84.0
level of pain: 3
level of acuity: 3.0 | ASSESSMENT & PLAN: ___ yo male with history of ESRD s/p failed
kidney transplant now on HD (MWF), DM, and HTN presenting with
pain and swelling at graft site with likely thrombosed AV graft.
#Thrombosed AV graft: The patient came to the hospital
complaining of pain and tenderness at the site after restarting
dialysis for approximately one month. Recent balloon dilatation
two weeks ago for narrowing was noted. He has had succesful
hemodialysis since but unsuccessful on ___. In the emergency
department, initial vital signs were 98.1 71 199/84 16 100% on
RA. The transplant consult service suggested admission to
medicine, as did the renal consult service (transplant surgery
following) and either interventional radiology the following day
or AV Care in ___ He was given labetalol for elevated BP's
with repeat BP 177/80. The patient was admitted to medicine and
the following day received a fistulogram in ___ followed by
successful thrombectomy. Afterwards, good flow with appropriate
bruit and thrill at graft site confirmed by renal
fellow/attending. Hemodialysis was done successfully, confirming
graft viability
#ESRD status post failed transplant now on HD: The patient was
stable in terms of electrolytes without any signs of volume
overload or uremia. As described above, he did well on
hemodialysis status post thrombectomy. His tacrolimus level was
found to be low. He was continued on his sevelamer,
multivitamin, tacrolimus, and leuflonamide. He was started on
nephrocaps per renal recommendations.
#HTN: losartan and labetalol were continued with good effect.
#DM: lantus with a humalog insulin sliding scale were continued
with good effect. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abnormal movements
Major Surgical or Invasive Procedure:
Pacemaker placement ___.
History of Present Illness:
This is a ___ year old right handed woman with a history of
sebaceous carcinoma of the nose s/p Mohs and radiation who
presents with several episodes concerning for seizure today.
History obtained from son as patient does not want to relate
story again. Her reports that starting this ___ the patient has
been having episodes where she feels an aura of "everything
draining away" and nausea then she turns her head to the right,
stares off, and goes "stiff". The stiffening seems to be just in
the arms and the son is not sure if it's just one side. She also
gets flush and has labored breathing. It lasts about 20 seconds
and is followed by ___ hours of confusion and disorientation.
The patient seems to be aware of the start of it but then has no
memory of the event. There is no incontinence or tongue bite.
The first episode was ___. Before today she had had a total
of 4 episodes. The most recent one was 4 days ago. On that
occassion she was standing when it occured so she fell to the
ground. The patient went to a cardiologist appointment today
(for ? if these episodes were cardiogenic) and patient had 3
typical events while lying on a stretcher in the office. There
was no focality described in clinic note.
While in the ED the patient had another event. The end of this
was witnessed by the resident who heard her cry out and saw her
right arm flying upward. She was given 1mg IV ativan.
Her son reports that the patient had been reporting shortness of
breath, fatigue and anorexia recently. She has also had diarrhea
the past few days.
From Cardiology note today regarding prior cards workup "She had
previously seen Dr. ___ in ___ and had a Persantine
nuclear stress study. It is reported that she had
minimal shortness of breath and no chest pain and no diagnostic
ECG changes. The nuclear imaging was read as showing near
complete inferopostero apical defect with minimal reversible at
the posterior inferior border. The left ventricle was reported
as showing inferior hypokinesis and apical akinesis/dyskinesis
though with an ejection fraction reported as 61%. An ECG at
that time showed right bundle-branch block and left anterior
fascicular block with no evidence of infarction. She also had
Holter monitoring on ___, which showed only
occasional atrial premature beats with one 10-beat run of PSVT
at a rate of 130 and rare ventricular premature beats. There
were no significant pauses."
Patient denies focal weakness, numbness, vertigo, unsteadiness
with walking, recent illnesses, cough, chest pain, abdominal
pain, vomiting, dysuria. rash.
__________________________
On Transfer to Cardiology:
Mrs. ___ is a ___ year old very pleasant woman with PMH HL,
HTN, legally blind due to macular degeneration, history of skin
cancer s/p MOHS procedure/radiation who presented to ___ on
___ from cardiology clinic after 3 witnessed episodes of
nonresponsiveness infront of Dr. ___. During this time, Dr
___ was manually monitoring her pulse which was noted to
be regular. She was thought to be post-ictal for a short time
after this event. Per the patient and her family, these symptoms
started in ___ and have been becoming more frequent.
She was admitted to the(when she had a right head turn,
bilateral shaking concerning for seizure). Neurology service
where her MRI brain showed only mild atrophy, and her EEG was
negative for seizure. She was started on keppra durign this time
which has subsequently been discontinued. During EEG monitoring,
patient did have an episode of feeling flushed, presyncopal,
with decreased responsiveness which was associated with a 4
second pause. She had been on metoprolol XL 100mg daily. EP was
consulted and on review of the telemetry, she was noted to have
frequent nonconductive beats, Q2-4beats. Baseline ECG left
anterior hemiblock (RBBB, and left axis). Cardiology fellow
overnight performed carotid massage which did not seem to have
an affect. Per neurology, the thought is that her sinus pauses
and likely vascular disease cause decreased perfusion to her
brain which may trigger myoclonus and the above symptoms if more
prolonged. Given conduction disease and sinus pause, patient was
transferred to ___ for likely pacemaker. Metoprolol was stopped
prior to transfer.
On cardiac review of symptoms, no chest pain, orthopnea, PND.
All other ROS negative. She does note she gets SOB with exertion
and continued speaking.
Past Medical History:
sinus pause, infranodal conduction disease s/p PPM ___
HTN
hyperlipidemia
Macular degeneration, legally blind
sebaceous carcinoma on the nose s/p MOHS and radiation
? gastric ulcer per son
Social History:
___
Family History:
There is no known family history of cardiac disease.
Physical Exam:
Initial Exam:
Vitals:98.1 92 135/92 18 95% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR
Extremities: trace edema at the ankles, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. 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. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Pt. was able to register
3 objects and recall ___ at 5 minutes. The pt. had good
knowledge of current events. There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Blind at baseline
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 adventitious movements, such as tremor, 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, cold sensation,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was upgoing bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
Gait: deferred, patient unwilling at this time
Discharge Exam:
VS: 98.1 113/68 61 22 97% on RA
Weight:
I/O: ___
Tele: runs of atrial flutter
Neuro: face symmetric. unwilling to move extremities.
CV: No rubs, Normal S1, S2.
Lungs: CTA throughout
Vasc: No edema.
Ext: L arm in sling.
Pertinent Results:
ADMISSION LABS:
___ 05:48PM COMMENTS-GREEN TOP
___ 05:48PM GLUCOSE-106* NA+-145 K+-4.8 CL--105 TCO2-18*
___ 05:15PM URINE HOURS-RANDOM
___ 05:15PM URINE HOURS-RANDOM
___ 05:15PM URINE UHOLD-HOLD
___ 05:15PM URINE GR HOLD-HOLD
___ 05:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 05:15PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:15PM URINE HYALINE-1*
___ 05:15PM URINE MUCOUS-FEW
___ 04:20PM GLUCOSE-121* UREA N-20 CREAT-1.1 SODIUM-137
POTASSIUM-5.5* CHLORIDE-104 TOTAL CO2-17* ANION GAP-22*
___ 04:20PM estGFR-Using this
___ 04:20PM WBC-13.3* RBC-4.46 HGB-12.6 HCT-41.9 MCV-94
MCH-28.3 MCHC-30.1* RDW-14.0
___ 04:20PM NEUTS-88.3* LYMPHS-6.2* MONOS-4.3 EOS-0.2
BASOS-1.0
___ 04:20PM PLT COUNT-508*
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-10.9 RBC-3.92* Hgb-11.0* Hct-35.0*
MCV-89 MCH-27.9 MCHC-31.3 RDW-13.8 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-110* UreaN-16 Creat-0.9 Na-136
K-4.7 Cl-101 HCO3-28 AnGap-12
___ 06:40AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0
SELECT IMAGING:
___ CT HEAD W/O CONTRAST:
IMPRESSION: No acute intracranial abnormality.
___ ECHO:
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. There are three aortic valve leaflets. The aortic
valve leaflets are moderately thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function. Aortic
valve sclerosis with minimal stenosis. No LVOT gradient.
___ MRI HEAD:
IMPRESSION: Unremarkable examination, with no anatomic
substrate for seizure and only global atrophy.
___: XRAY FOREARM & HUMERUS:
IMPRESSION: Transverse fracture through the distal ulna without
apparent
dislocation at the distal radioulnar joint or the radial head.
___ CXR:
IMPRESSION: AP and lateral view compared to ___ and ___:
Transvenous right atrial and right ventricular pacer leads
follow their
expected courses from the left pectoral generator. No
pneumothorax, pleural effusion or mediastinal widening. Heart
size normal. Moderate-sized hiatus hernia has increased. Lungs
are clear. No pleural abnormality.
Medications on Admission:
Calcium Carbonate 500 mg PO/NG TID
Docusate Sodium 100 mg PO BID
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH HS
Heparin 5000 UNIT SC TID
Lorazepam 1 mg IV Q4H:PRN seizure >5 min or cluster of >3 per
hour
Magnesium Sulfate 4 gm IV ONCE Duration: 1 Dose
Senna 17.2 mg PO/NG HS
Simvastatin 10 mg PO/NG DAILY
Vitamin D 800 UNIT PO/NG DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Hold for loose stools.
4. Calcium Carbonate 500 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH HS
7. Lidocaine 5% Patch 1 PTCH TD QAM
Apply 12hrs on, 12hrs off.
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) place one patch in
your arm QAM Disp #*14 Each Refills:*0
8. Senna 17.2 mg PO HS
Hold for loose stools.
9. Simvastatin 10 mg PO DAILY
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg Half tablet(s) by mouth Q6hr-prn Disp #*56
Tablet Refills:*0
11. Vitamin D 800 UNIT PO DAILY
12. Metoprolol Tartrate 12.5 mg PO Q6H
13. Rivaroxaban 15 mg PO DINNER
RX *rivaroxaban [Xarelto] 15 mg One tablet(s) by mouth Daily
with the evening meal Disp #*30 Tablet Refills:*0
14. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg One capsule(s) by mouth Q6hr-prn Disp #*2
Capsule Refills:*0
15. removable long risk splint
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Subnodal block in the setting of Fixed His-Purkinje
Disease. s/p Pacemaker placement.
Secondary: Traumatic L distal ulnar fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: New onset seizures.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest were obtained. There are
low lung volumes. There is moderate elevation of the right hemidiaphragm with
overlying atelectasis. No definite focal consolidation is seen. There is no
pleural effusion or pneumothorax. Slight prominence of the right hilum may
relate to patient's elevated right hemidiaphragm and subsequent lower volume
of the right lung.
The cardiac and mediastinal silhouettes is not enlarged. The aorta is
calcified. Retrocardiac density with lucency within seen both on the frontal
and lateral views likely represents a large hiatal hernia.
IMPRESSION:
1. Large hiatal hernia.
2. Elevated right hemidiaphragm. No definite focal consolidation.
Radiology Report
INDICATION: New-onset seizures.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal, and thin section bone reconstruction algorithm
images were prepared.
COMPARISON: None.
FINDINGS: There is no hemorrhage, edema, mass effect, or evidence of
infarction. The ventricles and sulci are normal in size and configuration.
The basal cisterns are patent and gray-white matter differentiation is
preserved. The calvaria are unremarkable. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
INDICATION: ___ female with complex partial seizures; evaluate for
epileptogenic focus.
COMPARISON: Head CT from ___.
TECHNIQUE: MR images through the brain were obtained on a 3T magnet, before
and after the administration of gadolinium-based contrast. Spin-echo and
gradient-echo sequences were obtained in a multiplanar fashion.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. The ventricles and sulci are prominent representing global brain
atrophy. The medial temporal lobes, including the hippocampal formations,
appear small, but are symmetric and proportionate to the degree of atrophy of
the remainder of the brain. The major intracranial vessel flow voids are
preserved. No mass or abnormal enhancement is seen after contrast
administration.
The orbits are symmetric and unremarkable. There is no mucosal thickening or
fluid level in the visualized paranasal sinuses. The included salivary glands
and soft tissues of the face and scalp are unremarkable.
IMPRESSION: Unremarkable examination, with no anatomic substrate for seizure
and only global atrophy.
Radiology Report
INDICATION: Heart block, history of skin cancer, status post fall,
complaining of arm pain, query fracture.
TECHNIQUE: AP view of the humerus, AP and lateral views of the forearm.
COMPARISON: None available.
FINDINGS: There is a transverse fracture through the distal ulna. No
dislocation of the distal radioulnar joint or the radial head. No additional
fractures seen. Degenerative changes at the thumb carpometacarpal joint.
Mild degenerative changes at the acromioclavicular joint. The visualized
portions of the lungs are clear.
IMPRESSION: Transverse fracture through the distal ulna without apparent
dislocation at the distal radioulnar joint or the radial head.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Interval placement of a dual-lead pacing device via a left
subclavian approach, with leads terminating in the expected locations of the
right atrium and right ventricle. There is no visible pneumothorax.
Cardiomediastinal contours are stable. Lungs are grossly clear, and note is
made of persistent elevation of right hemidiaphragm.
Radiology Report
PA AND LATERAL CHEST ON ___
HISTORY: A ___ woman with subclavian access for pacemaker. Evaluate
lead positions and complications.
IMPRESSION: AP and lateral view compared to ___ and ___:
Transvenous right atrial and right ventricular pacer leads follow their
expected courses from the left pectoral generator. No pneumothorax, pleural
effusion or mediastinal widening. Heart size normal. Moderate-sized hiatus
hernia has increased. Lungs are clear. No pleural abnormality.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: UNRESPONSIVE EPISODES
Diagnosed with OTHER CONVULSIONS
temperature: 98.1
heartrate: 92.0
resprate: 18.0
o2sat: 95.0
sbp: 135.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | ___ PMHx macular generation (legally blind), HTN, HL, RBBB with
LAFB concerning for infranodal conduction disorder who presented
with recurrent episodes of altered states of consciousness in
the setting of sinus pauses, now s/p PPM placement.
# Diminished Responsiveness d/t complete heart block: Multiple
events in the past several months with stiffening, LOC,
preceeded by an aura and followed by ___ hours of confusion.
Accompanied by weeks of SOB, fatigue and anorexia. No focal
deficits on neurologic exam except bilateral upgoing toes.
Neurologic imaging unrevealing for cause. While here, she was on
both cardiac telemetry and EEG. She had a typical event WITHOUT
EEG correlate, but WITH 4 second pause on tele. Thus, her
episodes most likely represent bradyarrythmia with brain
hypoperfusion leading to myoclonus and seizure-like movements,
and not primary epilepsy. She was tranferred to the cardiology
service for pacemaker placement after an unwitnessed fall ___
with HR ___ and EKG showing 3:1 conduction block. She had
placemaker placed ___ without complication. She was treated
with vancomycin for 48 hrs after pacemaker placement and keflex
x1 day.
# Lt ulnar fracture: due to fall. Orthopedics was consulted and
recommended orthoplast ulnar gutter splint. Physical therapy and
occupational therapy was consulted.
# Atrial flutter: Pt was noted to have atrial flutter on
telemetry. She was started on rivaroxaban 15mg daily.
# Hypertension: Intermittently off beta-blocker while
bradycardia was managed as above, restarted after pacemaker
placement. Pt was discharged on metoprolol tartrate 12.5mg bid.
# Hyperlipidemia: Continued home dose statin.
# Wheezing/Shortness of Breath: Continued Fluticasone-Salmeterol
Diskus (250/50) with albuterol and ipratropium Q6h as needed.
Discharged on Advair and albuterol PRN. |
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:
___ presenting with 3 days of RLQ abdominal pain. Patient
was having severe nausea/vomiting x 9 times initially. She was
seen at ___ 3 days ago. Patient was tender in the RLQ, WBC
was 15.___bd/pelvis was reported as normal appendix,
some free fluid in the pelvis and an adnexal cyst. She was
discharged home and followed up with her GYN. Patient had
persistent abdominal pain localized in the RLQ, no nausea or
vomiting, no fevers/chills. Pt went to OBGYN which did a pelvic
exam which was normal and negative pregnancy test. Pelvic US was
also negative.
Past Medical History:
PE ___ s/p anticoagulation for 6 months
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
Vitals: 98.0 74 115/79 16 100%
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, severe tenderness to palpation in the
RLQ, mild localized rebound and guarding.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 06:05PM GLUCOSE-90 UREA N-7 CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
___ 06:05PM estGFR-Using this
___ 06:05PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-50 TOT
BILI-1.2
___ 06:05PM LIPASE-14
___ 06:05PM HCG-<5
___ 06:05PM WBC-14.7* RBC-4.41 HGB-13.6 HCT-40.6 MCV-92
MCH-30.9 MCHC-33.5 RDW-12.2
___ 06:05PM NEUTS-86.0* LYMPHS-8.5* MONOS-5.1 EOS-0.2
BASOS-0.2
___ 06:05PM PLT COUNT-254
CT abd/pelvis:
IMPRESSION:
1. Thickening of the appendiceal wall with surrounding
stranding and a small amount of fluid in the tip consistent with
appendicitis.
2. 2.2 x 2.4 cm soft tissue lesion in the medial aspect of the
right breast most likely represents a fibroadenoma. Correlation
with direct physical exam and mammography if indicated (with a
positive family history) is recommended.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *Cipro 500 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every ___ hours as
needed Disp #*25 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days
RX *Flagyl 500 mg 1 tablet(s) by mouth three times a day Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with persistent severe abdominal pain and
leukocytosis. Evaluate for appendicitis.
COMPARISON: Abdomen radiograph from ___, pelvic ultrasound from
___, a CT scan from ___ from ___ where the ___
medical record ___.
TECHNIQUE: MDCT images were acquired through the abdomen and pelvis with IV
and oral contrast. Multiplanar reformations were obtained and reviewed.
FINDINGS:
The partially imaged lungs show bibasilar atelectasis. The partially imaged
heart is unremarkable.
CT OF THE ABDOMEN WITH IV CONTRAST:
The partially imaged breast shows a more nodular opacity in the medial portion
on the right (2:4). This could represent a fibroadenoma.
CT OF THE ABDOMEN WITH IV CONTRAST:
The liver, spleen, both adrenals, both kidneys, pancreas and gallbladder are
unremarkable. No abdominal, retroperitoneal or mesenteric lymphadenopathy by
CT size criteria is present. The colon is unremarkable. The appendix shows a
thickened wall with significant adjacent stranding, ending in a 1.1 x 2.0 cm
fluid-filled tip. This is worsened compared to the previous examination.
There is a small amount of nonhemorrhagic free fluid in the pelvis. Multiple
dilated loops of small bowel show no transition point is likely related to
ileus. Contrast fills the colon.
CT OF THE PELVIS WITH IV CONTRAST:
The rectum, sigmoid colon, bladder and uterus are unremarkable. Bilateral
ovarian cysts were better evaluated on concurrent pelvic ultrasound. No
pelvic or inguinal lymphadenopathy is present.
OSSEOUS STRUCTURES:
The visible osseous structures show no suspicious lytic or blastic lesions or
fractures.
IMPRESSION:
1. Thickening of the appendiceal wall with surrounding stranding and a small
amount of fluid in the tip consistent with appendicitis.
2. 2.2 x 2.4 cm soft tissue lesion in the medial aspect of the right breast
most likely represents a fibroadenoma. Correlation with direct physical exam
and mammography if indicated (with a positive family history) is recommended.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ACUTE APPENDICITIS NOS, ABDOMINAL PAIN RLQ
temperature: 98.0
heartrate: 74.0
resprate: 16.0
o2sat: 100.0
sbp: 115.0
dbp: 79.0
level of pain: 7-8
level of acuity: 3.0 | She was admitted to the Acute Care Surgery team and under CT
imaging of her abdomen and pelvis showing thickening of the
appendiceal wall with surrounding stranding and a small amount
of fluid in the tip consistent with appendicitis. She was
consented, prepped and taken to the operating room for
laporascopic appendectomy. There were no complications. She was
continued on IV Cipro and Flagyl postoperatively. Her diet was
advanced to regular and she was able to tolerate solids without
difficulty. The antibiotics were also changed to oral form and
were recommended to be continued for another 7 days after
discharge. Her pain was well controlled with po pain
medications.
Her PCP was contacted for questions pertaining to
anticoagulation given her history of PE in ___ and no further
anticoagulation was indicated at this time. She was placed on
subcutaneous Heparin tid during her stay.
She was discharged to home with instructions for follow up with
her PCP and in the Acute Care Surgery Clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ketamine / morphine / Zosyn / Unasyn / Magnesium Sulfate / IV
Dye, Iodine Containing Contrast Media
Attending: ___.
Chief Complaint:
G-TUBE SITE PAIN
Major Surgical or Invasive Procedure:
___ Wound exploration and sharp debridement percutaneous
endoscopic gastrostomy.
History of Present Illness:
___ yo M with h/o congenital intestinal pseudo-obstruction s/p
resection and failed intestinal transplant x 2, TPN dependent
and with G tube for venting who presents with abdominal pain.
The patient noted worsening abdominal pain starting 5 days ago
associated with the sensation that the G tube balloon was
stretching and dilating the fistula tract. The patient has tried
deflating, re-inflating, and repositioning the balloon without
any relief. With the tube malposition, the patient has noted
leakage of gastic contents around the site with mild maceration
of the skin. The patient notes that this has happened before
about ___ year prior, but spontaneously resolved with pain control
and good wound care.
With this pain, the patient has been in and out of the ED. In
the ED, the patient was evaluated by GI and by ACS, both of whom
said that there was no emergent issue with the tube. The patient
was discharged from the ED, but returned later the evening with
the same pain. The patient was then admitted for pain control.
Of note, he had a recent admission for redness around ___
site. Blood cultures were negative. The patient did have MRSA
cultured from catheter tip ___ weeks ago and is currently on IV
vancomycin.
With being in and out of the ED, the patient has gotten behind
on his TPN and hydration. He notes increased thirst and dark
urine.
Past Medical History:
- Congenital intestinal pseudoobstruction s/p multiple bowel
resections including total colectomy
- History of small bowel transplant x2 (___), both
complicated by rejection and removal ___
- V. fib arrest in ___, now s/p removal of single-chamber
ICD ___ for infection, hematoma
- Recent (___) ICU admission for MRSA septicemia ___ pocket
infection s/p device removal ___ and partial lead extraction
___ -> completed 6-week course of daptomycin (last day
___. Course c/b hypoxic respiratory failure requiring 2-day
intubation ___ multifocal aspiration pneumonia after vomiting.
- Right upper extremity brachial DVT dx ___ with plan for
lovenox 60mg BID until ___, but pt reports he never used
lovenox
- s/p appendectomy
- s/p cholecystectomy
- large volume bladder
- G-tube resite ___, used for venting only (he eats and then
vents back out)
- ___ albicans fungemia
Social History:
___
Family History:
Sister, only sibling, is in good health
Physical Exam:
PHYSICAL EXAMINATION:
VITALS: 97.8, 107/55, 79, 16, 98% RA
GENERAL: NAD
HEENT: PERRL, EOMI
NECK: no carotid bruits, JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Scaphoid abdomen from previous surgeries, multiple
surgical scars, PEG tube with mild erythema and maceration
around site, dry gauze, tunneled ___ catheter CDI without
evidence of infection, mild tenderness to palpation near G tube
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
DISCHARGE EXAM:
VS 98.3 ___ 16 98%RA
Gen: Lying in bed, AAOx3
CV: S1S2 RRR no m/g/r, no JVD
PULM: Decreased breath sounds at bases (likely atelectasis).
Otherwise CTAB.
Abd: Mild tensing but no peritoneal signs. Tenderness at site of
Gtube. No BS (no intestines), G tube draining, stomach ostomy
(all to gravity) with connecting bag
Ext: No c/c/e
Pertinent Results:
ADMISSION LABS
___ 08:30PM WBC-2.5* RBC-4.14* HGB-9.0* HCT-29.3* MCV-71*
MCH-21.7* MCHC-30.7* RDW-18.8*
___ 08:30PM NEUTS-65.2 ___ MONOS-4.8 EOS-1.3
BASOS-0.8
___ 08:30PM PLT COUNT-68*
___ 08:30PM ___ PTT-39.0* ___
___ 08:30PM GLUCOSE-81 UREA N-21* CREAT-0.7 SODIUM-147*
POTASSIUM-3.0* CHLORIDE-109* TOTAL CO2-31 ANION GAP-10
___ 08:35AM SODIUM-147* POTASSIUM-3.1* CHLORIDE-107
___ 10:55PM GLUCOSE-73 UREA N-21* CREAT-0.9 SODIUM-150*
POTASSIUM-2.6* CHLORIDE-101 TOTAL CO2-39* ANION GAP-13
RELEVANT IMAGING
___ CXR
IMPRESSION: No acute findings. PEG tube resides in the mid
upper abdomen. No free air.
___ Right upper extremity ultrasound
IMPRESSION: Small region of echogenic material within one of
the two right
brachial veins may represent a non-occlusive thrombus versus
visualization of venous valve. This is unchanged from ___.
___ CXR
FINDINGS: As compared to the previous radiograph, the lung
volumes have
decreased. There is subsequent increase in density of the lung
parenchyma.
Unchanged is the course of the right venous access line and
position of the
defibrillator devices. Also unchanged is the appearance of a
mild scar in the
left lung. There is continued elevation of the left
hemidiaphragm. Neither
the frontal nor the lateral radiographs show evidence of focal
parenchymal
opacities suggesting pneumonia. Unchanged normal size of the
cardiac
silhouette. No pneumothorax.
___ ABDOMINAL FILM
IMPRESSION: Bowel gas pattern suggestive of obstruction.
This study and the report were reviewed by the staff
radiologist.
The study and the report were reviewed by the staff radiologist.
___ Right upper extremity non-vascular ultrasound
IMPRESSION: Right-sided central venous catheter with no
evidence to suggest adjacent infection.
___ Panorex: no abscess
___ CHEST X-RAY: Unchanged chest radiograph from previous
imaging with no evidence
of pneumonia.
___ CT chest with contrast:
1. Left lower lobe consolidation consistent with pneumonia.
2. G-tube is displaced with balloon sitting within the abdominal
wall.
3. Presumed bladder outlet obstruction resulting in severe
enlargement of the
bladder and moderate bilateral renal pelvicaliectasis.
4. Unchanged appearance of the stomach and residual small bowel.
5. Small pleural effusions and free abdominal fluid.
___ Renal ultrasound
IMPRESSION:
1. Bilateral prominent collecting systems suggestive of mild
bilateral
hydronephrosis.
2. The bladder appears decompressed with a Foley placed inside.
___ CXR
FINDINGS: The NG tube tip is in the stomach. The epicardial
defibrillator
device is again visualized. Venous access line is again seen
with tip in the
right atrium. There is new obscuration of the left
hemidiaphragm, compatible
with left lower lobe infiltrate or region of volume loss.
___ PET-CT
1. No PET/CT evidence for FDG-avid infection near the cardiac
pacer
wires.
2. Gastrostomy balloon displaced and inflated within the
abdominal wall,
also seen on the CT from ___, with high neighboring
FDG-avidity
representing inflammation. Superinfection cannot be excluded.
3. Worsening bilateral pleural effusions with FDG-avid
consolidations, likely pneumonia.
4. Massively distended bladder with severe bilateral
hydronephrosis, also seen on the recent CT examination. A foley
catheter has been placed.
___ - CXR
Increasing left lower lobe opacity.
___ - ABDOMEN SUPINE & ERECT
The tip of the nasogastric tube lies within the stomach. The
prior CT of
___ shows a massively distended stomach and also a markedly
distended
bladder. On the upright film, air-fluid level is present which
probably
represents air within the distended bladder but could actually
represent airwithin the markedly distended stomach.
A drain or catheter is seen extending into the right upper
quadrant of the
abdomen. There is no free air under the diaphragm.
___ - ABDOMINAL ULTRASOUND
IMPRESSION: No focal fluid collection or abscess identified.
___ - RECTUS MUSCLE ULTRASOUND
IMPRESSION: Deep epigastric arteries, both patent. Veins not
demonstrated. Perforators are present. Fatty infiltration of
right rectus muscle.
UNILAT LOWER EXT VEINS RIGHT ___
IMPRESSION: Small region of nonocclusive thrombus again
identified in the right brachial vein. No change from the prior
studies.
CXR ___
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Parenchymal opacities at both the left and the right
lung bases,
potentially is associated to a small pleural effusion on the
left. In the appropriate clinical setting, these opacities
could represent pneumonia. The monitoring and support devices,
including the defibrillator patches are constant. Moderate
pulmonary edema. Moderate cardiomegaly.
MICROBIOLOGY
___ URINE CULTURE-FINAL {YEAST}
___ SWAB WOUND CULTURE-FINAL ___
ALBICANS, PRESUMPTIVE IDENTIFICATION}
___ Blood Cx
Blood Culture, Routine (Final ___:
LACTOBACILLUS SPECIES.
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE ROD(S).
Reported to and read back by ___ # ___.
Numerous negative blood cultures, including mycolytic blood
cultures.
DISCHARGE LABS
___ 04:30AM BLOOD WBC-2.0* RBC-3.10* Hgb-7.3* Hct-24.1*
MCV-78* MCH-23.6* MCHC-30.4* RDW-22.3* Plt ___
___ 05:39AM BLOOD PTT-116.3*
___ 04:30AM BLOOD Glucose-103* UreaN-18 Creat-0.4* Na-137
K-3.7 Cl-108 HCO3-25 AnGap-8
___ 06:56AM BLOOD ALT-38 AST-51* AlkPhos-___* TotBili-1.9*
___ 04:30AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.8
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Vancomycin 1000 mg IV Q 12H
2. DiphenhydrAMINE 50 mg IV BID
3. Pantoprazole 80 mg IV Q12H
Discharge Medications:
1. DiphenhydrAMINE 50 mg IV BID
RX *diphenhydramine in 0.9 % NaCl 50 mg/50 mL infuse 50mL of
50mg/50mL solution twice daily Disp #*3000 Milliliter Refills:*0
2. Pantoprazole 80 mg IV Q12H
RX *pantoprazole [Protonix] 40 mg infuse 40mg IV solution twice
daily Disp #*2400 Milligram Refills:*0
3. Doxycycline Hyclate 100 mg IV Q12H MRSA bacteremia,
suppression dose
day 1 is ___
RX *doxycycline hyclate 100 mg 100mg IV doxycycline twice daily
Disp #*600 Milligram Refills:*0
4. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
(Tunneled Access Line) 2 mL DWELL DAILY Not for IV use. To be
instilled into EACH central catheter port for local dwell daily
Right After TPN finishes in AM. Please leave in for 1.5-2 hrs,
then Aspirate and Flush with saline and heparin afterwards
5. Fentanyl Patch 75 mcg/h TP Q72H
RX *fentanyl [Duragesic] 75 mcg/hour Apply one to skin, change
every 72 hours Change every 72 hours Disp #*12 Transdermal Patch
Refills:*0
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g. ___), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
RX *heparin lock flush (porcine) [Heparin Lock] 10 unit/mL
Instill 2mL of 10 unit/mL solution as needed Disp #*1000
Milliliter Refills:*0
7. TPN
Volume(ml/d) ___, Amino Acid(g/d) 100, Dextrose(g/d) 400,
Fat(g/d) 45. Trace Elements will be added daily. Standard Adult
Multivitamins will be added. NaCL 200, NaAc 115, NaPO4 0, KCl
50, KAc 10, KPO4 25, MgS04 32, CaGluc 8. Famotidine(mg) 100,
Zinc(mg) 15. Cycle over 18hrs. Start at 1800 Decrease rate to
half at 1100, Stop at 1200.
8. catheter dwell
Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
(Tunneled Access Line) 2 mL DWELL DAILY Not for IV use. To be
instilled into EACH central catheter port for local dwell daily
Right After TPN finishes in AM. Please leave in for 1.5-2 hrs,
then Aspirate and Flush with saline and heparin afterwards
Dispense 1000mL
Duration: Ongoing
9. Outpatient Lab Work
Needs weekly CBC, AST/ALT/ALK Phos/T Bili/Alb, Chem 7. Please
fax results to Dr. ___.
10. Peridex *NF* (chlorhexidine gluconate) 15 mL PO BID:PRN
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
RX *chlorhexidine gluconate [Peridex] 0.12 % Mouthwash with 15mL
Twice a day Disp #*2 Bottle Refills:*0
11. Miconazole Powder 2% 1 Appl TP BID
around G tube per wound care recs
RX *miconazole nitrate [Anti-Fungal] 2 % Apply to surrounding
wound area Twice a day Disp #*2 Bottle Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: G-TUBE MIGRATION
Secondary: Congenital intestinal pseudoobstruction s/p
intestinal transplant x2, Upper extremity DVT
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 right upper extremity clot who is
not on anticoagulation.
COMPARISON: Right upper extremity venous ultrasound ___.
RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: Gray-scale, spectral Doppler
examination of the right internal jugular, subclavian, axillary, brachial,
basilic, and cephalic veins was performed. A small region of non-occlusive
echogenic material is again noted within one of the two right brachial veins
in the upper arm, which may represent small non-occluded thrombus versus
valve, unchanged in appearance since ___. Vascular flow is
identified within this vein, and the vein was noted to completely compress.
Normal flow is noted within the right subclavian vein. Normal flow and
compression is noted within the remainder of the upper extremity veins.
IMPRESSION: Small region of echogenic material within one of the two right
brachial veins may represent a non-occlusive thrombus versus visualization of
venous valve. This is unchanged from ___.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Low-grade temperature, questionable pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes have
decreased. There is subsequent increase in density of the lung parenchyma.
Unchanged is the course of the right venous access line and position of the
defibrillator devices. Also unchanged is the appearance of a mild scar in the
left lung. There is continued elevation of the left hemidiaphragm. Neither
the frontal nor the lateral radiographs show evidence of focal parenchymal
opacities suggesting pneumonia. Unchanged normal size of the cardiac
silhouette. No pneumothorax.
Radiology Report
HISTORY: ___ with congenital intestinal obstruction and long-term
G-tube. Pain around G-tube site.
COMPARISON: CT of the torso from ___.
FINDINGS: Two frontal images of the abdomen show a paucity of bowel gas.
There is an air-fluid level in the right upper quadrant as well as a probable
air-fluid level in the stomach, a finding that is suggestive of obstruction.
Surgical clips are noted in the right upper quadrant as well as a gastrostomy
tube with button in the mid abdomen. Visualized osseous structures are
unremarkable.
IMPRESSION: Bowel gas pattern suggestive of obstruction.
This study and the report were reviewed by the staff radiologist.
Radiology Report
INDICATION: ___ man with right Hickman for TPN, increased pain and
fevers of unclear etiology. Please evaluate Hickman site for infection or
abscess.
COMPARISON: Comparison is made to chest radiograph performed on ___ as well as upper extremity venous ultrasound performed on ___.
FINDINGS: Right-sided tunneled central line identified. Sonographic
evaluation of the surrounding subcutaneous tissues demonstrates no evidence of
focal fluid collection or hyperemia.
IMPRESSION: Right-sided central venous catheter with no evidence to suggest
adjacent infection.
Radiology Report
INDICATION: ___ male with fevers and decreased breath sounds on the
left, now with concern for pneumonia.
COMPARISON: Comparison is made with chest radiographs from ___ and
___.
FINDINGS: PA and lateral images of the chest demonstrate slightly decreased
lung volumes likely due to poor inspiration, but lungs are clear. The left
hemidiaphragm is elevated slightly. Epicardial defibrillators are seen.
Venous access line is again seen with the tip in the right atrium. There is
no pneumothorax or pleural effusion. Cardiomediastinal silhouette is
unremarkable. Visualized osseous structures are unremarkable.
IMPRESSION: Unchanged chest radiograph from previous imaging with no evidence
of pneumonia.
Radiology Report
COMPARISON: ___ CT chest, ___ CT torso.
CLINICAL INDICATION: ___ man with G-tube for drainage. Question
occult infection or urinary retention. Also, history of small-bowel
transplant x 2.
TECHNIQUE: 5-mm axial series with coronal and sagittal reformats through the
chest, abdomen and pelvis without contrast.
DLP: 443.05.
FINDINGS: There are bilateral level 6 lymph nodes measuring 1 cm in short
axis on the right and 11 mm on the left (2:3, 2:5). Lack of IV contrast
limits mediastinal lymph node evaluation. There is a 12-mm prevascular lymph
node, a 1 cm paratracheal lymph node (2:18) and a 1 cm carinal node (2:21). A
right chest port is noted with tip seen at the superior cavoatrial junction.
Epicardial pacing leads are present without a battery pack identified. Heart
size within normal limits. No pericardial effusion. Normal small hiatal
hernia. Fluid is seen in the esophagus.
Small bilateral pleural effusions with bilateral dependent atelectasis. There
is a focus of consolidation in the left lower lobe (2:21). No other air space
consolidation is seen. No suspicious nodules or masses.
Lack of IV contrast limits evaluation of the solid organs of the abdomen.
There is a stable 1.7 cm left hepatic lobe hypodensity, which has been
characterized on previous ultrasound as a simple cyst. Patient is status post
cholecystectomy. Normal non-contrast appearance of the pancreas. Spleen is
enlarged measuring 15.6 cm. The stomach and duodenum are markedly distended
with normal caliber of the fourth portion. The appearance is not changed from
___ comparison. The gastric tube balloon is outside the stomach on current
exam and was documented to be within the stomach on ___ CT chest exam.
Staple line at the end of the duodenum suggests discontinuity with the distal
bowel. The bladder is severely distended occupying much of the pelvis. A
colonic remnant is seen in the pelvis. There is bilateral hydronephrosis,
likely due to bladder outlet obstruction.
Normal caliber and course of the vasculature. No acute osseous abnormality.
IMPRESSION:
1. Left lower lobe consolidation consistent with pneumonia.
2. G-tube is displaced with balloon sitting within the abdominal wall.
3. Presumed bladder outlet obstruction resulting in severe enlargement of the
bladder and moderate bilateral renal pelvicaliectasis.
4. Unchanged appearance of the stomach and residual small bowel.
5. Small pleural effusions and free abdominal fluid.
Dr ___ the above findings with Dr ___ on ___ at 1410 hours
via telephone approximately 1 hours after the findings were made.
Radiology Report
INDICATION: Evaluation of patient with bladder outlet obstruction with
hydronephrosis status post decompression.
COMPARISON: CT torso from ___.
FINDINGS:
The right kidney measures 13.5 cm.
The left kidney measures 13.0 cm.
Bilateral kidneys demonstrate mild prominence of the collecting system
suggestive of mild hydronephrosis. A Foley catheter is noted in the bladder
and the bladder is decompressed.
IMPRESSION:
1. Bilateral prominent collecting systems suggestive of mild bilateral
hydronephrosis.
2. The bladder appears decompressed with a Foley placed inside.
Radiology Report
CHEST
HISTORY: NG tube placement after G-tube dislodged.
FINDINGS: The NG tube tip is in the stomach. The epicardial defibrillator
device is again visualized. Venous access line is again seen with tip in the
right atrium. There is new obscuration of the left hemidiaphragm, compatible
with left lower lobe infiltrate or region of volume loss.
Radiology Report
INDICATION: ___ male with fever, tachycardia, please assess for
abscess around partially extruded G-tube.
COMPARISON: Comparison is made to PET-CT performed ___.
FINDINGS: G-tube balloon is identified within the superficial soft tissues of
the upper abdomen. Exam is limited due to air within the balloon, though no
large fluid collections are evident. Surrounding tissue is minimally
thickened consistent with reactive change.
IMPRESSION: No focal fluid collection or abscess identified.
Radiology Report
INDICATION: ___ male with fever, tachycardia, and concern for
pneumonia.
COMPARISON: Comparison is made with chest radiographs from ___
and ___.
FINDINGS: Single frontal image of the chest demonstrates low lung volumes
which are likely secondary to poor inspiration. There has been interval
increase in the left lower lobe opacity. The increase in opacity of the right
perihilar region likely represents vascular crowding secondary to low lung
volumes. Cardiomediastinal silhouette is slightly more obscured by the
increasing left opacity but appears to be unchanged from prior exam. The
right central line, defibrillator devices, and NG tube appear to be in
unchanged positions.
IMPRESSION: Increasing left lower lobe opacity.
Radiology Report
CLINICAL HISTORY: Status post bowel resection for intestinal obstruction,
non-functioning gastric tube, fever, abdominal distention. Evaluate for free
air.
ABDOMEN SUPINE AND UPRIGHT
The tip of the nasogastric tube lies within the stomach. The prior CT of
___ shows a massively distended stomach and also a markedly distended
bladder. On the upright film, air-fluid level is present which probably
represents air within the distended bladder but could actually represent air
within the markedly distended stomach.
A drain or catheter is seen extending into the right upper quadrant of the
abdomen. There is no free air under the diaphragm.
Radiology Report
CLINICAL HISTORY: Patient with intestinal atresia and multiple bowel
surgeries with failed G-tube which needs to be re-sited. Evaluate for
arterial supply of rectus muscle.
ANTERIOR ABDOMINAL WALL WITH DOPPLER ANALYSIS
The rectus muscle on both sides was evaluated. The right is somewhat more
echogenic and shows evidence of fatty infiltration, while the left rectus
shows normal muscle texture.
The deep epigastric artery on both sides was normal and patent and Doppler
showed normal arterial flow. The veins are not demonstrated, but this is
probably due to stretching of the veins by the distended abdomen.
Evaluation for perforators was made, two were seen on the right and one on the
left, both approximately 1 cm below the umbilicus.
If the original films are reviewed, mirror artifact is present in the anterior
abdominal wall which gives the impression of paired arteries. In all cases,
only one artery is present, the other is artifactual as is the Doppler
tracing.
IMPRESSION: Deep epigastric arteries, both patent. Veins not demonstrated.
Perforators are present. Fatty infiltration of right rectus muscle.
Radiology Report
INDICATION: ___ man with congenital interstitial pseudoobstruction
status post resection, failed intestinal transplant, now TPN dependent s/p NG
tube placement.
COMPARISONS: ___ to ___.
FINDINGS: An NG tube extends into the body of the stomach and folds back on
itself with the tip pointing cranially. Right-sided subclavian central
catheter terminates in the right atrium. Defibrillator devices are in
unchanged positions. External lead wires and tubes overlying the patient
limit evaluation. Lung volumes are low. There is no new pulmonary opacity.
Pulmonary markings accentuated by the low lung volumes.
IMPRESSION: NG tube folds back on itself in the body of the stomach.
Radiology Report
HISTORY: ___ man with known right upper extremity DVT. Question
progression.
Comparison is made to ___ and ___.
FINDINGS: Grayscale and color and spectral Doppler images were obtained of
the right IJ, subclavian, axillary, brachial, basilic and cephalic veins. A
small region of nonocclusive thrombus is again seen in one of the two right
brachial veins. Vascular flow is identified within this vein. Normal flow,
compression, augmentation is seen in the remainder of the veins.
IMPRESSION: Small region of nonocclusive thrombus again identified in the
right brachial vein. No change from the prior studies.
Radiology Report
CHEST RADIOGRAPH
INDICATION: PICC placement, evaluation for pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. Parenchymal opacities at both the left and the right lung bases,
potentially is associated to a small pleural effusion on the left. In the
appropriate clinical setting, these opacities could represent pneumonia. The
monitoring and support devices, including the defibrillator patches are
constant. Moderate pulmonary edema. Moderate cardiomegaly.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: G TUBE EVALUATION
Diagnosed with ABDOMINAL PAIN GENERALIZED, OTHER GASTROSTOMY COMPLICATION
temperature: 98.4917
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 10
level of acuity: 3.0 | # G-tube migration - Patient presented with severe pain
secondary to G-tube migration. He required IV dilaudid for pain
control. Restarted TPN per nutrition recs, used home TPN
regimen with some electrolyte additives. ACS & Dr. ___
___ and performed wound exploration and sharp debridement
percutaneous endoscopic gastrostomy on ___. They replaced
the G tube and created a stomach osteomy (which will close by
secondary intention). The tubes showed good output on suction
and was eventually left to gravity with connecting bags. The
pain was then controlled with IV Dilaudid and the pt was slowly
weaned off of IV Dilaudid over a span of a week. Seen by Pain
Medicine for pain control, however, patient was unwilling to try
suggested alternatives. Pt cannot take PO medications due to
lack of intestines. Patient did not object to being sent home
without pain medications other then Fentanyl patches (cannot
send patient on IV dilaudid due to risk of overuse). Fentanyl
patches and pain control will be followed-up with the patient's
PCP. Octeotride was suggested to decrease gastric output,
howver, patient verbalized that he could maintain good
hydration. Also, electrolytes were stable s/p surgery.
# Fever / Sepsis - Patient was febrile between ___.
Met sepsis criteria based on fever, tachycardia (as high as 140,
sinus tachycardia, consistent with temperature elevation),
leukopenia, and suspected infection. Infectious disease
specialists were consulted. Ultimately, the source could not be
confirmed as there were many possible sources (outlined below).
Continued to spike fevers despite vancomycin, cefepime,
daptomycin. On ___, pt was febrile most of the day to ___,
had sinus tachycardia to the 130-140s. Gave fluid bolus, used
cooling blankets, IV tyelenol & toradol. Fevers ultimately
resolved with initiation of broad spectrum antibiotics
(linezolid, metronidazole, cefepime). Cefepime and
metronidazole were discontinued on ___. Linezolid course, ___
- ___, per ID. Lineziolid was discontinued due to
agranulocytosis and thus was switched to Doxycycline.
Doxycycline would be continued until pt is seen by ID in clinic
(treatment for MRSA catheter tip infection). Pt was afebrile on
Doxycycline except for one fever s/p surgery. At time of
discharge, patient was afebrile and had stable VS.
ANTIBIOTICS HISTORY
Vancomycin: preadmission - ___
Ciprofloxacin: ___
Fluconazole: ___
Daptomycin: ___
Cefepime: ___
Metronidazole: ___
Linezolid: ___
Doxycycline: ___- ___ Visit
# RUE DVT - pt did not adhere to lovenox therapy prescribed in
___. During this admission, RUE US showed stable clot, lovenox
was restarted during this admission, but patient refused lovenox
shots after 3 days. Heparin drip also tried but discontinued as
the patient refused a dedicated line for heparin drip. He
communicated full understanding of risks of not treating DVT.
After further discussion with patient, heparin drip was started
___. Developed increased RUE swelling ___, and repeat
RUE ultrasound showed stable DVT. At time of discharge, pt was
explained the risk and benefits of anti-coagulation. The pt
fully understood the risk of PE without anticoagulation. He was
unwilling to have daily Lovenox shots or Coumadin PR. He
persistently declined anticoagulation and is aware of the risk
of DVT's, including PE and possible death.
.
# Pancytopenia - rec'd 2U PRBCs on ___, HCT increased
appropriately from ___. He has chronic pancytopenia likely
from nutritional deficiency and repeated courses of broad
spectrum antibiotics. Got 2U PRBCs on ___ with suboptimal
response. Hemolysis labs unremarkable. However, reticulocytes
were depressed at 0.9 on ___, likely secondary to linezolid.
Linezolid was discontinued ___. The pancytopenia improved after
discontinuation of Linezolid, however, patient is still
pancytopenic likely from nutritional deficit. It has been stable
over the last 2 weeks of his admission.
.
# Catheter tip infection
He has a ___ catheter for TPN. He had a MRSA catheter tip
infection on ___ for which he had been started on
vancomycin. We continued IV vancomycin, originally planned to
complete 4 week course of vancomycin until ___. However, as he
developed fevers on ___, vancomycin was continued until ___,
at which point vancomycin was changed to daptomycin because of
concern that fevers were drug-related. Daptomycin was changed
to linezolid on ___ because fevers persisted. CBC monitored
daily because marrow suppression is an adverse effect of
linezolid. On ___, reticulocytes were low, so linezolid was
stopped and changed to doxycycline on ___ for the MRSA
catheter tip infection. Because he is TPN-dependent, he is at
risk for fungemia, but mycolytic cultures x2 were negative.
Soft tissue ultrasound was not suggestive of pocket infection or
abscess. Doxycycline was continued until ___ clinic visit
for the MRSA catheter tip infection. Discharged with IV
Doxycycline.
.
# Lactobacillus bacteremia - ___ blood culture from ___
catheter grew lactobacillus. Empirically treated with cefepime
and metronidazole ___. All other blood cultures negative.
.
# ___ urinary tract infection - He complained of dysuria on
___, UA was suggestive of UTI, so he received two days of IV
ciprofloxacin ___, which was stopped because urine cultures
grew yeast. He was treated with fluconazole for 3 days.
.
# ICD lead infection - Patient had an ICD placed ___ at ___
for Vfib arrest in ___, pocket revision ___, and partial
lead and generator removal on ___. CTS has seen and felt
that the operative risk of removal of ICD leads is too high.
PET-CT did not show increased FDG uptake suggestive of lead
infection.
.
# HCAP - CT showed LLL consolidation, treated with cefepime
___.
.
# Tooth pain - he complained of tooth pain and a recently
chipped tooth, so a panorex was done, he was seen by an oral
surgeon, who recommended no intervention for his tooth pain.
.
# Chronic urinary retention: Has atonic bladder secondary to
congenital intestinal obstruction. Renal ultrasound and PET-CT
showed hydronephrosis and large, distended bladder. Seen by
urology in-house. Required intermittent straight
catheterization for bladder decompression during this admission.
Will have f/u with Dr. ___.
.
# Hypernatremia, Hypokalemia, Metabolic Alkalosis - On
presentation, was hypernatremic, hypokalemic, and had a
metabolic alkalosis. Occurred in the setting of missing 2 days
of TPN because of repeated ED visits. Improved with 3.5L
hypotonic IV fluids. Venous blood gas consistent with pure
metabolic alkalosis. Most likely etiology is
gastrointestinal/insensible losses of free water and H+ through
the leaky G-tube. Contraction alkalosis likely also contributed
in the setting of volume depletion as he was unable to get TPN
or hydration. After initial volume resuscitation, electrolytes
normalized and were maintained with daily TPN and occassional
electrolyte replacement. Normal electrolytes at time of
discharge.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues / Codeine / shellfish derived
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F with a history of bipolar
disorder, hypertension, anxiety disorder, with multiple recent
syncopal episodes who presents with a syncopal episode.
She had a syncopal episode in the waiting room of her PCP office
on the day of admission (___), profusely sweating with severely
elevated BP, disorganized thoughts for a moment as she slumped
down, recovered after a brief nap; denies seizure like
sensations and no tonic or clonic movements observed by nursing
staff. She improved over an hour with light snacks, ice packs
and p.o. water in the clinic. She had some tinnitus and nausea
post episode. She had been fasting for 12 hours, no water and
didn't take her Clonidine or other medications today, thinking
she would have lab work done.
Steph has been passing out more than once weekly for the past
month. This is the third day in a row with episodes. They occur
at work and at home. It starts with lightheadedness and profuse
sweating followed by slumping to the floor or passing out
briefly, and she has refused ambulance or ER visit until today.
She states that she has never hit her head. She has a remote hx
of seizures, most recently ___ yrs ago per her report. She
believes her full time work as a ___ is too stressful, and
she did not generally work 40 hour weeks due to psychiatric
issues over the years. She's now at ___ since ___
40hr week there. They feel she has exceptional skills and are
okay about her taking sick leave this week. (Formerly: ___
___ before that and she worked 35hours, more physical job, no
passing out there)
In the ED, initial vitals were: 98.1 59 168/107 17 100% RA. Exam
notable for normal neuro exam, CV, pulm benign. EKG: HR 57,
Sinus brady, RA, QTc 437, NI, no STE (unchanged from ___ She
received 1 L NS.
Upon transfer to the floor, she affirms the story listed above.
She endorses about a month of diarrhea which tends to occur at
night, not associated with food which happens every other day,
described as loose stool. The diarrhea is associated with
abdominal pain with the episodes. She also endorses night
sweats. She also endorses a 7 lb weight loss over the past two
months.
Past Medical History:
Syncope and Collapse
Migraine
Hx of Hypercholesterolemia
Presbyopia
Astigmatism
Tobacco Abuse
Glaucoma Suspect
Anxiety Disorder, Generalized
Sleep Arousal Disorder
Hypertension
Fibroids, Uterine
Bipolar Affective Disorder, Mixed
Herpes Zoster (ICD-05___.9)
Hx of Polysubstance Dependence (STABLE)
Fibroid Uterus.
GYN Hx: Menarche age ___, periods regular, no spotting b/w
cycles, mod cramping, never on OCP, G0P0, LMP ___, no abnl
PAP's.
Social History:
___
Family History:
M - dec age ___ d/t Hep C
F - dec age ___ from MI, HTN, CVA his father d. ___ ___
died
Father's sister d.late ___ Alzheimers
Father's brother d. esophageal CA son ___ Cell
Father's sister d. late ___, dx'd earlier Breast CA; daughter
d.
Lymphoma
Father's brother late ___ Heart dz.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 98.1 173/102 59 20 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, mild wheezes
diffusely, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T: 97.8 BP:158/109 (24 hr:120s-170s/70s-100s) P:67 R:18
O2:98
General: Alert, oriented, no acute distress
HEENT: 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: Inspiratory wheezes diffusely, no rales or rhonchi
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities
Pertinent Results:
ADMISSION LABS:
================
___ 02:00PM BLOOD WBC-7.5 RBC-4.06 Hgb-12.8 Hct-38.5 MCV-95
MCH-31.5 MCHC-33.2 RDW-13.9 RDWSD-48.4* Plt ___
___ 02:00PM BLOOD Neuts-60.1 ___ Monos-6.6 Eos-2.0
Baso-0.4 Im ___ AbsNeut-4.53 AbsLymp-2.31 AbsMono-0.50
AbsEos-0.15 AbsBaso-0.03
___ 02:00PM BLOOD Plt ___
___ 02:00PM BLOOD Glucose-105* UreaN-13 Creat-0.7 Na-137
K-4.0 Cl-103 HCO3-22 AnGap-16
___ 02:00PM BLOOD ALT-18 AST-21 AlkPhos-62 TotBili-0.7
___ 02:00PM BLOOD cTropnT-<0.01
PERTINENT LABS:
===============
___ 06:24AM BLOOD TSH-2.6
___ 06:24AM BLOOD LD(LDH)-271*
___ 01:00PM URINE UCG-NEGATIVE
PERTINENT IMAGING/STUDIES:
==========================
(___) CXR: In comparison with the study of ___,
the cardiac silhouette remains at the upper limits of normal in
size and there is mild tortuosity of the aorta. No acute
pneumonia, vascular congestion, or pleural effusion.
Specifically, no evidence of old tuberculous disease.
(___) Carotid US: No evidence of atherosclerotic disease in
the bilateral carotid vasculature.
(___) ECHO: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF =61 %). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Normal biventricular size wall thickness, cavity size, and
regional/global systolic function. Normal valvular
structure/function.
MICRO:
=======
___ 1:00 pm URINE
URINE CULTURE: No growth
DISCHARGE LABS:
===============
___ 06:33AM BLOOD WBC-6.8 RBC-4.38 Hgb-13.6 Hct-41.7 MCV-95
MCH-31.1 MCHC-32.6 RDW-14.0 RDWSD-49.2* Plt ___
___ 06:33AM BLOOD Plt ___
___ 06:33AM BLOOD Glucose-82 UreaN-13 Creat-0.6 Na-138
K-4.6 Cl-104 HCO3-21* AnGap-18
___ 06:33AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.0
___ 06:33AM BLOOD QUANTIFERON-TB GOLD-PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloNIDine 0.1 mg PO DAILY
2. ClonazePAM 2 mg PO BID:PRN Anxiety
3. Gabapentin 600 mg PO TID
4. Multivitamins 1 TAB PO DAILY
5. Claritin-D 24 Hour (loratadine-pseudoephedrine) ___ mg
oral DAILY
6. Mucinex DM (dextromethorphan-guaifenesin) ___ mg oral
Q6H:PRN Congestion
Discharge Medications:
1. Gabapentin 600 mg PO TID
2. ClonazePAM 2 mg PO BID:PRN Anxiety
3. Claritin-D 24 Hour (loratadine-pseudoephedrine) ___ mg
oral DAILY
4. Mucinex DM (dextromethorphan-guaifenesin) ___ mg oral
Q6H:PRN Congestion
5. Multivitamins 1 TAB PO DAILY
6. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Syncope
Hypertensive Urgency
Secondary:
Generalized Anxiety Disorder
Bipolar Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with wheezing and night sweats, concern for TB.
// evaluate for infection/TB. evaluate for infection/TB.
IMPRESSION:
In comparison with the study of ___, the cardiac silhouette
remains at the upper limits of normal in size and there is mild tortuosity of
the aorta. No acute pneumonia, vascular congestion, or pleural effusion.
Specifically, no evidence of old tuberculous disease.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old woman with syncope. // evaluate for carotid stenosis
bilaterally
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None available
FINDINGS:
RIGHT:
The right carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 93 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 49, 70, and 71 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 35 cm/sec.
The ICA/CCA ratio is 0.76.
The external carotid artery has peak systolic velocity of 90 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 82 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 54, 47, and 82 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 38 cm/sec.
The ICA/CCA ratio is 1.0.
The external carotid artery has peak systolic velocity of 44 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
No evidence of atherosclerotic disease in the bilateral carotid vasculature.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Syncope, Hypertension, Diarrhea
Diagnosed with Syncope and collapse
temperature: 98.1
heartrate: 59.0
resprate: 17.0
o2sat: 100.0
sbp: 168.0
dbp: 107.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ F with a history of bipolar
disorder, hypertension, anxiety disorder, with multiple recent
syncopal episodes who presents following a syncopal episode.
#Syncope: Patient has had multiple episodes of syncope over last
month, with episodes occurring almost daily the week prior to
admission. Prodrome of diaphoresis in addition to a prolonged
recovery from the episodes suggest vasovagal etiology, likely in
the setting of her recent life stressors with work. Syncope
work-up for other etiologies was negative. In particular, ECHO
and carotid US showed no signs of stenosis or outflow
obstruction. EKGs showed sinus bradycardia, and patient has no
history of heart disease, palpitations, arrhythmia thus unlikely
a cardiac cause. However, she will go home with ___ of Hearts
monitoring. Patient was educated about vasovagal and encouraged
to maintain PO intake and use physical counterpressure
techniques when she feels symptoms.
#Episodic Hypertension: Patient presented with hypertensive
urgency at 170/102 on admission, with baseline at 110's/70's,
per patient. Patient has had episodic elevations in blood
pressure throughout admission, ranging from 110s-170s/70s-100s,
though has been asymptomatic. Initial elevation may have been
attributed to clonidine rebound (which she takes for night
sweats/anxiety). Clonidine was stopped and patient was started
on captopril 6.25 TID in the hospital. She was discharged on
lisinopril 5 mg daily, and will follow up with PCP for
medication titration. Given episodic elevations in blood
pressure, sweating, weight loss, there was concern for
pheochromocytoma. Urine metanephrines are pending at discharge.
#Night Sweats: Patient endorses 7 lb weight loss over past two
months with daily night sweats, dissimilar to her hot flash
symptoms. CXR normal with no signs of lung mass or TB infection.
LDH slightly elevated, though hemolyzed specimen. Patient has
had history of longstanding night sweats, often triggered but
life stressors.
#Diarrhea: Patient endorses watery diarrhea at nights every ___
days, usually attributed to stress episodes. No recent
antibiotics, exposure, no association with food, no significant
caffeine intake. During hospital stay, patient had no bowel
movements.
#Wheezing: Patient is asymptomatic, though diffuse bilateral
wheezing was heard on exam. Patient notes history of
asthma/allergies, particularly worse during this time of year.
She uses home mucinex and claritin, which successfully manages
her symptoms.
***TRANSITIONAL ISSUES***
[ ] f/u quantiferon gold due to concern for night sweats and
weight loss
[ ] f/u ___ of Hearts
[ ] f/u urine metanephrines due to concern for pheochromocytoma.
[ ] Started on lisinopril 5 mg daily, may need uptitration.
[ ] Check electrolytes at next visit due to starting lisinopril
# CODE: Full, but doesn't want to be kept alive if
neurologically not intact.
# CONTACT: ___ (private care-friend) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine-Iodine Containing / Tapazole / IV Dye, Iodine Containing
Contrast Media
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ Redo Sternotomy, AVR(23mm tissue), and Coronary Artery
Bypass Grafting x 4 (SVG-LAD, SVG-Diag, SVG-RI, SVG-rPDA)
___
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a PMH of extensive CAD
s/p 4-vessel CABG ___ years ago, s/p DES to SVG-RCA and SVG-OM in
___ moderate AS (peak systolic velocity ___, peak/mean
gradients ___ mmHg), peripheral vascular disease s/p stenting,
s/p L CEA, insulin-dependent diabetes c/b neuropathy and
nonhealing ulcer with R ___ toe amp, HTN, HLD, Stage II CKD and
hypothyroidism, admitted with acute on chronic dyspnea.
Patient has been having increasing dypsnea with exertion, and a
few episodes of orthopnea since ___. Dyspnea has been
occurring after climbing one flight upstairs, but has progressed
over the past two days to where he becomes dyspneic on transfer
from stretcher to the bed. Episodes of dyspnea have been
associated with lightheadedness and cold diaphoresis, but no
chest pain. Over the past month, he has also developed lower
extremity edema worse on the right. On ___ at 2 am, he woke
up feeling like he was "gurgling" and not breathing well lying
flat in bed (baseline lies flat, but had to use two pillows for
comfortable breathing). Later that day, he experienced an
episode of syncope when getting up out of bed (going from lying
to standing), not preceded by any lightheadedness. He then
presented to ___, where he was given Lasix IV and sent
home.
After discharge from ___ on ___, he subsequently
had increasing orthopnea, and dyspnea during daily activities.
During his outpatient cardiology visit on ___, Dr. ___
___ that his AS was likely progressing, and that he may
need a surgical AVR with revascularization of his RCA territory,
given results of stress-nuclear study in ___. He adjusted
his Lasix from 40 mg TID to 80 mg in the morning and 40 mg at
night. He also decreased his amlodipine from 10 mg to 5 mg, so
as not to exacerbate an orthostatic hypotension.
On ___, Mr. ___ dyspnea on minimal exertion continued,
prompting him to present to ___ again. Per ED notes,
patient had had dull chest pain the morning prior to arrival,
but patient denies this on interview. He developed bradycardia
to the ___ and syncopized without preceding lightheadedness on
moving from stretcher to the bed. There, he was found to have
troponin elevated to 0.11 (CK 60, CK-MB 3.7), and started on
heparin drip at 14:53. He was given 1 inch of topical
nitrpoglycerin. He had taken aspirin 325 mg on the morning of
presentation. He was treated with CPAP for his dyspnea. He was
also given levofloxacin 500 mg PO for ?foot infection. He was
then transferred to ___.
In the ___ ED, initial vitals were: 84 122/55 14 96%. Patient
reported that his SOB has improved significantly since
presentation to OSH. CXR showed cardiomegaly, layering
effusions, fullness in the hilum and fluffiness consistent with
pulm edema. Labs significant for trop 0.10m CK 54, MB 4; BUN/Cr:
40/1.7 (baseline Cr 1.0) Na 129 (baseline 133), Glu 419, ALT 22,
AST 45, Alk Phos 119, Tbili 1.7, Alb 3.4. ProBNP 7402, WBC 11.8
(N:89.4 L:5.2 M:5.1 E:0 Bas:0.3). H/H: 11.3/34.8 (baseline Hct
36.7) ___: 15.6 PTT: 66.6 INR: 1.4. Heparin drip was continued,
and patient was also given insulin 10 units given hyperglycemia.
ED resident spoke, with cardiology attending, with plan to admit
to ___ for evaluation of symptoms. Vitals prior transfer: 91
112/48 18 95%.
On arrival to the floor, patient was feeling fine. He reports
that his shortness of breath has improved substantially over the
course of the day. He is concerned for underlying infection, as
his FSBS have been difficult to control over the past week. His
dry weight a few days ago is reported as 185 lbs.
REVIEW OF SYSTEMS:
(+) Per HPI. Also positive for nocturnal cough over the past
few weeks with some wheezing; dietary indiscretion with a lot of
pickles; drinking "a lot of bottled water; right plantar ulcer
over the past month that is followed by a podiatrist; elevated
FSBS in the past week; chest tightness while mowing the lawn
about one year ago (c/w prior episodes of angina).
(-) Cardiac: Denies chest pain, palpitations, paroxysmal
nocturnal dyspnea.
(-) General: Denies fatigue, subjective fevers at home, chills,
rigors, night sweats, headache, diplopia, odynophagia,
dysphagia, lymphadenopathy, prior history of stroke or TIA,
cyanosis, hemoptysis, pleuritic chest pain, nausea, vomiting,
diarrhea, melena, hematochezia, hematemesis, known pulmonary
embolism or DVT, myalgias, joint pains, new brusing, new
bleeding, dysuria.
Past Medical History:
Aortic stenosis
Coronary Artery Disease, prior CABG ___
Dyslipidemia
Hypertension
Carotid artery disease, History of Left CEA
Pheripheral vascular disease, s/p Bilateral iliac artery
stenting
Insulin Dependent Diabetes (nephropathy, neuropathy,
retinopathy)
Chronic Kidney Disease
Social History:
___
Family History:
Father: passed away from ___ at age ___, HTN
Mother: passed away age ___ cardiac death vs. stroke, HTN
2 sisters: HTN
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: T 98.4 BP 136/84 HR 90 RR 20 SaO2 92-95% on ___ Wt 191.4
lbs.
GENERAL: WDWN male in NAD, appears stated age. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: JVP elevated to angle of jaw with HOB at 45 degress. No
carotid bruits.
CARDIAC: RRR. Tight-sounding crescendo-decrescendo systolic
murmur loudest at RUSB with radiation to LLSB and apex.
Prominent S2. No thrills, lifts. No S3 or S4.
LUNGS: Decreased breath sounds at bases bilaterally with rales
___ way up lungfield at the end of inspiration. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: RLE edema 2+ pitting, LLE edema 1+ pitting. No TTP,
no overlying erythema. No clubbing or cyanosis.
SKIN: Grade 3 ulcer with dark center, well-defined round border
without any erythema on the plantar aspect of the ball of the
right foot; no TTP. No rashes.
PULSES:
Right: Carotid 2+ Radial 2+ DP trace
Left: Carotid 2+ Radial 2+ DP trace
NEURO: decreased sensation on the plantar surfaces of his feet
Discharge Exam:
VS T HR BP RR O2sat
Gen:
Neuro:
CV:
Pulm:
Abdm:
Ext:
Pertinent Results:
Admission Labs:
___ 05:30PM ___ PTT-66.6* ___
___ 05:30PM PLT COUNT-205
___ 05:30PM NEUTS-89.4* LYMPHS-5.2* MONOS-5.1 EOS-0
BASOS-0.3
___ 05:30PM WBC-11.8*# RBC-3.60* HGB-11.3* HCT-34.8*
MCV-97# MCH-31.3 MCHC-32.5 RDW-13.2
___ 05:30PM OSMOLAL-294
___ 05:30PM ALBUMIN-3.4*
___ 05:30PM CK-MB-4 proBNP-7402*
___ 05:30PM cTropnT-0.10*
___ 05:30PM ALT(SGPT)-22 AST(SGOT)-45* CK(CPK)-54 ALK
PHOS-119 TOT BILI-1.7*
___ 05:30PM GLUCOSE-415* UREA N-40* CREAT-1.7*
SODIUM-129* POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-24 ANION GAP-16
___ 05:50PM LACTATE-1.8
___ 10:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 10:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:56PM CK-MB-4 cTropnT-0.13*
___ 11:56PM CK(CPK)-45*
___ Intra-op TEE
Conclusions
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. There is moderate to severe
regional left ventricular systolic dysfunction with
anteroseptal, inferoseptal and inferior wall hypokinesis.
Overall left ventricular systolic function is severely depressed
(LVEF=20%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the aortic root. There
are simple atheroma in the ascending aorta. There are complex
(mobile) atheroma in the descending aorta. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Mild to moderate (___) aortic regurgitation
is seen. The mitral valve leaflets are moderately thickened.
There is moderate thickening of the mitral valve chordae. There
is no pericardial effusion.
POST-BYPASS The patient is AV paced. The patient is receiving
epinephrine, norepinephrine, milrinone, and vasopressin by IV
infusion. The right ventricle displays normal basal and mid
function with mild apical hypokinesis. The left ventricle
displays areas of septal dyskinesis with inferoseptal and
anteroseptal akinesis. The rest of the left ventricular segments
display mild global hypokinesis. The left ventricular ejection
fraction is about 25%. There is a bioprosthesis located in the
aortic position. It appears well seated. The leaflets are only
very poorly seen. The peak gradient through the aortic valve was
20 mmHg with a mean gradient of a 12 mmHg at a cardiac output
near 5 liters/minute. No significant aortic regurgitation is
appreciated. The mitral regurgitation is worsened and is now
moderate in intensity and centrally directed. The rest of
valvular function appears unchanged. The mobile atheroma seen in
the descending thoracic aorta iin the pre-bypass study is no
longer seen. The thoracic aorta appears intact after
decannulation.
Radiology Report CAROTID SERIES COMPLETE PORT Study Date of
___ FINDINGS: Of note, patient is on intra-aortic balloon
pump during the
examination.
Grayscale images demonstrate mild heterogeneous plaque in
bilateral internal carotid arteries, right worse than left.
Peak systolic velocity in the proximal, mid and distal right
internal carotid artery was 86, 72, and 42 cm/sec with
end-diastolic velocity of 16, 14, and 12 cm/sec respectively.
Right CCA peak systolic velocity was 57 segment with
end-diastolic velocity of 9 cm/sec. Right external carotid peak
systolic velocity was 88 cm/sec. Right vertebral artery is
antegrade with proximal peak systolic velocity of 33 cm/sec.
ICA/CCA ratio is 1.5. Findings suggest less than 40% stenosis
of the right internal carotid artery.
Peak systolic velocity in the proximal, mid and distal left
internal carotid artery was 101, 81, and 73 cm/sec respectively
with end-diastolic velocity of 34, 25, and 23 cm/sec
respectively. Left CCA peak systolic velocity was 77 cm/sec
with end-diastolic velocity of 20 cm/sec. Left external carotid
peak systolic velocity was 122 cm/sec. Left vertebral artery
was antegrade with proximal peak systolic velocity of 84 cm/sec.
Left ICA/CCA ratio was 1.3.
Findings suggest less than 40% stenosis of the left internal
carotid artery.
CONCLUSION: Less than 40% stenosis in either internal carotid
artery.
Radiology Report ___ DUP EXTEXT BIL (MAP/DVT) Study Date of
___ 4:30
FINDINGS: Bilateral lower extremity vein mapping was performed.
Right
greater saphenous vein is surgically absent. Further attempted
imaging was not performed because of bandage in the groin and
knee immobilizer.
The left greater saphenous vein is patent with small diameters
below the knee ranging from 1.0-1.8 mm. The knee-to-groin
diameters are 1.5, 2.2, 3.4, 4.3, 4.5 mm.
The left small saphenous vein is heavily diseased with areas of
calcification and not usable for conduit.
IMPRESSION: Status post right greater saphenous stripping. The
left greater saphenous vein is small below the knee, but may
have some available length in the thigh. The left small
saphenous vein is calcified.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
___ 9:34
FINDINGS: As compared to prior chest radiograph from ___, there has been interval placement of a right PICC line,
with its tip projecting over the mid SVC. The line demonstrates
an unremarkable course. There is no pneumothorax. There has
been interval removal of support devices. Lung volumes have
increased and bilateral pleural effusions have recurred. The
mediastinal and cardiac contours are stable and mildly enlarged.
IMPRESSION: Right-sided PICC line tip at the level of the mid
SVC, with
interval recurrence of bilateral pleural effusions.
These findings were discussed with ___, RN by Dr.
___ via telephone on ___ at 10:00 a.m., at
time of discovery.
___ 05:55AM BLOOD WBC-9.3 RBC-2.90* Hgb-8.5* Hct-26.3*
MCV-91 MCH-29.4 MCHC-32.4 RDW-13.3 Plt ___
___ 05:55AM BLOOD Plt ___
___ 05:02AM BLOOD ___
___ 05:55AM BLOOD UreaN-28* Creat-1.0 Na-134 K-4.6 Cl-97
___ 05:55AM BLOOD Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. alpha lipoic acid *NF* 50 mg Oral daily
2. Amlodipine 5 mg PO DAILY
hold for SBP < 110
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Calcium Carbonate 1500 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Furosemide 40 mg PO QPM
Hold for SBP < 110
8. garlic *NF* 1,000 mg Oral daily
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold for SBP < 110
10. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Levothyroxine Sodium 300 mcg PO DAILY
12. Levothyroxine Sodium 25 mcg PO EVERY OTHER DAY
on M ___
13. Atorvastatin 40 mg PO DAILY
14. Fish Oil (Omega 3) ___ mg PO DAILY
15. Prasugrel 10 mg PO DAILY
16. Testim *NF* (testosterone) 50 mg/5 gram (1 %) Transdermal
daily
apply 2 tubes
17. Metoprolol Succinate XL 100 mg PO DAILY
hold for SBP < 110 or HR < 60
18. Cyanocobalamin 1000 mcg PO DAILY
19. Vitamin E 100 UNIT PO DAILY
20. Furosemide 80 mg PO DAILY
in the morning
Hold for SBP < 110
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Calcium Carbonate 1500 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Levothyroxine Sodium 300 mcg PO DAILY
6. Acetaminophen 650 mg PO Q4H:PRN fever, pain
7. Carvedilol 12.5 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
10. alpha lipoic acid *NF* 50 mg Oral daily
11. Ascorbic Acid ___ mg PO DAILY
12. Fish Oil (Omega 3) ___ mg PO DAILY
13. garlic *NF* 1,000 mg Oral daily
14. Vitamin D ___ UNIT PO DAILY
15. Testim *NF* (testosterone) 50 mg/5 gram (1 %) Transdermal
daily
16. Vitamin E 100 UNIT PO DAILY
17. Glargine 33 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
18. Clopidogrel 75 mg PO DAILY
19. Heparin 5000 UNIT SC TID
20. Milk of Magnesia 30 ml PO DAILY
21. ertapenem *NF* 1 gram Intravenous 24hrs Reason for Ordering:
per ID
22. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
23. ertapenem *NF* 1 gram Intravenous x1 stat Reason for
Ordering: per ID
24. Potassium Chloride 20 mEq PO BID
25. Ranitidine 150 mg PO DAILY
26. Vancomycin 1000 mg IV Q 12H
27. Furosemide 40 mg PO QPM
28. Furosemide 80 mg PO DAILY
29. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
30. Levothyroxine Sodium 25 mcg PO EVERY OTHER DAY
31. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
32. Amlodipine 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aortic stenosis
Coronary Artery Disease, prior CABG ___
Dyslipidemia
Hypertension
Carotid artery disease, History of Left CEA
Pheripheral vascular disease, s/p Bilateral iliac artery
stenting
Insulin Dependent Diabetes (nephropathy, neuropathy,
retinopathy)
Chronic Kidney Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned-non weightbearing right foot
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg: Left - healing well, no erythema or drainage.
Edema: trace bilat
Followup Instructions:
___
Radiology Report
HISTORY:
___ male with elevated troponin.
COMPARISON: None.
FINDINGS:
There is mild to moderate cardiomegaly as well as mild pulmonary edema. Right
lower lobe and retrocardiac opacities may be atelectasis although underlying
infection is difficult to exclude. The patient is status post median
sternotomy and CABG. There is a small right pleural effusion. There is no
pneumothorax.
IMPRESSION: Mild congestive heart failure with small right pleural effusion.
Bibasilar airspace opacities likely reflect atelectasis, but infection is not
excluded.
Radiology Report
HISTORY: Ulcer. Assess for osteomyelitis.
Three views of the right foot show amputation of the fifth toe at the level of
the proximal fifth metatarsal. There is unusual tapering of the distal fourth
metatarsal and nonspecific abnormality of the adjacent fourth MP joint. There
is a large erosion of the distal articular surface of the second metatarsal.
Smooth periosteal new bone along several metatarsals presumably reflecting
abnormal weight bearing post resection. There is a nonspecific abnormality
and possible bone destruction at the third PIP joint. Vascular
calcifications. The hindfoot is normal. Since remote last previous exam ___, there has been further amputation of the fifth toe with changes and
bone destruction in the second, third, and fourth toes all having appeared.
IMPRESSION: Findings are consistent with osteomyelitis in several toes.
Localizing history would be helpful in this regard.
Radiology Report
INDICATION: ___ man with peripheral vascular disease, and CHF and
nonhealing right foot ulcer.
COMPARISON: None.
FINDINGS: Doppler waveform analysis, pulse volume recordings, and
ankle-brachial indices were evaluated bilaterally. Of note, there are
noncompressible vessels at the level of the ankles.
On the right, there is a triphasic waveform at level of the femoral artery,
and conversion to a monophasic waveform at the level of the popliteal,
posterior tibial, and dorsalis pedis artery regions. Additionally, there is
reduction in amplitude at level of the ankle and metatarsal on the right. The
ankle-brachial index could be assessed.
On the left, there is triphasic waveform at the level of the femoral and
popliteal arteries, and conversion to a monophasic waveform at the level of
the posterior tibial and dorsalis pedis arteries, with reduction of amplitude
at the level of the ankle and metatarsal.
IMPRESSION: Findings consistent with bilateral tibial arterial insufficiency,
and additionally, right SFA disease.
Radiology Report
INDICATION: History of congestive heart failure and aortic stenosis, now with
new-onset seizure. Evaluate for acute intracranial process.
COMPARISON: None.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material. Multiplanar reformats were
performed.
FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of
normally midline structures, hydrocephalus, or acute large vascular
territorial infarction. Mild prominence of the ventricles and sulci is
consistent with age-related global atrophy. Subcortical white matter
hypodensities are a nonspecific finding that can be seen in the setting of
chronic small vessel ischemic disease. Extensive dural calcifications are
seen along the falx cerebri and tentorium cerebelli.
The orbits are remarkable only for evidence of bilateral ocular lens surgery.
The visualized portions of the paranasal sinuses and mastoid air cells are
well aerated. Extensive atherosclerotic calcifications are seen of the
bilateral cavernous carotid and vertebral arteries. No suspicious lytic or
blastic bone lesion is identified.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Aortic stenosis, CHF, new onset seizure.
Comparison is made with prior study ___.
Moderate cardiomegaly is stable. Moderate pulmonary edema has increased.
Small to moderate bilateral pleural effusions with adjacent atelectasis have
increased. Sternal wires are aligned. Patient is status post CABG.
Radiology Report
INDICATION: NSTEMI, evaluate line placement.
COMPARISON: ___.
TECHNIQUE: Portable frontal chest radiograph.
FINDINGS: Cardiac silhouette remains moderately enlarged with stable
mediastinal silhouette and hilar contours. There has been interval placement
of a femoral approach Swan-Ganz catheter which is located in a lower right
segmental pulmonary artery 3.5 cm beyond the border of the mediastinum. A
femoral-approach intraaortic balloon pump is in place projecting at the
superior contour of the aortic arch. Pulmonary edema is unchanged with slight
increase in the bilateral pleural effusions. Atelectasis is unchanged.
IMPRESSION: Femoral approach Swan-Ganz positioned 3.5cm past the border of
the mediastinum in a lower segmental pulmonary artery. Recommend withdrawal of
Swan-Ganz by 3.5 cm. Intraaortic balloon pump at the level of the superior
border of the aortic arch. Recommend withdrawal by 1 cm. Otherwise, little
change compared to ___.
Results discussed over the telephone with ___ by ___ at 4:20
p.m. on ___ at the time of initial review.
Radiology Report
INDICATION: ___ male with four-vessel CABG ___ years ago and multiple
prior percutaneous interventions. Evaluate for conduit for potential redo
CABG/AVR.
FINDINGS: Bilateral lower extremity vein mapping was performed. Right
greater saphenous vein is surgically absent. Further attempted imaging was
not performed because of bandage in the groin and knee immobilizer.
The left greater saphenous vein is patent with small diameters below the knee
ranging from 1.0-1.8 mm. The knee-to-groin diameters are 1.5, 2.2, 3.4, 4.3,
4.5 mm.
The left small saphenous vein is heavily diseased with areas of calcification
and not usable for conduit.
IMPRESSION: Status post right greater saphenous stripping. The left greater
saphenous vein is small below the knee, but may have some available length in
the thigh. The left small saphenous vein is calcified.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Intra-aortic balloon pump.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. The Swan-Ganz catheter has been pulled back and is now in correct
position. The tip projects over the central aspect of the right pulmonary
artery. The intra-aortic balloon pump is also unchanged, the device could be
pulled back by approximately 1 cm, as it is only 4-5 mm below the superior
aspect of the aortic arch. No pneumothorax. Unchanged mild pleural
effusions. Borderline size of the cardiac silhouette.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Intra-aortic balloon pump, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the position of the
intra-aortic balloon pump is unchanged, with the tip being located just
several millimeters below the superior aspects of the aortic arch. The device
could be pulled back by approximately 1 to 2 cm.
The Swan-Ganz catheter is in unchanged position.
Unchanged appearance of the cardiac silhouette. Unchanged mild bilateral
pleural effusions.
Radiology Report
INDICATION: Preoperative examination before coronary bypass, remote
left-sided carotid endarterectomy.
COMPARISON: Carotid ultrasound, ___.
TECHNIQUE: Realtime grayscale and Doppler ultrasound examination of bilateral
neck arteries.
FINDINGS: Of note, patient is on intra-aortic balloon pump during the
examination.
Grayscale images demonstrate mild heterogeneous plaque in bilateral internal
carotid arteries, right worse than left.
Peak systolic velocity in the proximal, mid and distal right internal carotid
artery was 86, 72, and 42 cm/sec with end-diastolic velocity of 16, 14, and 12
cm/sec respectively. Right CCA peak systolic velocity was 57 segment with
end-diastolic velocity of 9 cm/sec. Right external carotid peak systolic
velocity was 88 cm/sec. Right vertebral artery is antegrade with proximal
peak systolic velocity of 33 cm/sec. ICA/CCA ratio is 1.5. Findings suggest
less than 40% stenosis of the right internal carotid artery.
Peak systolic velocity in the proximal, mid and distal left internal carotid
artery was 101, 81, and 73 cm/sec respectively with end-diastolic velocity of
34, 25, and 23 cm/sec respectively. Left CCA peak systolic velocity was 77
cm/sec with end-diastolic velocity of 20 cm/sec. Left external carotid peak
systolic velocity was 122 cm/sec. Left vertebral artery was antegrade with
proximal peak systolic velocity of 84 cm/sec. Left ICA/CCA ratio was 1.3.
Findings suggest less than 40% stenosis of the left internal carotid artery.
CONCLUSION: Less than 40% stenosis in either internal carotid artery.
Radiology Report
INDICATION: History of four-vessel coronary artery bypass grafting with
stenosis, also with severe aortic stenosis, now in need of preoperative
evaluation for revision CABG and aortic valve replacement.
TECHNIQUE: Multidetector helical CT scan of the chest was obtained without
the administration of contrast. Coronal and sagittal reformations were
prepared.
COMPARISON: None available.
FINDINGS: There are severe vascular calcifications of the native coronary
arteries as well as calcifications of apparent previous bypass grafts. There
is also moderate-to-severe calcification of the aortic root, extending to the
aortic arch. There are additionally severe calcifications of the mitral
valve. Multiple surgical clips from prior CABG are seen. The retrosternal
soft tissues appear grossly unremarkable. There is no pericardial effusion.
At the level of the main pulmonary artery, the ascending aorta measures up to
3.4 cm (4:115). At the same level, the main pulmonary artery measures 3.2 cm
in diameter. The aortic arch measures approximately 2.6 cm in diameter and
the descending aorta measures 2.5 cm. Incidental note is made of common
origin of the brachiocephalic and left common carotid arteries.
Mediastinal lymph nodes are within normal limits. No evidence of
endobronchial lesion is seen.
Within the lung parenchyma, there is bilateral symmetric dependent opacity
most consistent with atelectasis. There are small bilateral pleural
effusions. No findings to suggest pneumonia are seen. No pneumothorax is
present.
No concerning osseous lesion is seen. Sternal wires appear intact.
Limited views of the upper abdomen demonstrate vascular calcifications but are
otherwise grossly unremarkable.
IMPRESSION: Extensive atherosclerotic vascular calcifications including
native coronary arteries and aortic and mitral valves. No pericardial
effusion.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: Patient with redo AVR, CABG.
COMPARISON: ___.
FINDINGS:
New ET tube ends 4.1 cm above the carina. Right-sided Swan-Ganz is in the
right pulmonary artery. Intra-aortic balloon has been removed. NG in the
stomach. There is no pneumothorax. Moderate pulmonary edema is unchanged with
bilateral small pleural effusion. Mediastinal and cardiac contour is
unchanged and mildly enlarged.
CONCLUSION:
1. Tube and lines are in adequate position. There is no pneumothorax.
2. Unchanged moderate pulmonary edema.
Radiology Report
HISTORY: Chest tube removal.
FINDINGS: In comparison with the study of ___, the right chest tube has been
removed and there is no convincing evidence of pneumothorax. Otherwise,
little change except for the streak of atelectasis or thickening of the minor
fissure having cleared in the right mid zone.
Radiology Report
INDICATION: ___ male patient with new right PICC line placement.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: Portable AP chest radiograph.
FINDINGS: As compared to prior chest radiograph from ___, there
has been interval placement of a right PICC line, with its tip projecting over
the mid SVC. The line demonstrates an unremarkable course. There is no
pneumothorax. There has been interval removal of support devices. Lung
volumes have increased and bilateral pleural effusions have recurred. The
mediastinal and cardiac contours are stable and mildly enlarged.
IMPRESSION: Right-sided PICC line tip at the level of the mid SVC, with
interval recurrence of bilateral pleural effusions.
These findings were discussed with ___, RN by Dr. ___ via
telephone on ___ at 10:00 a.m., at time of discovery.
Radiology Report
VENOUS DUPLEX UPPER EXTREMITY
Patient in need of CABG.
Duplex evaluation was performed of both upper extremity venous systems. Right
cephalic vein is patent but very diminutive. Basilic vein shows diameters of
0.4 to 0.56. Left cephalic vein is diminutive and has thrombus at several
locations. Left basilic vein is diminutive except at the upper portion.
IMPRESSION: Thrombus in the left cephalic vein. Patent bilateral basilic and
right cephalic vein with diameters as noted. Most suitable conduit is right
basilic vein.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ELEVATED TROP/SOB
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, AORTIC VALVE DISORDER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | MEDICINE COURSE:
Mr. ___ is a ___ year old male with known coronary artery
disease who was transferred from OSH for treatment of severe SOB
and DOE. CXR on admission was consistent with pulmonary edema.
He was initially admitted to the ___ service and started with
IV lasix boluses for diuresis. On hospital day 2 he syncopized
with precedent lightheadedness. He also triggered for hypoxia
with O2 sats to mid ___ on 5L NC. He was switched to a high flow
face mask and started on lasix and nitroglycerin drips. A TTE
performed that day was notable for severe regional left
ventricular systolic dysfunction with focal near-akinesis of the
septum, anterior wall, inferior wall and apex and EF of ___ (
down from 60% on Echo rom ___. He was taken to the cath lab
on hospital day 3 given progressive hypoxia and syncope. His
cath was notable for a newly occluded SVG-RCA and SVG to ramus
with significant stenosis. Aortic valve area of ~0.5-0.6cm. .
Right heart cath was notable for RA pressure 15, PCWP ~30,
cardiac index 1.6 consistent with cardiogenic shock. An
intra-aortic ballon pump was placed in the cath lab and he was
transferred to the CCU. In the CCU he remained on a lasix drip
and nitro drip, titrated to maintain a a CVP of ___. The nitro
gtt was weaned on hospital day 5. Isosorbide and hydralalzine
were also added for afterload reduction. The patient was weaned
from the ballon pump on hospital day 8. The lasix drip was
discontinue on hospital 9 and he was started on torsemide for
diuresis. The patient likely had progressive demand ischemia of
his myocardium secondary to re-stenosis of his grafts and
progression of his AS, leading to decreased EF and WMA and
cardiogenic shock. The patient also had progression of his AS,
now severe with Aortic Valve mean gradient = 24 mmHg. ___ 0.6 sq
cm.. His severe AS and decreased EF likely contributed his poor
CI and CO. He was evaluated BY CT surgery for aortic valve
replacement and revision of CABG, which was initially delayed to
allow to time for washout of his prasurgrel. During this time he
was also seen by the infectious disease, vascular surgery and
podiatry services for non healing ulcer of right foot.
He was started on Vancomycin and Zosyn for osteomyelitis of
foot. |
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, urinary frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ CVA Hx, CKD, glaucoma, presents with generalized
weakness, confusion. Pt was normal ___ night upon going to
bed, woken up by care taker am of morning of presentation, weak
and confused. Patient was slumping when placed on toilet. She
took his blood pressure which was 117/75 and his heart rate was
reportedly 127. They called his neurologist, Dr. ___
recommended he come to the emergency department. They report he
has had increased urinary frequency and odor of his urine the
past few days. They deny fevers, nausea, vomiting, diarrhea,
black or bloody stools or abdominal pain. Patient did have a
cough last week which has since resolved. Daughter states that
he has had a similar presentation and found to have a UTI in the
past.
In ED:
VS: triggered for SBP <90
89/66 --> 114/72, HR 136 --> 99
Labs: wbc 15, hb 14, 87% neutrophils, Cr 1.9 (b/l 1.3-1.6), AG
17, AP 188, Phos 1.2; Utox neg
UA: hazy, large ___, mod blood, tr prot, wbc over assay, many
bact
lact 2.8
Blood cx x2, Urine Cx sent
Got CTX 1g and 1.75L NS
Neuro consult in ED: pt at neuro baseline per notes, rec cont
ASA
as 2o prevention CVA, speech/aspiration/fall precautions
Care discussed with children and his persona caretaker at
bedside, providing additional history. Family states his mental
status has improved since this morning, now at baseline. Less
pallor. Patient at present eating popsicle. Tolerating with
assistance.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- Neurocardiogenic Syncope
- HLD
- HTN
- Erectile Dysfunction
- DM
- Pontine CVA (___) - residual slurred speech and mild gait
impairment
Social History:
___
Family History:
No family history of stroke, CAD, sudden cardiac arrest.
Physical Exam:
Admission Physical Exam:
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: Rales in Left lower lobe > right; poor cough when
attempting to clear; 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
Discharge physical exam:
Gen: Alert and oriented x 3, pleasant and interactive
HEENT: NCAT, no oral lesions
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, nontender, nondistended
Ext: no edema
Neuro: alert, oriented x3, no focal deficits, able to walk with
walker
Pertinent Results:
___ 03:20PM LACTATE-1.7
___ 10:00AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG*
___ 10:00AM URINE RBC-7* WBC->182* BACTERIA-MANY*
YEAST-NONE EPI-0
___ 09:37AM GLUCOSE-137* UREA N-21* CREAT-1.9* SODIUM-141
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
___ 09:37AM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-188* TOT
BILI-0.8
___ 09:37AM LIPASE-26
___ 09:37AM cTropnT-<0.01
___ 09:37AM WBC-15.8* RBC-4.87 HGB-14.5 HCT-43.5 MCV-89
MCH-29.8 MCHC-33.3 RDW-14.3 RDWSD-43.0
Discharge labs:
___ 06:20AM BLOOD WBC-6.5 RBC-3.95* Hgb-11.6* Hct-35.4*
MCV-90 MCH-29.4 MCHC-32.8 RDW-14.2 RDWSD-44.6 Plt ___
___ 06:20AM BLOOD Glucose-113* UreaN-19 Creat-1.3* Na-140
K-4.2 Cl-104 HCO3-26 AnGap-10
___ 06:43AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9
Micro:
___ Urine culture > 100 k E coli
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
___ Blood cultures x 2 no growth to date
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 12.5 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Atorvastatin 20 mg PO QPM
4. Tamsulosin 0.4 mg PO QHS
5. Cilostazol 100 mg PO BID
6. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) BID
7. Lumigan (bimatoprost) 0.01 % OD QHS
8. Aspirin 162 mg PO DAILY
9. ValACYclovir 1000 mg PO Q12H
10. Ciprofloxacin 0.3% Ophth Soln 1 DROP RIGHT EYE BID
11. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE DAILY
12. netarsudil 0.02 % ophthalmic (eye) QHS
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 4
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice per day Disp #*8 Capsule Refills:*0
2. Aspirin 162 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Cilostazol 100 mg PO BID
5. Ciprofloxacin 0.3% Ophth Soln 1 DROP RIGHT EYE BID
6. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye)
BID
7. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE DAILY
8. Lumigan (bimatoprost) 0.01 % OD QHS
9. Metoprolol Tartrate 12.5 mg PO DAILY
10. netarsudil 0.02 % ophthalmic (eye) QHS
11. Pantoprazole 40 mg PO Q24H
12. Tamsulosin 0.4 mg PO QHS
13. ValACYclovir 1000 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___.
Discharge Diagnosis:
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Portable chest radiographs
INDICATION: ___ with confusion// r/o infiltrate or ich
TECHNIQUE: AP chest x-ray
COMPARISON: ___
FINDINGS:
Lung volumes are decreased from prior. There is increased bilateral haziness
about the hila, with obscuration of the left heart border. Retrocardiac
opacity is likely secondary to atelectasis. This may represent increased
pulmonary vascular congestion. No pneumothorax. No pleural effusion. The
mediastinal contour is less well-defined than on prior.
IMPRESSION:
Increased hilar haziness may represent pulmonary congestion versus decreased
lung volumes. Retrocardiac opacity, likely atelectasis though infection is
not excluded. If further clarification, repeat with PA and lateral views with
improved inspiration could be performed.
Radiology Report
INDICATION: ___ p/w encephalopathy and UTI, improving mental status post
IVF/abx; ?- further characterize question of retrocardiac opacity on admission
AP film// ? retrocardiac opacity
COMPARISON: Radiographs from ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There are very low lung
volumes. There is crowding of the pulmonary vascular markings particularly at
the bases. There is also haziness about the perihilar regions which may
represent mild pulmonary edema, unchanged. No definite consolidation is seen.
There are no pneumothoraces. Retrocardiac opacity seen on the prior chest
radiograph, relates to a hiatus hernia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with Urinary tract infection, site not specified
temperature: 97.9
heartrate: 136.0
resprate: 18.0
o2sat: 97.0
sbp: 89.0
dbp: 66.0
level of pain: 0
level of acuity: 1.0 | ___ male with h/o CVA and glaucoma who presents with
marked weakness and AMS in the setting of a UTI.
# UTI w/ acute encephalopathy
- he was treated with IV ceftriaxone 1 gram daily x 3 doses with
rapid improvement in mental status to baseline by hospital day 1
- on hospital day 2, he continued to feel well and walked with
physical therapy with the aid of a walker and was seen to have
strength and functioning close to his baseline
- he will be discharged with Macrobid ___ bid to complete a
total 7 day course of antibiotics based on resistance profile
from urine culture
# Sinus tachycardia w/ PAC's
- tachycardic on admission, improved with 1.5 L of saline given
over 24 hours
- heart rate returned to baseline 90's-100 at discharge on qAM
metoprolol 12.5 daily
# ___ on CKD - Cr 1.9 on admission
- renal function improved to Cr 1.3 on discharge
CHRONIC/STABLE PROBLEMS
# Glaucoma - continued on eye drops and oral antiviral during
hospitalization
# BPH - continued on home tamsulosin
# CVA - continued on home ASA
Post discharge care:
- he will have home physical therapy initiated after discharge
- he will continue his other home supports with nursing/aide
- he will follow up with PCP, ___ as scheduled the
following week
Patient seen and examined on day of discharge and stable for
discharge. >30 min spent on DC planning and coordination of
care |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
floxacillin / Motrin
Attending: ___.
Chief Complaint:
Encephalopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ man with history of colon cancer
s/p right hemicolectomy and RFA of liver met, now with
glioblastoma on treatment with bevacizumab. He was recently
admitted early ___ after fall at rehab facility and
subsequently received inpatient becacizumab. Per neuro-onc note
___, patient had been very somnolent with decreased verbal
output. UA was reportedly positive for a UTI and he was started
on levofloxacin. Since his discharge from the hospital ___, he
has continued to see urology for urinary retention. At his last
appointment ___, it appeared the patient was able to pass a
voiding trial. However, patient required foley replacement in
the ED later that day for urinary retention. He presents to the
ED today for altered mental status, fever, and urinary symptoms.
He was noted to have decreased urine output and blood clot in
his Foley, which was replaced. He was noted to be markedly
agitated and required restraints.
Per ___, his son, he has had declining function with worsening
hyperactive delirium since a fall at a rehab facility earlier in
___. Over the past two to three weeks, he has become
agitated in the evenings and at times, has had personality
changes marked by disinhibition. At the beginning of ___,
he had some memory problems, but was ambulatory with walker and
conversational. His rehab course has been complicated by
acinetobacter UTI presenting with hypoactivity and somnolence.
He received some improvement with one day of levofloxacin but
his somnolence/hypoactivity returned and after a few days he
went to the ED for fever and encephalopathy.
In the ED, initial VS were:
99.6 Tmax: 103.8 80 117/47 24 95%
Imaging included: CXR, CT Head as below
Treatments received: 2L NS, Vancomycin, Cefepime, foley replaced
with continued bloody drainage, acetaminophen
On arrival to the floor, patient was alternately asleep and
agitated. When he was awake, he attempted to take off his mitts
and does not provide coherent thoughts. His son corroborated
that he has complained of discomfort with the foley catheter as
well as urinary retention over the past few days.
Past Medical History:
PAST ONCOLOGIC HISTORY:
(1) moderately differentiated colorectal cancer (T3 N0 M0) from
a right hemicolectomy on ___,
(2) radiofrquency ablation on ___ of a liver metastasis,
(3) admission to the neurosurgery service from ___ to
___,
(4) stereotaxic brain biopsy by Dr. ___ on ___,
(5) started on ___ minvolved-field cranial irradiation and
daily temozolomide, and
(6) started methylphenidate on ___,
(7) discontinued dexamethasone on ___,
(8) MRI on ___ showed slight interval disease progression
(9) Portacath placement on ___
(10) MRI/ASL on ___: stable centrally necrotic peripherally
enhancing right temporal mass measuring 6.3 x 3.3 centimeter.
Increased perfusion in the region of previously noted right
temporal mass anterolateral increased peripheral nodular
enhancement. No new lesions are seen.
PAST MEDICAL HISTORY:
T3N0 colon cancer
-s/p R-hemicolectomy
-s/p RFA to oligometastatic liver lesion
DMII
Hyperlipidemia
Glaucoma
Social History:
___
Family History:
Colon cancer in one brother
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: T 97.4 F, BP 122/80, HR 55, RR 22, O2 Sat 100%2LNC
GENERAL: Alternately agitated and lethargic, non-cooperative
with exam. Appears to be in discomfort; attempting to remove
mitts
HEENT: PERRL, No supraclavicular or cervical lymphadenopathy
CARDIAC: RRR, normal S1 & S2, no m/r/g
LUNG: clear to auscultation, no wheezes/rales/rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No cyanosis, clubbing, or edema
GU: Foley in place with red-tinged urine; no suprapubic
tenderness
PULSES: 2+DP pulses bilaterally
NEURO: arousable, oriented x0, non-coherent vocalizations,
moving extremities non-purposefully, withdraws from pain.
Brudzinski's sign and Kernig's sign negative,
SKIN: Warm and dry, without rashes
DISCHARGE PHYSICAL EXAM:
VS: RR 20
GENERAL: Lying in bed, somewhat restless, not coherent.
EXT: without restraints or mitts
GU: Foley in place as well as "decoy foley"
Pertinent Results:
ADMISSION LABS:
___ 10:20AM BLOOD WBC-6.7 RBC-3.73* Hgb-12.6* Hct-36.9*
MCV-99* MCH-33.8* MCHC-34.1 RDW-11.3 RDWSD-40.7 Plt ___
___ 10:20AM BLOOD ___ PTT-33.1 ___
___ 10:20AM BLOOD Plt ___
___ 10:20AM BLOOD Glucose-196* UreaN-29* Creat-1.3* Na-139
K-4.5 Cl-102 HCO3-24 AnGap-18
___ 10:20AM BLOOD ALT-22 AST-41* AlkPhos-99 TotBili-0.7
___ 10:20AM BLOOD Lipase-13
___ 10:20AM BLOOD cTropnT-0.01
___ 10:20AM BLOOD Albumin-3.2* Calcium-9.1 Phos-2.9 Mg-1.6
___ 10:34AM BLOOD Lactate-1.8
___ 11:25AM URINE Color-Red Appear-Cloudy Sp ___
___ 11:25AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 11:25AM URINE RBC->182* WBC-164* Bacteri-MOD Yeast-NONE
Epi-0
___ 11:25AM URINE WBC Clm-FEW Mucous-FEW
MICRO: ___ 11:25 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
Imaging:
___ CXR
IMPRESSION:
No acute cardiopulmonary process. Bilateral pleural plaques are
unchanged.
___ CT head
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Biopsy proven glioblastoma in the right temporal lobe is re-
demonstrated.
Adjacent edema appears stable to slightly improved as compared
to ___.
Discharge labs:
___ 05:05AM BLOOD WBC-6.1 RBC-3.89* Hgb-12.9* Hct-37.7*
MCV-97 MCH-33.2* MCHC-34.2 RDW-10.9 RDWSD-39.1 Plt ___
___ 04:14AM BLOOD Neuts-75.2* Lymphs-12.7* Monos-10.5
Eos-0.9* Baso-0.2 Im ___ AbsNeut-4.78 AbsLymp-0.81*
AbsMono-0.67 AbsEos-0.06 AbsBaso-0.01
___ 05:05AM BLOOD Glucose-99 UreaN-16 Creat-0.9 Na-142
K-4.0 Cl-106 HCO3-28 AnGap-12
___ 05:05AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 2 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. Famotidine 20 mg PO BID
4. LeVETiracetam 500 mg PO BID
5. MethylPHENIDATE (Ritalin) 15 mg PO DAILY
6. Sertraline 25 mg PO DAILY
7. Tamsulosin 0.8 mg PO QHS
8. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
9. Vitamin D 800 UNIT PO DAILY
10. Acetaminophen 1000 mg PO Q6H:PRN pain
11. Calcium Carbonate 500 mg PO TID
12. Milk of Magnesia 30 mL PO DAILY PRN not defined in records
13. multivitamin 1 tablet oral DAILY
Discharge Medications:
1. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
2. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN agitation
RX *olanzapine 5 mg 1 tablet(s) by mouth twice daily Disp #*10
Tablet Refills:*0
3. OLANZapine (Disintegrating Tablet) 10 mg PO QHS
RX *olanzapine 10 mg 1 tablet(s) by mouth bedtime Disp #*5
Tablet Refills:*0
4. Lorazepam 0.5-1 mg SL Q4H:PRN seizure/agitation
Please note this medication is very sedating for the patient.
5. Bisacodyl 10 mg PR QHS:PRN constipation
6. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q2H:PRN
pain/shortness of breath
7. Acetaminophen 650 mg PR Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Encephalopathy secondary to UTI
Glioblastoma
Dementia
Malnutrition
___
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with AMS, hx of glioblastoma // eval for bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 17.3 cm; CTDIvol = 46.4 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head dated ___, and MR head dated ___.
FINDINGS:
The patient has biopsy proven glioblastoma, which is better evaluated on prior
MRI. The corresponding area of edema in the right anterior temporal lobe,
extending into the right external capsule and posterior limb of the internal
capsule appears grossly stable to slightly improved as compared to ___. There is no evidence of hemorrhage. As before, there is mild local
mass effect, without evidence of midline shift or impending herniation.
Prominent ventricles and sulci are consistent with age-related involutional
change. Periventricular white matter hypodensities are consistent with
sequela of chronic small vessel ischemic disease.
There is a burr hole in the right temporal bone. No fracture is identified.
The visualized paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The globes are unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Biopsy proven glioblastoma in the right temporal lobe is re- demonstrated.
Adjacent edema appears stable to slightly improved as compared to ___.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ male with a history of glioblastoma and colon cancer,
presenting for evaluation of altered mental status. T-max 103.8 degrees.
Normal WBC.
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph ___ right shoulder radiograph ___
FINDINGS:
There is no significant interval change compared to the prior radiograph on ___. Again noted are extensive bilateral pleural plaques, which
limits the evaluation for subtle parenchymal abnormalities. No substantial
pleural effusion. No pneumothorax. Heart size is top-normal. Collapse of
the right humeral head and adjacent heterotopic calcification is unchanged
from the reference radiograph on ___.
A right sided Port-A-Cath is unchanged in position, terminating at the level
of the cavoatrial junction.
IMPRESSION:
No acute cardiopulmonary process. Bilateral pleural plaques are unchanged.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with ALTERED MENTAL STATUS , FEVER, UNSPECIFIED
temperature: 99.6
heartrate: 80.0
resprate: 24.0
o2sat: 95.0
sbp: 117.0
dbp: 47.0
level of pain: c
level of acuity: 2.0 | ___ is a ___ man with history of colon
cancer s/p R hemicolectomy and RFA of liver met, now with
glioblastoma on treatment with bevacizumab presented with fever,
___, and AMS concerning for UTI.
1. Encephalopathy secondary to urosepsis: Alertness has been
improving, however still oriented x 0. This is likely closer to
the patient's recent baseline secondary to dementia and
glioblastoma. Patient initially presented with fever, urinary
retention, and altered mental status likely secondary to
continued issues with foley catheter/urinary retention. There
may be element of post-renal obstruction with blood
clots/bleeding leading to ___ and decreased excretion of drug
metabolites. Appears to have failed outpatient levofloxacin
therapy for previous acinetobacter UTI.
-Urine culture revealed levofloxacin resistant staph.
-Received 6 days of antibiotics, transitioned to comfort-focused
care at discharge.
-Blood Cx NGTD
-Failed voiding trial so foley was re-inserted.
2. Malnutrition: Given delirium, patient with very minimal PO
intake. Occasionally can tolerate ice cream and has been
swallowing meds with this. Despite aspiration risk, feeding for
comfort is acceptable.
3. ___: Improved. Likely elements of post-renal given urinary
retention and blood clot obstructing foley and pre-renal from
decreased PO intake in setting of encephalopathy. Improved with
foley and IVFs. Baseline 0.9-1.0
4. Agitation: Initially required restraints during acute
encephalopathic process from pulling foley. His foley was
removed with plans for straight cath to prevent him from needing
restraints to keep him from pulling his foley, but he failed
voiding trial and foley reinserted. He was continued on Zydis 10
mg QHS for agitation; additional Zydis available PRN.
Benzodiazepines were avoided as they were extremely sedating to
him.
5. Glioblastoma: S/p chemoradiation and recent bevacizumab
treatment. Decision made to no longer pursue treatment and focus
on comfort, as his overall prognosis is poor.
-If seizures, may use SL Ativan as abortive therapy |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lovenox
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH vascular dementia, h/o ICH, NPH s/p shunt, PE with IVC
not on anticoagulation, CAD s/p CABG and LAD stent, AFib (not on
coumadin d/t falls), complete heart block s/p pacemaker, BIBA
for AMS. Per ED history taken from daughter, at baseline uses a
walker and is AOx1. For the past ___ he has had increased
agitation and combativeness requiring more seroquel (120mg total
past 24hrs). Found to be more somnolent, nonconversant and
lethargic today, with new twitching. Over past few weeks patient
also noted to be bruising more, ASA81 was discontinued 3 days
ago. No sources of bleeding, no diarrhea or fevers noted.
Daughter suspects possible UTI, also noted new cough over past
few days. UCx recently checked ___ with fecal contaminants.
In the ED, initial vitals were 97.6 60 132/86 16 98%RA. Renal
was consulted for renal failure and hyperkalemia, dialysis was
deferred with medical management recommended. While being
evaluated, he was found to be hypotensive at 2200 to 76/38.
Review of his ED BPs showed that his SBP fell over the course of
an hour. He was given 1L IVF, with vanc/cef also started; his BP
recovered over another hour to 103/37. He was also given 10mg IV
dexamethasone. For acute hypotension, he was admitted to the
ICU.
Other notable ED findings included: Hct 25.1 (___) -> 22.3
___ Cr 2.6 -> 2.9; K 4.7 -> 6.4 -> 5.3 after insulin and
dextrose with kayexelate and calcium gluconate also given; Na
134 -> 126 -> 129 (though in the high 120's previously). Lactate
was unremarkable at 0.8, UA unremarkable. No coagulation
abnormalities. CXR was obtained. EKG per ED read was paced w/o
peaked T waves.
In the unit, the daughter was concerned for overdosing his
seroquel, but believes that his fluid has been appropriately
managed given h/o R heart failure. Received torsemide at 3a
yesterday morning along with his seroquel. The daughter confirms
that the patient has been diffusely twitching since yesterday.
The patient is unable to give further history.
Review of systems:
(+) Per HPI
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: LAD CABG done at ___ in ?___
-PERCUTANEOUS CORONARY INTERVENTIONS: LAD stents x3 in ___
-PACING/ICD: CHB s/p ___ ___ pacemaker, ___
___ 5826 that was implanted (generator change) on ___
-AF: Not anticoagulated due to multiple falls and ICH
-CHF, preserved EF
3. OTHER PAST MEDICAL HISTORY:
-Pulmonary embolus s/p IVC filter ___
-NSVT
-AAA s/p emergent repair ___
-Carotid disease s/p CVA
Vascular dementia s/p multiple intracranial insults
-Small intraventricular hemorrhage s/p fall ___ left occipital SDH
-Possible TIA ___
-CKD
-Adenocarcinoma, T3 NO resected ___ (ileocolectomy)
-BPH
Social History:
___
Family History:
Per record:
Mother CHF, rheumatoid arthritis; Father died in accident age
___, 3 brothers with "heart disease"; ___ colonic polyps
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===================================
Vitals: 99.7 60 114/83 98%RA
General: Arousable, responds to name and withdraws from stimuli,
otherwise not oriented, conversant, NAD, diffuse dyssynchronous
twitches
HEENT: NCAT, EOMI, sclera anicteric, conjunctiva w/o pallor, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: II/VI SEM LUSB, otherwise no r/g/m, nl S1 S2, regular rhythm
Abdomen: Distended with minor tympany to percussion, non-tender,
bowel sounds present
GU: foley in place draining yellow urine
Ext: warm, well perfused, 2+ pulses b/l, no edema
PHYSICAL EXAM ON DISCHARGE:
===================================
Vitals: Tm 98.0 Tc97.4, BP 133/65(133-162/65-76), HR 100(59-100)
RR 20, SpO2 98%RA
General: Arousable, responds to name and withdraws from stimuli,
otherwise not oriented, minimal talking, follow commands
appropriately, does not answer questions appropriately, NAD,
diffuse dyssynchronous twitches
HEENT: NCAT, EOMI, sclera anicteric, conjunctiva w/o pallor, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Right lower lobe rhochi, no wheezes, rales
CV: II/VI SEM LUSB, otherwise no r/g/m, nl S1 S2, regular rhythm
Abdomen: Distended with minor tympany to percussion, non-tender,
bowel sounds present
GU: foley in place draining yellow urine
Ext: warm, well perfused, 2+ pulses b/l, no edema
Neuro: A&Ox1(only oriented to name), moving all four extremities
Pertinent Results:
LABS ON ADMISSION:
========================================
___ 07:25PM BLOOD WBC-5.8 RBC-2.23* Hgb-7.3* Hct-22.3*
MCV-100* MCH-32.8* MCHC-32.7 RDW-15.9* Plt ___
___ 07:25PM BLOOD Neuts-81.2* Lymphs-12.6* Monos-5.6
Eos-0.5 Baso-0.2
___ 07:25PM BLOOD ___ PTT-35.8 ___
___ 07:25PM BLOOD Glucose-85 UreaN-98* Creat-2.9* Na-126*
K-6.4* Cl-93* HCO3-27 AnGap-12
___ 02:37AM BLOOD CK-MB-6 cTropnT-0.06*
___ 08:15AM BLOOD CK-MB-6 cTropnT-0.05*
___ 04:10PM BLOOD CK-MB-6 cTropnT-0.06*
___ 07:25PM BLOOD Calcium-9.2 Phos-4.7* Mg-2.0
___ 07:32PM BLOOD Lactate-0.8 K-6.1*
LABS ON DISCHARGE:
========================================
___ 06:10AM BLOOD WBC-6.5 RBC-2.62* Hgb-8.4* Hct-26.4*
MCV-101* MCH-32.1* MCHC-31.8 RDW-16.3* Plt ___
___ 06:10AM BLOOD Glucose-97 UreaN-49* Creat-1.9* Na-146*
K-4.0 Cl-112* HCO3-27 AnGap-11
___ 06:15AM BLOOD ALT-31 AST-29 AlkPhos-127 TotBili-0.3
___ 06:10AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.7
Additional Relevant Labs:
___ 08:15AM BLOOD Lipase-26
___ 04:10PM BLOOD CK-MB-6 cTropnT-0.06*
___ 08:15AM BLOOD CK-MB-6 cTropnT-0.05*
___ 02:37AM BLOOD CK-MB-6 cTropnT-0.06*
___ 05:50AM BLOOD Albumin-3.1* Mg-2.0
___ 04:10PM BLOOD calTIBC-283 VitB12-951* Folate-GREATER TH
Ferritn-148 TRF-218
___ 05:50AM BLOOD Hapto-195
___ 06:45AM BLOOD TSH-4.5*
___ 12:45PM BLOOD Free T4-1.2
___ 08:15AM BLOOD Cortsol-35.6*
___ 06:10AM BLOOD Vanco-17.4
___ 05:50AM BLOOD Vanco-16.3
___ 02:21AM BLOOD Vanco-8.5*
___ 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:10PM BLOOD METHYLMALONIC ACID- ___ H
MICRO:
========================================
___ Blood cultures x2 Negative
___ Urine culture Negative
___ Urine legionella Ag Negative
IMAGING:
========================================
-CT HEAD W/O CONTRAST Study Date of ___:
IMPRESSION:
Motion limited exam; but within that limitation no evidence of
acute
intracranial process.
-CHEST (SINGLE VIEW) Study Date of ___:
IMPRESSION: No definite acute cardiopulmonary process.
Persistent left
basilar opacity likely represents persistent loculated effusion.
IMPRESSION:
1. No acute abnormality detected in the abdomen and pelvis
within the
limitations of a non-contrast study.
2. Small volume ascites in the abdomen in the setting of VP
shunt.
3. Diverticulosis without diverticulitis.
4. Stable postoperative changes following right colectomy.
-CT CHEST W/O CONTRAST Study Date of ___:
IMPRESSION:
1. New right lower lobe and scattered right upper lobe opacities
most
consistent with aspiration pneumonia. Persistent left lower lobe
atelectasis.
2. Large loculated left pleural effusion with new convexity to
the anterior margin; consider indolent infection. Small right
pleural effusion.
3. Pulmonary hypertension and chronically large thoracic aorta.
4. Dense coronary artery and mild aortic valvular
calcifications.
CT ABD/PELVIS ___:
IMPRESSION:
1. No acute abnormality detected in the abdomen and pelvis
within the
limitations of a non-contrast study.
2. Small volume ascites in the abdomen in the setting of VP
shunt.
3. Diverticulosis without diverticulitis.
4. Stable postoperative changes following right colectomy.
Video Speech+Swallow Study (___):
IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Lisinopril 2.5 mg PO QAM
5. Metoprolol Succinate ___ 25 mg PO HS
6. Pantoprazole 40 mg PO Q24H
7. Torsemide 30 mg PO DAILY
8. QUEtiapine Fumarate 25 mg PO TID
9. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
10. Docusate Sodium (Liquid) 100 mg PO DAILY:PRN constipation
11. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
12. Ferrous Sulfate 325 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Senna 1 TAB PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Docusate Sodium (Liquid) 100 mg PO DAILY:PRN constipation
3. Ferrous Sulfate 325 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Mirtazapine 7.5 mg PO HS
6. Multivitamins W/minerals 1 TAB PO DAILY
7. QUEtiapine Fumarate 12.5 mg PO BID:PRN agitation
8. Senna 1 TAB PO BID
9. Acetaminophen 650 mg PO QHS
10. Finasteride 5 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Cyanocobalamin ___ mcg PO DAILY Duration: 2 Weeks
13. Metoprolol Succinate ___ 25 mg PO HS
Discharge Disposition:
Expired
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Aspiration Pneumonia, Acute on Chronic Kidney
Failure
Secondary Diagnosis: Anemia, Diastolic Congestive Heart Failure,
Vascular Dementia, Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___
HISTORY: ___ male with altered mental status.
COMPARISON: Chest xray ___. CT chest ___
FINDINGS: Two supine views of the chest. There is persistent left basilar
opacity, which silhouettes the hemidiaphragm. At CT on ___
this was a loculated pleural collection, which it still may be. The lungs
otherwise are clear. Left chest wall triple-lead pacing device is unchanged.
Postoperative changes of median sternotomy wires and mediastinal clips are
again noted. No acute osseous abnormality detected. VP shunt catheter
projects over the right chest wall. Coronary artery stent is also noted.
IMPRESSION: No definite acute cardiopulmonary process. Persistent left
basilar opacity likely represents persistent loculated effusion.
Radiology Report
HISTORY: Altered mental status. Evaluate for bleed
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Multiplanar reformatted images in
coronal and sagittal axes and thin-section bone algorithm reconstructed images
were acquired.
DLP: 2308 mGy-cm
COMPARISON: Nonenhanced head CT from ___
FINDINGS:
The exam is limited by motion despite attempts to repeat sequences. Within
that limitation, there is no evidence of large hemorrhage, edema, mass effect
or acute large vascular territory infarction. There is unchanged left
occipital encephalomalacia with ex vacuo dilatation of the occipital horn of
the left lateral ventricle. The right frontal approach ventricular shunt
catheter is seen in unchanged position with the tip in the region of the ___
ventricle. Prominent ventricles and sulci suggest age-related atrophy.
Periventricular white matter hypodensities are nonspecific but likely
represent sequelae of chronic small vessel ischemic disease. The basal
cisterns appear patent and there is preservation of gray-white
differentiation.
No acute fracture is identified. The visualized paranasal sinuses, right
mastoid air cells and middle ear cavities are clear. Partially opacified left
mastoids. Old left lamina papyracea defect noted. Atherosclerotic mural
calcification of the internal carotid arteries is noted. The globes are
unremarkable.
IMPRESSION:
Motion limited exam; but within that limitation no evidence of acute
intracranial process.
Radiology Report
HISTORY: Altered mental status, bilious vomiting and aspiration. Evaluate
recent NG tube placement.
TECHNIQUE: Single, AP, portable view of the chest was obtained with the
patient in an upright position.
COMPARISON: Comparison is made to radiographs dated ___, findings
CT thorax dated ___.
FINDINGS:
Contrary to the stated indication, there is no nasogastric tube identified.
As compared to the prior examination, there has been a mild interval increase
in the opacification of the right middle lobe and right lower lobe, concerning
for potential aspiration versus infectious etiology. Redemonstrated is a
persistent, left basilar opacity which obscures the left hemidiaphragm, and
likely correlates with the patient's known loculated effusion. There is no
evidence of pneumothorax or overt pulmonary edema identified. Stable, mild
cardiomegaly is noted. A triple lead pacer device is seen overlying the left
chest, with its corresponding leads unchanged in position. The patient is
postoperative with median sternotomy wires noted to be well-aligned. There is
a VP shunt catheter again seen projecting over the right chest wall.
IMPRESSION:
1. No radiographic evidence for NG tube placement.
2. Increasing opacification of the right middle and right lower lobes,
concerning for aspiration versus pneumonia.
3. Stable, loculated left pleural effusion .
Radiology Report
INDICATION: Distended abdomen, aspiration event after bilious vomiting.
Evaluate for pneumonitis or pneumonia.
COMPARISON: CT torso, ___.
TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen
and pelvis without IV or oral contrast. Multiplanar axial, coronal and
sagittal images were generated.
TOTAL BODY DLP: 2512 mGy-cm
FINDINGS:
Evaluation of the left abdomen is limited due to significant streak artifact
from the arms being down by the patient's side.
CT ABDOMEN WITHOUT CONTRAST: Within the limitations of a non-contrast
technique, the liver is normal without focal lesions, intra- or extra-hepatic
biliary duct dilation. Spleen is homogenous. The pancreas is atrophic with
fatty replacement, but otherwise normal. The adrenal glands are unremarkable.
The kidneys are atrophic. A 3cm right lower pole cyst is stable. There is no
hydronephrosis or perinephric abnormality. There is a chronic calcification of
the left anterior renal fascia.
The stomach, duodenum and small bowel are within normal limits, without
evidence of obstruction. The colon shows scattered diverticula, most
prominently in the sigmoid without diverticulitis. There are postoperative
changes in the right colon following right colectomy.
There is small volume ascites, most prominently about the liver around the VP
shunt. The abdominal aorta and iliac vessels are heavily calcified. There
are also calcifications at the origins of the celiac, SMA, renal arteries.
The abdominal aortic caliber is normal. There is an IVC filter in the
infrarenal inferior vena cava. There is no mesenteric or retroperitoneal
lymphadenopathy, and no abdominal wall hernia.
CT PELVIS WITHOUT CONTRAST: The bladder is drained by a Foley catheter. The
rectum, prostate and seminal vesicles are normal. There is no pelvic wall or
inguinal lymphadenopathy, and no free fluid. There is a small left
fat-containing inguinal hernia.
OSSEOUS STRUCTURES: There are no concerning blastic or lytic lesions. There
are mild degenerative changes most prominently in the lumbar spine with disc
vacuum phenomenon at L5-S1 and small osteophytes.
IMPRESSION:
1. No acute abnormality detected in the abdomen and pelvis within the
limitations of a non-contrast study.
2. Small volume ascites in the abdomen in the setting of VP shunt.
3. Diverticulosis without diverticulitis.
4. Stable postoperative changes following right colectomy.
Please note that the chest will be reported separately by the thoracic imaging
section.
Radiology Report
INDICATION: History of colon cancer with an episode of bilious vomiting and
likely aspiration. Evaluate for pneumonia.
COMPARISONS: CT of the torso from ___.
TECHNIQUE: MDCT axial imaging was obtained through the chest without the
administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
FINDINGS: The thyroid gland is unremarkable. There are no enlarged
supraclavicular, axillary, mediastinal or hilar lymph nodes. There are dense
coronary artery and aortic annular calcifications. A left chest wall
pacemaker sends leads to the right atrium and right ventricle. There is no
pericardial effusion. The aorta is generally enlarged but not focally
aneurysmal, 4.1cm in the ascending aorta, and 3.8cm in the descending. The
main pulmonary artery is enlarged, diameter 4.2 cm. The large, loculated high
density left pleural effusion with associated pleural thickening is similar in
size to ___ but now has a more convex anterior border which might
be due to active infection. Extensive, new parenchymal opacities in the right
lower lobe, and scattered opacities in the right upper lobe are most likely
due to aspiration pneumonia. Left lower lobe atelectasis is unchanged.
Evaluation of fine details of the lungs is limited due to respiratory motion.
The previously mentioned spiculated nodule in the left lower lobe is not
clearly identified due to adjacent consolidation. A small right pleural
effusion is present. Evaluation of the airways is also limited due to motion,
but they remain grossly patent.
This study is not tailored for evaluation of subdiaphragmatic structures.
Please see dedicated CT abdomen report for further details.
There are no bony lesions of concern for metastatic disease.
IMPRESSION:
1. New right lower lobe and scattered right upper lobe opacities most
consistent with aspiration pneumonia. Persistent left lower lobe atelectasis.
2. Large loculated left pleural effusion with new convexity to the anterior
margin; consider indolent infection. Small right pleural effusion.
3. Pulmonary hypertension and chronically large thoracic aorta.
4. Dense coronary artery and mild aortic valvular calcifications.
Please see report of abdomen CT for further details.
Radiology Report
AP CHEST, 3:51 A.M., ___
HISTORY: An ___ man with worsening hypoxia. Is there evidence of
aspiration.
IMPRESSION: AP chest compared to ___, 4:26 a.m.:
New large area of consolidation in the right lower lobe is most likely acute
pneumonia. Moderate cardiomegaly and left lower lobe atelectasis persist.
Transvenous right atrial and ventricular pacer leads are in standard
placements. Pulmonary vascular engorgement has decreased, indicating this is
not asymmetric pulmonary edema.
Radiology Report
HISTORY: PICC line placement.
TECHNIQUE: Single, AP, portable view of the chest was obtained with the
patient in a supine position.
COMPARISON: Comparison is made to radiographs dated ___, and CT
chest dated ___.
FINDINGS:
There has been interval placement of a right-sided PICC line which terminates
in the mid-lower SVC. There is no pneumothorax. Lung volumes are decreased.
As compared with the prior examination, the there has been mild interval
improvement in the right lower lobe consolidation. The patient is status post
CABG with median sternotomy wires noted well aligned. A pacemaker is seen
with leads terminating in the right atrium and right ventricle. There is
stable moderate cardiomegaly.
IMPRESSION:
Right PICC line terminating in the mid-lower SVC.
Findings were conveyed by Dr. ___ to ___ via telephone at 15:25 on ___, 5 min after discovery.
Radiology Report
HISTORY: PICC placement.
FINDINGS: The right subclavian PICC line has been removed. No evidence of
pneumothorax. There is continued opacification at the right base that has
somewhat decreased. Retrocardiac opacification is consistent with substantial
volume loss in the left lower lobe with pleural effusion.
Radiology Report
HISTORY: Aspiration pneumonia. Assess for aspiration.
COMPARISON: None.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
FINDINGS: Barium passes freely through the oropharynx and esophagus without
evidence of obstruction. There was no gross aspiration or penetration. For
details, please refer to the speech and swallow division note in OMR.
IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with HYPERKALEMIA, SEMICOMA/STUPOR, HYPOTENSION NOS, HYPOSMOLALITY/HYPONATREMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED, ANEMIA NEC
temperature: 97.6
heartrate: 60.0
resprate: 16.0
o2sat: 98.0
sbp: 132.0
dbp: 86.0
level of pain: 13
level of acuity: 2.0 | PRIMARY REASON FOR HOSPITALIZATION:
================================================
Mr. ___ is an ___ with a PMHx of vascular dementia, h/o
ICH, NPH s/p shunt, PE with IVC not on anticoagulation, CAD s/p
CABG and LAD stent, AFib (not on coumadin d/t falls), complete
heart block s/p pacemaker, BIBA for AMS. Found to have ___,
hyperkalemia, and developed hypotension in the ED. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
morphine
Attending: ___.
Chief Complaint:
Metastatic SCC to cervical spine causing stenosis/dislocation
Major Surgical or Invasive Procedure:
1. Posterior fusion craniocervical.
2. Posterior fusion C1-C2.
3. Posterior fusion C2-C3.
4. Laminectomy, biopsy, intraspinal lesion, extradural, C2.
5. Posterior instrumentation occiput, C1, C2, C3.
6. Open treatment, posterior, cervical fracture.
7. Allograft, for fusion.
8. Wound vacuum-assisted closure application and treatment.
History of Present Illness:
___ yo M with metastatic squamous cell carcinoma to skull base
and upper cervical spine. He has extraordinary pain, cervical
settling, causing stenosis, and difficulty swallowing secretions
because of abnormal alignment and dislocation. Because of the
severity of the illness, the natural history of this disease,
and with the goal of preserving his spinal cord and restoring
the stability of his craniocervical junction, he elected to
undergo surgical treatment.
Past Medical History:
PAST MEDICAL HISTORY:
1. Squamous cell carcinoma of the left tonsil, HPV+, induction
___ x3 cycles ___ - ___, then
concurrent chemoXRT with carboplatin/paclitaxel ___ to
___.
2. Comminuted, traumatic fracture to right ___ digit in ___.
3. ___ nerve palsy since childhood.
4. H&N cancer-associated dermatomyositis.
Social History:
___
Family History:
Father alive at ___, has CAD, first CABG at ___, also with
prostate cancer. Mother alive at ___ with prior DVT.
Grandmother with rheumatoid arthritis. Denies family history of
esophageal, gastric, colon, breast, ovarian, or lung cancer.
Physical Exam:
AVSS
Alert and Oriented, NAD, uncomfortable in C-collar, poor
cervical alignment
BUE: SILT C5-T1 dermatomal distributions
BUE: ___ Del/Tri/Bic/WE/WF/FF/IO
BUE: tone normal, negative ___, 2+ symmetric DTR
bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: ___ ___
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Pertinent Results:
___ 01:32PM BLOOD WBC-9.7 RBC-4.47* Hgb-12.6* Hct-37.7*
MCV-84 MCH-28.1 MCHC-33.3 RDW-14.1 Plt ___
___ 01:32PM BLOOD Glucose-183* UreaN-12 Creat-0.7 Na-133
K-5.1 Cl-96 HCO3-28 AnGap-14
___ 01:32PM BLOOD Calcium-8.8 Phos-4.0 Mg-2.2
Medications on Admission:
Levothyroxine
Oxycodone
Remeron
Reglan
Lorazepam
Lansoprazole
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Senna 1 TAB PO BID:PRN Constipation
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Acetaminophen 650 mg PO Q6H
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 1 mg/mL ___ Liquid(s) G tube Q3HRS Disp #*3
Bottle Refills:*0
7. OxycoDONE Liquid 10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 10 mL G tube Q4HRS Disp #*3 Bottle
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. C1 fracture.
2. C2 fracture.
3. Occipital fracture.
4. Infiltrative lesion occiput, C1, C2.
5. Metastatic disease consistent with squamous cell
carcinoma, tonsillar.
6. Neck pain.
7. Spinal cord stenosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ man with C1-C2 instability, evaluate C-spine.
TECHNIQUE: Helical axial MDCT sections were obtained from the skull base
through the T2 level. Reformatted images in sagittal and coronal axes were
obtained.
DLP: 1885 mGy-cm
CTDIvol: 82.5 mGy
COMPARISON: MRI of the C-spine from ___.
FINDINGS:
Again seen is infiltrative bony destruction involving the occipital condyle
and lateral mass of C1 on the right. Sclerotic and erosive changes seen along
the odontoid process are unchanged. Widening of the atlantodental interval
upto 7 mm is relatively unchanged; however, upward migration of the odontoid
process is more prominant on this study. These findings are concerning for
atlantoaxial and the craniocervical junction instability.
Multilevel degenerative changes are relatively unchanged compared to the prior
study. No acute compression fracture is identified. The remainder of the
cervical spine shows normal alignment.
Several enlarged level 2 nodes are again noted that are not well characterized
on this study.
IMPRESSION:
1. Atlntoaxial and craniocervical instability caused by destruction of the
right occipital condyle and mass of C1 with widening of the atlantoaxial
interval is re-demonstrated. Slightly increased upward migration of the dens
is noted. A predominantly lytic process favors metastatic disease, however,
osteonecrosis remains a possible underlying etiology.
2. Several potentially enlarged lymph nodes are again seen at level 2, but are
not well characterized on this noncontrast study. Correlation with PET-CT is
advised if clinically warranted.
NOTIFICATION:
Findings were entered into Critical Radiology Results dashboard at 5pm on
___ by Dr. ___, as Dr. ___ was not available by page.
Radiology Report
CERVICAL SPINE RADIOGRAPH PERFORMED ON ___
COMPARISON: CT of the cervical spine from same day.
CLINICAL HISTORY: C-spine instability with new metastatic cervical lesions
present, preoperative planning.
FINDINGS: Lateral, swimmer's lateral and AP views of the cervical spine were
provided. The destructive cervical spine lesion involving C1 is not clearly
visualized. There is reversal of cervical lordosis, with alignment preserved
from C2 inferiorly to T1. Prevertebral soft tissues appear prominent, though
this is better assessed on the same day CT.
Radiology Report
HISTORY: Occipital-cervical instability. Pre assessment for occiput fusion.
TECHNIQUE: Axial helical MDCT images were obtained from the level of the
temporal bones to the level of the inferior endplate of T3. Multiplanar
reformatted images were generated the sit sagittal and coronal planes.
DLP: 798.11 mGy-cm.
COMPARISON: CT-spine ___, MR spine from ___.
FINDINGS:
The study is severely limited by patient positioning. Findings are not
significantly changed since previous exam dated ___.
Again seen is infiltrative bony destruction involving the occipital condyles
and lateral masses of C1 on the right side. Subchondral cystic and sclerotic
changes in the odontoid process are unchanged. Again seen is the widening of
the atlantodental interval as well as mild invagination of the odontoid
process superiorly into the foramen magnum unchanged from prior exam and
concerning for atlantoaxial instability.
Multilevel degenerative changes are unchanged compared to the prior study. No
acute compression fracture is identified. The remainder of the cervical spine
shows normal alignment. Several enlarged cervical lymph nodes are noted that
are not well characterized on this exam.
IMPRESSION:
Unchanged exam from prior study, showing atlantoaxial and craniocervical
instability caused by erosive destruction of the right occipital condyle and
masses of C1, with widening of the atlantodental interval and mild
invagination of the odontoid process into the foramen magnum.
Radiology Report
HISTORY: New dizziness and previous C-spine CT showing atlantoaxial and
craniocervical instability.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformations were prepared.
COMPARISON: ___.
FINDINGS:
The examination is markedly limited due to patient positioning. Within this
limitation, no acute intracranial hemorrhage, edema, mass effect or major
vascular territorial infarction is identified. There is no shift of normally
midline structures. The ventricles and sulci are mildly prominent consistent
with age-related involutional changes. Gray-white matter differentiation
appears preserved. The imaged paranasal sinuses and mastoid air cells partial
opacification of the left mastoid air cells.
Infiltrative bony destruction involving the right occipital condyle and
lateral mass of C1 is re-demonstrated with persistent widening of the
atlantodental interval measuring 7 mm with accompanying mild lytic/erosive
changes within the odontoid process itself along with invagination of the
odontoid process into foramen magnum and depression of the right occipital
condyle into the eroded lateral mass.
IMPRESSION:
No acute intracranial process with unchanged appearance of erosive destruction
of the right occipital condyle and lateral mass of C1 with accompanying
appearance of atlantoaxial and craniocervical instability.
Radiology Report
STUDY: Two intraoperative fluoroscopic images of the cervical spine,
___.
COMPARISON: CT of the head and cervical spine, ___.
INDICATION: Status post posterior occiput to C3 fusion.
FINDINGS AND IMPRESSION: Multiple surgical instruments are noted posterior to
the upper cervical spine. Status post occiput to C3 posterior fusion. The
hardware appears intact. Endotracheal tube and temperature probe present.
Please see operative report for further details.
Radiology Report
CERVICAL SPINE RADIOGRAPHS
HISTORY: Status post occipitocervical fusion.
COMPARISONS: Intraoperative radiographs from ___ as well as
recent cervical spine radiographs from ___ and CT from ___.
TECHNIQUE: Cervical spine, three views.
FINDINGS: The patient is status post occipitocervical fusion. The fusion
hardware appears intact, fixating the occiput with the posterior elements of
C1 and C2. Moderate cervical spondylosis along the mid-to-lower cervical
spine appears unchanged. Contours of the upper C2 vertebral body are
indistinct, corresponding to a known lesion depicted better on the prior CT.
The alignment of the cervical spine appears unchanged with reversal of the
usual expected lordotic curvature. Anticipated post-operative gas is present
in soft tissues overlying the operative site and a bone graft material was
apparently placed as well.
IMPRESSION: Unremarkable post-operative appearance.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: NECK SWELLING/PAIN
Diagnosed with PATHOLOGIC FX VERTEBRAE, SECONDARY MALIG NEO BONE
temperature: 98.7
heartrate: 102.0
resprate: 18.0
o2sat: 99.0
sbp: 124.0
dbp: 97.0
level of pain: 6
level of acuity: 2.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was initially
transferred to the TSICU and remained intubated for airway
protection given difficulty handling secretions. He was weaned
off the vent without difficulty and extubated on POD#1 and
subsequently transferred to the floor. TEDs/pnemoboots were used
for postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Nutrition saw the patient to
make recommendations for tube feeds, which were advanced to goal
and tolerated well by the patient. The patient was transitioned
to pain medication via G-tube. Foley was removed on POD#2.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating tube feeds. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
IV dye
Attending: ___.
Chief Complaint:
fevers, possible pancreatic mass
Major Surgical or Invasive Procedure:
ERCP
EUS
History of Present Illness:
Mr. ___ is an ___ yo man with a h/o HTN, depression, ?
dementia, admitted to the hospital from the ED with fevers,
choledocolithiasis with sludge and intra and extra hepatic
biliary ductal dilitation seen on U/S. He has a h/o recent
diagnosis of fullness to the pancreatic head, ? malignancy vs
inflammation in the setting of ___ lb weight loss over the
past year. One year ago he was thought to have developed Celiac
disease, but the diagnosis is not secure. Numerous notes in OMR
from Drs ___ are reviewed and provide
detail.
He is a poor historian but his friend ___ is a terrific
historian who reports that he's had fevers for over a week, was
seen in urgent care in ___ ~ 1 week ago, T102 at home, took
Tylenol and then by the time he got to Urgent Care, T99, so he
was sent home. He normally lives by himself but on weekends
stays with ___. She says that she noted he was febrile, not
able to care for himself/lethargic and she summoned EMS.
On arrival to the ED, he was febrile to 102, HR 84 BP 130/59
RR 20 96% RA. He was treated with IV Pip/tazobactam at 0700
and acetaminophen. 12 lead EKG showed no ischemic changes but
did reveal Atrial Fibrillation. He is now admitted to the ___
campus for ERCP and further evaluation and management.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
1) ? Celiac disease x ___ yr
2) Hypertension - no longer on HCTZ
3) Glaucoma
4) BPH
5) hypothyroidism
6) compression fracture of thoracic spine
7) Depression
8) h/o syncope in ___ attributed to hypovolemia
Social History:
No tobacco since age ___. No drug use, occaisional EtoH. Lives
alone in ___. Volunteers for the ___
___. Previously worked in ___. No children.
FUNCTIONAL STATUS:
Resides alone, still drives a car. Friend ___ NOT
drive with him. He lives with ___ on weekends per her
report. He says he mostly lives with her all the time.
ADVANCE DIRECTIVES:
HCP: patient identifies ___ (H) ___ (C)
___ as his HCP. She is not thrilled with this. She
tells him that his family ought to be involved and provides
numerous names and phone #'s.
Brother-in-law: ___ ___
Nephew: ___: ___
Niece: ___: # not known by ___
CODE STATUS: FULL for now; patient has never considered this.
Seems to have limited comprehension of discussion
Family History:
FAMILY HISTORY: Mother died ___, Father died ___ MI. No fhx of
cancer.
Physical Exam:
Admission:
PE: Elderly man, looks stated age, lying in bed, NAD
VS: 98.8 149/70 90 16
HEENT: Icteric, dry mucous membranes
NECK: Supple, no JVP seen
CV: Irreg rate, distant
LUNGS: CTA bilaterally
ABD: soft/nt/nd, no palp masses
EXT: Warm, no edema
NEURO: Alert, speech and language intact. Poor historian, does
not remember what Dr. ___ told him last month; Thinks
he just needs a medicine to make him better. Full neuro exam
not performed as patient in holding area ready to go to ERCP;
good attention
Psych: Pleasant, cheerful
Discharge:
Afebrile 161/65 p51 R18 98RA
Non-toxic, comfortable, pleasant.
RESP: CTA B
CV: RRR.
Abd: +BS. soft, nt/nd.
Ext: no edema
Pertinent Results:
ECG Study Date of ___
Irregular rhythm which appears to be a combination of occasional
sinus beats with junctional beats with retrograde P waves along
with probably some ectopic atrial beats. Left axis deviation,
likely due to left anterior fascicular block. Compared to the
previous tracing of ___ the rhythm is more regular with the
above mentioned abnormalities.
CHEST (PA & LAT) Study Date of ___
IMPRESSION: No acute cardiopulmonary process.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
IMPRESSION:
1. Choledocholithiasis with new intra- and extra-hepatic
biliary ductal
dilatation, not present on CT of ___. Both stones and
sludge within the CBD.
2. Stable 2.1-cm multiloculated cyst within the right lobe of
the liver.
EUS:
Impression: EUS: The bile duct was markedly dilated to 20 mm
with large Intrinsic stones or large amount of sludge.
The bile duct and the pancreatic duct were imaged within the
ampulla and appeared normal.
Examination of the pancreas was limited due to the presence of
acoustic shadowing by the stones in the bile duct, no discrete
mass was noted in the pancreas.
Recommendations: Proceed with ERCP
Consider an MRI or CT scan to assess the head of the pancreas
ERCP:
Impression: Multiple large stones were noted in the bile duct.
A moderate diffuse dilation was seen at the biliary tree with
the CBD measuring 12 mm.
A sphincterotomy was performed.
4 stones were extracted successfully using a balloon.
Recommendations: Follow-up with Dr. ___
___ to ___ for management of cholangitis
NPO overnight with aggressive IV hydration
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
If any fever, worsening abdominal pain, or post procedure
symptoms, please call the advanced endoscopy fellow on call
___/ pager ___
******
MRI ABDOMEN W/O CONTRAST Study Date of ___
Formal read pending. Please follow up results.
******
___ 03:50AM BLOOD WBC-11.8* RBC-3.95* Hgb-11.8* Hct-35.6*
MCV-90 MCH-29.8 MCHC-33.1 RDW-13.7 Plt ___
___ 07:35AM BLOOD WBC-6.4 RBC-3.51* Hgb-10.9* Hct-31.7*
MCV-91 MCH-31.1 MCHC-34.3 RDW-13.7 Plt ___
___ 03:50AM BLOOD Neuts-90.7* Lymphs-4.7* Monos-4.1 Eos-0.4
Baso-0.2
___ 05:37AM BLOOD ___ PTT-35.0 ___
___ 07:35AM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-139
K-3.6 Cl-103 HCO3-27 AnGap-13
___ 03:50AM BLOOD ALT-102* AST-74* AlkPhos-534*
TotBili-4.7*
___ 07:35AM BLOOD ALT-51* AST-22 AlkPhos-378* TotBili-1.9*
___ 03:50AM BLOOD Lipase-969*
___ 07:35AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.8
___ 05:37AM BLOOD VitB12-369
___ 05:37AM BLOOD TSH-2.0
___ U/a Negative; UCx - contaminated
___ 3:50 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
CEFEPIME-------------- S
CEFTAZIDIME----------- S
CIPROFLOXACIN--------- S
GENTAMICIN------------ S
TOBRAMYCIN------------ S
PENDING:
Blood culture x2, ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO HS:PRN insomnia
2. Sertraline 75 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Timolol Maleate 0.25% Dose is Unknown BOTH EYES Frequency is
Unknown
------------------
Patient is NOT taking: Prednisone, Creon, or Vit D.
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Lorazepam 0.5 mg PO HS:PRN insomnia
3. Sertraline 75 mg PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H
Continue this medication as prescribed until all of the pills
are gone.
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*20 Tablet Refills:*0
5. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Cholangitis with biliary obstruction (choledocolithiasis)
# Pancreatic fullness; MRCP report pending
# Weight loss/malnutrition, chronic loose stool
# Acute GNR acute blood stream infection
# New onset Atrial Fibrillation
Secondary:
# Depression
# Hypothyroidism
# Glaucoma
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: Fever.
COMPARISONS: ___.
FINDINGS: PA and lateral chest radiographs. There is no focal consolidation,
pleural effusion, or pneumothorax. The cardiomediastinal silhouette is
normal.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Two to three weeks of intermittent fevers. Elevated LFTs and
bilirubin.
TECHNIQUE: Abdominal ultrasound, right upper quadrant.
COMPARISON: Abdominal ultrasound, ___. CT torso, ___.
FINDINGS: There is new intra- and extra-hepatic biliary ductal dilatation.
The common bile duct measures 1.2 cm and contains both stones and sludge. The
visualized pancreas appears normal. The tail is not seen, likely due to
overlying bowel gas. 2.1 x 2.0 x 1.2 cm multicystic lesion in the right lobe
of liver corresponds to abnormality on prior CT. Trace perihepatic ascites is
seen. The spleen is enlarged measuring 15.4 cm.
IMPRESSION:
1. Choledocholithiasis with new intra- and extra-hepatic biliary ductal
dilatation, not present on CT of ___. Both stones and sludge within
the CBD.
2. Stable 2.1-cm multiloculated cyst within the right lobe of the liver.
Radiology Report
HISTORY: ___ male admitted with cholangitis and gram negative
bacteremia. Query pancreatic head mass.
COMPARISON: Prior ultrasound liver from ___ and prior CT abdomen and
pelvis from ___.
TECHNIQUE: Multiplanar T1 and T2 weighted breath hold independent imaging was
performed on a 1.5 tesla magnet. No IV contrast was administered given
patient's history of contrast allergy. MRCP was also performed.
FINDINGS:
This is a limited examination given lack of intravenous contrast
administration, due to patient's history of contrast allergy.
Minor linear atelectasis is identified at both lung bases. Mild basal
bronchiectasis is identified.
Again identified is a multiloculated cyst in segment 8 of the liver measuring
1.8 cm x 2.0 cm (AP, TV). An additional tiny cyst is identified in segment 4A
of the liver. Moderate intrahepatic ductal dilatation is identified. Signal
voids are identified within the proximal intrahepatic ducts on the T2 weighted
imaging, related to pneumobilia from recent sphincterotomy. Previously
identified stone in CBD is not evident. Small amount of perihepatic fluid is
identified. The gallbladder is markedly contracted, unchanged in appearance
compared to prior CT.
A 9 mm slightly lobulated cystic lesion is identified in the head of the
pancreas, in communication with the main pancreatic duct, statistically
representing a small side branch IPMN. No suspicious features are identified.
The remainder of the pancreas demonstrates normal signal and morphology. No
pancreatic ductal dilatation. No suspicious pancreatic mass is identified.
Stable compression fracture of the T12 vertebral body is noted. Levoconvex
scoliosis of the lumbar spine is evident. The abdominal aorta is tortuous and
slightly ectatic. Moderate sigmoid diverticulosis is evident.
The urinary bladder demonstrates multiple small diverticuli, which may be a
sequelae of chronic obstruction or less likely infection.
IMPRESSION:
1. Limited examination due to the absence of intravenous contrast, however no
suspicious pancreatic mass. A cystic lesion in the pancreatic head in
communication with pancreatic duct, likely representing a small side branch
IPMN. No further follow-up is needed for this.
2. Slightly prominent proximal intrahepatic biliary ducts. Pneumobilia,
related to recent sphincterotomy. Trace perihepatic fluid.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, HYPOTHYROIDISM NOS
temperature: 102.0
heartrate: 84.0
resprate: 20.0
o2sat: 96.0
sbp: 130.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | ___ yo man with a history of hypertension (not on meds),
depression, hypothyroidism now with a fullness in the head of
his pancreas, ___ lb weight loss, and biliary obstruction with
choledocolithiasis and cholangitis. There was concern for
possible malignancy given "fullness" in pancreas. Pt underwent
EUS/ERCP, during which stones were extracted from the bile duct.
There was "fullness" in the pancreas, which could be concerning
for possible malignancy, so pt underwent MRCP evaluation, final
read pending. During the hospitalization, pt was treated for
cholangitis with an acute GNR blood stream infection. He was
treated with Pip/Tazo, and then transitioned to Cipro based upon
sensitivities. He was afebrile at the time of discharge, and
will complete 10 more days of Cipro. Final culture results
remain pending.
Surgery followed throughout the hospitalization, and they plan
cholecystectomy in outpatient follow up.
# Cholangitis with biliary obstruction (choledocolithiasis)
# Pancreatic fullness - concerning for possible malignancy; MRCP
report pending
# Weight loss/malnutrition, chronic loose stool
# Acute GNR acute blood stream infection; ___ to cipro
Biliary obstruction resolved s/p ERCP with stone extraction.
Leukocytosis improving, responding to antibiotics.
- Cipro based on sensitivities; will prescribe 10 more days from
discharge.
- PCP to follow up MRCP
- Planning CCY in outpt follow up
# Possible new onset Atrial Fibrillation -
CHADS2 score = 2 (1 point for hypertension, 1 point for age)
At the time of admission, there was concern for new onset afib.
Final cardiology read of EKG from ___ shows "appears to be a
combination of occasional sinus beats
with junctional beats with retrograde P waves along with
probably some ectopic
atrial beats". His HR remained controlled throughout the
hospitalization. Consider follow up EKG as an outpatient to
clarify.
# Depression
- continued sertraline
# Cognitive impairment - may be a component of
delirium/encephalopathy but concerning re: dementia.
- follow up with PCP
# ___
- continue levothyroxine
# Glaucoma
- continue home timolol gtt
FULL CODE
VTE Prophylaxis: Pneumoboots
DISP: home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Phenobarbital / E-Mycin / Zofran / Compazine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ gastroparesis presents with abdominal pain since last
night when she went off her liquid/pureed diet and ate pork
chops and potatoes. This is her typical response to solid foods
according to her. Pain is sharp, was acute onset, located in
LUQ, radiating to L back, worse with inspiration. This was
accompanied by nausea and vomiting, though no fever. She
reports a ___ doctor (___) who wanted to her
to see motility specialist Dr. ___ in the near future. She
does not recall seeing any other ___ doctor at ___, though OMR
indicates she met Dr. ___ in ___.
She indicates ___ admission ___ - ___ and
states was diagnosed with recurrent C. diff colitis at that time
on ___, has been on PO Flagyl 500mg TID since then (last dose
taken yesterday).
She was last admitted on ___ for coffee-ground emesis
after a thorough workup including EGD revealed no definitive
diagnosis at other facilities. CT abdomen was negative for any
acute intra-abdominal process and her pain was considered most
likely functional. Per the discharge summary, she demanded
treatment with IV Dilaudid and IV Phenergan for her symptoms.
When other medications which were more medically appropriate for
her situation were offered, she reported that she was allergic
to them. Within seconds of getting Reglan IV, she claimed that
she had hives on her body (not visually present by MD) and
throat closing up (normal O2 sats and speaking in full
sentences). She was given Zyprexa ODT for nausea; however, she
was seen by the nurse putting the pill behind her back after
initially putting it under her tongue. When confronted by the
nursing staff regarding this issue, the patient decided it would
be in her best interest to leave the hospital against medical
advice. She was not seen by an attending physician prior to
leaving. Today she indicates she left because staff would not
let her child visit her.
Review of her prior OSH records show the following work-up of
her GI symptoms:
___ - negative pelvic US, TAH for pelvic pain at ___,
___ - abd CT neg,
___ - ___ workup - nl abd/pelvic CT, nl EGD, Hida
with EF of 5%, gastric emptying showed gastroparesis,
___ US - multiple small stones. ccy and appendectomy at
___, appendix dilated mid shaft(?), exploratory lap did not
reveal any sm bowel pathology, CT at ___ neg,
___ - ER visit at ___ for abd pain and transient elev LFT's,
HIDA
nl, CT neg, hamartoma noted,
___ - MR nl, fatty liver, surgical clips, sm biliary hamartoma
___ - CT for R flank pain neg
In the ED today , initial VS: 99 128 144/89 16 100%.
Tachycardia normalized with IV fluid. She was given:
Today 03:19 Promethazine 25mg/mL Amp ___ Yeroshalmi, ___
Today 03:19 Morphine 5 mg Vial [class 2] ___ Yeroshalmi, Dalida
Today 03:59 Morphine 5 mg Vial [class 2] ___ Yeroshalmi, Dalida
Today 04:46 Promethazine 25mg/mL Amp ___ Yeroshalmi, ___
Today 04:51 HYDROmorphone (Dilaudid) 2mg/mL Syringe [class 2] ___
Yeroshalmi, Dalida
.
Currently, complaining of diffuse abdominal pain ___.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
She had scant loose stool with scant blood yesterday.
Past Medical History:
- IBS
- C. diff colitis ___
- Asthma
- C-section
- S/p Laparoscopy x2 for ?SBO/LOA; ___
- S/p Seven laparoscopies when she was young for ovarian cysts.
- S/p partial hysterecomy (including cervix) for menorrhagia
(?presumed fibroid)
- S/p cholecystectomy
- S/p appendectomy
- Deaf in R ear (per her report)
- Pulmonary Embolus ___ (spontaneous): treated x 9mo with
warfarin
- Hiatal herniorrhaphy
- Reported SBO ___ ___
Social History:
___
Family History:
Per her report today:
Mother died of COPD
Father with ___, and reported MS
___ with reported MS
___: Cancer of cervix/lung
Maternal GM: Breast Cancer
This is a different FHx than that reported in her last
admission.
Physical Exam:
PHYSICAL EXAM:
VS - Temp 97.8F, BP 127/79 , HR 82, RR 18 , O2-sat 96% RA
GENERAL - Alert, interactive, in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - voluntary guarding, reports "tender everywhere", exam
inconsistent when distracted. Active bowel sounds, soft/NT/ND,
no masses or HSM, multiple cutaneous ecchymosis from SQ Heparin.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
___ 03:00AM GLUCOSE-129* UREA N-6 CREAT-0.7 SODIUM-141
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17
___ 03:07AM LACTATE-3.0*
___ 03:00AM WBC-6.3 RBC-3.66* HGB-11.0* HCT-33.0* MCV-90
MCH-30.1 MCHC-33.4 RDW-12.9
___ 03:00AM PLT COUNT-227
___ 03:00AM NEUTS-67.0 ___ MONOS-4.5 EOS-1.3
BASOS-0.2
___ 03:00AM HCG-LESS THAN
___ 03:00AM ALT(SGPT)-19 AST(SGOT)-30 ALK PHOS-78 TOT
BILI-0.3
___ 03:00AM LIPASE-69*
___ 03:00AM ALBUMIN-4.2 CALCIUM-9.8 PHOSPHATE-2.7
MAGNESIUM-1.6
___ 04:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
ABD CT/PELVIS ___
Final Report
INDICATION: ___ female with severe left lower quadrant
pain and
tenderness treated recently for C. difficile. Evaluate for
colitis,
diverticulitis or abscess.
COMPARISON: CT of the abdomen and pelvis with contrast ___.
TECHNIQUE: MDCT axial images were obtained through the abdomen
and pelvis
with the administration of IV contrast. Multiplanar reformats
were generated and reviewed.
CT OF THE ABDOMEN AND PELVIS: The visualized heart and
pericardium appear
unremarkable. The visualized lung bases show dependent
atelectasis. A 3-mm
nodule in the right lung base (series 2, 3) is incompletely
evaluated on this study.
The liver shows diffuse fatty infiltration. The patient is
status post
cholecystectomy. The spleen, pancreas, and bilateral adrenal
glands are
unremarkable. The common bile duct is prominent measuring up to
12 mm and may reflect post-cholecystectomy state. There are
clips along the inferior liver edge as before. The kidneys
enhance and excrete contrast symmetrically. Both kidneys show no
evidence of hydronephrosis. There is no free air or free fluid
within the abdomen. Retroperitoneal and mesenteric lymph nodes
do not meet CT size criteria for pathology.
The patient is status post appendectomy. Large and small bowel
are of normal caliber and appearance. Surgical clips are noted
in the pelvis. The bladder is normal. There is no free pelvic
fluid. Mild pelvic stranding is noted adjacent to the sigmoid
colon (2:72). No colonic wall thickening or abscess. Pelvic
lymph nodes do not meet CT size criteria for pathology. The
uterus is not clearly visualized and is consistent with known
history of partial hysterectomy. A small 1.4-cm hypodensity in
the left hemipelvis may represent a left adnexal cyst.
Visualized osseous structures show no focal lytic or sclerotic
lesions
suspicious for malignancy.
IMPRESSION:
1. Mild inflammatory change in the lower pelvis adjacent to the
sigmoid
colon. No abscess.
2. Diffuse fatty deposition within the liver.
3. 1.4-cm hypodensity in the left hemipelvis may represent
adnexal cyst in
setting of partial hysterectomy. This may be further evaluated
with an
ultrasound if clinically warranted.
Medications on Admission:
Pulmicort 2puff BID
Vitamin C daily
Albuterol 2puffs q4-6hr
Prilosec 40mg daily prn
Flagyl 500mg TID through ___
Discharge Medications:
Patient left against medical advice and was advised to complete
her prior Flagyl prescription and continue her outpatient meds
noted on admission as prescribed by her physicians.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Discharge Condition:
Patient leaving against medical advice.
Ambulatory
Mental status clear and coherent
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with severe left lower quadrant pain and
tenderness treated recently for C. difficile. Evaluate for colitis,
diverticulitis or abscess.
COMPARISON: CT of the abdomen and pelvis with contrast ___.
TECHNIQUE: MDCT axial images were obtained through the abdomen and pelvis
with the administration of IV contrast. Multiplanar reformats were generated
and reviewed.
CT OF THE ABDOMEN AND PELVIS: The visualized heart and pericardium appear
unremarkable. The visualized lung bases show dependent atelectasis. A 3-mm
nodule in the right lung base (series 2, 3) is incompletely evaluated on this
study.
The liver shows diffuse fatty infiltration. The patient is status post
cholecystectomy. The spleen, pancreas, and bilateral adrenal glands are
unremarkable. The common bile duct is prominent measuring up to 12 mm and may
reflect post-cholecystectomy state. There are clips along the inferior liver
edge as before. The kidneys enhance and excrete contrast symmetrically. Both
kidneys show no evidence of hydronephrosis. There is no free air or free
fluid within the abdomen. Retroperitoneal and mesenteric lymph nodes do not
meet CT size criteria for pathology.
The patient is status post appendectomy. Large and small bowel are of normal
caliber and appearance. Surgical clips are noted in the pelvis. The bladder
is normal. There is no free pelvic fluid. Mild pelvic stranding is noted
adjacent to the sigmoid colon (2:72). No colonic wall thickening or abscess.
Pelvic lymph nodes do not meet CT size criteria for pathology. The uterus is
not clearly visualized and is consistent with known history of partial
hysterectomy. A small 1.4-cm hypodensity in the left hemipelvis may represent
a left adnexal cyst.
Visualized osseous structures show no focal lytic or sclerotic lesions
suspicious for malignancy.
IMPRESSION:
1. Mild inflammatory change in the lower pelvis adjacent to the sigmoid
colon. No abscess.
2. Diffuse fatty deposition within the liver.
3. 1.4-cm hypodensity in the left hemipelvis may represent adnexal cyst in
setting of partial hysterectomy. This may be further evaluated with an
ultrasound if clinically warranted.
Findings discussed with Dr. ___ on the morning of ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with GASTROPARESIS
temperature: 99.0
heartrate: 128.0
resprate: 16.0
o2sat: 100.0
sbp: 144.0
dbp: 89.0
level of pain: 8
level of acuity: 2.0 | ___ yo woman with prior history of gastroparesis, now with
abdominal pain, nausea, vomiting, after attempt to eat regular
solid food. She has an unconfirmed report of C. difficile
diarrhea from recent hospitalization.
# Abdominal Pain: Likely gastroparesis. GI was consulted and
recommended IV Reglan or erythromycin bth of which she has
claimed allergies to. Patient requested opiate narcotic pain
medication. She has 2 contrainidications to opiates
(gastroparesis, and presumed C. diff infection with sigmoid
stranding). I declined to give this to her. She had no
localizing signs to her abdominal pain on exam, and findings
were not consistent with pain throughout the exam. She was
afebrile, has no leukocytosis or Left shift), and UA was also
clear. She was instructed to keep NPO in hospital. She decided
to leave against medical advice, similar to her last
hospitalization.
# Nausea w/ vomiting in ER: Patient no longer nauseous on
medical ward. Received promethazine in the ED.
# C. difficile diarrhea: Uncomfirmed. Keep on contact
precautions. Will request OSH records. Continued IV Flagyl for
now. Patient left against medical advice.
# Asthma: Chronic, intermittent. Give Fluticasone 110mcg 2puff
BID for now (pulmicort not on formulary). Albuterol prn.
Patient left against medical advice.
# GERD: patient reports history of GERD for which she takes
intermittent PPI (hasn't taken in 2 weeks). As this class of
drug is associated with increased C. diff infection, I have
advised her to not restart this med without speaking first with
her PCP. Patient left against medical advice.
# Hypokalemia: 3.3 on admission. Will replete with 40mEq in
fist liter of NS
# Hypomagnesemia: 1.6 on admission. Will replete with 2mg IV now
# Incidental pulmonary nodule: 3mm. Patient with low risk
features for malignancy. I informed patient of this finding and
low risk of malignancy, and instructed her to follow-up with PCP
for further discussion and follow-up imaging as indicated.
# Code: Full
# DVT prophy: SC Heparin TID |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Alcohol intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with ETOH abuse with
recurrent alcohol withdrawal, alcoholic cirrhosis, hepatitis C,
bipolar disorder, homelessness, history of multiple prior falls
and hospitalizations who presented to the ED with alcohol
intoxication.
He was admitted here ___ with alcohol withdrawal and
was
transferred to the ICU for loading with phenobarbital and was
then transferred to floor and monitored on CIWA. He was noted
to
have prolonged QTc and hypomagnesemia and hypophosphatemia.
During that hospitalization, psychiatry was consulted.
He was seen in the ___ ED on ___ with alcohol intoxication
again and discharged home. His husband ___ said that he called
an
ambulance on ___ because the patient had fallen and could
not
get up and was taken to ___ ED and
discharged the same day. Another person called an ambulance on
___ and he went back to the ___ ED and was discharged.
Most of the history was obtained from his husband ___.
The patient has chronically low magnesium and he said that when
he does not take his magnesium supplement, he gets "incoherent,
belligerent, antagonistic" and has memory problems. He has not
been taking his medications for the past 1.5 weeks. Over the
last week, he has been sleeping the majority of the time and
barely eating. On ___, per his husband ___, the patient did
not know what was going on and was covered in urine. He did not
have a witnessed seizure or any stool incontinence.
The patient says he has been decreasing his alcohol consumption
from half a handle to 1 pint of alcohol per day. However, he
was
very shaky on ___ and ___ was concerned for alcohol
withdrawal, so he gave him 2 shots of alcohol at 11 AM and 5 ___,
which was his last drink.
In the ED, he was initially afebrile, tachycardic to 128, BP
144/91, RR 16, SaO2 99% on room air. He has been persistently
tachycardic to 100s-110s. Labs were notable for K 2.7, Mg 0.7,
AP 177, TBili 2.9, Albumin 3.2, AST 149, INR 1.6. He had normal
lipase of 57. He received IVD5NS + 40meq KCl, folic acid 1g,
thiamine 100mg, total 4g mag sulfate, diazepam 20mg, and
phenobarbital load 715mg.
On arrival to the floor, the patient was alert, oriented x3, and
conversant. He was still mildly tachycardic. He was scoring
___ on CIWA scale. He denies pain. His last bowel movement
was yesterday in the ED and denies any blood or black color. He
recalls 1 episode of vomiting 2 days ago, which he thinks was in
setting of withdrawal, and denied coffee-ground emesis but
thinks
there was a small amount of blood (dime-sized).
Past Medical History:
- Decompensated EtOH Cirrhosis (Child C, MELD-Na 14) c/b grade
II varices c/b UGI bleed, ascites, HE, & concern for HCC on MRI,
then resolved. S/p TIPS
- Hepatitis C (s/p spontaneous clearance)
- EtOH use disorder: Drinks approx. ___ gallon vodka/day),
complicated by EtOH withdrawal seizures, previously requiring
phenobarbitol
- L ankle pain: XR on past hospitalization negative for fracture
- Bipolar disorder
- Insomnia
- Plaque Psoriasis
- Homelessness
- IV drug use: recent meth use, reports using primarily heroin
and cocaine in past, quit ___ years ago
- Scoliosis
Social History:
___
Family History:
Father died of "old age"
Mother died of H. flu infection and COPD
Siblings are healthy, not in touch with them
Maternal grandmother died of leukemia
Physical Exam:
ADMISSION EXAM:
VITALS: 24 HR Data (last updated ___ @ 849)
Temp: 98.3 (Tm 98.3), BP: 152/92, HR: 106, RR: 18, O2 sat:
98%, O2 delivery: Ra
GENERAL: Alert and in no apparent distress, appears comfortable,
conversant
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Moist
mucus membranes.
CV: RRR, no murmurs/rubs, no S3, no S4. 2+ radial pulses
bilaterally.
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. No
ascites. Bowel sounds present.
GU: No GU catheter present
MSK: Moves all extremities, no edema or swelling
SKIN: Widespread psoriatic patches on extremities and trunk
including low back; right anterior lower leg with psoriatic
patch
and significant excoriations; no ulcers
NEURO: Alert, oriented x3, face symmetric, speech fluent, moves
all limbs, slightly tremulous
PSYCH: Pleasant, appropriate affect, calm, cooperative
===========================
VITALS:
___ 1518 Temp: 98.2 PO BP: 108/68 HR: 72 RR: 18 O2 sat:
100% O2 delivery: Ra
GENERAL: Alert and in no apparent distress, appears comfortable,
conversant
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Moist
mucus membranes.
CV: RRR, no murmurs/rubs, no S3, no S4. 2+ radial pulses
bilaterally.
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 GU catheter present
MSK: Moves all extremities, no edema or swelling
SKIN: No jaundice. Multiple psoriatic patches on extremities,
trunk, low back; right anterior lower leg with largest patch
with
multiple excoriations but no open areas
NEURO: Alert, oriented x3, face symmetric, speech fluent, moves
all limbs, not tremulous
PSYCH: Pleasant, appropriate affect, calm, cooperative
Pertinent Results:
ADMISSION EXAM:
___ 10:20AM BLOOD WBC-1.1* RBC-2.81* Hgb-8.5* Hct-26.0*
MCV-93 MCH-30.2 MCHC-32.7 RDW-19.9* RDWSD-67.0* Plt Ct-37*
___ 10:20AM BLOOD Neuts-33.3* Lymphs-53.2* Monos-10.8
Eos-2.7 Baso-0.0 AbsNeut-0.37* AbsLymp-0.59* AbsMono-0.12*
AbsEos-0.03* AbsBaso-0.00*
___ 05:40AM BLOOD ___ PTT-33.0 ___
___ 10:51PM BLOOD Glucose-90 UreaN-4* Creat-0.5 Na-141
K-2.7* Cl-106 HCO3-23 AnGap-12
___ 10:51PM BLOOD ALT-25 AST-149* AlkPhos-177* TotBili-2.9*
___ 10:51PM BLOOD Lipase-57
___ 10:51PM BLOOD Albumin-3.2* Calcium-7.8* Phos-3.7
Mg-0.7*
===============
DISCHARGE EXAM:
___ 05:14AM BLOOD WBC-3.6* RBC-2.61* Hgb-7.9* Hct-23.8*
MCV-91 MCH-30.3 MCHC-33.2 RDW-19.9* RDWSD-66.7* Plt Ct-44*
___ 05:14AM BLOOD Neuts-53.8 ___ Monos-13.6*
Eos-2.2 Baso-0.3 Im ___ AbsNeut-1.93 AbsLymp-1.07*
AbsMono-0.49 AbsEos-0.08 AbsBaso-0.01
___ 05:14AM BLOOD Glucose-89 UreaN-4* Creat-0.5 Na-140
K-3.6 Cl-98 HCO3-30 AnGap-12
___ 05:14AM BLOOD ALT-18 AST-68* AlkPhos-150* TotBili-2.4*
___ 05:14AM BLOOD Calcium-8.5 Phos-5.3* Mg-1.6
===============
CXR ___:
Newly placed right-sided PICC with the tip projecting over the
inferior right atrium. Retraction of ___ tip in the
superior cavoatrial junction.
RUQ ULTRASOUND ___:
1. No evidence of biliary duct dilatation.
2. Patent TIPS.
3. Cholelithiasis.
4. Nonobstructing right renal stones.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
2. Calcium Carbonate 1000 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
5. FoLIC Acid 1 mg PO DAILY
6. Lactulose 30 mL PO TID
7. LevETIRAcetam 500 mg PO BID
8. Mirtazapine 30 mg PO QHS
9. Multivitamins 1 TAB PO DAILY
10. Propranolol 10 mg PO TID
11. Ranitidine 150 mg PO DAILY
12. Rifaximin 550 mg PO BID
13. Spironolactone 25 mg PO DAILY
14. Sucralfate 2 gm PO BID
15. Thiamine 100 mg PO DAILY
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
17. Furosemide 20 mg PO DAILY
18. Magnesium Oxide 800 mg PO QID
19. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Propranolol 20 mg PO BID
RX *propranolol 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
3. Calcium Carbonate 1000 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Lactulose 30 mL PO TID
10. LevETIRAcetam 500 mg PO BID
11. Magnesium Oxide 800 mg PO QID
12. Mirtazapine 30 mg PO QHS
13. Multivitamins 1 TAB PO DAILY
14. Ranitidine 150 mg PO DAILY
15. Rifaximin 550 mg PO BID
16. Spironolactone 25 mg PO DAILY
17. Sucralfate 2 gm PO BID
18. Thiamine 100 mg PO DAILY
19. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Hypomagnesemia
Hypokalemia
Hypophosphatemia
Alcohol dependence with withdrawal
History of seizures
Cirrhosis with history of esophageal varices
Elevated LFTs
Neutropenia
Pancytopenia
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with picc// s/p R 45cm picc Contact name: ___,
___: ___
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Chest radiograph ___
FINDINGS:
The tip of the right-sided PICC terminates in the inferior right atrium with
arms down.
There is few platelike retrocardiac atelectasis. No focal areas of
consolidation, pneumothorax or pleural effusion. Cardiomediastinal contours
are normal.
Tiny linear opacity projecting over the right upper quadrant is unchanged
since prior.
IMPRESSION:
Newly placed right-sided PICC with the tip projecting over the inferior right
atrium. Retraction of ___ tip in the superior cavoatrial junction.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with cirrhosis, alcohol dependence, hepatitis C,
here with ETOH intoxication and electrolyte abnormalities, as well as rising
alk phos and Tbili with elevated direct bilirubin.// Is there evidence of
biliary obstruction that could explain his rising alk phos and Tbili?
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Abdominal ultrasound on ___ and ___, renal
ultrasound on ___
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. Again seen is a 1.3 x 1.0 x 1.0 cm echogenic avascular lesion in
the left hepatic lobe. No new focal liver lesions are identified.
There is no ascites.
There is stable borderline splenomegaly, with the spleen measuring 13.0 cm.
There is no intrahepatic biliary dilation. The CHD measures 2 mm.
Cholelithiasis without gallbladder wall thickening.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 41 cm/sec, previously 52 cm/sec
Proximal TIPS: 183 cm/sec, previously 164 cm/sec
Mid TIPS: 126 cm/sec, previously 146 cm/sec
Distal TIPS: 139 cm/sec, previously 148 cm/sec
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior portal vein is towards the TIPS. The hepatic veins are not
well seen, similar to prior. Appropriate flow seen in the IVC. There is a
recannulized paraumbilical vein.
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.
KIDNEYS: Limited views of the kidneys demonstrates 2 nonobstructing stones
measuring up to 4 mm in dilated calices in the right interpolar region. No
frank hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No evidence of biliary duct dilatation.
2. Patent TIPS.
3. Cholelithiasis.
4. Nonobstructing right renal stones.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ETOH, Lethargy
Diagnosed with Other fatigue
temperature: 97.0
heartrate: 128.0
resprate: 16.0
o2sat: 99.0
sbp: 144.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ male with ETOH abuse with recurrent
alcohol withdrawal, alcoholic cirrhosis, hepatitis C, bipolar
disorder, homelessness, history of multiple
prior falls and hospitalizations who presented to the ED with
alcohol intoxication. He was found to have severe hypokalemia
and hypomagnesemia. He has been trying to decrease alcohol
intake and presented with signs of alcohol withdrawal. He was
loaded
with Phenobarbital in the ED. He was not having significant
signs of withdrawal at discharge. His LFTs are improving and
had no evidence of biliary obstruction on ultrasound. He
hypokalemia and hypophosphatemia have resolved, and
hypomagnesemia is nearly resolved. |
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with recurrent ovarian cancer currently
chemotherapy who presented to the ED this AM with progressively
worsening diffuse abdominal pain that began last night. Her pain
began last night, but became worse and unbearable this AM around
5am, ___ in intensity at which time she called an ambulance and
was brought to the ED. This pain was associated with nausea, but
no vomiting. She is passing flatus. Her last BM was ___ AM.
Prior to this onset of pain she was feeling well.
In the ED, she received 3 L of NS as well as one fioriect and
5mg
of IV morphine. Her pain is now ___ and her nausea has
resolved.
Of note, she was hospitalized for an SBO from ___ for
an SBO. She was treated conservative with NPO/IV fluids/NG tube
and her sx resolved.
Her ONC History is as follows:
- ___: p/w abd discomfort/bloating
- ___ ex lap w Bx --> PATH: inv poorly diff carcinoma,
stains
c/w gyn primary
- ___ - completed 3C neoadj ___ taxol
- ___ - ex lap TAH/BSO, resection of pelvic tumor,
infragastric omentectomy --> optimal cytoreduction/no gross
residual disease
- ___ - completed 3 cycles of adjuvant
carboplatin/weekly taxol
- ___ CT TORSO confirmed recurrent disease suspected based
on rising CA125.
- ___ - ___: 6 cycles of ___ for
platinum-sensitive recurrence, complicated by delays for low
counts.
- ___ Enrolled on clinical trial of PARP inhibitor (v
placebo) for maintenance. Treatment held due to low platelets
and then held due to SEVERE anemia (hgb - 5) and re-started.
Then, stopped due to disease progression. ___ CA-125
elevated
at 50, then 98.
- ___ Taxol/Avastin x 6 cycles.
- ___: Increased CA125, CT confirmed recurrent disease
- ___ C1D1 ___
- ___ C2D1 ___
Past Medical History:
PAST MEDICAL HISTORY:
- exercise induced asthma
- LCIS with 2mm area of invasive breast cancer right breast
- depression
- hypercholesterolemia
- osteopenia
- carpal tunnel syndrome
- history of Bell's Palsy
- recurrent ovarian cancer as above
PAST SURGICAL HISTORY:
- LSC Tubal Ligation
- Breast Reduction and Mammoplasty
- ___ Eye Surgery
- Finger Surgery
- Tonsillectomy
- Ex lap TAH/BSO, resection of pelvic tumor, infragastric
omentectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
T 98.1 HR 76 BP 146/78 RR 18 98% RA
General: Pleasant, A&O x 3, comfortable
CV: RRR
LUNGS: CTAB
Abd: mildly distended, soft, nontender, no rebound, no guarding,
palpable hernia to right of umbilicus
Pelvic: Deferred
Ext: nontender, no edema
On discharge:
Gen: NAD, well-appearing
CV: RRR
Lungs: CTAB
Abd: +bowel sounds, soft, non-distended, non-tender, no
rebound/guarding, palpable hernia to right of umbilicus
Ext: non-tender, no edema
Pertinent Results:
___ 05:15AM BLOOD WBC-5.4 RBC-3.47* Hgb-10.1* Hct-31.3*
MCV-90 MCH-29.1 MCHC-32.3 RDW-14.6 RDWSD-46.6* Plt ___
___ 06:11AM BLOOD WBC-5.2 RBC-3.40* Hgb-10.0* Hct-30.6*
MCV-90 MCH-29.4 MCHC-32.7 RDW-14.3 RDWSD-45.9 Plt ___
___ 07:41AM BLOOD WBC-4.7 RBC-3.33* Hgb-9.9* Hct-30.4*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.6 RDWSD-47.8* Plt ___
___ 08:15AM BLOOD WBC-7.1 RBC-3.75* Hgb-10.9* Hct-33.7*
MCV-90 MCH-29.1 MCHC-32.3 RDW-14.5 RDWSD-46.6* Plt ___
___ 05:15AM BLOOD Neuts-69.7 Lymphs-18.7* Monos-6.9 Eos-3.7
Baso-0.4 Im ___ AbsNeut-3.77 AbsLymp-1.01* AbsMono-0.37
AbsEos-0.20 AbsBaso-0.02
___ 06:11AM BLOOD Neuts-66.3 ___ Monos-7.4 Eos-3.5
Baso-0.4 Im ___ AbsNeut-3.41 AbsLymp-1.13* AbsMono-0.38
AbsEos-0.18 AbsBaso-0.02
___ 07:41AM BLOOD Neuts-67.7 ___ Monos-7.0 Eos-2.7
Baso-0.4 Im ___ AbsNeut-3.20 AbsLymp-1.02* AbsMono-0.33
AbsEos-0.13 AbsBaso-0.02
___ 08:15AM BLOOD Neuts-79.5* Lymphs-13.1* Monos-5.8
Eos-0.6* Baso-0.4 Im ___ AbsNeut-5.64 AbsLymp-0.93*
AbsMono-0.41 AbsEos-0.04 AbsBaso-0.03
___ 06:11AM BLOOD Glucose-103* UreaN-4* Creat-0.5 Na-139
K-3.7 Cl-102 HCO3-28 AnGap-13
___ 07:41AM BLOOD Glucose-122* UreaN-7 Creat-0.6 Na-137
K-4.1 Cl-103 HCO3-27 AnGap-11
___ 08:15AM BLOOD Glucose-119* UreaN-15 Creat-0.7 Na-135
K-4.3 Cl-98 HCO3-27 AnGap-14
___
CT Abdomen and pelvic with contrast
1. Small bowel obstruction transition in the right lower
quadrant may reflect a malignant obstruction. Small volume
ascites. 2. Peritoneal/omental/serosal nodularity as detailed
above reflects peritoneal carcinomatosis. 3. Additional
nonemergent findings detailed above.
Medications on Admission:
Albuterol sulfate, burpropion, fioricet, adderall, dicyclomine,
famotidine, lorazepam, oxycodone, prochlorperazine, sertraline,
simvastatin.
Discharge Medications:
1. BuPROPion (Sustained Release) 100 mg PO QAM
2. Sertraline 50 mg PO DAILY
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Do not drive or combine with alcohol.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
6. Famotidine 20 mg PO BID
7. Acetaminophen 650 mg PO Q8H:PRN pain
8. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Ovarian cancer
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: ___ with abd pain similar to prior sbo with metastatic ovarian
cancer.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque. Coronal and
sagittal reformations were performed and reviewed on PACS. No oral contrast
was administered.
DOSE: Total DLP (Body) = 470 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
CT torso dated ___.
FINDINGS:
LOWER CHEST: Port-A-Cath tip terminates within the right atrium. The imaged
lung bases are clear without worrisome nodule or mass. No pericardial or
pleural effusion is seen. There is a small hiatal hernia.
ABDOMEN:
HEPATOBILIARY: The liver enhances normally without focal concerning lesion.
Main portal vein is patent. No biliary ductal dilation. The gallbladder is
normal. There is trace perihepatic ascites as well as mild peritoneal
thickening.
PANCREAS: The pancreas is normal.
SPLEEN: Spleen is normal in size without focal lesion. Trace perisplenic
fluid is present.
ADRENALS: Both right and left adrenal glands appear normal.
URINARY: Kidneys enhance symmetrically and excrete contrast promptly without
hydronephrosis, signs of pyelonephritis or worrisome focal renal lesion.
GASTROINTESTINAL: The stomach is decompressed. The duodenum appears normal.
There is dilation of the distal small bowel measuring up to 3.2 cm. There is
a point of abrupt caliber transition in the right lower quadrant best seen on
series 601 B image 25 and 26. There is soft tissue thickening at the level of
the transition point potentially raising concern for a malignant obstruction.
In this region, there is slight tethering of bowel loops which may also
indicate adhesive disease. There is omental nodularity in the right upper
quadrant seen on series 2, image 17 in this patient with known peritoneal
carcinomatosis. There is a nodular implant in the right lower quadrant on
series 2, image 46 measuring 1.6 x 1.3 cm. No signs of appendicitis. There
is heterogeneous thickening of the splenic flexure of the colon which likely
reflects serosal metastatic disease. There is no evidence of colitis. No
free air. In addition, there is a Richter's hernia in the periumbilical
region (S2: 48), uncomplicated.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus and ovaries have been surgically removed.
Patient also status post prior debulking surgery with history of ovarian
cancer.
LYMPH NODES: No retroperitoneal hematoma or lymphadenopathy is seen. No
pelvic or inguinal adenopathy is seen.
VASCULAR: The abdominal aorta is mildly calcified though normal in caliber.
BONES: No worrisome lytic or blastic osseous lesion is seen. There is
multilevel facet arthropathy in the lumbar spine with grade 1 anterolisthesis
of L4 on L5. Mild disc disease at L1-2 and L5-S1 noted.
SOFT TISSUES: Minimal retrolisthesis of L2 on 3 is unchanged. Mild
anterolisthesis of L4 on L5 is unchanged.
IMPRESSION:
1. Small bowel obstruction transition in the right lower quadrant may reflect
a malignant obstruction. Small volume ascites.
2. Peritoneal/omental/serosal nodularity as detailed above reflects peritoneal
carcinomatosis.
3. Additional nonemergent findings detailed above.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Lower abdominal pain
Diagnosed with Unspecified intestinal obstruction
temperature: 98.0
heartrate: 90.0
resprate: 16.0
o2sat: 96.0
sbp: 125.0
dbp: 61.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ woman with recurrent ovarian cancer on
chemotherapy admitted to the gyn-oncology service with SBO with
concern for malignant obstruction.
Abdominal/pelvic CT on arrival revealed SBO transition in the
RLQ concerning for malignant obstruction and peritoneal
carcinomatosis. She was made NPO, started on IV fluids and given
IV zofran, ativan, and pepcid for nausea. Her pain was
controlled with IV morphine. Over the week her diet was slowly
advanced and she was transitioned to PO pain meds.
On hospital day #4 she was tolerating a regular diet without
nausea, emesis, and pain was controlled on oral medications. She
was discharged home in stable condition with appropriate
outpatient follow-up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, AMS
Major Surgical or Invasive Procedure:
Lumbar puncture ___
History of Present Illness:
HPI: Ms. ___ is a ___ year old female with past medical
history notable for multiple myeloma, recently on pomalyst/dex,
and HTN, with recent admission for AMS thought to be due to
HSV-2
encephalitis, readmitted due to confusion/AMS and c/f CNS
infection.
Of note, she was recently discharged on ___ for similar
presentation of altered mental status, thought to be due to
HSV-2
aseptic meningitis. This was not known but she did receive 5d
dose of meningitis-dosing of acyclovir empirically while
inpatient. The PCR results of this came back positive after
discharge and so she was sent a prescription for valacyclovir 1g
TID which she states she did pick up and complete. Following
this, she resumed her ppx acyclovir. CSF cytology was pending at
discharge due to atypical lymphocytes.
For this admission, she states she developed a very mild
nonproductive cough 2 days prior to arrival to the ED. On
___
morning, she states she felt normal in her usual state of
health,
but when her son came to check in on her he told her she was
acting abnormal. She does not recall any particular behaviors,
however was told that she was putting on 5 shirts on top of one
another and exhibiting other confused behaviors. She did not
have
any other symptoms that she can recall at the time - denies
subjective f/c, HA, changes in vision/hearing, dizziness,
dysphagia, facial pain, rhinorrhea, SOA, CP, N/V. No sick
contacts. No travel history. No outdoor exposures.
Due to her confusion, her son brought her to the ED for further
evaluation. Of note, patient spent 36 hours in the ED due to
lack
of bed availability.
In the ED she was noted to have T101.6, HR 120, BP 174/72
satting
well on room air. Her exam was largely unremarkable with
exception of mild exophthalmos but otherwise normal neuro exam.
Initial infectious workup included BCx and UCx drawn and
pending,
flu swab done and negative. LP demonstrating
lymphocyte-predominant leukocytosis, with Gm stain showing PMNs
but no bacteria. Further CSF studies pending. Noncontrast head
CT
did not show any acute intracranial pathology.
Other relevant lab values included presenting WBC count of 16.7
Chemistries were otherwise unremarkable. Serum and urine tox
only
notable for opiate + and opioid + (pt on chronic oxycodone).
She was started on vancomycin, ceftriaxone, ampicillin, and
acyclovir. Ceftriaxone transitioned to cefepime.
Of note, on review of ED documentation, patient defervesced and
symptoms (including altered mental status) resolved prior to
receiving any antimicrobial agents. Repeat WBC count 6.3.
Vitals prior to transfer: T 98.3, HR 96, BP 153/83, satting well
on RA.
Upon arrival to the floor, she states she feels well. States she
feels like she is now coming down with a cold because she
started
sneezing several hours prior to transfer to floor. otherwise
denying F/C, facial pain, rhinorrhea, SOA/congestion.
Review of Systems:
(+) Per HPI.
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
PAST ONCOLOGIC HISTORY
- Monoclonal IgG multiple myeloma identified ___ on an
abnormal SPEP and normocytic anemia; bone marrow showed 30%
plasma cells on smear and 20% on core biopsy
- Initially treated with thalidomide, dex, Coumadin, and monthly
Zometa
- Large lytic lesion in the right femoral head with possible
impending fracture. She underwent right total hip arthroplasty
on ___.
- She ultimately underwent an autologous stem cell
transplant in ___.
- Continues on Zometa every ___ months until ___ with increasing pain in R hip; imaging showed marrow
changes w/o cortical destruction; biopsy was negative; PET
negative; pain improved with physical therapy with return to
normal function by ___ continued on oxycontin/oxycodone for
pain control
- Gradual increase in myeloma paraprotein; started Revlimid
___ which was complicated by hypokalemia
- Changed to Pomalidomide ___ which she continues until
the present; it is dosed at 4 mg daily for a 21 day cycle with
decadron 10 mg weekly for 3 weeks of each cycle
- Pomalidomide/Dex held ___ following initial admission for
altered mental status thought to be due to HSV-2 aseptic
meningitis
PAST MEDICAL/SURGICAL HISTORY:
HTN
Multiple Myeloma
CVA asx - seen on MRI ___
Secondary Hyperparathyroidism iso MM
Social History:
___
Family History:
No known family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 24 HR Data (last updated ___ @ 1354)
Temp: 99.8 (Tm 99.8), BP: 159/83, HR: 91, RR: 18, O2 sat:
100%, O2 delivery: RA, Wt: 135.3 lb/61.37 kg
Gen: sitting upright in NA
NEURO: A&Ox3. CNs2-12 intact. Finger-to-nose intact. Sensation
intact to light touch in all extremities. Motor strength ___ in
all extremities and equal bilaterally.
HEENT: NC/AT EOMI MMM sclera nonicteric, no nuchal rigidity, no
facial tenderness, oropharynx poorly visualized w/ Malampati 3,
no oral mucosal lesions.
NECK: No obvious JVD.
LYMPH: No occipital, posterior/anterior cervical,
submandibular/submental, axillary LAD
CV: ___ SEM RUSB. RRR
LUNGS: CTAB
ABD: ND, nl bowel sounds, NT, no HSM.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions on extremities
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1141)
Temp: 98.4 (Tm 98.9), BP: 152/85 (147-166/79-91), HR: 80
(60-84), RR: 18, O2 sat: 100% (98-100), O2 delivery: Ra, Wt:
132.4 lb/60.06 kg
NEURO: A&Ox3. CNs2-12 intact. Finger-to-nose intact. Sensation
intact to light touch in all extremities. Motor strength ___ in
all extremities and equal bilaterally.
HEENT: NC/AT EOMI MMM sclera nonicteric, no nuchal rigidity, no
facial tenderness, oropharynx poorly visualized w/ Malampati 3,
no oral mucosal lesions or oropharyngeal erythema.
NECK: No obvious JVD.
LYMPH: No occipital, posterior/anterior cervical,
submandibular/submental, axillary LAD
CV: ___ SEM RUSB. RRR
LUNGS: CTAB
ABD: ND, nl bowel sounds, NT, no HSM.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions on extremities
Pertinent Results:
ADMISSION LABS:
===============
___ 10:00PM CMV VL-NOT DETECT
___ 07:50AM GLUCOSE-117* UREA N-15 CREAT-0.7 SODIUM-145
POTASSIUM-4.8 CHLORIDE-109* TOTAL CO2-25 ANION GAP-11
___ 07:50AM CALCIUM-8.5 PHOSPHATE-2.2* MAGNESIUM-2.2
___ 07:50AM WBC-6.3 RBC-3.60* HGB-9.1* HCT-31.6* MCV-88
MCH-25.3* MCHC-28.8* RDW-16.3* RDWSD-52.8*
___ 07:50AM PLT COUNT-268
___ 05:50PM URINE HOURS-RANDOM
___ 05:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS*
cocaine-NEG amphetmn-NEG oxycodn-POS* mthdone-NEG
___ 05:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-70* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 08:19AM CEREBROSPINAL FLUID (CSF) PROTEIN-24 GLUCOSE-71
___ 08:19AM CEREBROSPINAL FLUID (CSF) TNC-19* RBC-3 POLYS-0
___ ___ 08:19AM CEREBROSPINAL FLUID (CSF) TNC-24* RBC-176*
POLYS-0 ___ ___ 07:24AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 04:20AM GLUCOSE-146* UREA N-17 CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
___ 04:20AM estGFR-Using this
___ 04:20AM ALT(SGPT)-7 AST(SGOT)-19 ALK PHOS-59 TOT
BILI-0.3
___ 04:20AM ALBUMIN-4.1 CALCIUM-9.8 PHOSPHATE-3.1
MAGNESIUM-1.6
___ 04:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-17 tricyclic-NEG
___ 04:20AM LACTATE-1.7
___ 04:20AM WBC-16.7* RBC-3.39* HGB-8.6* HCT-29.7* MCV-88
MCH-25.4* MCHC-29.0* RDW-16.5* RDWSD-52.9*
___ 04:20AM NEUTS-73.5* LYMPHS-14.5* MONOS-10.1 EOS-1.1
BASOS-0.2 IM ___ AbsNeut-12.29* AbsLymp-2.42 AbsMono-1.68*
AbsEos-0.18 AbsBaso-0.03
___ 04:20AM PLT COUNT-270
___ 04:20AM ___ PTT-26.6 ___
PERTINENT STUDIES:
==================
___ Imaging CTA HEAD & CTA NECK
1. Few focal areas of hypodensity within the left frontal lobe
and left parietal lobe are of indeterminate chronicity.
Recommend
comparison to prior imaging if available, and if not previously
obtained, then further evaluation with MRI is recommended for
characterization.
2. No evidence of intracranial hemorrhage.
3. Patent intracranial and neck arterial vasculature.
4. Stable appearance of a 1.2 cm hypodense nodule within the
left
thyroid lobe, unchanged in size compared to prior thyroid
ultrasound from ___.
5. Redemonstration of a 2.2 cm hypodense nodule within the right
thyroid lobe, unchanged in appearance compared to prior studies
and found to be benign on recent biopsy from ___.
___ Imaging MR HEAD W & W/O CONTRAS
1. No evidence of infarction, hemorrhage, or abnormal
collection.
2. 1-2 mm focus of enhancement in the right IAC partly obscured
by motion artifact, is nonspecific, possibly a small vessel. If
there is a history of sensorineural hearing loss or vertigo,
consider MRI ___ for further evaluation.
3. Otherwise, no other abnormal enhancement.
4. Mild-to-moderate changes of chronic white matter
microangiopathy.
___ Herpes Simplex Virus, PCR, CSF
HSV 1 negative; HSV 2 positive "This specimen yielded a low
positive result, which may not be reproducible and should be
interpreted in the context of the patient's clinical
presentation"
___ Pathology Tissue: Immunophenotyping: CSF
INTERPRETATION
Nonspecific T cell predominant lymphoid profile; diagnostic
immunophenotypic features of involvement by leukemia are not
seen
in this specimen. Correlation with clinical, morphologic (see
separate pathology report ___-___) and other ancillary findings
is recommended. Flow cytometry immunophenotyping may not detect
all abnormal populations due to topography sampling or artifacts
of sample preparation.
___ 08:19AM CEREBROSPINAL FLUID (CSF) TNC: 19* RBC: 3
Polys:
0 Lymphs: ___ Monos: ___ 08:19AM CEREBROSPINAL FLUID (CSF) TotProt: 24 Glucose:
71 Clear appearance
___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
___ Imaging CT HEAD W/O CONTRAST
No evidence for acute intracranial abnormalities.
___ Imaging MR HEAD W & W/O CONTRAS
1. No acute intracranial abnormalities. No abnormal enhancement
to suggest intracranial infection.
2. Moderate chronic microvascular ischemic changes.
3. Mild pansinus disease. Scattered fluid within the mastoids
bilaterally.
___ Herpes Simplex Virus, PCR, CSF - Negative for HSV-1
and HSV-2
DISCHARGE LABS:
===============
___ 05:40AM BLOOD WBC-8.0 RBC-3.71* Hgb-9.4* Hct-31.4*
MCV-85 MCH-25.3* MCHC-29.9* RDW-16.2* RDWSD-49.8* Plt ___
___ 05:40AM BLOOD Neuts-53.9 ___ Monos-12.8
Eos-0.9* Baso-0.1 Im ___ AbsNeut-4.31 AbsLymp-2.53
AbsMono-1.02* AbsEos-0.07 AbsBaso-0.01
___ 05:40AM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-146 K-4.0
Cl-111* HCO3-21* AnGap-14
___ 05:40AM BLOOD ALT-9 AST-10 AlkPhos-50 TotBili-0.3
___ 05:40AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9
___ 06:55AM BLOOD IgG-1205 IgA-158 IgM-114
___ 10:00PM BLOOD CMV VL-NOT DETECT
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Acyclovir 400 mg PO Q12H
4. Spironolactone 25 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
8. Lidocaine 5% Patch 1 PTCH TD QPM
9. Dexamethasone 10 mg PO ASDIR
10. Pomalyst (pomalidomide) 2 mg oral DAILY
11. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. amLODIPine 5 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Spironolactone 25 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. HELD- Dexamethasone 10 mg PO ASDIR This medication was
held. Do not restart Dexamethasone until discussing with Dr.
___
11. HELD- Pomalyst (pomalidomide) 2 mg oral DAILY This
medication was held. Do not restart Pomalyst until discussing
with Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
#Meningoencephalitis NOS
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 T9112 MR HEAD
INDICATION: ___ year old woman with h/o MM, prior recent admit for HSV-2
aseptic meningitis, readmitted with fevers and meningismus c/f malloret's
meningitis// cause of episodic encephalopathy, findings suggestive of
encephalitis?
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CT head dated ___.
MR head dated ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or acute territorial infarction. Moderate subcortical, deep, and
periventricular white matter T2/FLAIR hyperintensities are nonspecific, but
likely represent the sequela of chronic microvascular ischemia. The
ventricles and sulci are normal in caliber and configuration. There is no
abnormal enhancement after contrast administration.
Circle of ___ and dural venous sinuses are grossly patent. Orbits are
unremarkable. Mild mucosal thickening within the bilateral ethmoid,
maxillary, and sphenoid sinuses. Scattered fluid within the mastoids
bilaterally, left greater than right.
IMPRESSION:
1. No acute intracranial abnormalities. No abnormal enhancement to suggest
intracranial infection.
2. Moderate chronic microvascular ischemic changes.
3. Mild pansinus disease. Scattered fluid within the mastoids bilaterally.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with Fever, unspecified
temperature: 101.6
heartrate: 120.0
resprate: 16.0
o2sat: 96.0
sbp: 174.0
dbp: 72.0
level of pain: 0
level of acuity: 1.0 | =======
SUMMARY
=======
Ms. ___ is a ___ year old female with past medical history
notable for multiple myeloma, with recent admission due to
concerns for HSV-2 aseptic meningitis, readmitted due to fevers
and confusion at home. Her repeat infectious workup was largely
unremarkable (including negative HSV-2 CSF PCR) except for
persistent, although decreased, lymphocytes in her CSF. She was
treated empirically with a 10d course of vancomycin, cefepime,
ampicillin, and acyclovir for possible HSV-2 meningitis, and
other possible bacterial causes. Her hospital course was
unremarkable.
==============
ACUTE PROBLEMS
==============
#Altered mental status
#Fevers
Recent discharge for presumed aseptic HSV-2 meningits, as
patient had presented at that time with similar symptoms of AMS
and fevers, with CSF PCR notable for low-level positive HSV-2.
She had at that time received both a full IV acyclovir course as
well as PO valacyclovir in the outpatient setting. She was
subsequently readmitted after several days due to similar
symptoms. Of note, her initial fever of T 101.6 in the ED had
defervesced prior to initiation of antimicrobial agents.
Presumptive diagnosis of HSV-2 aseptic meningitis vs Malloret's
meningitis vs undertreated viral/bacterial etiology that was not
adequately covered during last admission. Infectious workup
largely unremarkable - CSF PCR for this admit was negative for
HSV-2, although did demonstrate lymphocytes. She ultimately
received a total of 10 days of vancomycin, cefepime, ampicillin,
and acyclovir for empiric coverage of possible undertreated
viral and bacterial causes.
================
CHRONIC PROBLEMS
================
#Multiple Myeloma
She had not been taking her pomalyst on admission per outpatient
oncology direction. This was not continued while inpatient as
well. She had normal quantitative Ig levels during this
admission.
# CODE: Full (presumed)
# EMERGENCY CONTACT:
Name of health care proxy: ___
___: daughter
Phone number: ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old right-handed woman with history of
pseudotumor cerebri diagnosed in ___, who is being followed by
Neurology for recurrence of headaches and papilledema, recently
restarted on Acetazolamide, who presents with fatigue, worsening
headache and tingling in hands and feet.
Of note, patient was seen in Neurology clinic on ___ by Dr.
___ Dr. ___ evaluation of recurrent headaches and
papilledema, with concern for recurrent pseudotumor.
In terms of her history, per Dr. ___: "She was
initially
diagnosed with pseudotumor in ___ ___. At that time
she
presented with right occipital headaches that worsened with
valsalva maneuver and responded easily to mild analgesics. She
was found to have optic disk swelling. She had gained 30 pounds
shortly before that evaluation and the diagnosis was idiopathic
intracranial
hypertension (pseudotumor cerebri). She had an elevated opening
pressure of 23 cm H20 on flouro-guided LP, which was not a large
volume tap. She was started on acetazolamide 1000 mg a day and
remained on it for ___ years. The symptoms resolved fairly
quickly, she stopped the medication ___ years later."
When patient was seen in clinic on ___, she reported that
headaches had retruned 6 months ago. Again these were right
occipital, more sharo than previously (were dull on first
presentation). They were also noted to be precipitated by
coughing, laughing and straining. At that visit, she denied any
visual symptoms such as transient visual obscurations (TVOs) or
permanent vision loss, however did note occasional diplopia on
end gaze. She reported that on recent ophthalmology evaluation
dilated fundoscopic exam revealed papilledema. She also noted
other symptoms of numbness in her right hand (median nerve
distribution) and clumsiness of that hand, as well as episode of
dysequilibrium.
At that visit, Dr. ___ was likely recurrence of
pseudotumor cerebri, but also wanted to rule out other
etiologies
such as venous sinus thrombosis or intracranial mass. She
recommended MRI/MRV and large volume tap. Patient refused
outpatient LP given she would prefer ___ guided LP from
experience
in past. Dr. ___ her on Acetazolamide 500mg BID.
MRI/MRV was done which showed downward displacement of the
cerebellar tonsils with a "peg-like" configuration, that
together
with empty sella may be consequent to pseudotumor cerebri rather
than congenital Chiari I malformation.
Patient now presents with worsening fatigue since starting
Acetazolamide as well as more constant headache which is more
dull, and not only brought on by Valsalva maneuver. Furthermore,
she notes increasing numbness and tingling of her hands and
feet.
She also notes right posterior neck pain which is very sensitive
and feels like a spasm. She again notes diplopia on distal end
gaze but no other visual symptoms. No nausea or vomiting. No
positional aspect to headaches. Also notes some trouble finding
the right words more recently. States she was driving and can't
remember the streets as well. Lastly, her right hand feels a
little weaker, not as strong as it typically is as well.
Past Medical History:
- Pseudotumor cerebrii (___)
- Obesity
- Seasonal allergies
Social History:
___
Family History:
Father had cerebral aneurysm in his ___. Mother with
diabetes, hypertension, CHF and strokes. No family history of
MS,
headaches or autoimmune disorders.
Physical Exam:
Physical Exam:
Vitals: T: 99.6 P: 86 BP: 115/75 RR: 16 O2sat: 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx
Neck: Supple, no nuchal rigidity. No carotid bruits
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, able to name
___ backward without difficulty. Able to relate history without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good knowledge of current events. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Unable to
visualize fundi.
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 and has symmetric strengh.
-Motor: Normal bulk. No pronator drift. No adventitious
movements. No asterixis. Increased LLE tone.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5- ___ 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: Decreased pinprick sensation over thumb and
forefinger, dorsal and palmar aspects up to the lateral wrist.
Decreased pinprick sensation over upper middle back and back of
neck.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally. UE RAMs
symmetric.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem with little difficulty. Romberg
absent.
>
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>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Discharge Exam: Unchanged
Pertinent Results:
___ 08:25PM URINE HOURS-RANDOM
___ 08:25PM URINE HOURS-RANDOM
___ 08:25PM URINE UCG-NEGATIVE
___ 08:25PM URINE GR HOLD-HOLD
___ 08:25PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:45PM GLUCOSE-79 UREA N-12 CREAT-0.8 SODIUM-138
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-20* ANION GAP-13
___ 02:45PM estGFR-Using this
___ 02:45PM CALCIUM-9.0 PHOSPHATE-3.2 MAGNESIUM-2.2
___ 02:45PM WBC-5.4 RBC-4.64 HGB-12.3 HCT-38.0 MCV-82
MCH-26.6* MCHC-32.5 RDW-14.1
___ 02:45PM NEUTS-63.6 ___ MONOS-7.2 EOS-1.6
BASOS-0.2
___ 02:45PM PLT COUNT-237
___ 02:45PM ___ PTT-30.9 ___
Medications on Admission:
1. AcetaZOLamide 500 mg PO Q12H
Discharge Medications:
1. AcetaZOLamide 500 mg PO Q12H
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth daily
Disp #*30 Capsule Refills:*0
3. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron HCl 8 mg 1 tablet(s) by mouth q8hrs Disp #*9
Tablet Refills:*0
4. ketorolac 10 mg oral q6hrs PRN headache
RX *ketorolac 10 mg 1 tablet(s) by mouth q6hrs Disp #*8 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. chiari malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with headache. Assess for hydrocephalus.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal, sagittal, and
thin section bone algorithm reconstructed images were generated.
DOSE: DLP: 891.93 mGy-cm
COMPARISON: MRI brain ___. Brain MRI from ___.
FINDINGS:
No evidence of hemorrhage, edema, mass effect, or acute large territorial
infarction.The ventricles and sulci are normal in size and configuration.
Again seen is an empty sella as well as downward displacement of the
cerebellar tonsils inferior to the foramen magnum similar to MR dated ___.
The basal cisterns remain patent and there is preservation of gray-white
matter differentiation.
No fracture identified. The visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Empty sella. Persistent inferior tonsil herniation, similar to MR dated
___ which can be seen in setting of intracranial hypertension as
described in:
___ AM, ___ PA. Incidence of cerebellar tonsillar
ectopia in idiopathic intracranial hypertension: A mimic of the Chiari I
malformation. Am J Neuroradiol ___ 33: ___.
Inferior tonsillar herniation is not thought to be due to Chiari I given lack
of presence on remote prior exam.
2. No hydrocephalus.
Radiology Report
INDICATION: ___ year old woman with h/o pseudotumor + low-lying tonsils who
presents with HA, neck pain, ___ like sensory deficit // evaluate for
___ compression/syrinx
TECHNIQUE: MRI of the cervical spine without IV contrast
COMPARISON: No prior MR ___ study; MRI of the brain ___ and
___
FINDINGS:
Low lying pointed tonsils, 1.5 cm below the margins of foramen magnum similar
to the recent MRI study of ___ and new since the study of ___.
No of obvious syrinx noted in the cervical and upper thoracic cord included.
The signal intensity of the cord is within normal limits, without obvious
focal lesions.
Reversal of cervical lordosis, with mild kyphosis.
No suspicious marrow signal intensity changes are noted.
Disc desiccation noted at multiple levels.
C2-C3, C3-4, C4-5, C6-7: No disc herniation, no canal or foraminal narrowing.
Mildly prominent root sleeve diverticula around the nerves.
C5-6: Disc desiccation, mild diffuse bulge with a small central component of
extrusion indenting the thecal sac outline and abutting the ventral cord,
better seen on the sagittal sequences.
Mild canal and possible mild foraminal narrowing.
No significant foraminal narrowing.
T3-T4: Minimal bulge/ small right-sided protrusion indenting the thecal sac
outline.
No significant canal or foraminal narrowing.
No pre or paravertebral soft tissue swelling noted.
Small perineural cysts at multiple levels in the cervical and the upper
thoracic spine included.
Partially empty sella.
IMPRESSION:
1. Pointed low-lying cerebellar tonsils, approximately 1.5 cm below the
margins of foramen magnum and partially empty sella, similar to the recent MRI
head study of ___.
This can relate to pseudotumor cerebri more than Chiari 1 malformation
2. No evidence of syrinx in the cervical cord or upper thoracic cord
included.
3. C5-6: Mild diffuse bulge, with small focal central extrusion, with mild
canal and foraminal narrowing.
4. Upper thoracic T3-T4: Mild bowel/right paracentral protrusion ; no
significant canal or foraminal narrowing on the sagittal sequences.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Headache
Diagnosed with HEADACHE
temperature: 99.6
heartrate: 86.0
resprate: 16.0
o2sat: 100.0
sbp: 115.0
dbp: 75.0
level of pain: 5
level of acuity: 3.0 | Ms ___ headaches were different from her previous
headaches associated with pseudotumor. This headache was bad
throughout the day (regardless of cough/laugh) and was
associated with neck pain, upper back numbness, and right more
than left hand numbness. her headache was thought to be
primarily related to her Chiari malformation. We performed a
cervical spine MRI during the stay given her C5/6 distribution
numbness and also given her left lower extremity mild proximal
weakness and spasticity. This exam was remarkable for low lying
cerebellar tonsils consistent with Chiari malformation and also
for mild disc bulge at C5/6 that abutted the cord but without
cord signal change and with open canal. Ms. ___ will follow
up with Neurosurgery for further Chiari evaluation, MRI CSF CINE
flow study, and for discussion of neurosurgical evaluation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left subdural hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is a ___ female on Eloquist for Afib
who presents to ___ on ___ with a moderate to
severe TBI s/p fall. The patient is ___ speaking only,
however, her daughter is at bedside, assisting with
communication
with the patient and proving medical history. The patient has
all
medical care here at ___. Per the patient and daughter she lives
alone. The patient states that yesterday she began to feel
nauseas after taking some pills, she put two fingers down her
throat to stimulate emesis, when she suddenly passed out. When
she awoke she was on the floor, denies headsrike. This morning
she complained to her daughter about left ankle pain, her
daughter brought her to the urgent care center here at ___. A
head
CT was obtain along with other imaging, which revealed an acute
SDH with minimal MLS. The patient denies n/v, dizziness, blurred
vision, but endorses intermittent headaches.
Past Medical History:
- renal transplant, DDRT in ___ ___
- ___: on mycophenolate and tacrolimus, Bactrim
SS for PCP ppx
- recurrent MDR Klebsiella pneumoniae UTI; required IV
antibiotic therapy. She was started on fosfomycin for
treatment/prophylaxis and took this for about ___ months,
stopped because of loose stools.
- HTN
- CKD bone and mineral disorder
- Excision of Left ___ AVF in ___
- history of nephrolithiasis
- Afib on Eliquis
- history of Hematuria attributed to cyst rupture
- Anemia
- Uterine prolapse
- history of latent Coccidiomycosis s/p Fluconazole PPX
- REVISION OF L ___ AV FISTULA ANEURYSM ___
- L ___ CEPH AVF ANEURYSM REVISION ___
Social History:
___
Family History:
Uncle w/ ___, father deceased in ___, maternal aunt w/ CVA
Physical Exam:
on admission:
Physical Exam:
T:98.6 BP: 156/81 HR: 61 RR: 20 O2 Sat: 98% RA
GCS at the scene: 15
GCS upon Neurosurgery Evaluation: 15
Airway: [ ]Intubated [x]Not intubated
Exam:
Gen: WD/WN, comfortable, NAD.
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
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
-----------
AT DISCHARGE: (with ___ interpreter)
Alert oriented x 3.
PERRL. ___. TML. EMOI
Strength ___ throughout.
Sensation intact.
No pronator drift.
Pertinent Results:
CT HEAD W/O CONTRAST Study Date of ___ 12:09 ___
IMPRESSION:
Left subdural hematoma measuring up to 1.1 cm with mild mass
effect. No shift of normally midline structures. No evidence
of intraparenchymal hemorrhage.
CHEST (PA & LAT) Study Date of ___ 12:28 ___
FINDINGS:
On the frontal view, there are slightly lower lung volumes which
gives the
impression of increased opacity in the left lower lung, however
on the lateral view the lungs are clear. As before, there is
moderate cardiomegaly and enlargement of the pulmonary
vasculature consistent with pulmonary congestion, but no
pulmonary edema. No definite acute fracture, though vertebral
bodies appear osteopenic, limiting the sensitivity for detection
of fractures.
FOOT AP,LAT & OBL LEFT Study Date of ___ 12:29 ___
FINDINGS:
The alignment of the bones of the left foot is normal. No
fracture or
concerning bone finding. Mild swelling is seen about the dorsum
of the
midfoot. ___ left first MTP osteoarthritis is noted.
___ SHOULDER (W/ Y VIEW) RIGHT Study Date of
___ 12:29 ___.
FINDINGS:
The alignment of the bones of the right shoulder is normal. No
fracture or concerning bone finding. Mild degenerative changes
seen in the right AC joint.
CT HEAD W/O CONTRAST Study Date of ___ 6:05 ___
IMPRESSION:
No substantial interval change in appearance of acute subdural
hematoma
overlying the left cerebral convexity and left aspect of the
falx. No new
areas of hemorrhage identified.
Medications on Admission:
ALENDRONATE - alendronate 35 mg tablet. 1 tablet(s) by mouth
weekly
AMLODIPINE - amlodipine 5 mg tablet. 1 tablet(s) by mouth once a
day
APIXABAN [ELIQUIS] - Eliquis 5 mg tablet. 1 tablet(s) by mouth
twice a day
CIPROFLOXACIN HCL - ciprofloxacin 500 mg tablet. 1 tablet(s) by
mouth twice a day x 14 days
___ - dorzolamide 22.3 ___ 6.8 mg/mL eye
drops. 1 gtt both eyes Twice a day - (Prescribed by Other
Provider)
ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000
unit capsule. 1 capsule(s) by mouth weekly
HYDRALAZINE - hydralazine 50 mg tablet. 1 tablet(s) by mouth
twice a day - (Prescribed by Other Provider)
LAMIVUDINE - lamivudine 100 mg tablet. 0.5 (One half) tablet(s)
by mouth once a day
___ - ___ 2.5 %-2.5 % topical
cream. apply to knees as needed
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr. 0.5 (One half) tablet(s) by mouth
Daily
MYCOPHENOLATE MOFETIL - mycophenolate mofetil 500 mg tablet. 1
tablet(s) by mouth twice a day Z94.0 - (Dose adjustment - no
new
Rx)
___ [BACTRIM] - Bactrim 400 ___ mg
tablet. 1 tablet(s) by mouth once daily
TACROLIMUS [PROGRAF] - Prograf 1 mg capsule. 2 (Two) capsule(s)
by mouth twice a day Z94.0
DOCUSATE SODIUM - docusate sodium 100 mg tablet. 1 tablet(s) by
mouth twice a day Hold for loose stool
SENNOSIDES [SENNA] - senna 8.6 mg capsule. 1 capsule(s) by mouth
twice a day Hold for loose stools - (Prescribed by Other
Provider)
SODIUM BICARBONATE - sodium bicarbonate 650 mg tablet. 1
tablet(s) by mouth twice a day
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. LevETIRAcetam 500 mg PO BID Duration: 7 Days
RX *levetiracetam 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*9 Tablet Refills:*0
4. Alendronate Sodium 35 mg PO WEEKLY
5. amLODIPine 5 mg PO DAILY
6. Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 2 Days
Continue through ___ then stop as previously prescribed
7. ___ mg/mL ophthalmic BID
8. HydrALAZINE 50 mg PO BID
9. LaMIVudine 50 mg PO DAILY
10. Metoprolol Succinate XL 12.5 mg PO DAILY
11. Mycophenolate Mofetil 500 mg PO BID
12. Sodium Bicarbonate 650 mg PO BID
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Tacrolimus 2 mg PO Q12H
15. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
subdural hematoma
atrial fibrillation
h/o kidney transplant
UTI
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 Q111 CT HEAD
INDICATION: History: ___ with syncopal event, on eliquis // r/o fracture,
injury
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: DLP: 746 mGy cm.
CTDIvol:
COMPARISON: Unenhanced head CT dated ___
FINDINGS:
There is an acute subdural hematoma which layers along the left frontal
convexity and falx that extends into the left middle cranial fossa. While the
hematoma varies in thickness,it measures up to 1.1 cm along the left frontal
lobe with subsequent mild effacement of adjacent sulci. No shift of normally
midline structures. Basal cisterns are patent. Gray-white matter
differentiation is preserved.
The orbits are unremarkable. Imaged paranasal sinuses demonstrate mucosal
thickening within the left anterior ethmoidal air cells with aerosolized
secretions. Moderate mucosal thickening of the imaged left maxillary sinus is
additionally present. Temporal bones are underpneumatized with mastoid air
cells which are clear as are middle ear cavities. Carotid siphon vascular
calcifications are moderate. No fractures are identified
IMPRESSION:
Left subdural hematoma measuring up to 1.1 cm with mild mass effect. No shift
of normally midline structures. No evidence of intraparenchymal hemorrhage.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 12:37 ___, 2 minutes after
discovery of the findings.
Radiology Report
INDICATION: History: ___ with syncopal event, on eliquis // r/o fracture,
injury
TECHNIQUE: PA and lateral chest
COMPARISON: ___
FINDINGS:
On the frontal view, there are slightly lower lung volumes which gives the
impression of increased opacity in the left lower lung, however on the lateral
view the lungs are clear. As before, there is moderate cardiomegaly and
enlargement of the pulmonary vasculature consistent with pulmonary congestion,
but no pulmonary edema. No definite acute fracture, though vertebral bodies
appear osteopenic, limiting the sensitivity for detection of fractures.
Radiology Report
INDICATION: History: ___ with syncopal event, on eliquis // r/o fracture,
injury
TECHNIQUE: Three views right shoulder
FINDINGS:
The alignment of the bones of the right shoulder is normal. No fracture or
concerning bone finding. Mild degenerative changes seen in the right AC joint.
Radiology Report
INDICATION: History: ___ with left foot lateral pain after a fall at home //
r/o fx ___ mt pain after fall
TECHNIQUE: Three views left foot
FINDINGS:
The alignment of the bones of the left foot is normal. No fracture or
concerning bone finding. Mild swelling is seen about the dorsum of the
midfoot. Mild-moderate left first MTP osteoarthritis is noted.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with subdural hematoma on coumadin // worsening
SDH?
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, 16.4 cm; CTDIvol = 49.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CTA ___ at 12:15
FINDINGS:
Acute left subdural hematoma overlying the left cerebral convexity and along
the left aspect of the falx measures up to 14 mm in maximal thickness (02:23),
and is without substantial interval change from the previous study. There is
no significant shift of normally midline structures. No new areas of
intracranial hemorrhage are demonstrated.
There is no evidence of acute large territorial infarction,edema, or mass.
There is prominence of the ventricles and sulci suggestive of involutional
changes. Periventricular, subcortical and deep white matter hypodensities are
nonspecific, but likely reflect the sequela of chronic microvascular
infarction. Atherosclerotic calcifications of the cavernous carotid distal
right vertebral arteries are re- demonstrated.
There is no evidence of acute fracture. Chronic left nasal bone deformity is
again noted. Mild to moderate mucosal thickening is seen involving the
maxillary sinuses bilaterally as well as scattered ethmoid air cells. The
visualized portion of the remaining paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
No substantial interval change in appearance of acute subdural hematoma
overlying the left cerebral convexity and left aspect of the falx. No new
areas of hemorrhage identified.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Syncope, SDH, Transfer
Diagnosed with Nontraumatic subdural hemorrhage, unspecified
temperature: 98.6
heartrate: 61.0
resprate: 20.0
o2sat: 98.0
sbp: 156.0
dbp: 81.0
level of pain: 7
level of acuity: 2.0 | #Subdural hematoma:
Patient was admitted to the neurosurgical ICU under Dr.
___ on ___ s/p fall with TBI. Repeat head CT showed
stable 1.4cm left subdural hematoma without mass effect/midline
shift, and no new areas of hemorrhage. Eliquis was held (see
below) and she was given 4 units FFP for reversal. She was
started on Keppra for seizure prophylaxis, to be continued for 1
week. She remained neurologically intact. She was transferred to
the floor on ___ and continued to be stable.
#Afib:
Eliquis was held on admission given intracranial hemorrhage. HR
controlled with home metoprolol. Cardiology was consulted, who
agreed with holding anticoagulation until safe from a
neurosurgical perspective. Patient was instructed to hold
Eliquis for 1 month, until follow up with Dr. ___
a repeat head ___ of Hearts monitor was also recommended
for evaluation of arrhythmia that could have lead to fall
(although unlikely given that likely vagal from inducing
vomiting). She will follow up with her outpatient cardiologist,
Dr. ___ discharge.
#Toe pain
L foot/toe pain from fall. ___ was negative for fracture.
Recommended rest, ice, elevation.
#Renal
Renal transplant team followed while inpatient. She was
continued on home medications and Tacrolimus level was
monitored. Renal function at baseline. She also has recurrent
UTIs and was continued on Cipro (completed ___.
She was instructed to follow up on ___ for routine labs.
#DISPO
She was cleared by ___ for discharge home with home ___ on ___.
Tertiary survey was completed by ___ with no further injuries
noted. At time of discharge pain was well controlled, she was
tolerating PO diet without nausea or vomiting, she was
ambulating, and voiding. Discharge instructions were reviewed
with patient and daughter (translated) and all questions were
answered. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
abacavir
Attending: ___.
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Chest tube placement
PICC
History of Present Illness:
Mr. ___ is ___ with history of HIV on HAART, last CD4 count
875 viral count 2422, presenting with shortness of breath. He
initially presented to his PCP's office today with complaint of
hematuria and was found to be hypoxic (80%) on room air. The
patient reports that for the past couple of days he has been
short of breath. He also reports associated fever, chills and
cough productive of greenish sputum and pleuritic chest pain on
the R. Denies any abdominal pain, n/v, diarrhea, consipation,
dysuria, frequency, palpitations, headache. He denies any
recent travel. He lives alone in an apartment and is on
disability.
In the ED, initial vitals were98.1, 110, 127/81, 24, 91% on 4 L
NC. ABG 7.33/___. Patient was put on biPAP did not
tolerate it well but did have some improvement in oxygen
saturation. He was then placed on a NRB 95%. Repeat ABG
___. Labs otherwise notable for WBC 29.4, PMN
87%,HCO3 38. A CXR showed large widespread opacification of the
right mid-to-lower hemithorax with mass effect, suspected to
represent a pleural effusion at least in part, including a
possible large loculated component; widespread atelectasis or
pneumonic consolidation. The patient was given ASA 81mg,
ceftriaxone 1 g, methylprednisone 125 mg, TMP-SMX 600 mg,
azithromycin 500mg.
CT chest showing large R effusion, likely empyema.
On arrival to the MICU, vitals were 97.6, 120, 157/82, 16, 95%
on NRB.
Past Medical History:
HIV
HTN
Obesity
Hepatitis C chronic
Tobacco dependence
Anxiety
COPD?
History of Opioid use on methadone
Social History:
___
Family History:
Father Cancer - ___
Mother- Lung condition
Physical Exam:
Admission exam:
General: Alert, oriented, no acute distress
HEENT: buffalo hump, Sclera anicteric, MMM, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Absent breath sounds and dullness to percussion R lower
___, crackles LLL
Abdomen: soft, distended, bowel sounds present, no organomegaly,
no tenderness to palpation, no rebound or guarding
Ext: clubbing, Warm, well perfused, 2+ pulses, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge exam:
Vitals: T 98.3, BP 132/98, HR 96, RR 20, SvO2 95% 1L NC
General: alert, oriented
CV: RR, nl rate, no rubs, callops or murmurs
Lungs: diffuse crackles on left lung sparing apex, crackles
lower half of right lung, has some pain on left side with deep
inspiration
Abdomen: soft, nontender, nondistended, +BS
Ext: clubbing, WWP, no pitting edema
Pertinent Results:
___ 10:31AM BLOOD WBC-29.4* RBC-5.06 Hgb-14.9 Hct-47.3
MCV-93 MCH-29.5 MCHC-31.5 RDW-12.8 Plt ___
___ 05:15AM BLOOD WBC-8.7 RBC-4.01* Hgb-12.0* Hct-37.1*
MCV-92 MCH-30.0 MCHC-32.5 RDW-13.0 Plt ___
___ 03:15AM BLOOD Glucose-119* UreaN-18 Creat-0.5 Na-137
K-4.5 Cl-96 HCO3-38* AnGap-8
___ 06:35AM BLOOD UreaN-14 Creat-1.0 Na-132* K-3.5 Cl-93*
HCO3-37* AnGap-6*
___ 05:15AM BLOOD UreaN-12 Creat-1.0 Na-132* K-4.5 Cl-91*
HCO3-35* AnGap-11
___ 05:20AM BLOOD ALT-35 AST-65* AlkPhos-73 TotBili-1.8*
___ 05:20AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.9
___ 02:45PM BLOOD Osmolal-270*
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 06:48AM URINE Hours-RANDOM UreaN-328 Na-65 K-27 Cl-88
___ 06:48AM URINE Osmolal-342
___ 2:14 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
THIS IS A CORRECTED REPORT (___).
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN
CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
.
PREVIOUSLY REPORTED AS.
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA
(___).
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
WORK-UP PER ___ ___ (___).
BETA STREPTOCOCCUS GROUP C. MODERATE GROWTH.
ENTEROBACTER AEROGENES. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/tazobactam sensitivity testing available
on request.
ACINETOBACTER BAUMANNII COMPLEX. SPARSE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. SPARSE
GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
| ACINETOBACTER BAUMANNII
COMPLEX
| |
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S 4 S
CEFTAZIDIME----------- <=1 S 8 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- <=0.12 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 8:41 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___. ___ ___ 08:30AM.
STREPTOCOCCUS ANGINOSUS (___) GROUP. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
CXR: IMPRESSION: Widespread opacification of the right
mid-to-lower hemithorax with mass effect, suspected to represent
a pleural effusion at least in part, including a possible large
loculated component; a mass could also be considered, in
addition to widespread atelectasis or pneumonic consolidation.
CTAP:IMPRESSION: ___. Large loculated right pleural
effusion; saccular bronchiectasis of the bilateral lower lobes
and consolidation of the right middle and right lower lobes with
heterogeneous hypoenhancement and rounded hypodensities that may
represent either the underlying saccular bronchiectasis versus
multifocal necrotizing pneumonia. 2. Cholelithiasis without
cholecystitis. 3. Hilar lymphadenopathy may be reactive; follow
up imaging after treatment is recommended to ensure resolution.
CXR: ___ Right lower lobe opacity a combination of
consolidation and pleural effusion has increased. Left lower
lobe retrocardiac consolidation has worsened consistent with
worsening atelectasis and/or pneumonic consolidation. There is
no evident pneumothorax. Cardiac size cannot be evaluated, is
obscured by the pleuroparenchymal abnormalities.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Atrius.
1. Amlodipine 5 mg PO DAILY
hold for SBP<100,
2. Clonazepam 1 mg PO BID:PRN anxiety
3. Vitamin D 1000 UNIT PO DAILY
4. Kaletra 2 TAB PO BID
5. Loratadine *NF* 10 mg Oral daily
6. Beclomethasone Dipro. AQ (Nasal) *NF* 42 mcg Other TID
7. Truvada 1 TAB PO DAILY
8. Ketoconazole 2% 1 Appl TP BID
9. Methadone
Discharge Medications:
1. Amlodipine 5 mg PO BID
hold for SBP < 105
2. Clonazepam ___ mg PO BID:PRN anxiety
hold pls if sedated or RR < 10
RX *clonazepam 1 mg ___ tablet(s) by mouth twice per day Disp
#*5 Tablet Refills:*0
3. Kaletra 2 TAB PO BID
4. Truvada 1 TAB PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipat
8. CefePIME 1 g IV Q12H
continue through ___
9. Docusate Sodium 100 mg PO BID
10. Heparin 7500 UNIT SC TID
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Methadone 90 mg PO DAILY
hold for sedation, RR<10
RX *methadone 10 mg 9 tabs by mouth daily Disp #*18 Tablet
Refills:*0
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
continue through ___
15. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
HOLD for sedation, RR<12, confusion
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*15 Tablet Refills:*0
16. Polyethylene Glycol 17 g PO DAILY
17. Senna 1 TAB PO BID:PRN constipation
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
19. Beclomethasone Dipro. AQ (Nasal) *NF* 42 mcg Other TID
20. Loratadine *NF* 10 mg Oral daily
21. Vitamin D 1000 UNIT PO DAILY
22. Outpatient Lab Work
Diagnosis: empyema
CBC with differential (weekly) (x)
Chem 7 (weekly) (x)
BUN/Cr (weekly) (x)
AST/ALT (weekly) (x)
Alk Phos (weekly) (x)
Total bili (weekly) (x)
ESR/CRP (weekly) (x)
All laboratory results should be faxed to the ___
R.N.s at ___. All questions regarding outpatient
parenteral antibiotics should be directed to the ___
___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Empyema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
HISTORY: Acute shortness of breath.
COMPARISONS: None.
TECHNIQUE: Chest, semi-upright AP portable.
FINDINGS: There is widespread opacification of the right lower hemithorax
including a suspected large pleural effusion on the right with an expansile
appearance. There may be a corresponding consolidation or extensive
atelectasis involving the right lower lobe and possibly parts of the right
middle and upper lobe. The lenticular shape of right mid lung opacity could
potentially be seen with a loculated pleural effusion, but a mass could also
be considered. The cardiac, mediastinal and hilar contours appear within
normal limits. The left costophrenic sulcus is excluded, but there is no
evidence of abnormality in the left hemithorax. Mild mass effect with
leftward shift of midline structures is noted. There is no pneumothorax. No
bone destruction is appreciated.
IMPRESSION: Widespread opacification of the right mid-to-lower hemithorax
with mass effect, suspected to represent a pleural effusion at least in part,
including a possible large loculated component; a mass could also be
considered, in addition to widespread atelectasis or pneumonic consolidation.
Radiology Report
HISTORY: ___ male with new right pleural effusion and abdominal pain.
STUDY: CT of the torso with contrast; 150 cc of Omnipaque intravenous
contrast was administered without adverse reaction or complication. Coronal
and sagittal reformatted images were also generated.
COMPARISON: Chest radiograph from ___ at 9:59 a.m.
FINDINGS:
CHEST: The visualized portion of the thyroid appears unremarkable. Scattered
axillary and mediastinal lymph nodes are present, although none meet
pathologic size criteria. Multiple prominent bilateral hilar lymph nodes are
present measuring 14 mm in their short axis on the right and 12 and 6 mm in
their short axis on the left (601:45). The aorta is of a normal caliber along
its course with incidental note made of a common origin of the brachiocephalic
and left common carotid arteries, a normal variant. The pulmonary arterial
trunk caliber is at the upper limits of normal, and there are no central
filling defects.
Again is noted a large loculated effusion with minimally complex to simple
fluid, unlikely to be hemorrhagic. There is associated consolidation of
nearly all the right lower and right middle lobes as well as compressive
atelectatic effect on the right upper lobe. Portions of these collapsed lobes
show variable enhancement, and multiple rounded hypodensities may in fact
represent saccular bronchiectasis versus multiple foci of necrotizing
pneumonia. The left lung shows a clear upper lobe and saccular bronchiectasis
of the lower lobe with diffuse bronchial wall thickenking in addition to some
dependent atelectasis. There is no pleural effusion on the left, and there is
no pericardial effusion.
ABDOMEN: The liver shows no focal lesion or intrahepatic biliary dilatation.
Subtle dense material in the neck of the gallbladder may represent small
stones or sludge, but there is no pericholecystic fluid, wall edema or
gallbladder distention. The pancreas shows no masses or peripancreatic fluid
collections. The spleen is normal in size and appearance with a small 1-cm
splenule noted anteroinferiorly. The adrenal glands show no nodules. The
kidneys enhance with and excrete contrast symmetrically. Multiple
well-circumscribed hypodensities are present in both kidneys, too small to
characterize but likely representing simple cysts. The small and large bowel
show no evidence of obstruction or wall edema. The aorta, IVC and portal vein
appear normal. There is no free fluid, free air or lymphadenopathy.
PELVIS: The bladder, prostate and rectum appear unremarkable. There is no
pelvic lymphadenopathy or free fluid.
BONES: A Schmorl's node is present at the inferior endplate of L4 and T12.
Otherwise, there are no aggressive-appearing lytic or sclerotic lesions.
IMPRESSION:
1. Large loculated right pleural effusion; saccular bronchiectasis of the
bilateral lower lobes and consolidation of the right middle and right lower
lobes with heterogeneous hypoenhancement and rounded hypodensities that may
represent either the underlying saccular bronchiectasis versus multifocal
necrotizing pneumonia.
2. Cholelithiasis without cholecystitis.
3. Hilar lymphadenopathy may be reactive; follow up imaging after treatment
is recommended to ensure resolution.
Radiology Report
HISTORY: Right pigtail catheter placed for pleural effusion, check position.
The pigtail catheter is curled up in the right outer lower chest. There has
been a marked reduction in the size of the right pleural effusion. There is
some effusion and probably atelectasis is still present.
Radiology Report
INDICATION: History of HIV, on HAART, initially presenting with shortness of
breath, found to have a large right pleural effusion, status post chest tube
placement. Evaluate for interval change in effusion and assess for possible
loculations.
TECHNIQUE: MDCT axial images were acquired through the chest without the
administration of intravenous contrast material. Multiplanar reformats were
performed.
COMPARISON: CT torso from ___.
CHEST CT: There has been interval placement of a right pigtail catheter from
an intercostal approach, with the pigtail located in the mid anterolateral
pleural space. Although there has been a substantial decrease in size of the
free-flowing right pleural effusion, the posterior component is not
significantly changed in size, as fluid in the dependent portion of the
pleural space is not accessible to the anteriorly positioned pigtail catheter
with the patient in a supine position. A tiny left pleural effusion is new.
The visualized portion of the thyroid gland is unremarkable. Multiple
prominent mediastinal lymph nodes are not significantly changed in overall
size or distribution, measuring up to 10 mm in the right paratracheal region
(2:24). Assessment for hilar lymphadenopathy is limited secondary to lack of
intravenous contrast material. There are no pathologically enlarged axillary
lymph nodes. Minimal aortic calcification is noted.
There is persistent near complete collapse/consolidation of the right lower
lobe, with aeration in this region slightly improved compared to the prior
study. Given the lack of intravenous contrast material, previously seen
rounded hypodensities within the right lower lobe consolidation cannot be
assessed on the present study. Aeration of the right middle lobe is
substantially improved. There is severe left lower lobe bronchiectasis with
surrounding cicatricial atelectasis/fibrosis, not significantly changed in
appearance. There is biapical bullous change, as before. The left upper lung
and lingula are well aerated. The central airways are patent. This study was
not optimized for evaluation of the subdiaphragmatic contents. A cluster of
small lymph nodes near the gastroesophageal junction is not significantly
changed in appearance. The remainder of the visualized portion of the upper
abdomen is unremarkable.
BONE WINDOW: No suspicious lytic or blastic lesions are identified.
IMPRESSION:
1. Decreased size of large right free-flowing pleural effusion, status post
placement of a percutaneous pigtail catheter. Given anterior positioning of
the pigtail catheter within the pleural space, right lateral decubitus patient
positioning may be helpful in allowing further drainage of this effusion.
2. Slight improvement in right lower lobe aeration. Previously seen rounded
hypodensities within the right lower lobe cannot be assessed on the present
study given the lack of intravenous contrast. Of note, these rounded
hypodensities were previously thought to be either mucous-filled saccular
bronchiectasis or areas of parenchymal necrosis.
3. Markedly improved aeration of the right middle lobe.
4. Unchanged extensive left lower lobe bronchiectasis.
Findings were discussed with Dr. ___ by Dr. ___ at 6:52 p.m. via
telephone on the day of the study.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: Patient with known empyema. Newly hypoxic. Rule out acute
process.
COMPARISON: ___.
FINDINGS:
Right lower lung mild-to-moderate pleural effusion has slightly improved with
pigtail projecting in mid hemithorax. There is no pneumothorax. Left lower
lobe consolidation has significantly improved. There is no new consolidation.
Mediastinal and cardiac contours are normal.
CONCLUSION:
1. Right small-to-moderate pleural effusion has slightly improved.
2. Left lower lobe consolidation has significantly improved.
Radiology Report
INDICATION: ___ male with empyema.
COMPARISON: Comparison is made with chest radiographs from ___
and ___.
FINDINGS: Single frontal image of the chest demonstrates well-expanded lungs.
The hazy opacity in the right lung base is again seen, unchanged from previous
imaging but much improved from earlier images. The left lung is clear. There
is no left pleural effusion. There is no pneumothorax. Cardiomediastinal
silhouette is unremarkable.A chest tube is again seen in place.
IMPRESSION: Right basilar opacity consistent with empyema, unchanged from
most recent imaging.
Radiology Report
AP CHEST, 1:01 A.M. ON ___
HISTORY: ___ man with empyema, hypoxia, and tachypnea.
IMPRESSION: AP chest compared to ___:
Moderate volume of residual right pleural effusion, and attendant atelectasis
or consolidation in the right lower lung have not improved since at least
___, despite the right pleural pigtail catheter in the lower chest
laterally. No pneumothorax is present. There is new consolidation at the
left lung base, which could be either atelectasis or new pneumonia. If the
patient can tolerate conventional radiographs, these, rather than bedside
studies, should be obtained. The heart size is normal.
Findings were discussed by telephone with the resident physician caring for
this patient at 9:03 a.m.
Radiology Report
INDICATION: ___ male with new PICC line.
COMPARISON: Comparison is made with chest radiographs from ___.
FINDINGS: Single frontal image of the chest demonstrates a right-sided PICC
line in place with the tip in the low SVC. There is no pneumothorax or other
complication seen. Again seen is a right pleural effusion that is unchanged
from previous exam. Right base atelectasis and right perihilar atelectasis
are also again seen unchanged. Right pigtail catheter is seen in same place
in the right chest. Atelectasis at the left lower lung base is unchanged.
Cardiomediastinal silhouette is stable but is partially obscured by the
right-sided pleural effusion and atelectasis.
IMPRESSION: New right-sided PICC in place with the tip in the low SVC,
otherwise unchanged chest radiograph.
These findings were communicated to ___ with IV nursing team at 11:36 a.m.
by phone.
Radiology Report
INDICATION: ___ man with empyema.
COMPARISON: ___ to ___.
FINDINGS: A moderate right pleural effusion is unchanged. A right-sided
pigtail catheter is in stable position, now above the meniscus of the
effusion. A right-sided PICC line terminates at the cavoatrial junction.
Left basal atelectasis is mild. The upper lungs are clear. There is no new
consolidation, effusion or pneumothorax. No new abnormal cardiac or
mediastinal contour.
IMPRESSION: Stable appearance of right pleural effusion.
Radiology Report
HISTORY: Empyema with chest tube.
FINDINGS: In comparison with study of ___, there is little overall change.
The opacification at the right base persists with the pigtail catheter
projected just above it. Opacification consistent with atelectasis and
effusion is also again seen at the left base and the central catheter remains
in place.
Radiology Report
HISTORY: PICC placement.
FINDINGS: In comparison with the study of ___, the tip of the PICC line is
again in the mid-to-lower portion of the SVC. The moderate right effusion is
essentially unchanged with a pigtail catheter above the level of the fluid
collection. Streak of atelectasis is seen at the left base and there is a
region of the retrocardiac opacification consistent with volume loss in the
left lower lobe.
No definite vascular congestion.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Patient with empyema with manipulation of pigtail catheter.
Comparison is made with prior study performed a day earlier.
The right pigtail catheter now is almost straight, with small distal loop.
Right PICC tip is in the low SVC. There are low lung volumes.
Right lower lobe opacity a combination of consolidation and pleural effusion
has increased. Left lower lobe retrocardiac consolidation has worsened
consistent with worsening atelectasis and/or pneumonic consolidation. There
is no evident pneumothorax. Cardiac size cannot be evaluated, is obscured by
the pleuroparenchymal abnormalities.
Radiology Report
HISTORY: Right effusion status post chest tube removal, to assess for
pneumothorax.
FINDINGS: In comparison with the study of ___, the right chest tube has been
removed and there is no evidence of pneumothorax. Otherwise, little change.
Gender: M
Race: UNABLE TO OBTAIN
Arrive by UNKNOWN
Chief complaint: SOB
Diagnosed with PLEURAL EFFUSION NOS, HYPOXEMIA, ASYMPTOMATIC HIV INFECTION
temperature: 98.1
heartrate: 110.0
resprate: 24.0
o2sat: 91.0
sbp: 127.0
dbp: 81.0
level of pain: 0
level of acuity: 1.0 | ___ with HIV on HARRT (CD4 count of 800), HCV (failed
treatment), history of IVDU on methadone, who presented with
dyspnea and was found to have pneumonia and empyema. He was
treated with antibiotics and had a chest tube placed. The
cultures from the sputum and pleural fluid returned and he was
switched to IV cefepime and PO flagyl for a 4 week course. ID
will follow as an outpatient.
# Pneumonia with empyema: He had hypoxemia, pneumonia and a
large empyema on chest CT. He was initially started on
vancomycin, cefepime, and levofloxacin. Interventional
pulmonology placed a chest tube on ___. The effusion was
loculated and required tPA and ___ injections. The results of
the pleural effusion cultures were strep milleri species. Sputum
cultures grew Beta streptococcus group C, enterobacter
aerogenes, acinetobacter baumannii complex, haemophilus
influenza and beta lactamase negative (see results secontion).
He improved with treatment and drainage and his chest tube was
pulled on ___. He was seen by infectious disease specialists
who recommended a 4 week course of cefepime and flagyl. He will
need to continue this until ___ (and will need to be seen
by ID prior to discontinuation). A picc line was placed. He
should not be discharged from rehab with the ___ as he is at
risk of IVDU. After completion of his antibiotics this should be
removed. At the time of discharge he was on 1L NC.
# Opioid dependence: He takes 91mg of methadone per day (Habit
OPAC on ___.). He was continued on methadone 90mg per day.
He is at risk of abuse of the PICC. This should be removed prior
to discharge. He is also getting oxycodone as needed for pain.
# Chronic CO2 retention: Likely secondary to COPD or obesity
hypoventilation syndrome. He has been relatively stable with NC
and has not required positive pressure ventilation. This should
be evaluated further after discharge. He was treated with PRN
nebulizers.
# Hyponatremia: He had hyponatremia. Initially he was treated
with IVF with some improvement in his sodium. However, the urine
lytes were suggestive of SIADH. Thus, he was put on a fluid
restriction. However, the patient was unhappy with this and
refused to comply. His Na was stable at 132 without treatment.
Sodium should be checked a couple of times per week to make sure
it is stable at rehab.
# HIV: His most recent CD4 count is 875 with a viral load of
2422. He should be continued on truvada and kaletra.
# Hypertension: He was continue on amlodipine BID. Blood
pressures largely controlled.
# Anxiety: He was continued on his clonazepam.
# Constipation: he was writted for a bowel regimen
# Asthma: stable, continued on inhalers. |
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 swelling
Major Surgical or Invasive Procedure:
___: large volume paracentesis (8L)
___: large volume paracentesis (10L)
History of Present Illness:
HISTORY OF THE PRESENTING ILLNESS:
Mr. ___ is a ___ who has not seen a physician ___ years who
presents with ascites and peripheral edema. Up until ___
the patient states that he was in his usual state of health with
no medical complaints. In ___ he experienced a fall and at that
time lost significant mobility. He noticed that his belly and
legs were swelling, as well as an enlargement of his scrotum
which he referred to as a "hernia." Of note, his brother says
that he has seen Mr. ___ have a gradual decline in activity
over the course of roughly ___ years.
He endorses an alcohol use history of roughly 6 beers per day
for ___ years while working, then ___ years of drinking ___
beers/day in retirement, with a recent reduction to ___
beers/day since his fall in ___. He denies any recreational
drug use. He endorses a morning cough productive of clear
sputum, difficulty urinating, and a "pink" colored urine. He
denies fever, chills, night sweats, chest pain and tightness,
orthopnea, PND, abdominal pain, hematochezia, or melena.
Past Medical History:
None (has not seen a physician ___ ___ years)
Social History:
___
Family History:
Mother - stroke
Physical ___:
============================
ADMISSION PHYSICAL EXAM:
Vital Signs: BP 124/69, HR 119, RR 21, O2 96RA
General: Weathered appearing with decreased muscle mass, alert,
oriented, no acute distress, notably jaundiced and malodorous
HEENT: Sclerae icteric, MMM, OP clear with poor dentition
Neck: JVP difficult to assess at 45 degrees
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Absent breath sounds at the bases bilaterally. No
crackles, wheezes, or rhonchi
Abdomen: Soft, distended, with dullness at the flanks. No
organomegaly, no rebound or guarding.
GU: Large scrotal edema, no foley
Ext: Extensive pitting edema to the thighs bilaterally. Warm,
well perfused, 2+ pulses.
Skin: Jaundiced, small stage 2 ulcer in the gluteal fold,
superficial erythema in the left inguinal fold with a small 1 cm
skin erosion
Neuro: No asterixis. Slight tremor of the hands with arms
extended.
============================
DISCHARGE PHYSICAL EXAM:
Vital Signs: T 98.0, BP 129 / 57, HR 85, RR 18, O2 94 RA
Weight: ___: 93.3
General: Weathered appearing with decreased muscle mass, alert,
oriented, no acute distress, notably jaundiced and malodorous
HEENT: Sclerae icteric, MMM, OP clear with poor dentition
Neck: JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB
Abdomen: Soft, distended, with dullness at the flanks. No
organomegaly, no rebound or guarding.
GU: Large scrotal edema, no foley
Ext: Edema much improved with thigh high compression stalkings.
Warm, well perfused, 2+ pulses.
Skin: Jaundiced
Neuro: No asterixis. Slight tremor of the hands with arms
extended.
Pertinent Results:
====================
ADMISSION LABS:
___ 11:25PM BLOOD WBC-7.2 RBC-3.09* Hgb-11.1* Hct-33.4*
MCV-108* MCH-35.9* MCHC-33.2 RDW-15.6* RDWSD-62.5* Plt Ct-91*
___ 11:25PM BLOOD ___ PTT-50.9* ___
___ 11:25PM BLOOD Glucose-102* UreaN-11 Creat-0.8 Na-131*
K-3.7 Cl-98 HCO3-24 AnGap-13
___ 11:25PM BLOOD ALT-19 AST-48* AlkPhos-108 TotBili-4.8*
DirBili-2.1* IndBili-2.7
___ 11:25PM BLOOD cTropnT-<0.01
___ 11:25PM BLOOD Albumin-1.9* Calcium-7.8* Phos-3.0 Mg-1.8
===========================
OTHER PERTINENT LABS:
___ 09:37AM BLOOD ANTI-LIVER-KIDNEY-MICROSOME ANTIBODY-Test
___ 09:37AM BLOOD HCV Ab-Negative
___ 09:00AM BLOOD IgG-1493 IgA-1204* IgM-65
___ 07:49AM BLOOD PEP-NO MONOCLO FreeKap-95.1*
FreeLam-94.0* Fr K/L-1.0
___ 09:37AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Negative IgM HAV-Negative
___ 09:37AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 09:37AM BLOOD AFP-3.7
___ 08:10AM BLOOD TSH-2.1
___ 08:10AM BLOOD Triglyc-43 HDL-LESS THAN
___ 07:35AM BLOOD LDLmeas-12
___ 08:10AM BLOOD %HbA1c-4.3 eAG-77
___ 09:37AM BLOOD calTIBC-82* Ferritn-989* TRF-63*
___ 08:10AM BLOOD proBNP-3675*
=====================
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-5.5 RBC-2.70* Hgb-9.7* Hct-28.3*
MCV-105* MCH-35.9* MCHC-34.3 RDW-15.9* RDWSD-61.1* Plt Ct-92*
___ 06:20AM BLOOD ___ PTT-53.6* ___
___ 06:20AM BLOOD Glucose-115* UreaN-15 Creat-0.7 Na-130*
K-3.9 Cl-93* HCO3-27 AnGap-14
___ 06:20AM BLOOD ALT-15 AST-40 LD(LDH)-119 AlkPhos-85
TotBili-3.8*
___ 06:20AM BLOOD Albumin-2.3* Calcium-8.0* Phos-3.5 Mg-1.8
========================
MICROBIOLOGY:
Peritoneal fluid culture ___ - Negative
Blood culture ___ x2 - negative
========================
IMAGING:
___ EGD
IMPRESSION:
No esophageal varices noted. Irregular z-line was noted.
Erythema, friability and mosaic appearance in the stomach
compatible with PHG
Erythema and tiny erosions in the bulb compatible with
duodenitis
Otherwise normal EGD to third part of the duodenum
___ TTE
IMPRESSION:
1) Moderate LV dilation and moderate global left ventricular
systolic dysfunction in the setting of LBBB and LBBB related
septal dyssynchrony as well as septal atrophy suggestive of
diffuse cardiomyopathic process.
2) Moderate mitral regurgitation and mild mitral annular
calcification with mild functional mitral stenosis.
3) Judging from the respirophasic variation of the IVC RA
pressure is not elevated. However, there is significant
interstitial/extravascular volume overload with pleural
effusions and ascites.
-----------------
___ CT Abdomen and Pelvis
IMPRESSION:
1. Cirrhotic liver without evidence of an enhancing lesion.
2. No evidence of portal venous thrombosis.
3. Large abdominal ascites.
4. Moderate lumbar spondylosis including age-indeterminate L4
compression deformity.
-----------------
___ CTA Chest
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Mild to moderate central bronchial wall thickening is most
likely due to airway inflammation.
3. Mild to moderate bibasilar atelectasis.
4. Enlargement of the main pulmonary artery up to 3.5 cm raises
the
possibility of pulmonary arterial hypertension.
5. Large amount of simple ascites in the upper abdomen and
bilateral
gynecomastia.
-----------------
___ abdominal ultrasound
1. Minimal sludge in the gallbladder. No indication of
obstructed
common duct.
2. Poor flow in the portal vein and question partial thrombosis.
3. Massive ascites.
4. Tiny left pleural effusion.
=============================
OTHER STUDIES:
___ Paracentesis
WBC 160 (24% poly, 16% lymph, 0% mono, 1% meso, 59% macrophage)
RBC 499
Pro 1.7
Glu 106
LDH 48
Amylase 10
Albumin 0.7
Gram stain: negative
Cultures: negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Furosemide 20 mg PO BID
RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Midodrine 10 mg PO BID
Take at 8 AM and 2PM
RX *midodrine 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Sodium Chloride Nasal ___ SPRY NU QID:PRN epistaxis, nasal
dryness
RX *sodium chloride [Saline Nasal] 0.65 % ___ spray intra nasal
BID:PRN Disp #*1 Bottle Refills:*0
8. Spironolactone 50 mg PO BID
RX *spironolactone 50 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
10.Outpatient Lab Work
Please check CBC, Chem10, LFTs on ___ and fax to 1)
___ Attn. Dr. ___ 2) ___ Attn. Dr.
___
11.Durable Medical Equipment
Rolling Walker
orthostatic hypotension. ICD 10: I95.1.
Duration: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: decompensated cirrhosis, alcohol-induced
Secondary diagnosis: chronic systolic heart failure, orthostatic
hypotension, protein energy malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen with contrast.
INDICATION: ___ year old man with ascites and new diagnosis this admission of
decompensated cirrhosis who was found to have a questionable portal vein
thrombus on ultrasound. // Please evaluate for portal vein thrombosis, masses
TECHNIQUE: Multiphasic Liver: Multidetector CT of the abdomen was done
without and with IV contrast. Initially, the abdomen was scanned without IV
contrast. Subsequently, a single bolus of IV contrast was injected and the
abdomen was scanned in the early arterial phase, followed by a scan of the
abdomen in the portal venous phase, followed by a scan of the abdomen in
equilibrium phase (3-min delay).
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 2,794 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Small bilateral pleural effusions, left greater than right, are
increased on the left and new on the right. Mild bilateral lower lobe
consolidations, right greater the left, appear similar to prior.
ABDOMEN:
HEPATOBILIARY: There is a shrunken, nodular liver, consistent with cirrhosis.
Hypertrophy of the caudate lobe is noted. A subcentimeter hypoattenuating
focus in segment 6 statistically represents a cyst. Otherwise no focal liver
lesions are identified. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder contains gallstones without wall
thickening or surrounding inflammation. Large amount of ascites are seen
throughout the included abdomen.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The decompressed stomach is unremarkable. Included small
bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. The visualized colon appears within normal limits.
LYMPH NODES: There are prominent portacaval lymph nodes, for example on
series 3b, image 219, there is a 3.1 x 1.9 cm lymph node. There is no
retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: The left and right intrahepatic portal veins are patent. The main,
superior mesenteric, and splenic veins are patent as well. Large varices are
noted in the region of the porta hepatis and upper abdomen. Incidental note
is made of a replaced left hepatic artery from the left gastric artery. There
is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted.
BONES: Degenerative changes are seen in the included upper lumbar spine,
including moderate compression deformity of L4, potentially related to a large
Schmorl's node
SOFT TISSUES: There is moderate anasarca. Bilateral gynecomastia is present.
IMPRESSION:
1. Cirrhotic liver without evidence of an enhancing lesion.
2. No evidence of portal venous thrombosis.
3. Large abdominal ascites.
4. Moderate lumbar spondylosis including age-indeterminate L4 compression
deformity.
Radiology Report
INDICATION: History: ___ with cirrhosis, DVT, tachycardia // Eval for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 9.1 mGy (Body) DLP = 4.6
mGy-cm.
2) Spiral Acquisition 3.4 s, 26.4 cm; CTDIvol = 13.9 mGy (Body) DLP = 365.9
mGy-cm.
Total DLP (Body) = 370 mGy-cm.
COMPARISON: None available
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The main pulmonary artery measures up to 3.5 cm. There
is coronary artery calcification. 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: There is a small left pleural effusion. No pneumothorax.
LUNGS/AIRWAYS: Evaluation is limited by respiratory motion and expiratory
phase imaging. There is significant elevation of the right hemidiaphragm.
There is mild streaky left basilar atelectasis and moderate right basilar
atelectasis. No focal consolidation. There is mild-to-moderate central
bronchial wall thickening. The airways are patent to the level of the lobar
bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen demonstrates a large amount of
simple ascites.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
There is bilateral gynecomastia.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Mild to moderate central bronchial wall thickening is most likely due to
airway inflammation.
3. Mild to moderate bibasilar atelectasis.
4. Enlargement of the main pulmonary artery up to 3.5 cm raises the
possibility of pulmonary arterial hypertension.
5. Large amount of simple ascites in the upper abdomen and bilateral
gynecomastia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Abdominal distention, B Leg swelling
Diagnosed with Abdominal distension (gaseous)
temperature: 97.3
heartrate: 124.0
resprate: 20.0
o2sat: 97.0
sbp: 115.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | SUMMARY:
Mr. ___ is a ___ year old male who had not seen an MD in
over ___ years prior to his presentation with volume overload
which was eventually diagnosed as decompensated alcohol-induced
cirrhosis. Patient had 48.5 lbs of fluid removed via a
combination of multiple large volume paracentesis and diuretics,
and further diuresis was limited by orthostasis, for which
midodrine therapy was initiated. A screening EGD showed no
gastro-esophageal varices. He did not display any signs of
hepatic encephalopathy. He had obvious protein-energy
malnutrition, for which Ensure Enlive with breakfast, lunch, and
dinner was recommended.
Given his elevated BNP on admission, an echocardiogram was
ordered which showed an EF of 35-40% with diffuse LV
dysfunction, suggesting a global cardiomyopathic process such as
alcohol cardiomyopathy. Cardiology evaluated patient and
deferred catheterization and recommended an outpatient
ischemic/viability workup with possibily a cardiac MRI. Given
his lack of elevated JVP, we tried to initiate beta blocker
therapy but coreg 3.125 BID was poorly tolerated as he developed
symptomatic orthostasis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ankle pain s/p fall
Major Surgical or Invasive Procedure:
Open Reduction Internal Fixation of Right Ankle trimalleolar
fracture dislocation.
History of Present Illness:
___ year old male w/ uncomplicated ___ presents s/p fall
during a baseball game this evening in which he sustained a
right
ankle injury. He had immediate pain and inability to bear weight
and was taken to ___ for further management.
ROS: No chest pain, shortness of breath, headache, vision
change,
abdominal pain, no weakness outside of H&P
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
AVSS
A&O x 3
Calm and comfortable
CV: RRR
PULM: CTAB
MSK:
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
Radial/Median/Ulnar/Axillary SITLT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Fires biceps/triceps/deltoid
RLE with incision clean/dry/intact
No erythema, induration, fluctuance or drainage
Thighs and legs are soft
Sensation: Saph Sural DPN SPN MPN LPN SITLT
Motor strength ___ R hip flexion, ___ R quad/ham, ___ Right
___,
unable to assess R ankle strength/gastr/TA ___ RLE posterior
splint knee to ankle
WWP
Contralateral extremity examined with good range of motion,
SILT, motors intact and no pain or edema
Pertinent Results:
___ 05:57AM BLOOD WBC-7.1 RBC-3.58* Hgb-10.9* Hct-33.1*
MCV-92 MCH-30.5 MCHC-33.0 RDW-11.9 Plt ___
___ 05:06AM BLOOD Glucose-113* UreaN-11 Creat-0.8 Na-136
K-4.9 Cl-100 HCO3-28 AnGap-13
___ 05:06AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.0
Medications on Admission:
None
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours).
Disp:*14 syringe* Refills:*0*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3h as needed for
Pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Ankle trimalleolar fracture dislocation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Right ankle injury with obvious deformity. For assessment.
TECHNIQUE: Multiple views were obtained.
REPORT: Comminuted complex fracture of the distal fibula with a spiral
fracture of the distal one-third of the shaft as well as further damage at the
ankle mortise where malleolar fractures are seen
There is significant separation of fragments and there is an apparent near
complete tibiotalar dislocation.
CONCLUSION:
Complex comminuted fracture dislocation.
Radiology Report
INDICATION: Patient with right ankle fracture and dislocation status post
reduction.
COMPARISONS: Pre- and post-reduction right ankle radiographs dated ___.
TECHNIQUE: MDCT-acquired contiguous images were obtained through the right
ankle without intravenous contrast at 1.25 mm slice thickness. Coronally and
sagittally reformatted images were displayed.
FINDINGS:
There is a displaced comminuted fracture involving medial malleolus. There is
apparent widening of the medial mortise. A 5 mm bony fracture fragment is
seen within the joint space superior to the talar dome. A posterior malleolar
fracture is also noted with approximately 5.7 mm distraction of the fracture
fragment. There is an oblique comminuted fracture involving the distal fibula
with intra-articular extension. There is likely disruption of tibiofibular
syndesmosis. Lateral malleolus (more distal fibula) appears intact. There is
extensive soft tissue edema overlying the right ankle. Small joint effusion
is noted.
The subtalar joint appears intact. There is no apparent fracture involving
talus or calcaneus. Tarsal bones are intact without dislocation. Normal
anatomic articulation of tarsal and metatarsal bones are maintained.
There is some bony rarefaction at the base of the ___ metatarsal (2:147-149)
without deifnite fracture line.
No suspicious lytic or sclerotic bony lesion is seen. Bone mineralization
otherwise appears normal.
IMPRESSION:
1)Displaced comminuted fractures involving medial malleolus and posterior
tibia tubercle. 5 mm intra-articular fracture fragment.
2) An oblique fracture involving the distal fibula with intra-articular
extension. 3) Medial mortise is widened. There is likely disruption of the
tibiofibular syndesmosis.
4) Some bony rarefaction at the base of the ___ metatarsal, without definite
fracture line. Attention to this on follow-up films is recommended.
Radiology Report
INDICATION: ___ male with right ankle dislocation status post
reduction.
COMPARISON: Ankle radiographs done on ___ at 21:00 hours.
RIGHT ANKLE RADIOGRAPH, THREE VIEWS: The overlying plaster splint obscures
bony detail. There has been interval reduction of previously seen tibiotalar
dislocation. There is mild persistent widening of the anterior tibiotalar
joint space. The talar dome apepars intact. Mildly displaced fracture of the
medial and posterior malleoli and a spiral fracture through the distal fibula
are redemonstrated.
RIGHT KNEE RADIOGRAPH, TWO VIEWS: The overlying cast obscures fine bony
detail. Within this limitation, no acute fracture or joint effusion is
detected in the knee.
IMPRESSION:
1. Interval reduction of previously seen tibiotalar dislocation, with
persistent mild widening of the anterior tibiotalar joint space. Complex
trimalleolar fractures, better evaluated in the concurrent CT study.
2. No acute fracture or joint effusion in the right knee.
Radiology Report
STUDY: 13 intraoperative fluoroscopic images of the right ankle ___.
COMPARISON: Radiographs ___.
INDICATION: ORIF right ankle.
FINDINGS AND IMPRESSION: Multiple views of the right ankle. Status post
bimalleolar ORIF. The hardware appears intact. Improved alignment of the
ankle. Posterior malleolus fracture is again noted, mildly displaced. Total
intraoperative fluoroscopic imaging time 146.4 seconds. Please see operative
report for further details.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RIGHT ANKLE INJURY
Diagnosed with FX TRIMALLEOLAR-CLOSED, OTHER FALL, ACTIVITIES INVOLVING BASEBALL
temperature: 99.0
heartrate: 108.0
resprate: 28.0
o2sat: 100.0
sbp: 160.0
dbp: 100.0
level of pain: 10
level of acuity: 2.0 | The patient was admitted to the Orthopaedic Trauma Service for
repair of a right trimalleolar ankle fracture. The patient was
taken to the OR and underwent an uncomplicated open reduction
internal fixation right trimalleolar ankle fracture without
fixation of the posterior malleolus. 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 a PCA with a
transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
progress with ___.
Weight bearing status: Right lower extremity non-weight bearing
The patient received ___ antibiotics as well as
Lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge home and the patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F with history of type 2 diabetes, atrial fibrillation,
chronic heart failure, and CAD who was found down in her home
after EMS was called by her family, who had not heard from the
patient. EMS arrived to find patient minimally responsive,
laying on floor, and covered in stool. Patient reported to the
ED that she normally sleeps in her recliner. She remembers
falling asleep in recliner and does not know how she got to the
floor. No chest pain at presentation, but did have some dyspnea.
In the ED reportedly had some abdominal pain, nausea, vomiting
and diarrhea.
In the ED, initial vs were: T 98.7, HR 100, BP 141/61, RR 15,
O2Sat 96% on RA. Labs at presentation were significant for a WBC
count of 13.5, bicarb of 17, anion gap of 30, glucose of 654, CK
of 2140, slight elevation in transaminases, and lactate of 9.9.
An insulin drip was started and 2 L IVF fluid resuscitation were
given. Imaging in the ED included a CXR, CT head, CT c-spine,
and CT abdomen and pelvis. Aside from some "fluffiness" to the
CXR, all imaging was reportedly unrevealing on preliminary
review by radiology. Prior to transfer to the MICU, VS were: T
98.9, HR 118, BP 142/44, RR 29, O2Sat 95% on 2L/min.
On the floor, she initially too somnolent to extract much
additional history. She reported dry mouth and thirst. Also
reported some diarrhea at home for about ___ days
Past Medical History:
1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
1. Cardiac catheterization, ___: 30% ___ LAD, 30% mid
LAD, 90% D1 (status post BMS), increased LV filling pressure
(LVEDP 18).
2. Echocardiogram, ___: ___, mild LVH, LVEF 60%, cannot
assess regional wall motion, mildly dilated ascending aorta,
minimal AS, borderline pulmonary artery systolic hypertension.
3. Nuclear Persantine stress test, ___: No symptoms, no
ECG changes, normal wall motion, normal perfusion, LVEF 59%, no
change versus ___.
4. Holter monitor, ___: Normal sinus rhythm, normal
intervals, no significant pauses, rare isolated APBs, three
atrial couplets, one atrial triplet, trivial isolated
ventricular
ectopy, three or four symptomatic episodes showed normal sinus
rhythm without ectopy or ST-T wave changes.
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to D1 in ___ as above
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
ASTHMA
COLON POLYP, ___ polypectomy
CORONARY ARTERY DISEASE, s/p stent ___
DEPRESSION
DYSPEPSIA
HYPERCHOLESTEROLEMIA
HYPERTENSION
INSULIN DEPENDENT DIABETES MELLITUS
IRRITABLE BOWEL SYNDROME
OBESITY
OSTEOARTHRITIS
SLEEP STUDY-DIAGNOSTIC
CELLULITIS
PERIPHERAL NEUROPATHY
Social History:
___
Family History:
Her father died at age ___ of unknown causes. He
suffered from several strokes. He sustained his first MI in his
___ and also had diabetes. Her mother died at age ___ of a
stroke. She has two brothers, two sisters, and no children. All
of her siblings suffer from hypertension. She has one sister who
died of a myocardial infarction at age ___, she suffered from
diabetes. One brother has diabetes. There is no family history
notable for hyperlipidemia or sudden cardiac death.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: see below
General: AOx2, somnolent but arousable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, c-spine collar in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardiac, no MRG
Abdomen: soft, +BS, obese, nontender
Ext: warm, well perfused, dry erythematous skin at feet with no
visable ulcers or skin breakdown
Discharge Physical Exam:
Vitals- T:99.1 165/68 72 24 100% 2LNC
General: AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Nl S1, S2, RRR no MRG
Abdomen: soft, +BS, obese, tenderness to palpation in the
epigastrum
Ext: warm, well perfused, erythematous skin bilaterally with a
band-aid on the right leg
Pertinent Results:
Admission Labs:
___ 11:45PM BLOOD WBC-13.5* RBC-4.61 Hgb-14.3 Hct-44.4
MCV-96# MCH-31.0 MCHC-32.2 RDW-14.3 Plt ___
___ 11:45PM BLOOD Neuts-89.3* Lymphs-5.4* Monos-4.6 Eos-0.2
Baso-0.5
___ 11:45PM BLOOD ___ PTT-24.8* ___
___ 11:45PM BLOOD Glucose-654* UreaN-31* Creat-1.4* Na-141
K-4.1 Cl-94* HCO3-17* AnGap-34*
___ 11:45PM BLOOD ALT-52* AST-96* CK(CPK)-2140*
AlkPhos-112* TotBili-1.4
Cardiac Enzymes:
___ 06:20AM BLOOD CK-MB-22* MB Indx-1.0 cTropnT-0.12*
___ 02:32PM BLOOD CK-MB-19* MB Indx-1.0 cTropnT-0.11*
___ 06:00PM BLOOD CK-MB-19* MB Indx-0.9 cTropnT-0.13*
___ 12:18AM BLOOD CK-MB-15* MB Indx-0.8 cTropnT-0.14*
___ 05:03AM BLOOD CK-MB-12* MB Indx-0.8 cTropnT-0.12*
___ 03:20PM BLOOD CK-MB-11* cTropnT-0.08*
Lactate:
___ 11:54PM BLOOD Lactate-9.9*
___ 02:06AM BLOOD Lactate-5.9*
___ 04:24AM BLOOD Lactate-6.3*
___ 06:26AM BLOOD Glucose-464* Lactate-6.1* Na-149* K-3.9
___ 09:32PM BLOOD Lactate-3.1* Na-146* K-3.9 Cl-106
___ 05:21AM BLOOD Lactate-2.9*
Imaging:
CXR 12.14:
No pneumothorax. Mild edema.
CT Head ___:
No acute intracranial process
CT Abdomen and pelvis ___:
1. No acute pathology.
2. Redemonstration of chronic findings, including
cholelithiasis and
hemorrhagic left renal cyst
CT C-spine ___:
No acute fracture or traumatic malalignment.
CXR ___:
As compared to the prior study obtained on ___ at
9:32 p.m.,
there is interval improvement in interstitial prominence and
vascular
engorgement but unchanged appearance of the prominence of the
azygos vein in vascular pedicle that is consistent with volume
overload, substantial but improving pulmonary edema.
Discharge Labs:
___ 07:05AM BLOOD WBC-11.3* RBC-4.03* Hgb-12.4 Hct-37.5
MCV-93 MCH-30.7 MCHC-33.0 RDW-14.0 Plt ___
___ 07:05AM BLOOD ___ PTT-30.3 ___
___ 07:05AM BLOOD Glucose-177* UreaN-32* Creat-1.1 Na-140
K-4.0 Cl-102 HCO3-26 AnGap-16
___ 07:05AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough, sob
2. Clopidogrel 75 mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Torsemide 100 mg PO DAILY
6. Warfarin 4 mg PO DAILY16
7. Losartan Potassium 50 mg PO DAILY
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Potassium Chloride (Powder) 20 mEq PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
11. Metolazone 2.5 mg PO 3X/WK diuresis
12. Gabapentin 600 mg PO Q12H
13. 70/30 85 Units Breakfast
70/30 85 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason:
14. Atorvastatin 10 mg PO DAILY
15. Ketoconazole 2% 1 Appl TP BID
16. Acetaminophen 650 mg PO Q8H:PRN pain
17. Aspirin 81 mg PO DAILY
18. Miconazole Powder 2% 1 Appl TP TID:PRN rash
19. Multivitamins 1 TAB PO DAILY
20. Lactaid (lactase) 3,000 unit Oral TID:prn with dairy
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
Hyperosmolar hyperglycemic state
Urinary tract infection
Secondary:
Diabetes Mellitus type 2
Atrial fibrillation
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
HISTORY: Found down.
COMPARISON: Chest radiograph ___.
FINDINGS:
Single AP view of the chest was reviewed. The cardiomediastinal and hilar
contours are stable given low lung volumes. There is no pneumothorax or large
pleural effusion. There is no focal consolidation. Mild pulmonary edema is
present.
IMPRESSION:
No pneumothorax. Mild edema.
Radiology Report
HISTORY: Found down.
COMPARISON: None.
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: 891.93 mGy-cm.
CTDIvol: 53.02 mGy.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect, or
infarction. The ventricles and sulci are mildly prominent, consistent with
age-related atrophy. Periventricular white matter hypodensities are
consistent with small vessel ischemic changes. The basal cisterns appear
patent, and there is preservation of gray-white matter differentiation.
There is no fracture. Calcifications of the carotid siphons is present.
Polypoid mucosal thickening of the right maxillary sinus with minimal mucosal
thickening of the left maxillary sinus is noted. Mucosal thickening of the
ethmoid air cells and sphenoid sinuses is also present. The mastoid air cells
and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
HISTORY: Found down.
COMPARISON: MR cervical spine ___.
TECHNIQUE: Axial MDCT images were taken from the skull base through the T1
level. Coronal and sagittal reformats were also examined.
DLP: 836.69 mGy-cm.
CTDIvol: 37.03 mGy.
FINDINGS:
There is no acute fracture or traumatic malalignment. Rounded calcific
densities to the left of midline anterior to the dens may represent soft
tissue calcifications. There is no prevertebral soft tissue swelling. Mild
multilevel degenerative changes are present. The visualized ouline of the
thecal sac is unremarkable. The lung apices are clear. There is no
lymphadenopathy by CT size criteria.
IMPRESSION:
No acute fracture or traumatic malalignment.
Radiology Report
HISTORY: Found on floor.
COMPARISON: CT abdomen pelvis ___. MRI abdomen ___.
TECHNIQUE: Axial MDCT images of the abdomen pelvis was obtained without IV or
oral contrast. Coronal sagittal reformats were also examined.
___: ___ mGy-cm
CTDIvol: 17.06 mGy.
FINDINGS:
The lung bases and visualized portions of the heart are unremarkable. The
liver shows fatty infiltration. Otherwise the noncontrast appearance of
liver, spleen, pancreas, and adrenal glands is unremarkable. Gallstones are
again seen in a nondistended gallbladder without pericholecystic stranding or
fluid. Again seen is a hyperdense lesion in the left kidney, stable and
previously characterized on MRI a as a hemorrhagic cyst. A small
nonobstructing stone is seen in the left kidney.
The small and large bowel maintain a normal caliber without any evidence of
wall thickening or obstruction. Atherosclerotic changes are present in the
abdominal aorta. There is no abdominal free air or free fluid. There is no
mesenteric or retroperitoneal lymphadenopathy.
The bladder is distended. There is no pelvic sidewall or inguinal
lymphadenopathy. Patient is status post hysterectomy. No suspicious lesions
are seen in the visualized osseous structures. Multilevel degenerative
changes are worst at L2-3 with endplate sclerosis.
IMPRESSION:
1. No acute pathology.
2. Redemonstration of chronic findings, including cholelithiasis and
hemorrhagic left renal cyst.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with congestive heart
failure, now with respiratory distress, re-assessment.
Portable AP radiograph of the chest was reviewed in comparison to ___.
As compared to the prior study, there is additional progression of vascular
engorgement, vascular indistinctness, dilatation of the vascular pedicle and
interstitial engorgement in the perihilar and lower lungs, finding consistent
with progression of pulmonary edema. Heart size and mediastinum appear to be
unchanged. Small pleural effusion is most likely present. There is no
evidence of pneumothorax.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after fluid resuscitation
and shortness of breath concerning for pulmonary edema.
AP chest radiograph.
As compared to the prior study obtained on ___ at 9:32 p.m.,
there is interval improvement in interstitial prominence and vascular
engorgement but unchanged appearance of the prominence of the azygos vein in
vascular pedicle that is consistent with volume overload, substantial but
improving pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FOUND DOWN
Diagnosed with ALTERED MENTAL STATUS , DEHYDRATION, VOMITING
temperature: 98.7
heartrate: 100.0
resprate: 15.0
o2sat: 96.0
sbp: 141.0
dbp: 61.0
level of pain: 13
level of acuity: 1.0 | Ms. ___ is a ___ yo F with history of type 2 diabetes, atrial
fibrillation, diastolic heart failure and CAD who was found down
in her home. Patient was found to have HONK with elevated
lactic acidosis, initially admitted to the MICU. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Penicillins / Sulfa (Sulfonamide Antibiotics) / aspirin
/ NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per HPI by admitting MD:
___ year old hx of T2DM, HTN, HLD, GERD, ___ BIBA complaining of
abdominal pain. Patient was seen in ED on ___ for same
complaints and dx with symptomatic cholelithiasis and UTI and
discharged with surgery follow-up and 5 days of macrobid.
Patient states since then has continued to have postprandial
RUQ/epigastric cramping pain. She states dysuria has resolved.
This AM, was lying in bed and had sudden onset RUQ/epigastric
cramping pain that was worse than usual and decided to call ___.
She denies any fever/chills, N/V, chest pain, SOB. Has had loose
stools but states she would not call it diarrhea. Pain has
gotten slightly better since early this AM but still present.
She says her sugars have been better controlled at home than
previously, typically in the 100-200 range.
In the ED, initial vitals were: 98.2 96 152/88 16 99% RA
- Exam notable for: RUQ TTP w/o rebound but with some guarding.
- Labs notable for:
Normal WBCs, H/H
Platelets ___ 7 AGap=12
------------< 186
3.9 23 0.5
___: 16.4 INR: 1.5
ALT: 31
AST: 47
Tbili: 1.4
AP: 238
Alb: 3.5
Lip: 117
UA with 1000 Glucose, otherwise unremarkable
- Imaging was notable for:
RUQ US Prelim Read:
1. Cirrhotic liver with no focal lesions identified.
2. Cholelithiasis and gallbladder sludge without findings of
cholecystitis.
3. Interval increase in splenomegaly now measuring 16 cm,
previously measuring 13 cm on MRCP from ___
indicating worsening portal hypertension.
- Patient was given:
Acetaminophen 1000 mg
IV Morphine Sulfate 4 mg
She was seen by the surgery team, who requested admission to
medicine for medical optimization prior to possible
cholecystectomy.
Upon arrival to the floor, patient is sitting up in chair eating
jello. She is comfortable and not having pain during our
interview.
Past Medical History:
DIABETES MELLITUS
DEPRESSION
HYPERLIPIDEMIA
HEPATIC STEATOSIS
OBESITY
ECZEMA
GASTROESOPHAGEAL REFLUX
MIGRAINE HEADACHES
ANKLE FX
Social History:
___
Family History:
Essential hypertension Father
Heart disease, ___
Type 2 diabetes mellitusFather
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
GENERAL: Obese lady, NAD, sitting up at bedside with clear
liquids
HEENT: PERRL, EOMI, no scleral icterus
NECK: Supple
CARDIAC: RRR, +S1/S2, no murmurs
LUNGS: CTAB
ABDOMEN: soft, nondistended, a little tender to palpation in
epigastrium
EXTREMITIES: wwp, good pulses, no edema, L ankle with bony
deformity from prior break
NEUROLOGIC: grossly intact
SKIN: no lesions
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: Temp: 98.1 PO BP: 120/80 HR: 87 RR: 17 O2 sat: 92% O2 RA
GENERAL: Obese female in NAD. Lying comfortably in bed.
HEENT: NCAT. Sclera anicteric and without injection. MMM.
NECK: Supple.
CARDIAC: RRR with normal S1 and S2. No murmur, rubs or gallops.
LUNGS: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
ABDOMEN: Normal bowels sounds, soft, obese. minimal tenderness
at RUQ and epigastric region. No rebound or guarding. No masses
appreciated.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
SKIN: Warm and dry. No rashes.
NEUROLOGIC: Alert and interactive. CN II-XII grossly intact.
Moves all extremities.
Pertinent Results:
ADMISSION LABS:
==============
___ 05:41AM BLOOD WBC-4.5 RBC-4.59 Hgb-13.5 Hct-40.9 MCV-89
MCH-29.4 MCHC-33.0 RDW-14.6 RDWSD-47.8* Plt ___
___ 05:41AM BLOOD Neuts-34.8 ___ Monos-8.6 Eos-3.5
Baso-0.2 Im ___ AbsNeut-1.57* AbsLymp-2.38 AbsMono-0.39
AbsEos-0.16 AbsBaso-0.01
___ 05:41AM BLOOD Glucose-186* UreaN-7 Creat-0.5 Na-143
K-3.9 Cl-108 HCO3-23 AnGap-12
___ 05:41AM BLOOD ALT-31 AST-47* AlkPhos-238* TotBili-1.4
PERTINENT LABS/MICRO:
===================
___ 12:56PM BLOOD ___
___ 06:16AM BLOOD ___ PTT-40.6* ___
___ 05:41AM BLOOD ALT-31 AST-47* AlkPhos-238* TotBili-1.4
___ 07:55AM BLOOD ALT-35 AST-62* AlkPhos-162* TotBili-2.7*
___ 08:11AM BLOOD ALT-42* AST-75* AlkPhos-149* TotBili-2.8*
___ 06:16AM BLOOD ALT-39 AST-62* LD(LDH)-238 AlkPhos-138*
TotBili-2.2*
___ 06:16AM BLOOD calTIBC-420 Ferritn-65 TRF-323
___ 06:18AM BLOOD %HbA1c-8.2* eAG-189*
___ 05:41AM BLOOD Lipase-117*
___ 08:11AM BLOOD Lipase-91*
___ 05:49AM BLOOD Lipase-63*
___ 06:16AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
___ 06:16AM BLOOD HCV Ab-NEG
___ 04:45AM BLOOD AMA-NEGATIVE Smooth-POSITIVE A
___ 04:45AM BLOOD ___ Titer-PND
___ Urine culture: No growth
___ BCx x2: No growth
DISCHARGE LABS:
==============
___ 06:12AM BLOOD WBC-5.4 RBC-4.80 Hgb-14.4 Hct-42.6 MCV-89
MCH-30.0 MCHC-33.8 RDW-14.6 RDWSD-46.5* Plt ___
___ 06:12AM BLOOD Glucose-235* UreaN-9 Creat-0.5 Na-139
K-4.4 Cl-100 HCO3-21* AnGap-18
___ 06:12AM BLOOD ALT-32 AST-43* AlkPhos-187* TotBili-1.9*
PERTINENT IMAGING:
================
___ CXR:
No acute intrathoracic process.
___ RUQ Ultrasound:
1. Cholelithiasis and gallbladder sludge without findings of
cholecystitis.
2. Splenomegaly measuring up to 16 cm.
3. Echogenic liver compatible with hepatic steatosis
___ RUQ Ultrasound:
1. Cirrhotic liver with no focal lesions identified.
2. Cholelithiasis and gallbladder sludge without findings of
cholecystitis.
3. Interval increase in splenomegaly now measuring 16 cm,
previously measuring 13 cm on MRCP from ___.
___ MRCP:
1. New gallbladder sludge and stones, with some sludge
obstructing the gallbladder neck. Marked gallbladder distension
is similar to ___. No evidence of acute cholecystitis or
cholangitis.
2. Cirrhotic liver morphology, with sequela of portal
hypertension including paraesophageal and perisplenic varices.
No ascites or splenomegaly.
3. Slightly enlarged upper abdominal lymph nodes measuring up to
13 mm are likely reactive.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: 80-180
2. Amitriptyline 100 mg PO QHS
3. Sumatriptan Succinate 100 mg PO DAILY:PRN migraine
4. Citalopram 20 mg PO DAILY
5. Cyclobenzaprine 10 mg PO QHS PRN back pain
6. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
7. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. Ursodiol 500 mg PO BID
RX *ursodiol 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
3. Cyclobenzaprine 5 mg PO QHS PRN back pain
4. Glargine 50 Units Dinner
novolog 12 Units Breakfast
novolog 12 Units Lunch
novolog 12 Units DinnerMax Dose Override Reason: per ___ recs
RX *insulin glargine [Lantus U-100 Insulin] 100 unit/mL 0.5 (One
half) ml subcutaneously nightly Disp #*1 Vial Refills:*0
RX *insulin admin supplies [InPen (for Novolog)] AS DIR 12
Units before breakfast; 12 Units before lunch; 12 Units before
dinner Disp #*1 Syringe Refills:*0
5. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine
6. Amitriptyline 100 mg PO QHS
7. Citalopram 20 mg PO DAILY
8. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
#Primary
Cholelithiasis
#Secondary:
Cirrhosis, unclear etiology
Diabetes mellitus type II, insulin dependent
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: History: ___ with known cholelithiasis here with sudden onset RUQ
pain// ? cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___ and MRCP from ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. Hepatic cyst in the left hepatic
lobe measures 1.3 cm. The main portal vein is patent with hepatopetal flow.
There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: Gallbladder sludge and stone without 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: The spleen is enlarged measuring up to 16 cm with normal echogenicity
throughout, previously measuring 13 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with no focal lesions identified.
2. Cholelithiasis and gallbladder sludge without findings of cholecystitis.
3. Interval increase in splenomegaly now measuring 16 cm, previously measuring
13 cm on MRCP from ___.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: ___ year old woman with cholelithiasis and elevated t-bili//
elevate biliary tree for choledocholithiasis or acute cholecystitis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 10 mL Gadavist.
COMPARISON: MRCP ___
FINDINGS:
Lower Thorax: There is no pleural effusion.
Liver: Liver is nodular, compatible with cirrhosis. There are scattered cysts
and biliary hamartomas. No concerning hepatic lesions.
Biliary: The gallbladder is well distended, and contained several gallstones
and sludge, which are new from ___. There is also sludge filling
the gallbladder neck, which may be obstructing given marked luminal
distension. There is no gallbladder wall edema or pericholecystic fat
stranding to suggest acute cholecystitis. No biliary dilation or
choledocholithiasis.
Pancreas: There is normal intrinsic T1 hyperintense signal throughout the
pancreas. No focal parenchymal lesions or ductal dilation.
Spleen: Spleen is normal in size, without focal lesions.
Adrenal Glands: Normal in size and shape.
Kidneys: No focal parenchymal lesions are identified. There is no
hydronephrosis.
Gastrointestinal Tract: The stomach is unremarkable. There is no bowel
obstruction or ascites.
Lymph Nodes: Several prominent porta hepatis and portacaval nodes are likely
reactive, the largest measuring up to 13 mm (20:55). There is no mesenteric
lymphadenopathy.
Vasculature: Abdominal aorta is not aneurysmal. Celiac artery is patent. The
left hepatic artery is replaced to the left gastric artery. The superior
mesenteric artery, bilateral renal arteries are patent. Portal venous system
is patent. Esophageal and paraesophageal varices are noted. There also
prominent perisplenic varices.
Osseous and Soft Tissue Structures: No worrisome osseous lesions are
identified. The soft tissues are unremarkable.
IMPRESSION:
1. New gallbladder sludge and stones, with some sludge obstructing the
gallbladder neck. Marked gallbladder distension is similar to ___. No
evidence of acute cholecystitis or cholangitis.
2. Cirrhotic liver morphology, with sequela of portal hypertension including
paraesophageal and perisplenic varices. No ascites or splenomegaly.
3. Slightly enlarged upper abdominal lymph nodes measuring up to 13 mm are
likely reactive.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Diarrhea
Diagnosed with Calculus of gallbladder w/o cholecystitis w/o obstruction
temperature: 98.2
heartrate: 96.0
resprate: 16.0
o2sat: 99.0
sbp: 152.0
dbp: 88.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ y/o female with a history of DM type II,
HTN, HLD, GERD and NASH who presented with abdominal pain
concerning for biliary colic, found to have cholelithiasis
without cholecystitis or choledocholithiasis. Surgery evaluated
and deferred given high surgical risk. She was managed medically
with improvement in her pain. Additionally, imaging showed a new
diagnosis of cirrhosis, etiology remains unclear but likely ___
NASH. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dyspnea, palpitations
Major Surgical or Invasive Procedure:
Technetium-___ Thyroid Scan
History of Present Illness:
___ year old woman with PMH hypothyroidism, pAF (on
flecainide and metoprolol) and AT presenting with palpitations
and dyspnea. Patient states that she developed palpitations
yesterday morning, intermittent in nature as well as brief
shortness of breath and palpitations. States that she has had
constant symptoms since 3pm ___, similar to prior AF.
Endorses
a chest tightness, non-pleuritic in nature. Denies recent
travel,
leg swelling. H/o DVT after surgery no longer on blood thinners.
Denies fever or cough. Denies changes in medication recently.
Here, ECG with AF 110, QRS 73, QTc 452. No ischemic changes. BP
stable. Trop negative. TSH pending.
Cardiology was consulted in the ED for ?___ in the ED. EP
prefers a more conservative approach with TEE/DCCV, likely
tomorrow. Heparin gtt started.
Past Medical History:
-Atrial fibrillation, paroxysmal in nature
-Atrial tachycardia, paroxysmal in nature, s/p EP study with
documented brief runs of non sustained tachycardia with early
activation around the His bundle and therefore no ablation was
performed.
-Antiarrhythmic therapy with low-dose flecainide and beta
blockade.
-Mild mitral valve prolapse with mild mitral regurgitation.
-Possible marfanoid connective tissue disorder with genetic
testing which was negative for known mutations. Mother with
similar body type and an aortic dissection. Recent
echocardiogram
with borderline ascending aortic dilation (35 mm).
-Subacute thyroiditis briefly on levothyroxine last fall
-Episode of BRPR with colonoscopy finding suggestive of
possible inflammatory bowel disease.
Social History:
___
Family History:
Significant for her father who has prostate cancer and a lung
nodule. Father and sister with thyroid dysfunction. Her mother
has ___ syndrome with aortic valve replacement after aortic
dissection and MVP.
Physical Exam:
On Admission:
VS: 97.9 PO, 104 / 45, 104, 16, 99 ra
General/Neuro: NAD [X] A/O [X] non-focal [X]
Cardiac: RRR [] Irregular [X] Nl S1 S2
[] Murmur: [] systolic []diastolic __/6 RUSB
[] JVD ___cm
Lungs: CTA [X] No resp distress [X]
Abd: NBS [X]Soft [X] ND [X] NT [X]
Extremities: edema [] ___: doppler [] palpable [X]
Access Sites: n/a
At Discharge:
VS: T: 98.1 BP: 100/70 HR: 103 RR: 20 O2 sat: 96% Ra
Physical Examination:
Gen: Patient is lying in bed comfortable, in no acute distress.
HEENT: Face symmetrical, trachea midline
Neuro: A/Ox3. Speaking in complete, coherent sentences. No face,
arm, or leg weakness.
Pulm: Breathing unlabored. Breath sounds clear bilaterally.
Cardiac: No JVD. No thrills or bruits heard on carotids
bilaterally. Irregular rate and rhythm. No splitting of heart
sounds, murmurs, S3, S4 or friction rubs heard.
Vasc: No edema noted in bilateral upper or lower extremities. No
pigmentation changes noted in bilateral upper or lower
extremities. Skin dry, warm. Bilateral radial, ___ 2+
Abd: Rounded, soft, non-tender.
Pertinent Results:
CXR ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The pulmonary vasculature is normal. Mild biapical
scarring is noted. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
___ 04:20PM cTropnT-<0.01
___ 04:20PM TSH-<0.01*
___ 04:20PM T4-15.1* T3-208* FREE T4-3.4*
___
FINDINGS: Thyroid images show faint tracer uptake in the
bilateral lobes of the thyroid compatible with subacute
thyroiditis. There is increased physiologic tracer uptake in
the salivary glands and mouth compared to the thyroid. The prior
scan was an I-123 scan at 24-hours, but it also showed subacute
thyroiditis.
IMPRESSION: Faint tracer uptake in the bilateral lobes of the
thyroid is
compatible with subacute thyroiditis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Vitamin D ___ UNIT PO WEEKLY
3. Flecainide Acetate 50 mg PO Q12H
4. HYDROcodone-acetaminophen 7.5-300 mg oral PRN
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Zolpidem Tartrate 5 mg PO QHS:PRN sleep aid
Discharge Medications:
1. Apixaban 5 mg PO BID
2. HYDROcodone-acetaminophen 7.5-300 mg oral PRN Pain
3. Metoprolol Succinate XL 25 mg PO BID
4. Flecainide Acetate 50 mg PO Q12H
5. Vitamin D ___ UNIT PO WEEKLY
6. Zolpidem Tartrate 5 mg PO QHS:PRN sleep aid
Discharge Disposition:
Home
Discharge Diagnosis:
Thyroiditis
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain//r/o cardiopuolmonary process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___, CT chest ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Mild biapical scarring is noted. Lungs are
clear. No pleural effusion or pneumothorax is seen. There are no acute
osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Palpitations
Diagnosed with Unspecified atrial fibrillation, Palpitations
temperature: 97.0
heartrate: 110.0
resprate: 12.0
o2sat: 98.0
sbp: 120.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Assessment: Ms. ___ is a ___ year old female with a h/o
hypothyroidism (on home levothyroxine 50mcg daily), pAF (on
flecainide and metoprolol) and AT who presented to ED ___
with palpitations and dyspnea since ___ at 1500. She was
found to be in AF on EKG with HR 110bpm with no ischemic
changes.
Trop negative. TSH <0.01, T4 15. She is not on home
anticoagulation therefore a heparin gtt was started in ED for
possible TEE/DCCV today, ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered mental status, pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of high grade SBO s/p ex-lap and SBR on ___,
Aortic valve replacement/Afib on coumadin, CHF, DM, paranoid
schizophrenia, transferred from nursing home with
confusion/agitation and abdominal distention. Patient mumbling
incomprehensibly, unable to obtain further history. Per
transfer notes, patient has been receiving 500 mg levaquin qday
since ___ for URI and had a cough productive of thick yellow
sputum. At baseline is conversational, but was noted to be
increasingly confused and agitated today. At nursing home,
oxygen saturation 84-88% on room air, 94-95% on 4L NC. Temp 97.
Per his daughter (via ACS), current mental status is nowhere
near his baseline. Received nebulizing treatment x3 at nursing
home. Otherwise had been doing well before today, no other
symptoms.
Exam in the ED was notable for abdomen distention, intermittent
myoclonic jerking movements of entire body, slurred speech,
orientation to self only, 3+ pitting edema of lower extremities,
and bilateral rhonchi.
KUB in ED showed dilated loops of mostly large bowel, most
markedly an enlarged and air-filled cecum. Patient was
intubated
in the ED out of concern for aspiration, given his waxing and
waning MS. ___ the ED, VS: T 100.4 HR 72 BP 136/78 RR 16 O2 96%.
The patient recieved norepi for BP 92/53; flagyl, vancomycin,
cefepime, and acetaminophen; propofol, midazolam, and fentanyl
given ___. The patient was noted to intermittently
bite his endotracheal tube, and his sedation was increased.
Given 3L of NS in ED.
Of note, during the patient's ___ admission for SBO, he was
noted be "only minimally lucid" on admission, and to have "a
history of dementia [and] became acutely agitated and difficult
to reorient on POD1." SW note from this admission notes that
the patient was oriented x0. Mental status improved by
discharge but was at times "pleasantly confused." Per an
outpatient neurology note from earlier this month, "He says he
has memory problems, dating these to the last few years. His
daughter agrees, but notes that his cognitive function is often
clouded by his psychiatric problems." Per prior notes, the
patient recieves his care at the ___.
Past Medical History:
1. AS s/p AVR (bovine)
2. Afib on coumadin
3. HTN
4. HLD
5. DM2
6. Per ED triage, treated for PNA three weeks ago
7. Paranoid schizophrenia w/bipolar disorder or Schizoaffective
Disorder
8. Meckel's diverticulum
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
General- originally sedated on fentyl/versed, no acute distress
and currenty extubated alert/orientedx2, not to place
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP to 3 cm infeior to angle of mandible, no LAD
Lungs- diminished breath sounds bilateral bibasilar, R>L, no
wheezes, mild rhonchi throughout
CV- irregulary irregualar, normal S1 + S2, no murmurs,
Abdomen- distended, overactive bowel sounds, passing flatus,
large anterior surgical scar
GU- foley
Ext- warm, well perfused, 2+ pulses, 1+ pitting edema to shins
Neuro- pupils equal and reactive, moves all extremities
DISCHARGE EXAM:
Vitals- 97.5, 117/71, 61, 18, 97%RA
General- Pleasant but confused but seems to be at baseline,
oriented x1 and to the year, city. No acute distress
HEENT- Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear,
poor dentition
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB. No appreciable wheeze, rales or rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no appreciable
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, 1+ edema on LLE, trace
edema on RLE, no clubbing or cyanosis
Neuro- CNs2-12 intact, motor function grossly normal, gait not
assessed
Pertinent Results:
ADMISSION LABS:
___ 11:34AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:34AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 11:34AM ___ PTT-39.6* ___
___ 11:34AM WBC-13.7* RBC-4.21* HGB-11.2* HCT-34.2*
MCV-81*# MCH-26.7*# MCHC-32.8 RDW-15.2
___ 11:34AM proBNP-6727*
___ 11:34AM ALT(SGPT)-26 AST(SGOT)-42* ALK PHOS-59 TOT
BILI-0.9
___ 11:53AM LACTATE-1.8
___ 10:00PM GLUCOSE-90 UREA N-14 CREAT-0.9 SODIUM-138
POTASSIUM-3.1* CHLORIDE-106 TOTAL CO2-26 ANION GAP-9
___ 10:00PM CALCIUM-7.9* PHOSPHATE-3.5 MAGNESIUM-2.1
___ 11:34AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:53AM BLOOD ___ pO2-109* pCO2-41 pH-7.43
calTCO2-28 Base XS-2 Comment-GREEN TOP
___ 03:31PM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-5
FiO2-100 pO2-222* pCO2-42 pH-7.43 calTCO2-29 Base XS-3 AADO2-455
REQ O2-77 -ASSIST/CON Intubat-INTUBATED
___ 11:53AM BLOOD Lactate-1.8
PERTINENT LABS:
___ 03:31PM BLOOD Lactate-1.1
___ 09:57PM BLOOD Lactate-0.8
___ 10:26PM BLOOD Lactate-0.9
___ 09:57PM BLOOD freeCa-1.12
___ 05:48AM BLOOD WBC-11.8* RBC-4.17* Hgb-11.4* Hct-33.8*
MCV-81* MCH-27.3 MCHC-33.6 RDW-15.2 Plt ___
___ 04:39AM BLOOD WBC-14.1* RBC-4.54* Hgb-12.2* Hct-37.0*
MCV-82 MCH-26.8* MCHC-32.8 RDW-15.3 Plt ___
___ 06:15AM BLOOD WBC-12.9* RBC-4.50* Hgb-12.2* Hct-37.7*
MCV-84 MCH-27.2 MCHC-32.4 RDW-15.3 Plt ___
___ 06:00AM BLOOD WBC-13.9* RBC-4.72 Hgb-12.7* Hct-39.2*
MCV-83 MCH-26.9* MCHC-32.4 RDW-15.2 Plt ___
___ 07:25AM BLOOD WBC-12.4* RBC-4.55* Hgb-12.2* Hct-37.1*
MCV-81* MCH-26.9* MCHC-33.0 RDW-15.4 Plt ___
___ 08:35AM BLOOD WBC-12.3* RBC-4.97 Hgb-13.3* Hct-40.7
MCV-82 MCH-26.8* MCHC-32.7 RDW-15.3 Plt ___
___ 02:23AM BLOOD WBC-12.6* RBC-4.94 Hgb-13.1* Hct-39.9*
MCV-81* MCH-26.5* MCHC-32.8 RDW-15.6* Plt ___
___ 07:55AM BLOOD WBC-13.7* RBC-5.21 Hgb-13.8* Hct-42.2
MCV-81* MCH-26.6* MCHC-32.8 RDW-15.6* Plt ___
___ 08:00AM BLOOD WBC-10.4 RBC-4.68 Hgb-12.7* Hct-37.7*
MCV-81* MCH-27.1 MCHC-33.7 RDW-15.4 Plt ___
___ 08:00AM BLOOD WBC-11.3* RBC-4.72 Hgb-12.1* Hct-38.1*
MCV-81* MCH-25.6* MCHC-31.7 RDW-15.4 Plt ___
___ 10:00PM BLOOD ___ PTT-40.8* ___
___ 05:48AM BLOOD ___ PTT-45.9* ___
___ 04:39AM BLOOD ___ PTT-46.4* ___
___ 06:15AM BLOOD ___ PTT-47.0* ___
___ 06:00AM BLOOD ___ PTT-41.7* ___
___ 07:25AM BLOOD ___ PTT-38.5* ___
___ 08:35AM BLOOD ___ PTT-38.5* ___
___ 02:23AM BLOOD ___ PTT-43.2* ___
___ 07:55AM BLOOD ___ PTT-42.5* ___
___ 08:00AM BLOOD ___ PTT-41.6* ___
___ 08:00AM BLOOD ___ PTT-41.2* ___
___ 07:25AM BLOOD ___ 06:15AM BLOOD Glucose-101* UreaN-15 Creat-0.8 Na-140
K-3.0* Cl-102 HCO3-28 AnGap-13
___ 07:25AM BLOOD Glucose-174* UreaN-21* Creat-0.9 Na-144
K-3.7 Cl-105 HCO3-30 AnGap-13
___ 07:55AM BLOOD Glucose-146* UreaN-18 Creat-0.9 Na-139
K-4.0 Cl-97 HCO3-35* AnGap-11
___ 05:48AM BLOOD ALT-21 AST-24 AlkPhos-53 Amylase-14
TotBili-1.0
___ 06:15AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.1
___ 06:00AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.1
DISCHARGE LABS:
___ 09:30AM BLOOD WBC-10.0 RBC-5.44 Hgb-14.2 Hct-43.6
MCV-80* MCH-26.2* MCHC-32.6 RDW-15.7* Plt ___
___ 09:30AM BLOOD ___ PTT-43.4* ___
___ 09:30AM BLOOD Glucose-149* UreaN-15 Creat-0.9 Na-141
K-3.6 Cl-98 HCO3-34* AnGap-13
___ 09:30AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.1
MICRO:
___ 11:34 am BLOOD CULTURE x2 NO GROWTH
___ 10:00 pm MRSA SCREEN No MRSA isolated.
___ 10:35 pm Legionella Urinary Antigen NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 10:01 am SPUTUM GRAM POSITIVE COCCI IN PAIRS.
___ 12:35 pm STOOL C. difficile DNA amplification assay
IMAGING:
___ CHEST (PORTABLE AP)
IMPRESSION: AP chest compared to ___, substantial
worsening of both moderate-to-large bilateral pleural effusions
and moderately severe pulmonary edema is evident since ___, 2:18 p.m. ET tube in standard placement. Nasogastric tube
would need to be advanced 10 cm to move all the side ports into
the stomach. I do not believe there is no pneumothorax, but an
upright chest radiograph would be very helpful in making that
determination.
___ PORTABLE ABDOMEN
IMPRESSION: Gaseous distension of large bowel without definite
evidence for obstruction.
___ CT TORSO WITH CONTRAST
IMPRESSION: No evidence of bowel obstruction. Large bilateral
pleural effusions, right greater than left, which are new from
prior exam with compressive bibasilar atelectasis. Low lying ET
tube at the level of the carina, requiring pull-back. Orogastric
tube tip terminates within the stomach, with sideport at the GE
junction and should be advanced. Ascending aortic aneurysm to
5.7 cm. Evidence of third spacing, including anasarca and
periportal edema. Mediastinal lymphadenopathy, likely reactive.
___ ECG
Atrial fibrillation with slow ventricular response. Left axis
deviation.
Intraventricular conduction defect. Anterior wall myocardial
infarction of indeterminate age. Inferior wall myocardial
infarction of indeterminate age.
___ PORTABLE ABDOMEN
IMPRESSION: Ongoing gaseous distention of multiple loops of
large bowel without evidence of ___ bowel obstruction.
___ CHEST (PORTABLE AP)
IMPRESSION: Possible increase in size of right pleural
effusion, however may be positional. No definitive evidence of
loculation, however this is difficult to exclude on plain
frontal radiograph. A lateral view would be helpful if the
condition of the patient permits. A right lateral decubitus
radiograph could demonstrate the extent of free pleural fluid.
Nevertheless, to definitely determine whether there is a
loculated fluid collection, CT would be necessary, especially
since the appearance could be compared with the study of 1 week
previously. Pulmonary edema appears unchanged.
___ CHEST (LAT DECUB ONLY)
FINDINGS: A lateral decubitus right-sided view is obtained in
addition to the radiograph obtained this morning. In right
decubitus position, a substantial amount of pleural effusion
along the chest wall increases and the component of effusion
that was located in the fissure substantially decreases.
Moderate cardiomegaly is unchanged. Unchanged appearance of the
lung
parenchyma.
___ ECG
Atrial fibrillation. Non-specific intraventricular conduction
delay. Poor R wave progression most likely due to conduction
abnormality. However, anterior wall myocardial infarction of
indeterminate age cannot be ruled out. Compared to the previous
tracing of ___ the ventricular rate is now slower.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
3. Fluoxetine 20 mg PO BID
4. LaMOTrigine 25 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID
10. Aspirin 81 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. OLANZapine 5 mg PO DAILY
4. Warfarin 2.5 mg PO DAILY16
5. Aspirin 81 mg PO DAILY
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
7. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID
8. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Simvastatin 20 mg PO DAILY
11. Fluoxetine 40 mg PO DAILY
12. LaMOTrigine 100 mg PO DAILY
13. Furosemide 40 mg PO DAILY
14. Outpatient Lab Work
Check INR and Chem 10 on ___.
ICD-9: 428.0 Congestive heart failure
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES:
Healthcare Associated Pneumonia
Altered mental status
SECONDARY DIAGNOSES:
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
HISTORY: Altered mental status and hypoxia. Evaluate for pneumonia.
COMPARISON: Chest radiograph ___.
FINDINGS: Portable frontal chest radiograph. There are small bilateral
pleural effusions, right greater than left. There is mild pulmonary edema.
The heart size is mildly enlarged. Dense calcifications are seen within the
aortic arch. Sternotomy wires and a valve prosthesis are present. Air-filled
loops of bowel are better evaluated on the same day abdominal radiograph.
IMPRESSION: Mild pulmonary edema with small bilateral pleural effusions.
Radiology Report
HISTORY: Altered mental status and hypoxia with abdominal distention. For
bowel obstruction.
COMPARISON: Abdominal radiograph ___ and CT abdomen pelvis ___.
FINDINGS: Supine and right lateral decubitus frontal views of the abdomen.
Gaseous distension of the large bowel is noted. There is no definite evidence
of small bowel obstruction. There is no free air. Stool and air are seen
within the rectum.
The lungs are better evaluated on the same day chest radiograph.
IMPRESSION: Gaseous distension of large bowel without definite evidence for
obstruction.
Radiology Report
HISTORY: Altered mental status.
COMPARISON: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm reconstructed images were acquired.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or
infarction. Prominent ventricles and sulci suggest age related involutional
changes or atrophy. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
No fracture is identified. Calcification is noted along the transverse
ligament. Left sphenonid and ethmoid sinus disease is seen. Otheriwise, the
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear.
IMPRESSION: No acute intracranial process.
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___.
COMPARISON: Prior exam from earlier today.
CLINICAL HISTORY: New endotracheal tube, OG tube, confirm placement.
FINDINGS: Supine portable AP view of the chest provided. The NG tube
descends along the thoracic midline, though the tip is not imaged. The
endotracheal tube is seen with its tip 2.7 cm above the carina. A layering
right pleural effusion likely accounts for increased veil-like opacity in the
right lung. Lower lobe opacities may represent atelectasis, aspiration, or
possibly pneumonia.
IMPRESSION: Tip of OG tube not included in field of view. Endotracheal tube
positioned appropriately. Otherwise, no change allowing for differences in
technique.
Radiology Report
HISTORY: Abdominal distention and confusion, also with hypoxia, history of
small bowel obstruction and small bowel resections.
TECHNIQUE: MDCT imaging of the chest, abdomen, and pelvis with intravenous
contrast was performed. Multiplanar reformats were prepared and reviewed.
COMPARISON: Comparison is made with CT abdomen and pelvis from ___.
FINDINGS:
CHEST: There are new large bilateral pleural effusions, right greater than
left, with compressive atelectasis in both lung bases. Nonspecific focal
areas of ground-glass opacities are noted in the right upper lobe. The ET
tube is seen to be in a low lying position at the level of the carina.
Airways are patent to the subsegmental levels bilaterally. Mediastinal
lymphadenopathy is noted with an enlarged 1.3 cm precarinal lymph node (2:20),
and 1.2 cm subcarinal lymph node, likely reactive. No pathologically enlarged
axillary, or hilar lymph nodes are identified. There is no pericardial
effusion. The heart is enlarged. Diffuse coronary arterial calcifications
are seen. The patient is status post aortic valve replacement. The ascending
aorta is dilated aneurysmally up to 5.7 cm, and moderate atherosclerotic
calcifications are noted. The thyroid gland is unremarkable.
ABDOMEN: The liver is homogeneous in texture with no focal lesions. There is
no biliary ductal dilatation. The gallbladder is normal. The spleen,
pancreas, and adrenal glands are normal. Cysts are noted in the bilateral
kidneys. The kidneys are otherwise unremarkable. An orogastric tube tip
terminates in the stomach, but the sideport is at the GE junction. The
stomach, duodenum, and intra-abdominal loops of bowel are normal in caliber
and unremarkable. A small bowel anastomosis is seen in the right hemipelvis.
There is no retroperitoneal or mesenteric lymphadenopathy. The
intra-abdominal aorta is normal in appearance. Evidence of third spacing,
including anasarca and periportal edema is seen. There is no free fluid in
the abdomen.
PELVIS: The sigmoid colon and rectum are normal in appearance. The Foley is
in place in the bladder. The prostate and seminal vesicles are unremarkable.
There is no pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis. A left inguinal hernia repair is seen.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for
infection or malignancy is seen. A bone island is noted in L1 vertebral body.
IMPRESSION:
1. No evidence of bowel obstruction.
2. Large bilateral pleural effusions, right greater than left, which are new
from prior exam with compressive bibasilar atelectasis.
3. Low lying ET tube at the level of the carina, requiring pull-back.
Orogastric tube tip terminates within the stomach, with sideport at the GE
junction and should be advanced.
4. Ascending aortic aneurysm to 5.7 cm.
5. Evidence of third spacing, including anasarca and periportal edema.
6. Mediastinal lymphadenopathy, likely reactive.
Radiology Report
AP CHEST, 12:14 A.M. ON ___
HISTORY: An ___ man with enlarging pleural effusion. Possible
consolidation.
IMPRESSION: AP chest compared to ___, substantial worsening of both
moderate-to-large bilateral pleural effusions and moderately severe pulmonary
edema is evident since ___, 2:18 p.m. ET tube in standard placement.
Nasogastric tube would need to be advanced 10 cm to move all the side ports
into the stomach. I do not believe there is no pneumothorax, but an upright
chest radiograph would be very helpful in making that determination.
Radiology Report
HISTORY: ___ male with abdominal distention. Evaluate for
obstruction.
COMPARISON: Plain film of the abdomen dated ___ and ___
dated ___.
FINDINGS:
A single supine frontal view of the abdomen demonstrates ongoing gaseous
distention of the large bowel without definite evidence of small bowel
obstruction. There are no secondary signs of free air. There is some stool
seen in the ascending colon. There is deep sulcus sign on the left, raising
concern for left-sided pneumothorax. A ___ tube is see with the tip
terminating in the stomach and the last side port above the GE junction. The
visualized osseous structures demonstrate moderate degenerative changes of the
lumbar spine. There are median sternotomy wires and an aortic valvular
prosthesis. There are bilateral pleural effusions.
IMPRESSION:
1. Persistent distention of large bowel without definite evidence of small
bowel obstruction.
2. Deep sulcus sign on the left raises concern for left-sided pneumothorax.
Recommend upright frontal chest radiograph for further assessment, if
clinically indicated.
3. ___ tube is see with the tip terminating in the stomach and the
last side port above the GE junction. Recommend advancement of NGT by 4-6 cm.
COMMENTS: These findings were discussed with Dr. ___ by Dr.
___ telephone at 3:20pm on ___, 20 minutes after their discovery.
Radiology Report
HISTORY: ___ male with abdominal distention. Evaluate for
obstruction.
COMPARISON: Plain film of the abdomen dated ___.
FINDINGS:
Two supine and left lateral decubitus frontal views of the abdomen demonstrate
ongoing gaseous distention of the large bowel without definite evidence of
small bowel obstruction. Again seen is a nasogastric tube in the stomach,
with the last side port above the GE junction. There is contrast seen
throughout the colon and in the rectum. There is no pneumatosis or free air.
Again seen are bilateral pleural effusions. The previously seen deep sulcus
sign is no longer visible, however given technique, the left upper quadrant is
not well imaged on the supine view.
IMPRESSION:
1. Ongoing gaseous distention of large bowel without definite evidence of
small bowel obstruction. Recommend CT of the abdomen and pelvis for further
evaluation of obstruction if clinically indicated.
2. Nasogastric tube seen with tip in stomach and last side port above the GE
junction. Recommend advancing NGT 4-6 cm.
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ male patient with history of small bowel obstruction,
status post SBR, AVR, on Coumadin, CHF, DM, paranoid schizophrenia,
transferred from nursing home with confusion/agitation and abdominal
distention with unclear read of pneumothorax on chest x-ray earlier on ___.
Deep sulcus sign on the left on previous abdominal film.
FINDINGS: AP single view of the chest has been obtained with patient in
semi-upright position. Analysis is performed in direct comparison with the
next preceding similar study obtained 15 hours earlier during the same day.
On the present examination, the pulmonary congestive pattern has decreased;
however, hazy densities over the bases are consistent with sizable bilateral
pleural effusions layering in the posterior compartments of the pleural space.
The patient remains intubated, the ETT in unchanged position terminating 3 cm
above the carina. Marked cardiac enlargement as before and unchanged position
of previously described metallic prosthesis of porcine type. On the present
image, there is no evidence of any area in the apical or upper pleural spaces
which rules out any pneumothorax as the patient is examined in semi-upright
position. The on previous examination suspected apical areas of linear
densities in the presence of much more marked congestion are again noted and
can be explained by skin folds as the patient was in close to flat supine
position.
Previous CT of ___ and abdominal films of ___ are also reviewed.
The present chest examination rules out complicating pneumothorax. Patient's
massive pleural effusion persists.
Radiology Report
HISTORY: ___ years old man intubated/sedated.
INDICATION: Is ET tube in place? Any sign of infection?
TECHNIQUE: Portable chest x-ray in AP view and erect position.
COMPARISON: Exam is compared to prior chest x-ray of ___.
FINDINGS: NG tube and ET tube have been removed. There is a minimal
improvement of lung opacification mainly for reduction of the bilateral
pleural effusion more evident on the left base. Persistent atelectasis of
right lower, right middle and left lower lobes. There is no pneumothorax.
Cardiomediastinal silhouette is unchanged and still mildly enlarged; moderate
aortosclerosis.
IMPRESSION: All the monitoring devices have been removed. The bibasilar
atelectasis with pleural effusion is minimally improved, mainly for reduced
pleural effusion especially on the left base. Persistent bibasilar
atelectasis with large atelectasis of the right middle lobe.
Radiology Report
HISTORY: ___ male with abdominal distention. Evaluate for interval
change or obstruction.
COMPARISON: Multiple plain films of the abdomen dated ___.
FINDINGS:
Two supine frontal views of the abdomen demonstrate gaseous distention of
multiple loops of large bowel without evidence of small bowel obstruction.
There has been interval removal of the previously seen nasogastric tube. There
are multiple skin folds seen projecting over the left upper abdomen. There is
contrast in the colon and rectum. There are bilateral pleural effusions and a
consolidation at the left lung base. Median sternotomy wires and an aortic
valve prosthesis are seen projecting over the chest. The visualized osseous
structures demonstrate moderate degenerative changes of the lumbar spine.
IMPRESSION:
Ongoing gaseous distention of multiple loops of large bowel without evidence
of small bowel obstruction.
Radiology Report
CHEST ON ___
HISTORY: Abdominal distention.
FINDINGS: There is moderate cardiomegaly. Prosthetic valve replacement is
again visualized. There is pulmonary vascular re-distribution with perihilar
haze. There are areas of volume loss and infiltrate in both lower lungs. The
heart is moderately enlarged. There are bilateral pleural effusions that are
moderate in size. Compared to the prior study, the fluid status is worse.
Radiology Report
HISTORY: Male with CHF and AFib, presenting with pneumonia status post
treatment, and with bilateral pleural effusions. Assess pleural effusions.
COMPARISON: Chest radiograph, ___.
TECHNIQUE: Single semi-erect portable frontal chest radiograph.
FINDINGS: Compared to ___, there appears to be an increase in the
right pleural effusion with fluid in the minor and possibly major fissure;
however, this may be related to change in positioning. No definitive sign of
loculated effusion. No pneumothorax. Bilateral pulmonary edema with enlarged
heart appears unchanged. Mediastinal contour appears unchanged. Prosthetic
heart valve again seen in correct position.
IMPRESSION:
1. Possible increase in size of right pleural effusion, however may be
positional. No definitive evidence of loculation, however this is difficult to
exclude on plain frontal radiograph. A lateral view would be helpful if the
condition of the patient permits. A right lateral decubitus radiograph could
demonstrate the extent of free pleural fluid. Nevertheless, to definitely
determine whether there is a loculated fluid collection, CT would be
necessary, especially since the appearance could be compared with the study of
1 week previously.
2. Pulmonary edema appears unchanged.
Results were conveyed via telephone to Dr. ___ by Dr. ___
___ on ___ at 11:30 a.m. within 10 minutes of results.
Radiology Report
CHEST RADIOGRAPH
INDICATION: History of chronic heart failure, treatment for pneumonia,
concern for loculated pleural effusion.
COMPARISON: ___.
FINDINGS: A lateral decubitus right-sided view is obtained in addition to the
radiograph obtained this morning. In right decubitus position, a substantial
amount of pleural effusion along the chest wall increases and the component of
effusion that was located in the fissure substantially decreases.
Moderate cardiomegaly is unchanged. Unchanged appearance of the lung
parenchyma.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ALT MS
Diagnosed with ALTERED MENTAL STATUS
temperature: 97.0
heartrate: 86.0
resprate: 26.0
o2sat: 97.0
sbp: 162.0
dbp: 131.0
level of pain: 13
level of acuity: 1.0 | ___ M h/o SBO s/p SBR, AVR on coumadin, CHF, DM, paranoid
schizophrenia, transferred from nursing home with
confusion/agitation and abdominal distention complicated by
acute decompensated dCHF and pulmonary edema. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine Sulfate / Flagyl
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Mr ___ is a ___ year old man with h/o CAD s/p 2 x stents to
RCA and LCX in ___ and recurrent CP in ___ with moderate
CAD throughout. He has been chest pain free after his last cath
and his artherosclerotic risk factors have been well controlled.
He continues however to smoke cigarettes. Today he noticed to
have chest pain with exercise that radiated into the left arm.
He presented to the ED after contacting his cardiology office
(Dr ___.
In the ED, initial vitals were pain ___ T97.1 HR87 BP 110/71
RR 18 O299% RA. CBC/Chem10 unremarkable, trop <0.01. EKG
unchanged without concerning ST changes, CXR with no acute
cardiopulmonary process. Dilauded failed to control pain and
started on nitro gtt. However, pressures dropped to 85 systolic
and nitro stopped, BP increased to mid ___ and transferred to
the floor.
On arrival to the floor, vitals: 98.2 BP 93/57 HR 67 RR 20 O2
98%RA. Patient felt pain completely resolved.
On review of systems, he 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. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
CAD s/p stenting to RCA and LCX with Promus 2.5 mm stents.
Recath with no further work in ___. During the cath deep
intubation of LAD caused severe vasospasm and pain which was
alleviated with nitro. Also slow flow was noted. This maybe
consistent with vasospastic angina/microvascular disease in
addition to his macrovascular disease.
OTHER PAST MEDICAL HISTORY:
Kidney stones s/p ureteroscopy and laser lithotripsy ___, ___
perirectal abscess and fistula excision ___
Bell's Palsy
GERD
30cm colectomy for diverticulitis ___
Social History:
___
Family History:
Mother with aortic stenosis who passed away in the postoperative
setting after an aortic valve replacement, thought secondary to
a large pericardial effusion. Multiple uncles and cousins with
myocardial infarctions and CABG in their ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.2 BP 93/57 HR 67 RR 20 O2 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
VS: Tm98.5, BP93-102/53-68, P66-80, R18-20, ___
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU-deferred but no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
LABS:
___ 06:25PM BLOOD WBC-8.0# RBC-5.48 Hgb-16.0 Hct-47.4
MCV-87 MCH-29.1 MCHC-33.7 RDW-12.4 Plt ___
___ 06:33PM BLOOD ___ PTT-37.8* ___
___ 06:25PM BLOOD Plt ___
___ 06:25PM BLOOD Glucose-81 UreaN-12 Creat-0.9 Na-142
K-4.1 Cl-103 HCO3-29 AnGap-14
___ 06:25PM BLOOD cTropnT-<0.01
___ 10:00PM BLOOD cTropnT-<0.01
___ 04:22AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:55AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9
___ 09:30AM BLOOD Triglyc-154* HDL-30 CHOL/HD-4.3
LDLcalc-67 LDLmeas-77
EKG: Sinus rhythm. RSR' pattern in lead V1, most likely a normal
variant. Compared to the previous tracing of ___ there is no
significant diagnostic change.
CXR: No acute cardiopulmonary process.
CATH:
Selective coronary angiography in this right dominant system
demonstrated moderate single vessel disease.
The left main coronary was free of angiographically apparent
disease. The left anterio descending had slightly slow coronary
flow consistent with microvascular dysfunction. There was a
proximal tubular 40% stenosis and a mid-LAD 50% lesion between
S1/D1 and S2/D2. The first diagonal contained a 50% lesion
proximally.
The circumflex similarly demonstrated slighly slow flow. It gave
off tiny first and second obtuse marginals and a modest caliber
___ marginal. There was a 45% stensois proximally in the long
modest caliber fourth obstuse marginal. There was a stent in the
major fifth obtuse marginal/LPL which was patent. OM6/LPL2 was
of
modest
Angiography of the RCA showed 20% stenosis in the proximal RCA
with
slightly slow flow, no cutoffs, and no apparent dissection and a
20% stenosis in the distal vessel prior to the posterior
descending. The PDA itself contained diffuse plaquing to 40%.
RPL1 was small, RPL2 of modest caliber. There was also slightly
slow flow in the RCA consistent with microvascular dysfunction.
Supravalvular aortography revealed no significant AI, no aortic
dilation and no angiographic evidence of aortic dissection in
the
ascending transverse and descending aorta to the distal aortic
bifurcation.
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Substernal chest pain radiating to left arm and jaw.
___.
FINDINGS: Lungs are clear without focal consolidation. No pleural effusion
or pneumothorax is seen. Cardiac and mediastinal silhouettes are
unremarkable. No displaced fracture is seen. There is no overt pulmonary
edema.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: CHEST PAIN
Diagnosed with INTERMED CORONARY SYND
temperature: 97.1
heartrate: 87.0
resprate: 18.0
o2sat: 99.0
sbp: 110.0
dbp: 71.0
level of pain: 10
level of acuity: 2.0 | BRIEF HOSPITAL COURSE:
====================
___ year old man with h/o CAD (s/p 2 x stents to RCA and LCX in
___ and recurrent CP in ___ with moderate CAD noted
throughout and mod single vessel disease of LAD) and heavy
tobacco use who presented w/ chest pain concerning for ACS
ACTIVE ISSUES
====================
1. CHEST PAIN
Given his known hx of CAD, pt's severe chest pain on admission
was concerning for unstable angina. Though his EKG did not show
any clear e/o ischemia and his cardiac biomarkers were negative,
he was treated empirically for ACS w/ ASA, Atorvastatin 80 and
Fondaparinux. Aortic Dissection was considered given the
"tearing quality" of his chest pain but his mediastinum was not
widened on CXR, and his vital signs remained stable. Chest pain
was initially treated with IV dilaudid and a nitroglycerin drip,
but pt became hypotensive requiring IVF, so the nitroglycerin
was discontinued, and further pain control was achieved with IV
Dilaudid alone. Notably, pain relented soon after being
transferred to the medicine ward.
Given his hx of extensive CAD, he was continued on Fondaparinux
anticoagulation pending cardiac catheterization, which revealed
stable coronary artery disease, not requiring percutaneous
coronary intervention, and no e/o vasospasm. LAD with proximal
tubular 40% stenosis; mid-LAD 50% lesion between S1/D1 and
S2/D2; first diagonal with 50% lesion proximally; 45% stenosis
proximally in the long modest caliber fourth obtuse marginal;
patent stent in the major fifth obtuse marginal/LPL; RCA with
20% proximal stenosis and 20% distal stenosis; PDA with diffuse
plaquing to 40%. Given concern for aortic dissection he had
supravalvular aortography done in the catheterization lab which
did not show any e/o dissection.
Initiation of isosorbide mononitrate or caclium channel blocker
was considered, but his blood pressure (90s-100s systolic) did
not permit during this admission. Since the findings on cardiac
catheterization did not require any intervention, he was
informed of the importance of managing his risk factors for CAD.
Specifically, the team spent much time with the pt educating him
regarding the risks of smoking, and potential methods for
quitting.
He was discharged chest pain-free in stable condition, w/
appropriate follow up appointments. He was instructed to
continue Aspirin 81mg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RLQ abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ male w/ PMH significant for Type-1
diabetes who presents with an ~6-hour history of abdominal pain.
Pain started ___ AM on day of admission and was diffusely
present around the umbilicus. The pain then migrated to the RLQ
pain. He denies any fevers or chills. He had not had any
nausea/vomiting until getting a dose of morphine in the ED and
then develop some mild nausea. He does report having an
appetite. He has had normal bowel habits. Denies urinary
symptoms.
Past Medical History:
PMH:
Type-1 diabetes with wireless monitor and wireless humalog pump
PSH:
Circumcision age ___
Social History:
___
Family History:
Sister w/ celiac disease
Physical Exam:
Physical exam:
VS: 97.6 73 152/74 18 98%
Gen: NAD, AAOx3, pleasant
CV: RRR
Pulm: CTAB
Abd: Soft, non-distended, +BS. Tender to palpation in RLQ,
negative guarding but mild rebound tenderness. Negative
Rovsing,
positive obturator/psoas signs.
Ext: Insulin monitor on R anterior thigh. Insulin pump on R arm
at triceps. Extremities WWP no c/c/e.
Discharge Physical Exam:
VS: 98.6, 64, 114/47, 18, 96%ra
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
incisionally, non-distended. Incisions: clean, dry and intact,
dressed and closed with steristrips.
EXTREMITIES: Warm, well perfused, pulses palpable, (+/-) edema.
Pertinent Results:
___ 09:35AM BLOOD WBC-15.0* RBC-5.10 Hgb-15.6 Hct-45.0
MCV-88 MCH-30.6 MCHC-34.7 RDW-12.8 Plt ___
___ 09:35AM BLOOD ALT-21 AST-18 AlkPhos-69 TotBili-0.7
___ 09:35AM BLOOD Lipase-17
___ 09:35AM BLOOD Albumin-4.8
CT A/P:
Acute appendicitis. No drainable fluid collection or
extraluminal
air.
Medications on Admission:
Insulin (humalog) sliding scale
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive or drink alcohol while taking this
2. Insulin Pump SC (Self Administering Medication)
Basal Rates:
Midnight - 4A: 1.75 Units/Hr
4A - 10A: 1.5 Units/Hr
10A - midnight: 1.3 Units/Hr
Meal Bolus Rates:
Breakfast = 1:5
Lunch = 1:5
Dinner = 1:5
Snacks = 1:5
MD acknowledges patient competent
MD has ordered ___ consult
MD has completed competency
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US APPENDIX
INDICATION: Right lower quadrant pain, assess for appendicitis.
TECHNIQUE: Grey scale ultrasound images were obtained.
COMPARISON: None available.
FINDINGS:
Views of the right lower quadrant and at the site of maximal tenderness are
unremarkable. The appendix is not visualized. There is no free fluid.
IMPRESSION:
Nonvisualization of the appendix. No free fluid.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with RLQ pain and guarding, evaluate for appendicitis.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after the administration of intravenous contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats. Oral contrast
was not administered.
DLP: 931 mGy-cm
COMPARISON: None available.
FINDINGS:
CHEST: The visualized lung bases are clear. The heart is normal in size and
there is no evidence of pericardial effusion.
ABDOMEN:
The liver enhances homogeneously and is without focal lesions. The portal
venous system is patent. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is normal and without gallstones.
The spleen and adrenal glands are unremarkable. The pancreas enhances
homogenously and is without focal lesions.
The kidneys display symmetric nephrograms and excretion of contrast. There are
no focal renal lesions. There is no hydronephrosis. The ureters are normal in
caliber along their course to the bladder.
The distal esophagus is normal without a hiatal hernia. The stomach is grossly
unremarkable in appearance. The small and large bowel are normal in caliber
and without evidence of wall thickening.
The appendix is fluid-filled with wall hyperenhancement and measures
approximately 10 mm (601b:26). There is a small amount of surrounding fat
stranding. There is no extraluminal air or fluid collection.
The abdominal aorta and its major branches are patent. The aorta and iliac
branches are normal in course and caliber. There is no retroperitoneal or
mesenteric lymphadenopathy by CT size criteria.
PELVIS:
The bladder is well distended and normal. There is no pelvic side-wall or
inguinal lymphadenopathy by CT size criteria. No free pelvic fluid is
identified.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
Acute appendicitis. No drainable fluid collection or extraluminal air.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RLQ abdominal pain
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 97.6
heartrate: 73.0
resprate: 18.0
o2sat: 98.0
sbp: 152.0
dbp: 74.0
level of pain: 7
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed acute appendicitis, no
drainable fluid collection or extraluminal air. WBC was elevated
at 15. The patient underwent laparoscopic appendectomy, which
went well without complication (reader referred to the Operative
Note for details). After a brief, uneventful stay in the PACU,
the patient arrived on the floor tolerating clear liquids, on IV
fluids, and PO/IV analgesia for pain control. The patient was
hemodynamically stable.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. He was noted to have a high
post void residual and was given a dose of Tamsulosin. During
this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. ___ was consulted to help manage the
patient's juvenile diabetes, for which he was on an insulin pump
for. During the hospitalization, the patient's blood sugars were
well controlled.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Lisinopril / Minoxidil /
Cilostazol / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ HD
History of Present Illness:
___ with h/o ESRD on MWF HD, CAD w/ prior MI, CVA, stable angina
presenting from HD with chest pain.
Ms. ___ was otherwise well this morning when she developed
acute onset of stabbing chest pain under her left breast unlike
any other pain she had felt before. Patient denied SOB, nausea,
diaphoresis. Of note, patient's usual stable anginal pain is
described as left sided chest pressure with SOB, diaphoresis and
nausea. At HD, patient was given SL NTG x1 with complete relief
of her pain. Due to her chest pain, HD was deferred and patient
was transferred to the ED.
On arrival to the ED, patient remained pain free. Initial
vitals: 98.5 83 189/101 12 100% 2L.
Labs notable for: H/H 10.4/31.7 (baseline), BUN 24, Cr 3.9, trop
0.04 (baseline 0.02-0.07)
Imaging notable for CXR with mild pulmonary edema and very small
b/l pleural effusions. EKG showed SR with LAFB, no i/i/i, c/w
previous.
Due to lack of HD today, decision was made for admission for HD
and rule out given need for complex rule out.
Prior to transfer, patient's blood pressure elevated at 196/75.
Patient given home labetalol 300mg PO and transferred to the
floor.
Vitals on transfer: 93 199/ 18 100% RA
On arrival to the floor, vitals: 98.4 173/79 82 18 100%RA FSBG
153, weight 65.9kg.
ROS: Full 10 pt review of systems negative except for above.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
1. CAD s/p MIs (___), NSTEMI ___ s/p PCI/BMS, normal
EF
2. Diabetes Mellitus II
3. HTN, c/b multiple hypertensive emergencies ___,
___: On Labetalol
4. CKD, end stage, dialysis dependent: S/p right nephrectomy
(___)
5. CVA (___): No deficits, bilateral MCA stenosis on MRA
6. Right CEA (___)
7. PVD: No intervention
8. Orthostatic hypotension: Requiring hospitalization in ___. Diastolic dysfunction: TTE EF 55%, ___
10. Obesity: BMI 38.3
11. GERD
12. Prior tobacco abuse
13. Mild cognitive impairment
Social History:
___
Family History:
Mother: Passed away from stomach cancer at age ___
No family history of heart disease, neurological disease,
diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.4 173/79 82 18 100%RA
Gen: Well appearing elderly woman in NAD
HEENT: MMM, OP clear without lesions, sclera anicteric
CV: RRR, no appreciable murmur
Pulm: CTAB with good air movement throughout, no w/c/r
Abd: normoactive bowel sounds, soft, nontender, nondistended
GU: no foley
Ext: WWP, no edema, left forearm fistula with palpable thrill
Skin: No rashes
Neuro: A&Ox3, CN II-XII intact, ___ strength in b/l lower
extremities
DISCHARGE PHYSICAL EXAM:
VS - T 98.4 BP 176/80 RR 18 SPO2 100% RA P 77
Gen: Well appearing elderly woman in NAD
HEENT: PERRL, MMM, OP clear without lesions, sclera anicteric
CV: RRR, no appreciable murmur, no chest wall tenderness
Pulm: CTAB with good air movement throughout, no w/c/r
Abd: normoactive bowel sounds, soft, nontender, nondistended
GU: no foley
Ext: WWP, no edema, left forearm fistula with palpable thrill
Skin: No rashes
Neuro: A&Ox3, CN II-XII intact, ___ strength in b/l lower
extremities
Pertinent Results:
___ 06:30AM BLOOD WBC-5.2 RBC-3.46* Hgb-10.5* Hct-32.4*
MCV-94 MCH-30.3 MCHC-32.4 RDW-15.0 Plt ___
___ 05:55PM BLOOD WBC-4.8 RBC-3.38* Hgb-10.4* Hct-31.7*
MCV-94 MCH-30.8 MCHC-32.9 RDW-14.7 Plt ___
___ 05:55PM BLOOD Neuts-60.0 ___ Monos-8.3 Eos-8.9*
Baso-0.5
___ 05:55PM BLOOD Glucose-112* UreaN-24* Creat-3.9* Na-137
K-3.9 Cl-99 HCO3-27 AnGap-15
___ 06:30AM BLOOD CK-MB-2 cTropnT-0.04*
___ 02:04AM BLOOD CK-MB-2 cTropnT-0.05*
___ 05:55PM BLOOD cTropnT-0.04*
___ 06:30AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0
CXR ___: Mild pulmonary interstitial edema with tiny bilateral
pleural effusions.
EKG ___: SR with LAFB, no i/i/i, c/w previous
PRIOR IMAGING AND STUDIES REVIEWED DURING THIS HOSPITAL STAY:
EKG ___: Sinus rhythm. Consider left anterior fascicular block.
Late R wave progression. Compared to the previous tracing Q
waves are possibly more apparent in lead I suggesting left
anterior fascicular block. Atrial premature beat is no longer
seen.
Dobutamine Stress ___:
This ___ year old IDDM woman with a PMH of old MI, PCI to the RCA
with untreated LAD disease was referred to the lab for
evaluation of chest discomfort. Due to past CVA and limited
mobility, she was infused with ___ mcg/kg/min of dobutamine
over 10 minutes. At
minute 9 of the infusion, 0.5 mg of atropine was given IV to
further augment HR response. The test was stopped due to
systolic hypertension.
No arm, neck, back or chest discomfort was reported by the
patient
throughout the study. There were no significant ST segment
changes
during the infusion or in recovery. The rhythm was sinus with
several isolated vpbs. Resting HTN with an exaggerated systolic
BP response to the infusion.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Echo
report sent separately.
TTE ___ w/ stress: No ECG or 2D echocardiographic evidence
of inducible ischemia to achieved workload. Baseline wall motion
abnormality persisted during dobtumine stress. Resting
hypertension. Abnormal hemodynamic response to physiologic
stress. Moderate mitral regurgitation at rest.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Labetalol 300 mg PO BID
6. Loratadine 10 mg PO DAILY
7. Mirtazapine 15 mg PO HS
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Simvastatin 40 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
11. fenofibrate 54 mg oral daily
12. FiberCon (calcium polycarbophil) 625 mg oral BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Labetalol 300 mg PO TID
RX *labetalol 300 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
6. Mirtazapine 15 mg PO HS
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Simvastatin 40 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
10. fenofibrate 54 mg oral daily
11. FiberCon (calcium polycarbophil) 625 mg oral BID
12. Loratadine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
- Atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with hx CAD/MI, ESRD on HD with chest pain today.
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest provided. Tiny bilateral pleural effusions
are present with associated minimal compressive lower lobe atelectasis. There
is mild pulmonary interstitial edema with cephalization. The heart size is
within normal limits. The mediastinal contour is normal. No pneumothorax. Bony
structures are intact.
IMPRESSION:
Mild pulmonary interstitial edema with tiny bilateral pleural effusions.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS, HYPERCHOLESTEROLEMIA
temperature: 98.5
heartrate: 83.0
resprate: 12.0
o2sat: 100.0
sbp: 189.0
dbp: 101.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ with known CAD who developed sharp left
sided chest pain at HD that felt different than her prior
anginal symptoms but did respond to SL NTG x 1. She was
transferred to ___, where three sets of cardiac enzymes were
at baseline and EKG showed no acute ischemic changes. Last
stress test was ___ and showed no symptoms or EKG changes.
There were WMA's at rest but no inducible ischemia.
She underwent HD. During HD, chest pain briefly recurred, then
resolved again. It is unclear what caused pain, as it was not
reproducible to suggest classic MSK pain, and she did not have
reflux or other GI symptoms to suggest clear GI etiology.
Given lack of acute EKG changes or enzyme elevation, patient
will follow-up as an outpatient with Cardiologist Dr. ___.
Please consider utility of repeat outpatient stress test at next
visit.
During stay, patient was persistently hypertensive to high
170's, even after HD, which diuresed her to just below dry
weight. Labetolol was increased from BID to TID, and blood
pressure will be rechecked at HD session tomorrow.
# Chest pain: Patient with acute onset of sharp, stabbing chest
pain unlike prior history of stable angina which resolved with
single dose of nitro. While pain could certainly represent
unstable angina, does not meet criteria for NSTEMI given trops
at baseline (likely elevated chronically due to CKD). Three sets
of cardiac enzymes were negative. EKG showed no acute ischemic
changes. We continued her aspirin, statin, and beta blocker.
# Hypertension: baseline HTN with SBPs 140s-160s per patient.
She remained persistently hypertensive here with SBPS in the
170s, even after dialysis to dry weight. We increased her
labetolol 300 mg BID to TID.
# ESRD: Low phos, low K diet. She received dialysis on ___.
# Diabetes: Type II, currently off of insulin and oral agents
given symptomatic on medications with hypoglycemia. We
maintained her on a conservative ISS while in house.
#CAD s/p MI, BMS, with dCHF: EG 55% in ___. We continued
aspirin and simvastatin.
# Peripheral Vascular Disease: Continued aspirin
# HLD: Continued simvastatin
# Depression/Anxiety: Continued ___ Mirtazapine
#Seasonal Allergies: Continued home loratadine
TRANSITIONAL ISSUES
- Follow-up with Dr. ___ consideration of outpatient
stress test
- Monitor BP on increased dose of labetolol (next BP check
tomorrow, ___, at HD)
-Consider d/c plavix (not clear indication given remote h/o bare
metal stent) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin
Attending: ___.
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with developmental delay, bipolar disorder, morbid obesity,
diabetes who presented to ___ ED with nausea, vomiting,
diarrhea, abdominal pain for about 24 hours prior to
presentation. She reports at least 6 bouts of NBNB emesis as
well as diarrhea. She states that she has been feeling very
weak, with dizziness and vertigo and multiple falls as a result
of being very unsteady on her feet. Per patient, first symptom
was abdominal pain but is not sure. She reports periumbilical
and lower abdominal tenderness. Denies any vaginal bleeding or
complaints, hCG negative in ED. Denies dysuria or frequency.
In the ED, initial vital signs were: 0 97.0 91 136/87 98% RA
Exam notable for abdominal tenderness in ED. Lipase elevated,
81->101, decision made to admit.
Labs were notable for WBC 12K, Bicarb 18.
Patient was given
___ 21:30 IVF 1000 mL NS 1000 mL
___ 21:55 IV Morphine Sulfate 5 mg
___ 21:55 IV Ondansetron 4 mg
___ 23:36 IVF 1000 mL NS 1000 mL
___ 01:58 IV Morphine Sulfate 5 mg
___ 01:58 IVF 1000 mL LR 1000 mL
On Transfer Vitals were: 7 97.5 74 107/69 18 99% RA.
Upon arrival, she is laying comfortably in bed but states she is
very concerned about being discharged too soon.
REVIEW OF SYSTEMS: As noted above, otherwise 10 pt ROS negative.
Past Medical History:
DMII
Bipolar disorder/Depression
Developmental Delay
History of salmonella colitis
GERD
Obesity
SURGICAL HISTORY
D&C x 2
TAB x 2
Social History:
___
Family History:
Mother, Aunt, Uncle - DM
Physical ___:
ADMISSION
Vitals: 124/70 81 18 T 98 98%RA
General: NAD, AxOx3, tired-appearing
HEENT: PERRL, EOMI, OP clear, sclerae anicteric, upper dentures,
MM dry
Neck: soft, supple, no LAD, old healed surgical scar left upper
neck
CV: RRR, S1, S2, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, nontender, nondistended, BS+, no rebound or
guarding
GU: deferred
Ext: warm, no cyanosis, clubbing, or edema
Neuro: AxOx3
Skin: warm, dry, no rash, numerous tattoos on her extremities
DISCHARGE
VS - 97.7 113/79 71 18 98%RA
___ - ___
I/O - yesterday ___ today she has already made 1700cc
urine
Gen - supine in bed, comfortable-appearing while supine;
immediately uncomfortable appearing with raising the bed
Eyes - EOMI, anicteric
ENT - OP clear, moist mucus mebranes
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft, obese, mild tenderness to deep palpation of
mid-epigastric area unchanged from day prior; no
rebound/guarding; normoactive bowel sounds
Ext - no edema
Skin - no rashes; multiple tattoos
Vasc - 2+ DP/radial pulses
Neuro - AOx3, CN II-XII wnl; ___ x 4 extremities; ___ beats
horizontal nystagmus; on sitting up exam limited given
discomfort, appeared to be horizontal nystagmus; no vertical
nystagmus; symptoms immediate resolve with laying supine
Psych - appropriate
Pertinent Results:
ADMISSION
___ 09:30PM BLOOD WBC-12.3* RBC-4.42 Hgb-11.2 Hct-35.1
MCV-79* MCH-25.3* MCHC-31.9* RDW-14.2 RDWSD-40.7 Plt ___
___ 09:30PM BLOOD Glucose-145* UreaN-15 Creat-0.6 Na-137
K-4.4 Cl-105 HCO3-18* AnGap-18
___ 09:30PM BLOOD Albumin-4.1 Calcium-8.9 Phos-3.2 Mg-1.6
___ 09:30PM BLOOD Lipase-101*
DISCHARGE
___ 06:21AM BLOOD WBC-8.2 RBC-4.36 Hgb-11.1* Hct-34.3
MCV-79* MCH-25.5* MCHC-32.4 RDW-14.0 RDWSD-39.8 Plt ___
___ 06:21AM BLOOD Glucose-323* UreaN-12 Creat-0.5 Na-133
K-3.9 Cl-104 HCO3-19* AnGap-14
___ 06:21AM BLOOD Calcium-8.6 Phos-4.7* Mg-1.6
___ - CT Abd/Pelvis
A normal appendix is visualized. Normal CT abdomen and pelvis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Oxcarbazepine 1200 mg PO QAM
3. Gabapentin 300 mg PO QHS
4. Omeprazole 20 mg PO DAILY
5. Aspirin 81 mg PO QHS
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO LUNCH
8. Invokana (canagliflozin) 300 mg oral DAILY
9. glimepiride 2 mg oral BID
10. liraglutide 1.8 mg subcutaneous DAILY
Discharge Medications:
1. Aspirin 81 mg PO QHS
2. Gabapentin 300 mg PO QHS
3. Omeprazole 20 mg PO DAILY
4. Oxcarbazepine 1200 mg PO QAM
5. glimepiride 2 mg ORAL BID
6. Invokana (canagliflozin) 300 mg oral DAILY
7. liraglutide 1.8 mg subcutaneous DAILY
8. Lisinopril 20 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. MetFORMIN (Glucophage) 500 mg PO LUNCH
11. Meclizine 12.5 mg PO TID
RX *meclizine 12.5 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
12. Outpatient Physical Therapy
Vestibular Outpatient Rehab for Left Peripheral Hypofunction
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Benign Positional Paroxysmal Vertigo
# Viral Gastroenteritis / Abdominal Pain / Nausea
# Type 2 Diabetes with neurologic complications
# Bipolar disorder
# Hyperlipidemia
# GERD
# Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: NO_PO contrast; History: ___ with nv/d rlq tenderness NO_PO
contrast // eval for appendicitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 8.0 s, 0.5 cm; CTDIvol = 38.5 mGy (Body) DLP =
19.3 mGy-cm.
4) Spiral Acquisition 5.6 s, 61.0 cm; CTDIvol = 16.9 mGy (Body) DLP =
1,031.7 mGy-cm.
Total DLP (Body) = 1,051 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is a tiny amount of focal pleural thickening at the right
lung base, otherwise the lungs are unremarkable. There is no evidence of
pleural or pericardial effusion. Coronary calcifications are mild.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. A small splenule is incidentally noted.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: A hypodensity in the region of the cervix likely
represents a nabothian cyst. Otherwise, the reproductive organs are
unremarkable.
LYMPH NODES: There are numerous prominent mesenteric lymph nodes in the mid
abdomen, near midline which are closely associated with very subtle misty
mesentery. There is no retroperitoneal lymphadenopathy. There is no pelvic
or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
A normal appendix is visualized. Normal CT abdomen and pelvis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: n/v/d
Diagnosed with Acute pancreatitis, unspecified, Nausea with vomiting, unspecified, Diarrhea, unspecified
temperature: 97.0
heartrate: 91.0
resprate: nan
o2sat: 98.0
sbp: 136.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old female with past medical history of
developmental delay, type 2 diabetes, bipolar disorder admitted
___ with abdominal pain, nausea and vomiting secondary to a
viral gastroenteritis, course complicated by a peripheral
vertigo (potentially BPPV), GI symptoms treated conservatively
and now tolerating a regular diet, vertigo symptoms improving
with meclizine and maneuvers, ready for discharge home with
close PCP ___ and outpatient physical therapy.
# Viral Gastroenteritis / Abdominal Pain / Nausea / Dehydration
- patient admitted with abdominal pain with nausea, vomiting and
diarrhea x 1 day; CT abd/pelvis without focal process; labs
notable only for mildly elevated lactate (resolved with fluid
resuscitation) and elevated lipase (less than 3x the upper limit
of normal). Patient rapidly improved with conservative
management, most consistent with viral gastroenteritis (and not
acute pancreatitis).
# Peripheral Vertigo - patient reported onset of symptoms around
time of her GI symptoms above-reported sensation of room
spinning, worse with changing of position; no tinnitus or
hearing deficit; no focal neuro findings; no orthostasis and did
not improve with volume repletion. Given onset with viral
infection felt to be possible related peripheral vertigo versus
potential BPPV. Symptoms resolved with trial of PO meclizine
treatment. Patient was seen by physical therapy for maneuvers,
who recommended outpatient ___ ___. At time of discharge,
patient was safely ambulating.
# Type 2 Diabetes with neurologic complications - continued home
oral glimepiride, Invokana, liraglutide, metformin. Continued
home gabapentin.
# Bipolar disorder - continued oxcarbazepine
# Hyperlipidemia - continued statin, ASA
# GERD - continued PPI
# Hypertension - continued lisinopril
TRANSITIONAL ISSUES
- Discharged home
- Contact - Legal Guardian ___ ___ - all
medical details relayed to her
- Discharged on trial of meclizine--given prescription for 1
weeks supply to get her to upcoming PCP ___
< 30 minutes spent on this discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ampicillin / Erythromycin Base / Tetracycline /
Sulfa (Sulfonamide Antibiotics) / Ceftriaxone / azithromycin /
Align / cefpodoxime
Attending: ___.
Chief Complaint:
unsteady gait
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/men___ disease presents with unsteady gait. Pt reports
sx for 1 week, also with N/V/D for 1 week. She lives in ___
and was admitted to ___ twice in the past week
due to GI illness and dehydration. Pt now with increased
difficulty ambulating, and weakness. States n/v has resolved but
has low PO intake. Still with intermittent diarrhea.
In ED pt received IVF. CT head wnl. Seen by neuro who stated pt
was improved with fluids and OK to d/c home with daughter. Pt
also with dirty UA, given macrobid.
On arrival to floor pt reports feeling dehydrated prior to
admission and now feels better since getting fluids. Felt much
more steady on her feet when she transferred from ambulance
gurney to bed just a few minutes ago. She has no other
complaints.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Bladder Cancer - underwent cystectomy/ileal loop (___). Now
with 25% Fxn of R kidney 75% on L and almost complete
obstruction of R ureter
Chronic pyelonephritis (pseudomonas)
Peristomal hernia
COPD - mild
Dyslipidemia
Hypertension - not on medication
h/o pneumothx after ileal loop
h/o pneumonia
___ disease
PSHx:
Tonsils/adenoids
Cystectomy/ileal loop
TAH, left oophorectomy
Appy
Exc groin cyst
Deviated septum repair
Finger surgery
___- s/p R lung resection for ? GERD
Social History:
___
Family History:
Mother died of stomach cancer at ___.
Father died of leukemia at age ___.
Physical Exam:
Vitals: T:afeb BP:190/95 P:76 R:16 O2:97%ra
PAIN:0
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd, urostomy tube
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 02:50PM GLUCOSE-84 UREA N-9 CREAT-0.8 SODIUM-144
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-18
___ 02:50PM WBC-7.4 RBC-5.38 HGB-15.6 HCT-48.7* MCV-91
MCH-29.0 MCHC-32.1 RDW-13.4
___ 02:50PM NEUTS-72.2* ___ MONOS-7.1 EOS-1.1
BASOS-0.7
___ 02:50PM PLT COUNT-133*
___ 02:50PM ___ PTT-32.7 ___
___ 04:40PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 04:40PM URINE RBC-2 WBC-2 BACTERIA-MOD YEAST-NONE
EPI-0
Head CT IMPRESSION: No acute intracranial process.
CXR IMPRESSION: Foci of of scarring in the lower lungs.
Possible tiny right pleural effusion versus pleural thickening.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO BID:PRN anxiety
2. Pantoprazole 40 mg PO Q12H
3. Rosuvastatin Calcium 10 mg PO QOD
4. Viactiv (calcium-vitamin D3-vitamin K) 500-500-40 mg-unit-mcg
oral BID
5. ___ (cranberry extract) 3000 mg oral daily
Discharge Medications:
1. Device
Type of equipment: Rolling walker
Reason: gait training
Length of need: Lifetime
Diagnosis: post-viral syndrome
prognosis: good
2. Lorazepam 0.5 mg PO BID:PRN anxiety
3. Pantoprazole 40 mg PO Q12H
4. Rosuvastatin Calcium 10 mg PO QOD
5. ___ (cranberry extract) 3000 mg oral daily
6. Viactiv (calcium-vitamin D3-vitamin K) 500-500-40 mg-unit-mcg
oral BID
7. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recent viral gastroenteritis
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: Hearing loss, dizziness, ataxia.
TECHNIQUE: Routine ___ non-enhanced MR examination including axial SE,
sagittal-MPRAGE, and post-contrast images, the latter with axial and coronal
reformations.
COMPARISON: Comparison is made to CT head dated ___.
FINDINGS:
Several tiny T2 bright foci are seen within the white matter of the left
frontal lobe, compatible with small subacute infarcts. There is no acute
infarct or intracerebral hemorrhage. Principal intracranial vascular flow
voids are preserved. No extra-axial blood or fluid collection is present.
Prominent vessels are suggestive of mild to moderate age related involutional
changes or atrophy. Multiple periventricular T2 bright foci are consistent
with chronic small vessel ischemic disease. No diffusion abnormality is
detected. No intracranial mass identified.
The brainstem, posterior fossa, and cervicomedullary junction are preserved.
The orbits, periorbital, and paracavernous spaces are normal. No abnormality
of the skull base and calvaria is identified.
IMPRESSION:
1. No evidence of acute infarction or hemorrhage.
2. Tiny left frontal subacute infarcts.
3. Cortical atrophy is evidence of chronic small vessel ischemic disease.
Findings were conveyed by Dr. ___ to Dr. ___ telephone at 5:15pm on
___, 5 minutes after interpretation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: UNSTEADY GAIT
Diagnosed with VERTIGO/DIZZINESS, ABNORMALITY OF GAIT, HYPERTENSION NOS
temperature: 97.9
heartrate: 78.0
resprate: 18.0
o2sat: 98.0
sbp: 171.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | ASSESSMENT AND PLAN: ___ yo with recent GI illness and
dehydration presents with difficulty ambulating and general
weakness
Ataxia/Weakness: improved, likely ___ dehydration and possible
component of UTI, no focal neuro symptoms
- change macrobid to cipro based on prior culture data and
multiple allergies will have to monitor closely for medication
induced delerium
- consult ___
- f/u urine culture
Bladder Cancer:chronic hydronephrosis of R ureter
- monitor renal function
HTN: poorly controlled, not on home meds
- start HCTZ and lisinopril
COPD: no acute exacerbation, not on home meds
Dyslipidemia: cont home meds
FEN: gen diet
PPX: heparin
ACCESS: piv
FULL CODE: presumed
CONTACT: daughter
DISPO: medicine, pending above
___, ___
signed electronically |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Lipitor
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
___ Cardioversion
___ Cardioversion
History of Present Illness:
___ w/ PMH DM, Afib, pacemaker, Total shoulder arthroplasty on
___ presenting with shortness of breath of ___ days. Began on
exertion, worsening over the past few days. Patient states he is
retaining a lot of fluid and has been monitoring his weight over
the past few months. He was on dialysis through ___ and ___,
last HD ___, discharged to ___ ___ but never needed HD there.
Discharged home ___. He still has his dialysis line in. He
believes his urine output has decreased recently. Was on
furosemide 80 mg bid at home, but last week dose increased to
120mg bid by his nephrologist, Dr. ___ worsening edema
in legs, without any effect. Denies any changes in diet,
medications. Denies an n/v/f/c/chest pain.
ED initial vitals were: T:97.9, HR:88, BP:95/57, RR:22, 99% RA.
ED exam: 2+ BLE edema, faint bibasilar rales, but breathing
comfortably.
Imaging: CXR no acute cardiopulmonary process.
Labs were notable for
* Cr 3.2 (Cr at discharge 4.2), K 4.2, HCO3 20.
*Troponin 0.07, BNP 9907 (18673 on last admission, previously
1100-5000 range)
*Hb 8.5, plt 79, INR 2.3. Renal was consulted -did not think
fluid overload related to renal function but rather to heart
failure.
*Pt was given 160 mg iv Lasix in the ED and admitted for
management of fluid overload.
Past Medical History:
1. History of coronary artery disease, inferior MI, s/p 4vCABG,
___
2. Aortic valve replacement with bioprosthetic valve, ___
3. Atrial fibrillation s/p catheter ablation ___ and ___, on
Coumadin and dofetilide
4. Status post pacemaker placement, ___ (___ Model
2210 dual-chamber pacemaker)
5. Gastroesophageal reflux disease
6. History of morbid obesity, status post gastric bypass, ___
7. Obstructive sleep apnea on CPAP
8. Status post right toe amputation, right foot osteomyelitis
9 Right groin AV fistula (likely ___ multiple percutaneous
procedures for AF
10. MRSA right ___ toe, s/p amputation for osteomyelitis
11. Hx. of GI Bleed possibly ___ peptic ulcer hospitalized
___
in ___
12. IDDM
13. Chronic bilateral ___ edema (thought to be multifactorial)
- IMI early ___
14. Iron deficiency anemia
15. B12 deficiency
16. ___ spine fusion ___
17. OA of bilateral shoulders, s/p humeral resurfacing of R
shoulder, receives cortisone shots to L shoulder q 3 months
18. Bilateral sacroilitis, has not been a problem in recent
months
19. Cholecystectomy ___
20. Peripheral Vascular Disease
Social History:
___
Family History:
Father had MI at age ___, died of heart disease at age ___.
Diabetes in paternal grandmother and cousins, breast cancer in
mom.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: Afebrile SBP 96/39 HR 73 SpO2 97% on 2L O2
Weight: 86.9 kg
GENERAL: WDWN in NAD. Oriented x3. Answers questions in short,
one-word phrases. Speech at times slightly garbled.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 9 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ systolic murmur heard throughout.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar rales and
decreased BS @ the bases.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema to knees bilaterally. No c/c. No
femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
========================
VS: Tm 97.9, 90-100/50-70s, 80s (** NORMAL SINUS RHYTHM **), RR
18, O2Sat 96% RA
Weight: 66.3 kg
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Mucous membranes
moist.
NECK: Supple with elevated JVD
CARDIAC: RR, normal S1, S2. ___ systolic murmur at left ___
intercostal, no radiation to carotids. No thrills, lifts.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: Warm, well perfused. 1+ edema bilaterally.
Pertinent Results:
ADMISSION LABS:
================
___ 02:45PM ___ PTT-37.9* ___
___ 02:45PM NEUTS-70.7 LYMPHS-16.2* MONOS-10.1 EOS-2.1
BASOS-0.7 NUC RBCS-0.5* IM ___ AbsNeut-3.02 AbsLymp-0.69*
AbsMono-0.43 AbsEos-0.09 AbsBaso-0.03
___ 02:45PM WBC-4.3 RBC-2.61* HGB-8.5* HCT-27.5* MCV-105*
MCH-32.6* MCHC-30.9* RDW-19.3* RDWSD-71.8*
___ 02:45PM CK-MB-7 cTropnT-0.07* proBNP-9907*
___ 02:45PM CK(CPK)-210
___ 02:45PM GLUCOSE-220* UREA N-79* CREAT-3.2* SODIUM-141
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-20* ANION GAP-19
DISCHARGE LABS:
================
___ 06:50AM BLOOD WBC-4.3 RBC-2.76* Hgb-9.0* Hct-28.5*
MCV-103* MCH-32.6* MCHC-31.6* RDW-16.3* RDWSD-61.5* Plt ___
___ 06:50AM BLOOD Glucose-114* UreaN-86* Creat-2.9* Na-140
K-4.4 Cl-96 HCO3-30 AnGap-18
___ 06:50AM BLOOD Calcium-9.7 Phos-4.5 Mg-2.4
INR TREND:
==========
___ 08:20AM BLOOD ___ PTT-81.5* ___
___ 08:05AM BLOOD ___ PTT-75.4* ___
___ 06:50AM BLOOD ___ PTT-39.2* ___
CARDIAC STUDIES:
==============
RHC ___:
Impressions:
1. Normal right and left heart filling pressures
2. Mild-moderate pulmonary artery hypertension
3. Hemodynamically insignificant AV fistula
___ Pyrophosphate Scan:
No evidence of cardiac amyloidosis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Carvedilol 3.125 mg PO BID
2. Cyanocobalamin 1000 mcg IM/SC QMONTH
3. Furosemide 120 mg PO BID
4. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using novolog Insulin
5. Pantoprazole 40 mg PO Q24H
6. Potassium Chloride 40 mEq PO BID
7. Pravastatin 20 mg PO QPM
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Warfarin 3 mg PO DAILY16
10. Aspirin 81 mg PO DAILY
11. Calcium Carbonate 1250 mg PO TID W/MEALS
12. Docusate Sodium 100 mg PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO BID
14. Bicitra 15 mL PO BID
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Rosuvastatin Calcium 20 mg PO QPM
RX *rosuvastatin 20 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet
Refills:*0
3. Torsemide 40 mg PO BID
RX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
5. Warfarin 7.5 mg PO DAILY16
RX *warfarin 2.5 mg 3 tablet(s) by mouth qday Disp #*30 Tablet
Refills:*0
6. Aspirin 81 mg PO DAILY
7. Calcium Carbonate 1250 mg PO TID W/MEALS
8. Cyanocobalamin 1000 mcg IM/SC QMONTH
9. Docusate Sodium 100 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO BID
11. Pantoprazole 40 mg PO Q24H
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13.Outpatient Lab Work
Draw labs on ___
Indication: Heart failure (ICD-9-CM 428.00)
Labs to draw: Chem-10 panel
Fax results to: Dr. ___ (F: ___ and Dr. ___
___ (F: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acutely Decompensated Heart Failure with preserved Ejection
Fraction
Atrial fibrillation
Acute on chronic kidney disease
SECONDARY DIAGNOSIS
Coronary artery disease
Diabetes
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with CHF on diuresis and infected right toe //
r/o gout
IMPRESSION:
No acute fractures or dislocations are seen. There are extensive vascular
calcifications. There are degenerative changes spurring worse within the
patellofemoral compartment. Chondrocalcinosis is seen. Corticated density is
seen adjacent to the superior aspect of the patella which may represent a
large osteophyte.No bony erosions are seen.
Radiology Report
EXAMINATION: DIALYSIS REMOVAL
INDICATION: ___ year old man with CHF exacerbation awaiting cardioversion.
Tunneled HD line to be removed.
COMPARISON: None.
TECHNIQUE: OPERATORS: 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: No sedation was provided.
DEVICES: None.
PROCEDURE:
1. Right internal jugular vein tunneled dialysis catheter removal.
PROCEDURE DETAILS:
The dressings and catheter sutures were removed. While maintaining manual
pressure over the right lower neck and right upper chest, the tunneled
catheter was removed without complication. Manual pressure was maintained for
10 minutes to achieve hemostasis. No bleeding was identified. Sterile
dressings were applied. The patient tolerated procedure well.
FINDINGS:
Right internal jugular vein tunneled dialysis catheter removal.
IMPRESSION:
Successful removal of right internal jugular vein tunneled dialysis catheter.
No complications.
Radiology Report
EXAMINATION: Lower extremity arterial duplex US.
INDICATION: ___ year old man with R femoral fistula // ? characterize R
femoral fistula
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the right lower extremity arteries was obtained.
FINDINGS:
On the right, the common femoral artery is patent with a peak velocity of 94.
The SFA is patent with velocities of 63 cm/sec.
There is a communication between the superficial femoral artery and adjacent
vein.
The distal superficial femoral artery is patent with a velocity of 66 cm/sec.
IMPRPRESSION: Evidence of right superficial femoral artery to common femoral
vein arterial venous fistula.
Radiology Report
INDICATION: ___ with dyspnea and leg swelling // r/o acute cardiopulmonary
process
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Lung volumes are relatively low with bibasilar atelectasis. Superiorly, lungs
are clear. There is no overt edema nor effusion. The cardiomediastinal
silhouette is stable. Prosthetic aortic valve and left chest wall dual lead
pacing device are unchanged. There is a new dual lumen right-sided central
venous catheter with distal tip in the right atrium. Bilateral shoulder
arthroplasties are noted as well as lumbar fixation hardware. .
IMPRESSION:
Low lung volumes without definite acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Leg swelling
Diagnosed with Shortness of breath
temperature: 97.9
heartrate: 88.0
resprate: 22.0
o2sat: 99.0
sbp: 95.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year-old gentleman with HFpEF, CKD, AF on
warfarin, s/p PPM for sick sinus who presented with dyspnea on
exertion and significant edema consistent with a diastolic HF
exacerbation, with concern for recurrent atrial fibrillation as
precipitating factor.
#Acutely Decompensated Heart Failure With Preserved Ejection
Fraction: LVEF = 50%. Unclear precipitant given non-ischemic EKG
with TnT elevation in proportion to renal dysfunction and no
history of medication non-compliance or dietary indiscretion. Pt
in atrial fibrillation, possibly contributing to exacerbation,
though his rates were generally in the ___ to 110s. On admission
he was significantly volume overloaded with 3+ pitting edema to
thighs and sacrum. Admission weight was 86.9 kg compared to
discharge weight of 88.2 on ___ (although the latter likely
did NOT represent his true dry weight). He was started on lasix
gtt upon admission and titrated up to 20 mg/h. He was resistant
to diuresis and dobutamine gtt 2.5 was added on ___. With
inotropic support he diuresed effectively. Patient was
cardioverted x2 from AF into NSR (see below). A pyrophosphate
scan performed on ___ to r/o amyloidosis as the etiology of his
heart failure but this was negative. Given his mod-severe TR and
MR on prior TTE (___), and the need for dobutamine to
diurese, a right heart cath (___) was performed to evaluate for
RV dysfunction and the possibility of high output heart failure
in the setting of a known right femoral AV fistula (iatrogenic
from prior caths at that site). The RHC revealed normal right
and left heart filling pressures and normal cardiac output (no
evidence of high output state). The patient was successfully
weaned off dobutamine following the cessation of Lasix and
cardioversion. He was transitioned to torsemide 40mg BID and
remained euvolemic on PO diuretics at discharge.
Admission weight: 86.9 kg
Discharge weight: 66.3 kg
#Atrial fibrillation with normal ventricular rates: HRs ___
in the hospital, and pt was asymptomatic. Pt previously on
dofetilide but this was discontinued prior to admission ___
renal failure. He was admitted on carvedilol but beta blockers
were discontinued during this admission for hypotension. INR was
therapeutic at 2.3 on admission. He was placed on heparin gtt
for better anticoagulation control in preparation for
cardioversion and cath, and then bridged back to warfarin, again
with a therapeutic INR on discharge. The patient was amiodarone
loaded and then cardioverted on ___. He maintained NSR for
several days but then on ___ he had recurrence of his atrial
fibrillation. He was continued on Amiodarone 200 mg PO/NG DAILY
and re-cardioverted on ___. At time of this second
cardioversion his rhythm pre-shock was actually atrial flutter
with 2:1 block (rather than atrial fibrillation). Post-shock on
___ he, again, was in normal sinus rhythm. EP recommended
continuing amiodarone 200mg PO qday (no change in
anti-arrhythmic therapy). Discharged on a warfarin dose of 7.5mg
daily with an INR of 2.8. He monitors his own INR at home and
calls in the results to his PCP who manages his warfarin dosing.
#Valvulopathies: moderate to severe MR and TR noted on TTE in
___ in the setting of significant volume overload. It is
less likely this represents a primary structural event but
rather was secondary to dilation of the valvular rings while
overloaded given the normal filling pressures observed on right
heart cath when dry. A follow-up TTE while dry could be
performed as an outpatient if warranted.
#Acute on Chronic Kidney Disease, Stage 4: Pt was on dialysis
through ___ and ___ subsequent to an episode of ATN
precipitated by volume overload after L shoulder arthropathy.
His last HD was ___ and the HD line was removed ___. as it was
no longer needed. He was able to diurese effectively on lasix
gtt with inotropic support and then on PO diuretic after the
dobutamine was discontinued. Cr prior to shoulder surgery and
ATN was 0.9-1.1, Cr in house ranged from 2.5-3.2, with most
values prior to discharge between 2.8 and 3.2. His renal
function changed little during diuresis, with his Cr hovering
around 3, and this likely represents a new baseline for him. He
will follow up with nephrology as an outpatient for ongoing
management.
CHRONIC ISSUES:
================
# Coronary artery disease s/p CABG: No chest discomfort or
angina equivalent was noted with no ischemic changes seen on
EKG. TnT elevation in proportion with renal dysfunction. Pt
was transitioned to rosuvastatin 20mg PO QPM and continued on
aspirin 81 mg daily. All beta blockers were discontinued ___
hypotension and not needed for rate control (nor for heart
failure since he has preserved EF).
# Diabetes Mellitus Type 2, controlled: Recent A1c 6.8%, and
patient has stopped using glargine--uses a carbohydrate scale at
home. Humalog sliding scale while in hospital and at discharge.
# Macrocytic anemia/Thrombocytopenia: Chronic, followed by Dr.
___. Platelets are lower than usual without use of
antibiotics, previously thought to be the culprit. SPEP was
normal in ___. He had gastric bypass in ___ with resulting
iron and B12 def and is on monthly B12 injections. Retic 2.7.
Normal B12, folate, LDH, hapto. Light chains assay w/ high free
kappa and lambda but with normal K:L ratio. TSH normal. MMA wnl.
___ recommended the initiation of EPO for Hgb < 9, which may be
started as an outpatient. The patient will follow-up with Dr.
___ discharge.
# GERD: Pt was continued on pantoprazole |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weight gain; edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o diastolic CHF and PAH (idiopathic vs. ___ hypoxia)
presents with progressive weight gain and edema despite
escalating of PO Lasix as outpatient. Seen by ___ cardiology
and ___ today. She was markedly volume overloaded on exam and
w/ ___, so they recommended admission for IV diuresis.
Patient has noted progressive lower extremity edema over the
past several months. She states that her respiratory status is
essentially at baseline. She is able to get around her home and
perform her normal daily activities w/o too much dyspnea. She
does not really leave the home except for doctor appointments
because she is concerned that she will fall.
In the ED initial vitals were: 98.6 79 81/42 18 93%
- Labs were significant for BNP ___ Cr 1.9
- Patient was given 80mg IV Lasix
Vitals prior to transfer were: 75 110/34 17 100% Nasal Cannula
On the floor, patient is comfortable and has no acute
complaints.
Past Medical History:
- Pulmonary arterial hypertension, persumed idiopathic, but with
resting hypoxemia. Significant by echo (PASP estimate >100), and
with confirmed PAH by RHC ___ (mPAP 37, PCW 10, PVR 4). Most
recent RHC ___ with mPAP 53, PVR 10.7; started on therapy at
this time.
- COPD, mild by spirometry
- HFpEF with diastolic dysfunction by echo
- OSA, not currently using PAP therapy due to feelings of
suffocation, on nocturnal O2
- Atrial fibrillation, anticoagulated for at least last ___ years
- Exertional and nocturnal hypoxemia, thought due to COPD
- Diabetes, previously diagnosed but now off medications
- Hypertension
- Hyperlipidemia
- GERD
- Gout
- Smoking history: current, total history ___ x ___ years.m
quit in ___
Social History:
___
Family History:
Mom died of MI at age ___. Dad died from "brain cancer" in ___.
Sister died from ESRD at age ___ and brother died of liver cancer
in ___. Another brother recently died of unknown cause. No known
FH of early MI or clotting disorders.
Physical Exam:
On Admission:
=====================
Vitals - 98.6 110/53 71 20 96%/4L nc
Wt: 77.7kg (171 lbs)
GENERAL: NAD. Well-appearing.
HEENT: MMM
NECK: JVP to angle of jaw w/ patient at 45 degrees
CARDIAC: irregularly irregular, S1/S2, no murmurs, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: 2+ pitting edema to mid-shin level bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: a&ox3. no focal deficits appreciated
On Discharge:
==============Vitals - 97.7 69 97/53 18 93%3L
Wt: 75.1kg
I/O: PO 600, IV 0, UOP 1050+. Net: -450+
GENERAL: NAD. Well-appearing.
HEENT: MMM
NECK: No JVD
CARDIAC: irregular rhythm, rate controlled, normal S1/S2, no
murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: 1+ pitting edema around ankles, right ankle tender
to palpation, pain with passive motion and active motion against
resistance
NEURO: a&ox3. no focal deficits appreciated =======
Pertinent Results:
ADMISSION LABS
___ 05:50PM BLOOD WBC-5.5 RBC-2.85* Hgb-9.8* Hct-30.7*
MCV-108* MCH-34.4* MCHC-32.0 RDW-16.1* Plt ___
___ 05:50PM BLOOD Neuts-45.9* Lymphs-44.2* Monos-8.1
Eos-1.6 Baso-0.3
___ 05:50PM BLOOD ___ PTT-37.6* ___
___ 05:50PM BLOOD Glucose-119* UreaN-39* Creat-1.9*# Na-137
K-4.0 Cl-95* HCO3-30 AnGap-16
___ 05:50PM BLOOD ___ 05:50PM BLOOD cTropnT-<0.01
DISCHARGE LABS
___ 05:50PM BLOOD WBC-5.5 RBC-2.85* Hgb-9.8* Hct-30.7*
MCV-108* MCH-34.4* MCHC-32.0 RDW-16.1* Plt ___
___ 05:50PM BLOOD Neuts-45.9* Lymphs-44.2* Monos-8.1
Eos-1.6 Baso-0.3
___ 05:50PM BLOOD ___ PTT-37.6* ___
___ 05:50PM BLOOD Glucose-119* UreaN-39* Creat-1.9*# Na-137
K-4.0 Cl-95* HCO3-30 AnGap-16
___ 05:50PM BLOOD ___ 05:50PM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD WBC-6.2 RBC-2.82* Hgb-9.8* Hct-30.8*
MCV-109* MCH-34.9* MCHC-32.0 RDW-15.6* Plt ___
___ 06:20AM BLOOD ___
___ 06:20AM BLOOD Glucose-101* UreaN-43* Creat-1.7* Na-139
K-3.9 Cl-96 HCO3-31 AnGap-16
___ 06:20AM BLOOD Calcium-9.8 Phos-4.6* Mg-1.9
IMAGING
___ CXR
FINDINGS
As compared to the most recent prior examination dated ___, there is a very small suspected right pleural effusion.
There is no evidence of lobar consolidation or parenchymal
edema. Cardiomegaly is noted, similar as compared to the prior
exam. No acute osseous abnormalities are detected.
IMPRESSION
Small right pleural effusion. Stable cardiomegaly. No evidence
of parenchymal edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 1.25 mg PO 3X/WEEK (___)
2. Warfarin 2.5 mg PO 4X/WEEK (___)
3. Lisinopril 2.5 mg PO DAILY
4. Magnesium Oxide 400 mg PO BID
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
6. Famotidine 20 mg PO BID
7. Furosemide 120 mg PO DAILY
8. sildenafil 20 mg oral TID
9. Omeprazole 20 mg PO DAILY
10. Calcium Carbonate 500 mg PO QID:PRN indigestion
11. macitentan 10 mg oral daily
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN indigestion
2. Famotidine 20 mg PO BID
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
4. Lisinopril 2.5 mg PO DAILY
5. macitentan 10 mg oral daily
6. Magnesium Oxide 400 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. sildenafil 20 mg oral TID
9. Vitamin D 1000 UNIT PO DAILY
10. Warfarin 2.5 mg PO 4X/WEEK (___)
11. Torsemide 20 mg PO DAILY
RX *torsemide [Demadex] 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
12. Warfarin 2.5 mg PO DAILY16
13. Acetaminophen 325 mg PO Q6H:PRN pain
14. 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
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Heart failure exacerbation
Secondary:
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Atrial fibrillation, anticoagulated for at least last ___ years
Hypertension
Hyperlipidemia
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with assist.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with CHF? // eval for fluid
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison is made to chest radiographs dated ___.
FINDINGS:
As compared to the most recent prior examination dated ___, there is a
very small suspected right pleural effusion. There is no evidence of lobar
consolidation or parenchymal edema. Cardiomegaly is noted, similar as compared
to the prior exam. No acute osseous abnormalities are detected.
IMPRESSION:
Small right pleural effusion. Stable cardiomegaly. No evidence of parenchymal
edema.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Fatigue, Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, PULMONARY HTN-SECONDARY, CHRONIC AIRWAY OBSTRUCTION
temperature: 98.6
heartrate: 79.0
resprate: 18.0
o2sat: 93.0
sbp: 81.0
dbp: 42.0
level of pain: 0
level of acuity: 1.0 | ___ w/ h/o moderate-severe PAH (presumed idiopathic, but also w/
h/o COPD, OSA, and hypoxemia), as well as diastolic CHF,
presents for persistent edema, fatigue, and dyspnea despite
increasing doses of oral diuretics; also found to have ___.
# Acute on chronic diastolic, biventricular CHF: Pt. w/
diastolic left-sided CHF as well as severe PAH (idiopathic vs.
___ hypoxia). She has had progressive volume overload despite
escalating doses of PO Lasix. It is possible that she is not
absorbing PO Lasix consistently due to gut edema. Patient
diuresed initially with IV lasix, transitioned to PO torsemide,
and euvolemic with dry weight of 75.1kg at discharge. Continued
home sildenafil and macitentan for PAH. Started low dose
metoprolol. Continued lisinopril. Discontinued lasix and started
torsemide.
# ___: Cr 2.0, up from baseline of 0.7. Given her overall
clinical presentation, this is likely due to renal venous
congestion w/ decompensated right heart failure. Creatinine
improved somewhat with diuresis to 1.7 at discharge.
# Macrocytic anemia: 9.8 from baseline of 11.8. No evidence of
active bleeding. B12 and folate were normal.
#Gout: Patient complained of right foot pain on ___, improved
with colchicine x1. ___ right foot pain resolved, but new
left ankle pain, now somewhat improved with repeat dose of
colchicine. Patient able to ambulate with ___ and with RN.
# COPD: stable. Continue home bronchodilators
# A-fib: rate within target range with metoprolol 25mg daily.
INR sub-therapeutic at 1.3 at the time of discharge. She
received one increased dose of 3mg on ___ and was discharged
on 2.5mg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hematuria and clot retention.
Major Surgical or Invasive Procedure:
Cystoscopy, evacuation of clot and fulguration of prostate bed.
History of Present Illness:
___ male with history of recent transurethral resection
of the prostate in an outside hospital who has had two prior
episodes of gross operative bleeding who presented to the
Emergency Department overnight with clot retention and
ultrasound showing organized clot in the bladder.
Past Medical History:
See anesthesia record/OMR notes.
Social History:
___
Family History:
See anesthesia record/OMR notes.
Physical Exam:
WDWN, NAD, AVSS
Abdomen soft, non-distended
IUC removed.
Bilateral lower extremities w/out edema, pitting or pain to deep
palpation of calves
Pertinent Results:
___ 07:10AM BLOOD WBC-9.8 RBC-2.57* Hgb-7.9* Hct-23.9*
MCV-93 MCH-30.7 MCHC-33.1 RDW-14.1 RDWSD-47.7* Plt ___
___ 08:40AM BLOOD Hct-30.9*
___ 04:05AM BLOOD WBC-18.2* RBC-3.41* Hgb-10.5* Hct-32.1*
MCV-94 MCH-30.8 MCHC-32.7 RDW-13.6 RDWSD-46.5* Plt ___
___ 04:05AM BLOOD Neuts-81.0* Lymphs-12.1* Monos-5.3
Eos-0.2* Baso-0.4 Im ___ AbsNeut-14.72* AbsLymp-2.19
AbsMono-0.97* AbsEos-0.03* AbsBaso-0.08
___ 07:10AM BLOOD Glucose-94 UreaN-19 Creat-1.1 Na-141
K-4.3 Cl-108 HCO3-20* AnGap-13
___ 04:05AM BLOOD Glucose-251* UreaN-27* Creat-1.6* Na-140
K-4.1 Cl-104 HCO3-13* AnGap-22*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO 5X/D ___ flare
2. Finasteride 5 mg PO DAILY
3. Tamsulosin 0.4 mg PO DAILY
4. Losartan Potassium 50 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain-Mild/Fever >100
2. Bacitracin Ointment 1 Appl TP QID
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg ONE capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Phenazopyridine 100 mg PO Q8H:PRN dysuria/urgency Duration:
3 Days
RX *phenazopyridine 100 mg ONE tablet(s) by mouth Q8hrs Disp #*9
Tablet Refills:*0
5. Senna 17.2 mg PO QHS
6. Acyclovir 400 mg PO 5X/D ___ flare
7. Finasteride 5 mg PO DAILY
8. Losartan Potassium 50 mg PO QHS
9. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hematuria, gross
retention, clot urinary
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: History: ___ with urinary retention and hematuria s/p TURP 1 mo
ago, unable to foley irrigate // Please evaluate bladder for clot burden
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
There is mild right-sided hydronephrosis. There are no stones, or masses
bilaterally. Normal cortical echogenicity and corticomedullary differentiation
are seen bilaterally.
Right kidney: 12.1 cm
Left kidney: 11.7 cm
Within the bladder lumen there is a large, heterogeneous, avascular mass
measuring 6.8 x 8.2 x 7.4 cm. Partially visualized is a Foley catheter within
the bladder.
IMPRESSION:
1. Mild right-sided hydronephrosis.
2. 6.8 x 8.2 x 7.4 cm avascular mass within the bladder lumen likely
represents residual clot.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Hematuria
Diagnosed with Hematuria, unspecified
temperature: 96.2
heartrate: 128.0
resprate: 28.0
o2sat: 100.0
sbp: 158.0
dbp: 116.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ was admitted to urology with hematuria and clot
retention and underwent cystoscopy, evacuation of clot and
fulguration of prostate bed. No concerning intraoperative events
occurred; please see dictated operative note for details. He
patient received ___ antibiotic prophylaxis.
Patient's postoperative course was uncomplicated. He received
intravenous antibiotics and
continuous bladder irrigation overnight. On POD1 the CBI was
discontinued and his Foley was removed after active voiding
trial and post void residuals were checked. His urine was clear
yellow and without clots. He remained a-febrile throughout his
hospital stay. At discharge, the patient's pain well controlled
with oral pain medications, tolerating regular diet, ambulating
without assistance, and voiding without difficulty. He is given
pyridium and oral pain medications on discharge and explicit
instructions to follow up in clinic. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / tramadol / Magnesium citrate bowel prep /
nitroglycerin
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ yo M w/ PMHx of CAD c/b STEMI s/p BMS, IE of AV s/p ___
porcine valve replacement, pulmonary hypertension, HTN, OSA not
on CPAP who p/w hyperkalemia. He was recently discharged in
___ for melena of unclear etiology. At the time of discharge,
his lisinopril and lasix had been discontinued during that
hospitalization but then re-started at a post-discharge f/u appt
with his PCP ___ ___. He returned for f/u with his PCP ___
___ and repeat labs were drawn and his K+ returned at 5.9.
He was instructed to re-draw his labs on ___ and his K+
returned at 6.8. His creatinine during this time went from
1.56->1.93. At the time of discharge from ___ on ___, his
creatinine was 1.3.
Mr. ___ states he has had poor PO intake over the past several
weeks because of an anal fissure. He is scheduled for anal
fissure repair next week. He also states he had problems with
low potassium earlier and started drinking more orange juice. He
denies NSAID use. He has been urinating the usual amounts. There
has been no change to his urine either - it is not foamy, there
is no blood, he has no dysuria or frequency.
In the ED initial vitals were: 98.2 108 102/57 16 95%RA
- Labs were significant for K+ 5.4, BUN/Cr 44/2.0, phos 4.8
- Patient was given nothing and admitted to medicine for further
management.
Vitals prior to transfer were: 98.1 104 101/56 25 98%RA.
On the floor, the pt states he is feeling great and hoping to
leave tomorrow.
Past Medical History:
1. STEMI on ___: BMS placed to occluded R-PLV
2. Aortic valve endocarditis (E. faecalis), S/P aortic valve
replacement with 23mm ___ porcine valve ___
3. Mild-to-moderate pulmonary hypertension (38 mmHg on echo
___.
4. Hypertension
5. Hyperlipidemia
6. Thoracic and lumbar spine discitis with lumbar spine
paraspinal abscess status post debridement ___
7. Chronic renal insufficiency
8. Asthma
9. Obstructive sleep apnea on home CPAP
10. Nephrolithiasis status post laser extraction ___
11. Left patellectomy in ___
12. Obesity
13. Right knee replacement (___)
14. Colonic polyps (___)
15. Anal fissure (___)
16. Atrial fibrillation (___)
Social History:
___
Family History:
There is family history of heart disease in his mother (age
unknown). His father had emphysema.
Physical Exam:
ADMISSION
Vitals - T:97.9 BP 105/47 HR: 108 RR: 18 02 sat: 98% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: mildly tachycardic, S1/S2, harch ___
crescendo-decrescendo murmur @ RUSM, no gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE
VSS
GENERAL: WDWM obese man in NAD
HEENT: NCAT EOMI MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RR S1/S2, harsh ___ crescendo-decrescendo murmur @
RUSM, no gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: +BS, soft protuberant NT/ND
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3
SKIN: warm and well perfused
Pertinent Results:
ADMISSION
___ 08:00PM BLOOD WBC-6.1 RBC-3.67*# Hgb-12.2*# Hct-40.3#
MCV-110* MCH-33.4* MCHC-30.4* RDW-16.1* Plt ___
___ 08:00PM BLOOD Plt ___
___ 08:00PM BLOOD Glucose-89 UreaN-44* Creat-2.0* Na-135
K-5.4* Cl-101 HCO3-18* AnGap-21*
___ 08:00PM BLOOD Calcium-9.6 Phos-4.8* Mg-1.9
___ 08:00PM BLOOD K-5.3*
DISCHARGE
___ 06:30AM BLOOD WBC-3.3* RBC-3.20* Hgb-10.5* Hct-34.2*
MCV-107* MCH-32.8* MCHC-30.7* RDW-15.9* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-104* UreaN-43* Creat-1.6* Na-136
K-5.4* Cl-105 HCO3-23 AnGap-13
___ 01:15PM BLOOD Glucose-122* UreaN-36* Creat-1.2 Na-139
K-5.3* Cl-107 HCO3-26 AnGap-11
___ 06:30AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.0
Renal U/S IMPRESSION:
No hydronephrosis. Small simple left renal cortical cyst noted.
___ 02:36AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:36AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
___ 02:36AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-1
___ 02:36AM URINE CastHy-41*
___ 02:36AM URINE Mucous-RARE
___ 02:36AM URINE Hours-RANDOM UreaN-578 Creat-268 Na-35
K-49 Cl-18 TotProt-17 Prot/Cr-0.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Allopurinol ___ mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. FoLIC Acid 1 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. Metoprolol Tartrate 75 mg PO BID
9. Montelukast 10 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Thiamine 100 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. Aspirin 81 mg PO DAILY
14. Warfarin 7.5 mg PO DAILY16
15. Omeprazole 40 mg PO DAILY
16. Clindamycin 300 mg PO Q8H
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Clindamycin 300 mg PO Q8H
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. FoLIC Acid 1 mg PO DAILY
8. Metoprolol Tartrate 75 mg PO BID
9. Montelukast 10 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Allopurinol ___ mg PO DAILY
14. Tiotropium Bromide 1 CAP ___ DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperkalemia and ___ of multifactorial origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with ___ // obstruction
TECHNIQUE: Grey scale ultrasound images of the kidneys were obtained.
COMPARISON: Abdomen MRI ___ and renal ultrasound ___
FINDINGS:
The right kidney measures 10.9 cm. The left kidney measures 11.0 cm. There is
no hydronephrosis. No stone or suspicious solid mass is seen in either kidney.
A simple cortical cyst is seen in the medial portion of the left kidney
measuring 1.3 x 1.2 x 0.9 cm. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally. No perinephric fluid
collection is identified.
The bladder is moderately well seen and normal in appearance.
IMPRESSION:
No hydronephrosis. Small simple left renal cortical cyst noted.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Hyperkalemia
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.2
heartrate: 108.0
resprate: 16.0
o2sat: 95.0
sbp: 102.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ y/o man with a hx of a flutter (on coumadin,
recently stopped for upcoming surgery), CAD c/b STEMI s/p BMS,
IE of AV s/p AVR with ___ porcine valve replacement,
pulmonary hypternsion, HTN, OSA not on CPAP who presented to our
hospital for concerning lab finding of hyperkalemia and ___. He
had bloodwork in the ED which showed a downtrend in potassium.
He was given IVF and monitored overnight. Repeat blood work in
the AM and ___ showed downtrending potassium and creatinine. He
was then discharged to outpatient follow up with his PCP.
___--
The patient was discharged from our hospital in ___ for
melena of unclear etiology, at the time of discharge his lasix
and lisinopril which had been d/c'd for the admission were
restarted. Because of his improved leg edema, lasix was
discontinued by one of his outpatient physicians. The patient
reports increasing his potassium intake with orange juice
because he thought he was previously low. He went to his PCP ___
___ and was found to have a K of 5.9 with repeat testing on
___ up to 6.8. There was also a change of 1.56->1.93 in his
creatinine over that time (at previous discharge in ___, as
1.3). he was admitted to the floors and given IVF (2 L NS @ 150
mL/hr). His labs improved during admission, from ED: Creatinine
2.0, K 5.4-->AM Crea 1.6, K ___ Crea 1.2, K 5.3. The
patient was discharged to ___ with PCP on ___.
He should have a CBC and CHEM7
(Na/K/Cl/Bicarb/BUN/Creat/Glucose) drawn ___ and faxed to his
PCP's office ___.
TRANSITIONAL ISSUES
-Patient told to start lovenox for anticoagulation (while
holding Warfarin) on discharge per recommendation of his
cardiologist for upcoming colorectal surgery for anal fissure.
-Patient to have labs drawn ___ to be faxed to PCP for
___ lisinporil during visit and told to stop at home for the
time being, please discuss restarting with PCP/cardiologist |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypercalcemia
Major Surgical or Invasive Procedure:
Parathyroidectomy ___
History of Present Illness:
___ is a ___ old woman with no PMH, who presented
from ___ for evaluation of incidental finding of
hypercalcemia.
Patient presented to ___ ___ ___ at ___ for
evaluation of productive cough and sore throat, where labs
showed
hypercalcemia 13.8, albumin 4.8 and negative rapid strep test.
She endorsed neck pain, sore throat. Of note, she returned from
a
three-week trip to ___ 3 days ago, where she had sick
contacts. She was prescribed PPI and tums for suspected GERD.
She
denied fever, night sweats, and chills, bone pan, excessive
fatigue, confusion, polyuria, polydipsia, constipation.
She presented to ___ ED today ___ for further evaluation of
hypercalcemia. VS: Temp 98.0 F, HR 69, BP 118/65, RR 18, 100% R.
Additional labs include: Hgb 11.1, PLT 259, Cr 0.7, ALP 126, Ca
___ (corrected 13.2), Mg 1.9, and pending TSH, PTH, 25-VitD.
She was alert and oriented, and received 1L NS x2 at 250cc/h for
hypercalcemia. CXR was unremarkable. ECG with QTc 370ms.
On arrival to the floor, the patient endorsed the above history,
and was clinically stable.
REVIEW OF SYSTEMS:
The patient denied fever, night sweats, chills, lightheadedness,
confusion, abdominal pain, constipation, nausea, vomiting,
polyuria, polydipsia, back pain, dyspnea, hemoptysis.
She endorsed productive cough of greenish sputum, weight loss
(1kg in 3 weeks), sore throat, fatigue, intermittent
palpitations
and history of murmur.
Past Medical History:
Microcytic anemia
Social History:
___
Family History:
Mother: migraines and palpitations
Father: stomach ulcers/reflux, "heart medication", back pain
Maternal Grandmother: pancreatic cancer (dx: ___, thyroidectomy
Breast cancer
Peptic ulcer disease (multiple members from paternal-side)
No history of pituitary tumors.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: @1547 Temp 98.0 F, HR 69, BP 118/65, RR 18, 100% R.
GENERAL: Well-nourished, well-appearing
HEENT: Head atraumatic, Pupils equal, Anicteric sclera, MMM
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Normal breathing effort. Lungs clear bilaterally except
for R lower lung field with rhonchi. No crackles or wheezing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm.
NEUROLOGIC: Alert and oriented. Moving all 4 limbs
spontaneously.
Patellar reflexes normal bilaterally.
UPON DISCHARGE:
========================
GEN: AOx3 WN, WD in NAD
HEENT: Incision is C/D/I without underlying hematoma. Mild
ecchymosis noted ___. NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing with symmetric chest rise, no
respiratory distress
ABD: soft, NT, ND, no mass, no hernia
EXT: WWP, no CCE, no tenderness, 2+ B/L ___
Pertinent Results:
ADMISSION LABS:
===============
___ 01:00PM BLOOD WBC-6.2 RBC-5.29* Hgb-11.1* Hct-36.7
MCV-69* MCH-21.0* MCHC-30.2* RDW-14.1 RDWSD-34.7* Plt ___
___ 01:00PM BLOOD Neuts-63.1 ___ Monos-6.6 Eos-1.6
Baso-0.6 Im ___ AbsNeut-3.93 AbsLymp-1.73 AbsMono-0.41
AbsEos-0.10 AbsBaso-0.04
___ 01:00PM BLOOD Glucose-74 UreaN-10 Creat-0.7 Na-137
K-4.4 Cl-104 HCO3-21* AnGap-12
___ 01:00PM BLOOD ALT-15 AST-22 LD(LDH)-261* AlkPhos-126*
TotBili-0.4
___ 01:00PM BLOOD Albumin-4.7 Calcium-13.8* Phos-1.6*
Mg-1.9
PERTINENT LABS/MICRO/IMAGING:
============================
___ 01:00PM BLOOD TSH-1.5
___ 03:18PM BLOOD PTH-313*
___ 06:10AM BLOOD PTH-290*
___ 01:00PM BLOOD 25VitD-45
___ 13:00
PARATHYROID HORMONE RELATED PROTEIN
Test Result Reference
Range/Units
PTH-RP 12 L ___ pg/mL
CXR ___:
No acute cardiopulmonary abnormality.
Parathyroid U/S ___:
The three visualized) is 2 right, 1 left) parathyroid glands
demonstrate
enlargement, consistent with parathyroid hyperplasia. However,
a fourth left
parathyroid gland could not be identified on current study. A
follow-up
sestamibi parathyroid or 4D CT scan may be considered to search
for a fourth
left parathyroid gland.
RECOMMENDATION(S): The follow up sestamibi parathyroid or 4D CT
scan may be
considered search for a fourth left parathyroid gland.
4D CT Parathyroid ___:
The 2 small nodules identified on ultrasound at the lower poles
bilaterally are not really confirmed on the 4DCT. In addition,
the more
superior nodule is demonstrated as a low-density defect within
the enhancing
thyroid rather than hyperenhancing nodule. In addition,
although it is
possible that this is an extrathyroidal nodule invaginating into
the thyroid
tissue, it could be actually intrathyroidal (subcapsular).
Review of the
ultrasound does tend to suggest that the 3 lesions suspicious
for parathyroid
gland enlargement. The lower pole nodules could represent small
lymph nodes
on the bases are non enhancement. As discussed with Dr. ___,
there is no
evidence to suggest an unusual ectopic parathyroid adenoma,
either undescended
or within the mediastinum. As result, a 4 gland exploration may
be warranted.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Ibuprofen 600 mg PO Q8H:PRN pain
Please take with water and food
Discharge Disposition:
Home
Discharge Diagnosis:
-Hypercalcemia
-Primary hyperparathyroidism
Discharge Condition:
Alert and oriented x3, cohesive
Ambulating per baseline
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with cough// r/o infiltrate
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.
Radiology Report
EXAMINATION: PARATHYROID US
INDICATION: ___ year old woman with primary hyperparathyroidism on labs//
evaluation for enlarged parathyroid gland
TECHNIQUE: Grey scale and color Doppler ultrasound images of the neck were
obtained.
COMPARISON: None.
FINDINGS:
The right lobe measures: (transverse) 1.9 x (anterior-posterior) 1.5 x
(craniocaudal) 4.9 cm.
The left lobe measures: (transverse) 1.7 x (anterior-posterior) 1.6 x
(craniocaudal) 4.4 cm.
Isthmus anterior-posterior diameter is 0.2 cm.
The thyroid parenchyma is homogenous and has normal vascularity.
Posterior to the mid thyroid lobe is a well-circumscribed homogeneous
hypoechoic structure with internal vascularity measuring 1.4 x 0.5 x 1.2 cm
consistent with an enlarged parathyroid gland.
Caudal to the lower pole right thyroid lobe is a well-circumscribed hypoechoic
structure measuring 0.5 x 0.4 x 0.6 cm, also consistent with an enlarged
parathyroid gland.
Caudal to the lower pole left thyroid lobe is a well-circumscribed hypoechoic
structure measuring 0.8 x 0.3 x 0.7 cm, again consistent with an enlarged
parathyroid gland. Anterior to the left parathyroid gland is a
well-circumscribed hyperechoic lesion which likely represents the fatty lymph
node.
IMPRESSION:
The three visualized) is 2 right, 1 left) parathyroid glands demonstrate
enlargement, consistent with parathyroid hyperplasia. However, a fourth left
parathyroid gland could not be identified on current study. A follow-up
sestamibi parathyroid or 4D CT scan may be considered to search for a fourth
left parathyroid gland.
RECOMMENDATION(S): The follow up sestamibi parathyroid or 4D CT scan may be
considered search for a fourth left parathyroid gland.
Radiology Report
EXAMINATION: 4DCT NECK W AND W/O CONTRAST
INDICATION: ___ year old woman with hypercalcemia, elevated PTH.//
?Parathyroid adenoma (4D CT/parathyroid CT)
TECHNIQUE: With the patient supine in the CT scanner, initial axial scans
were obtained through the level of the thyroid without contrast. Following
this, a bolus of 100 cc of contrast and 4 cc/second was administered into a
patent vein in the antecubital fossa in the right arm. Rapid sequence scans
were then obtained from the skullbase through the level just below the carina
at 30 and 60 seconds following initiation of the injection. Coronal and
sagittal reconstructions were performed.
DOSE: DLP: 337.08 mGy-cm; CTDI: 20 mGy
COMPARISON: Parathyroid ultrasound obtained ___
FINDINGS:
No significant cervical masses or adenopathy appreciated. The anterior
mediastinum demonstrates moderate amount of residual thymic tissue. The
visualized upper lung fields are unremarkable. The bony structures the
difficult to assess this young patient but may demonstrate slight
demineralization.
This CT examination is compared with the recent ultrasound. The 2 hypoechoic
nodules below the lower poles bilaterally, suspicious for parathyroid adenomas
on the ultrasound, are not really confirmed is hyperenhancing nodules on the
4DCT. Interestingly, the nodule in the posterior medial aspect of the right
thyroid lobe, in the mid to upper portion is demonstrated as a low-density
defect within the enhancing thyroid tissue. This would also be atypical for a
parathyroid adenoma which should enhance as bright if not brighter than the
thyroid and washout. At the left upper pole, there is extension of tissue
into the retroesophageal region. However, both from the density on the
noncontrast scan and the appearance on the enhanced scans, this likely
represents an extension of thyroid tissue and not a separate parathyroid.
IMPRESSION:
1. Incidental findings as indicated above.
2. The 2 small nodules identified on ultrasound at the lower poles
bilaterally are not really confirmed on the 4DCT. In addition, the more
superior nodule is demonstrated as a low-density defect within the enhancing
thyroid rather than hyperenhancing nodule. In addition, although it is
possible that this is an extrathyroidal nodule invaginating into the thyroid
tissue, it could be actually intrathyroidal (subcapsular). Review of the
ultrasound does tend to suggest that the 3 lesions suspicious for parathyroid
gland enlargement. The lower pole nodules could represent small lymph nodes
on the bases are non enhancement. As discussed with Dr. ___, there is no
evidence to suggest an unusual ectopic parathyroid adenoma, either undescended
or within the mediastinum. As result, a 4 gland exploration may be warranted.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abnormal labs, Chest pain
Diagnosed with Hypercalcemia
temperature: 96.8
heartrate: 69.0
resprate: 19.0
o2sat: 95.0
sbp: 115.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | ___ with PMH of microcytic anemia who presents from PCP at
___ for evaluation of incidental finding of
hypercalcemia. Likely primary hyperparathyroidism given elevated
PTH and enlarged parathyroid glands on imaging. Underwent
parathyroidectomy on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril / Levofloxacin / Penicillins
Attending: ___.
Chief Complaint:
Right hemiparesis and global aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is an ___ year-old right-handed woman with atrial fib on
prodaxin, HTN, HLD, and history of GI bleed on coumadin who was
transferred to ___ ER from ___ for a concern for acute
stroke. Patient was last seen well at 22:30 on ___ by her
daugher who was having a conversation with her and noted that
she
was fully alert, oriented and interactive with no notable
deficits. However, at 11:15, as the daughter went by her
mother's
room she noted that the patient's TV was on at a show that she
didn't watch and when she went in she noted that Ms. ___
was
lying down on her bed mumbling something. As per her daughter,
"she was trying to say something but the words would not come
out." The daughter also noted that the patient was not moving
the
right side of her body. She called ___ and Ms. ___ was
taken
to ___ where a CT head was done. The CT was degraded by
motion but read as negative for any acute process including
bleed
or infarct. Her ___ stroke scale there was 20. She was not
considered a candidate for Tpa at that time since she has been
on
prodaxin. Chemistry panel was done and was normal and
coagulation
panel was also normal. She was transferred to ___ for futher
management.
In the ER, patient's vitals were noted to be stable: 98.3 70
159/88 16 96% RA. She was noted to have dense hemiparesis on the
right, and a code stroke was called. We obtained a CTA as well
as
CT perfusion which showed a left MCA acute infarct as well as a
small old right occipital infarct. CTA showed left intracranial
carotid occlusion.
Patient's daughter does not report any recent fever or illness
prior to today's episode.
Past Medical History:
PMH:
Prior strokes
HTN
HLD
A fib; was placed initially on coumadin but had a GI bleed
leading to anemia that required iron transfusions; was switched
to Pradaxa
GERD
Social History:
___
Family History:
Family Hx:
Dad and sister with brain tumors
Family history of CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:38.6 P:87 R: 16 BP: 143/62 SaO2:100
General: Awake, unable to follow commands or communicate.
HEENT: NC/AT, no scleral icterus noted, MMM,
Neck: Supple
Cardiac: 2+ non pitting edema in b/l ankles
Abdomen: soft, NT/ND,
Extremities: warm, well perfused
Skin: multiple bug bite marks and excoriations on extremities.
Neurologic:
Mental Status: Awake, but inattentive. Does not respond to name
or touch. Will look at daughter ___ but not at the
examiner. Appears globally aphasic. Unable to follow both
midline and appendicular commands.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.
III, IV, VI: Does not move extra occumlar movements on command
V: Facial sensation intact to light touch.
VII: Right facial droop, facial musculature symmetric.
VIII: not tested
IX, X: Palate elevates symmetrically.
XI: unable to assess
XII: Tongue protrudes in midline.
Motor: Does not move right UE. Some spontaneous movement of
right
___ (but not against gravity) and full movement in left
extremities. Normal bulk, throughout. No adventitious movements,
such as tremor, noted. Unable to test individual muscle groups
since patient not able to follow commands.
Sensory: Unable to assess
DTRs:
___ responses mute b/l but brachioradialis 2 b/l. Plantar
response was extensor on the right and flexor on the left
Coordination: Unable to assess since patient would not follow
commands
Gait: Unable to assess since patient on stretcher
DISCHARGE EXAM:
GEN: in bed, not moving
HEENT: pupils filxed and dilated
CV: no heartbeat palpated or auscultated
RESP: no breaths auscultated or palpated
EXT: cool and pale
Pertinent Results:
___ 09:05AM GLUCOSE-135* UREA N-28* CREAT-0.7 SODIUM-143
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-23 ANION GAP-13
___ 09:05AM ALT(SGPT)-24 TOT BILI-0.5
___ 09:05AM ALBUMIN-3.8 CALCIUM-9.3 PHOSPHATE-2.9
MAGNESIUM-1.8 CHOLEST-177
___ 09:05AM %HbA1c-6.1* eAG-128*
___ 09:05AM TRIGLYCER-52 HDL CHOL-55 CHOL/HDL-3.2
LDL(CALC)-112
___ 09:05AM TSH-1.1
___ 09:05AM TSH-1.1
___ 09:05AM WBC-6.9 RBC-3.93* HGB-10.4* HCT-33.9* MCV-86
MCH-26.4* MCHC-30.6* RDW-15.3
___ 09:05AM ___ PTT-31.3 ___
___ 09:05AM SED RATE-19
___ 02:45AM GLUCOSE-132* UREA N-32* CREAT-0.7 SODIUM-143
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-24 ANION GAP-14
___ 02:45AM ALT(SGPT)-16 AST(SGOT)-29 ALK PHOS-136* TOT
BILI-0.5
___ 02:45AM cTropnT-<0.01
___ 02:45AM ALBUMIN-3.9 CALCIUM-9.1 PHOSPHATE-3.3
MAGNESIUM-1.8
___ 02:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:45AM WBC-8.4 RBC-4.00* HGB-10.7* HCT-34.5* MCV-86
MCH-26.9* MCHC-31.1 RDW-15.3
___ 02:45AM NEUTS-68.3 ___ MONOS-7.5 EOS-0.9
BASOS-0.3
___ 02:45AM PLT COUNT-228
EKG: done in ER; wnl
NECT (___): No acute hemorrhage. Loss of gray-white
differentiation in the left MCA territory with dense MCA is
consistent with acute
infarct. Encephalomalacia consistent with small old right
occipital infarct.
CTA (___): Tortuous neck vessels with mild atherosclerotic
calcification at the carotid bulbs. The right ICA and bilateral
vertebral arteries are unremarkable. There is progressive
hypoenhancement of the left internal carotid artery beginning in
the distal neck with haziness of the periphery of the vessel.
The
left ICA within the skullbase is minimally opacified consistent
with occlusion or markedly slow flow. The anterior communicating
artery fills the left ACA via collateral flow from the right
anterior circulation. There is slight retrograde filling of the
left A1 segment. The left MCA is minimally opacified, if at all,
over a 2.5-3 cm course with unchanged collateral flow
arising from both from the anterior and posterior communicating
arteries with reconstitution of many vessels in the distal MCA
territory. The remainder of the intracranial vessels are
unremarkable without aneurysm greater than 2 mm, stenosis or
occlusion. The imaged dural venous sinuses appear patent.
Enlargement of the pulmonary arteries suggest pulmonary arterial
hypertension. Collapse of the posterior wall of the trachea and
proximal bronchi suggests tracheobronchomalacia. Septal
thickening in the lung apices with ground-glass changes reflects
mild pulmonary edema.
CTP (___): While perfusion map is limited due to patient
motion and
respiration during the examination there is nonetheless an area
of decreased blood volume and blood flow with increased mean
transit time corresponding to infarct of the left MCA territory.
NECT (___): Persistent occlusion of the left middle
cerebral artery and its distal branches. Expected progression
of the large left middle cerebral artery infarction, without
significant mass effect at this time. No evidence for
hemorrhagic transformation.
CT Chest/Abdomen/Pelvis w/ ___:
1. Large hiatal hernia with the majority of the stomach in an
intrathoracic location.
2. Left adrenal nodule with indeterminate characteristics.
Dedicated adrenal CT may be obtained for further
characterization.
3. Right thyroid nodule. Ultrasound may be obtained if
clinically indicated.
4. Small right pleural effusion.
5. Incidental findings, including diverticulosis and renal
hypodensities which are too small to characterize.
MRI head (___): 1. Evolving extensive "early subacute"
infarction involving the entirety of the left middle cerebral
arterial territory.
2. Evidence of extensive hemorrhagic conversion involving the
deep gray and white matter structures within this territory;
there is an intraventricular hemorrhagic component.
3. Associated subfalcine herniation, new since the most recent
CT
examination.
CT head w/o contrast (___): Left MCA infarct with
hemorrhagic conversion and associated mass effect, including
effacement of the sulci and left lateral ventricle and rightward
midline shift, all unchanged from prior exam.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Furosemide 40 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. ValACYclovir 500 mg PO Q24H
6. Dabigatran Etexilate 75 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis: Large left MCA stroke with hemorrhagic
conversion
Cause of death: Cardiopulmonary arrest
Discharge Condition:
Pt expired on ___ at 9:59pm
Followup Instructions:
___
Radiology Report
TECHNIQUE: CTA of the head and neck with contrast. CT perfusion with
contrast.
HISTORY: Stroke.
COMPARISON: CT performed earlier in the day.
FINDINGS: There is abnormal perfusion in the left frontal and parietal lobe
in an anterior distribution compatible with acute ischemia. There appears to
be enlarged perfusion defect. On the CTA of the circle of ___, there is
occlusion of the left MCA as well as lack of flow in the distal cervical and
petrous, cavernous and supraclinoid ICA. There is mild to moderate stenosis
( < 50%)at the origin of the left ICA from a calcified plaque. Mild stenosis
at the origin of the right ICA. Mild calcification at origin of both vertebral
arteries. There is heavy calcification at the aortic arch. There is
calcification at the origin of the left subclavian artery. There is
heterogeneous appearance to the thyroid lobe on the right. There is a pleural
effusion in the right lung. There is large pulmonary artery. There is enlarged
right facial vein.There are prominent mediastinal nodes.
IMPRESSION: Occlusion of the left distal cervical and intracranial ICA as
well as the left MCA. Left MCA acute infarct.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: MCA stroke and pneumonia.
Comparison is made with prior study performed the same day earlier.
Severe cardiomegaly is stable. Enlarged pulmonary arteries are again noted.
Right lower lobe consolidation is less dense than before. Moderate pulmonary
edema has worsened. There is no pneumothorax or enlarging pleural effusions.
Radiology Report
NON-CONTRAST HEAD CT, ___
INDICATION: Left middle cerebral artery infarct and left internal carotid
artery stenosis. Assess infarct.
COMPARISON: ___ at 1 a.m. and at 2:54 a.m.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is cytotoxic edema in the left middle cerebral artery
territory involving the frontal, parietal, and temporal lobes, as well as the
insula, more extensive than what was visualized on the earlier non-contrast
head CTs, but corresponding to extent of the mean transit time and cerebral
blood volume abnormalities on the preceding CT perfusion study. The left
middle cerebral artery and its sylvian branches remain dense, indicating
persistent occlusion. Allowing for multiple foci of density in the distal
left MCA branches, there is no evidence for hemorrhagic transformation within
the infarction. There is no significant mass effect at this time. The right
lateral ventricle is larger than the left, but this is unchanged from the
earlier study, suggesting that this is a congenital or developmental finding.
There is no shift of midline structures. A small chronic right frontal
opercular infarct and a moderate chronic right occipital infarct are again
noted.
There is mild mucosal thickening in the left maxillary and sphenoidal sinuses.
The right frontal sinus is not pneumatized. Mastoid air cells are well
aerated.
IMPRESSION: Persistent occlusion of the left middle cerebral artery and its
distal branches. Expected progression of the large left middle cerebral
artery infarction, without significant mass effect at this time. No evidence
for hemorrhagic transformation.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Shortness of breath. Followup opacities in the right lower
lobe.
Comparison is made with prior study performed a day earlier.
Moderate-to-severe cardiomegaly is stable. Right lower lobe consolidation
consistent with pneumonia is unchanged. Enlarged pulmonary arteries are again
noted. Component of pulmonary edema has markedly improved. There is no
pneumothorax or increasing effusions.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Shortness of breath.
Comparison is made with prior study performed 12 hours earlier.
Pulmonary edema has improved. Right lower lobe opacity has improved due to
improvement of the component of atelectasis. Right lower lobe pneumonia is
still suspected. Right pleural effusion has improved. Cardiomegaly and
widened mediastinum are stable. There is no pneumothorax or large left
effusion.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with MCA stroke, new
Dobbhoff placement.
COMPARISON: Chest radiograph obtained the same day earlier at 11:30 a.m.
The Dobbhoff tube is coiled in the oropharynx with its tip being in the distal
esophagus. Cardiomegaly is unchanged as well as bilateral hilar enlargement.
No pneumothorax is seen.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with MCA stroke after
Dobbhoff placement.
AP radiograph of the chest was reviewed in comparison to ___.
The NG tube is coiled within the esophagus and should be re-positioned. There
are two radiographs obtained demonstrating overall similar appearance of the
coiled NG tube. Bilateral pleural effusions, cardiomegaly and tortuous aorta
are re-demonstrated.
Radiology Report
REASON FOR EXAMINATION: Assessment of the upper thoracic air-containing
abnormality seen on the prior radiograph.
AP radiograph of the chest was reviewed in comparison to prior study obtained
at 5:50 p.m. on the same day.
The NG tube has been removed. There is cardiomegaly, vascular engorgement,
bilateral pleural effusions and potentially bibasal atelectasis. The prior
study was obtained on an abnormal angle that the appearance of the esophagus
might be increasing concerns. On the current study, no definitive abnormal
air collection is demonstrated. If clinically warranted, correlation with CT
of the chest might be considered.
Radiology Report
MR OF THE BRAIN WITHOUT CONTRAST DATED ___.
HISTORY: ___ female with new left MCA stroke.
TECHNIQUE: Routine ___ non-enhanced MR examination was performed.
FINDINGS: The study is compared with the NECT and CTA, both dated ___,
corresponding to the findings on those studies. There is a large region of
slow diffusion with corresponding hypointensity on the ADC map and T2-/FLAIR
hyperintensity, representing "early subacute" infarction involving virtually
the entirety of the left MCA territory. While those studies demonstrated no
abnormal hyperdensity to suggest hemorrhagic transformation, there is now a
very large rounded focus of "blooming" susceptibility artifact measuring up to
4.1 cm (AP) x 0.3 cm (TRV) involving the deep gray and white matters,
representing relatively hyperacute hemorrhage involving the deep gray and
white matter structures. There is a substantial intraventricular component,
with layering blood products in the bilateral lateral ventricular horns, left
more than right. There is also a small hemorrhagic component in the overlying
subarachnoid space. This process is associated with substantial subfalcine
herniation with 8 mm rightward shift of the septum pellucidum, effacement of
the body of the left lateral ventricle.
The basal cisterns are maintained with no evidence of uncal or downward
transtentorial herniation. The flow voids of the remaining principal vessels
of the circle of ___ are preserved, and there is no evidence of acute
infarction in the additional vascular territory. Again demonstrated is cystic
encephalomalacia with surrounding gliosis and volume loss involving the right
frontal opercular region and the right occipital pole, as before, representing
regions of more remote infarction.
IMPRESSION:
1. Evolving extensive "early subacute" infarction involving the entirety of
the left middle cerebral arterial territory.
2. Evidence of extensive hemorrhagic conversion involving the deep gray and
white matter structures within this territory; there is an intraventricular
hemorrhagic component.
3. Associated subfalcine herniation, new since the most recent CT
examination.
COMMENT: Discussed with Dr. ___, via telephone, at
___, ___, the time of study interpretation.
Radiology Report
INDICATION: Assessment for PEG placement.
COMPARISON: None.
TECHNIQUE: Axial MDCT images were obtained through the chest, abdomen, and
pelvis after the administration of Omnipaque intravenous contrast using a
split bolus technique. Oral contrast was not administered.
DLP: 724.71 mGy-cm.
FINDINGS: Hypodense nodules are present within both lobes of the thyroid, the
larger on the right measuring 1.5 cm (2:2). The aorta maintains a normal
contour without any evidence of acute aortic syndrome. The main pulmonary
arteries are unremarkable. Heart is normal in size without pericardial
effusion. There is no mediastinal, hilar, axillary or supraclavicular
lymphadenopathy.
The central airways are patent. There is a small right pleural effusion and
bibasilar atelectasis. Vague mosaic attenuation of the lungs may relate to
phase of scanning. No nodule, mass, or confluent consolidation is
appreciated.
The liver enhances homogeneously without focal lesions or intrahepatic biliary
ductal dilatation. The portal vein is patent. The gallbladder is distended
but is otherwise unremarkable. The spleen is homogeneous and normal in size.
The pancreas has no focal lesions, peripancreatic stranding, or fluid
collection. A 1.7 cm indeterminate left adrenal nodule is present. The
kidneys present symmetric nephrograms and excretion of contrast. Multiple
hypodensities are present within both kidneys, too small to characterize.
The patient has a large hiatal hernia with almost the entire stomach in the
thorax. There is no dilatation of small bowel loops. There is a small
umbilical hernia containing loops of jejunum. Diverticulosis is present
without diverticulitis in the sigmoid and descending colons. There is no
mesenteric or retroperitoneal lymphadenopathy. There is no abdominal free air
or free fluid.
A Foley is present within a partly distended bladder. Patient is status post
hysterectomy. The adnexa are unremarkable. There is no pelvic sidewall or
inguinal lymphadenopathy. There is no pelvic free fluid.
Degenerative changes are present within the thoracic and upper lumbar spine. A
hemangioma is noted at T10.
IMPRESSION:
1. Large hiatal hernia with the majority of the stomach in an intrathoracic
location.
2. Left adrenal nodule with indeterminate characteristics. Dedicated adrenal
CT may be obtained for further characterization.
3. Small right pleural effusion.
4. Incidental findings, including diverticulosis and renal hypodensities
which are too small to characterize.
Radiology Report
HISTORY: Left MCA stroke with hemorrhagic conversion. Evaluate for interval
change/progression.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal and sagittal
and thin section bone algorithm-reconstructed images were acquired.
DLP: 1025.72 mGy-cm.
COMPARISON: MR ___ from ___ and NECT head from ___.
FINDINGS:
The extent of the left MCA infarct appears similar to MR from ___.
The hemorrhagic conversion involving the deep gray and white matter structures
within this territory, layering blood within the occipital horns of the
bilateral lateral ventricles, and the small hemorrhagic component within the
overlying subarachnoid space, are unchanged. The mass effect with effacement
of the sulci and left lateral ventricle and shift of midline structures to the
right are also unchanged. There is no new hemorrhage or infarct. The basal
cisterns remain patent. There is also unchanged right occipital lobe
encephalomalacia, likely related to an old infarct.
No fracture is identified. There is increased mucosal thickening within the
left sphenoid sinus. The globes are unremarkable.
IMPRESSION:
Left MCA infarct with hemorrhagic conversion and associated mass effect,
including effacement of the sulci and left lateral ventricle and rightward
midline shift, all unchanged from prior exam.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: CODE STROKE
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: 98.3
heartrate: 70.0
resprate: 16.0
o2sat: 96.0
sbp: 159.0
dbp: 88.0
level of pain: 13
level of acuity: 2.0 | ASSESSMENT AND PLAN:
___ year-old right-handed woman wit a fib on pradaxa, HTN, HLD,
and history of GI bleed on coumadin who presents to us with
dense right hemiparesis. Found on head CT to have a large MCA
stroke/ left carotid occlusion.
# Neuro: Held home pradaxa. Assessed vascular risk factors:
HbA1c (6.1%) and lipid panel (LDL 112). Patient underwent
MRI/MRA which showed hemorrhagic conversion involving deep gray
and white matter structures and some IVH components with
associated subfalcine herniation. Initially continued Aspirin,
which was held on ___ given hemorrhagic conversion. Repeat
Head CT showed stable hemorrhage. Patient became comfort measure
only on ___ after discussion with family members and
further interventions held.
# Cardiovascular: We rule-out MI with repeat cardiac enzymes
which showed negative troponins. Held home antihypertensives.
Patient placed on telemetry, which was discontinued once patient
became comfort measures only.
# Pulmonary: CXR revealed cardiomegaly, enlarged pulmonary
arteries, pulmonary edema and Right lower lobe consolidation
consistent with pneumonia. Started on antibiotic treatment for
pneumonia, which was discontinued once decision was made for
comfort emasures only.
# FEN: Patient with significant difficulty with NG placement so
NPO on IVF. Found to have hiatal hernia confirmed on CT
chest/abdomen/pelvis. Initially plan had been to place PEG for
long term feeding plan. However, after family meeting, plan
became comfort measures only and PEG placement was cancelled.
Withdrew IVF.
# Social: On ___ around 2pm, discussion with family
regarding goals of care determined that patient should be
comfort measure only. Palliative care team was consulted and
recommended IV Morphine for pain, Ativan po for
anxiety/agitation, Tylenol PR for fever/chills, Atropine SL
drops for excessive secretions and Lasix for comfort with
shortness of breath. Other interventions were withheld. Around
9PM, patient passed peacefully, cause of death likely
cardiopulmonary arrest. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ speaking male with a history of mixed
connective tissue disease with features of Sjogren's, systemic
sclerosis (sclerodactyly and achalasia s/p endoscopic myotomy)
and SLE with class V membranous nephritis, who presented with
abdominal pain.
He reports onset of symptoms last ___, with epigastric
pain,
frequent N/V, inability to keep down PO, also diarrhea.
Abdominal
pain is intermittent. Emesis has not been bloody or coffee
ground. He had 3 watery BMs in last day. He reports that at the
beginning he had a few drops of BRBPR but none recently. Stools
are recently dark brown-black in color.
He denies f/c, SOB. Notes dry cough that is not new, also
reports
pleuritic chest pain. Reports mild burning with urination. No
___.
In the ED:
- Initial vital signs were notable for: 98.5, 77, 84/51, 18,
100%
RA
He triggered for hypotension and received IVF and stress dose
steroids with improvement.
- Exam notable for: Abd is Soft, mild epigastric tenderness,
nondistended, no guarding, rebound or masses, brown guaiac
positive stool
- Labs were notable for:
4.9 10.8 249
>------<
36.0
128 98 35 99 AGap=13
------------<
5.7 17 1.6
AST 26, ALT 10, AP 57, Tbili <0.2, Alb 2.1, Lipase 87
INR: 1.2
Lactate:1.3
Trop-T: <0.01
UA 300 protein
- Studies performed include:
CT A/P with contrast
The study is limited by absence of oral contrast and minimal
intra-abdominal fat. Within these limitations, no acute
intra-abdominal process is identified. The esophagus is patulous
and air-filled. Apparent small bowel thickening is favored to be
artifactual secondary to decompression and absence of
intervening
intra-abdominal fat.
CXR: No acute intrathoracic process.
- Patient was given:
IV Zosyn 4.5 g
IV Hydrocortisone Na Succ. 100 mg
2L NS, 1L LR
IV pantoprazole 40 mg, PO Aluminum-Magnesium Hydrox.-Simethicone
30 ml, PO Donnatal 10 mL, PO Lidocaine Viscous 2% 10 mL
Vitals on transfer: 97.8, 57, 100/62, 17, 100% RA
Upon arrival to the floor, patient history reported as above.
Currently he is feeling well and does not have any nausea or
abdominal pain.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative except as HPI above.
Past Medical History:
- Hypothyroidism
- Iron deficiency anemia
- ? SLE, diagnosed abroad, previously on plaquenil
Social History:
___
Family History:
Aunt and cousin have lupus. Mother has diabetes. Reports no
family history of cancer or heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.4PO, 98 / 63L Lying, 43, 20, 100 RA
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. Sclera anicteric and without injection.
ENT: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: 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.
MSK: no ___
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. moving all extremities. appropriately
interactive
DISCHARGE PHYSCIAL EXAM:
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. Sclera anicteric and without injection.
ENT: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: 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.
MSK: no ___
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. moving all extremities. appropriately
interactive
Pertinent Results:
ADMISSION:
___ 08:45PM BLOOD WBC-4.9 RBC-4.61 Hgb-10.8* Hct-36.0*
MCV-78* MCH-23.4* MCHC-30.0* RDW-16.4* RDWSD-46.4* Plt ___
___ 08:45PM BLOOD Plt ___
___ 08:45PM BLOOD Glucose-99 UreaN-35* Creat-1.6* Na-128*
K-5.7* Cl-98 HCO3-17* AnGap-13
___ 08:45PM BLOOD ALT-10 AST-26 AlkPhos-57 TotBili-<0.2
___ 08:45PM BLOOD Albumin-2.1*
___ 08:55PM BLOOD Lactate-1.3
DISCHARGE:
___ 06:00AM BLOOD WBC-3.9* RBC-4.27* Hgb-9.9* Hct-33.8*
MCV-79* MCH-23.2* MCHC-29.3* RDW-16.9* RDWSD-48.3* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-84 UreaN-22* Creat-0.8 Na-136
K-4.4 Cl-105 HCO3-21* AnGap-10
___ 06:00AM BLOOD Calcium-7.3* Phos-3.6 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Hydroxychloroquine Sulfate 200 mg PO DAILY
3. Mycophenolate Mofetil 1500 mg PO BID
4. Levothyroxine Sodium 200 mcg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Ferrous Sulfate 325 mg PO DAILY
7. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID gastroenteritis
2. MetroNIDAZOLE 500 mg PO TID
3. Ferrous Sulfate 325 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID
6. Levothyroxine Sodium 200 mcg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Mycophenolate Mofetil 1500 mg PO BID
9. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
Gastroenteritis
Acute kidney injury
Hypovolemic hyponatremia
Hypotension
Bright red blood per rectum
SECONDARY DIAGNSES
Mixed connective tissue disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; abdominal pain, bloody stools,
immunosuppressedNO_PO contrast// eval PNA; eval colitis
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 6.0 s, 47.6 cm; CTDIvol = 9.1 mGy (Body) DLP = 430.6
mGy-cm.
Total DLP (Body) = 444 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: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. Subcentimeter
right renal hypodensities are too small to characterize but likely represent
cysts. There is no perinephric abnormality.
GASTROINTESTINAL: The esophagus is patulous and air-filled. The stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout.There is a moderate amount of fluid within the
small bowel, which could suggest nonspecific enteritis. 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. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Moderate amount of fluid within the small bowel could suggest nonspecific
enteritis, without CT signs to suggest IBD.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Epigastric pain
temperature: 98.5
heartrate: 77.0
resprate: 18.0
o2sat: 100.0
sbp: 84.0
dbp: 51.0
level of pain: 4
level of acuity: 1.0 | ====================
PATIENT SUMMARY:
====================
___ ___ speaking male with a history of mixed
connective tissue disease with features of Sjogren's, systemic
sclerosis (sclerodactyly and achalasia s/p endoscopic myotomy)
and SLE with class V membranous nephritis, who presented with
abdominal pain and N/V, found to have likely gastroenteritis as
per CT.
====================
TRANSITIONAL ISSUES:
====================
[ ] Ciprofloxacin and Flagyl - 7 day course to be completed
___
[ ] Please follow up stool cultures
[ ] Please follow up blood cultures - no growth to date
[ ] Restarted home lisinopril at discharge given resolution of
___
[ ] Discharge Cr 0.8
[ ] Noted to have sinus bradycardia to 40-50s while in hospital,
asx. Can consider further workup as needed as this does not
appear to be his baseline
#CODE: presumed full
#CONTACT: ___, Phone: ___
============ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hand table saw injury
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Irrigation and debridement of open fractures of the
index and middle fingers.
2. Primary arthrodesis of the ___ metacarpophalangeal joint
using autograft.
3. Open reduction, internal fixation of index finger
proximal phalanx.
4. Open reduction, internal fixation of index finger middle
phalanx.
5. Revision amputation of index finger at the level of
distal interphalangeal joint.
6. Excision of index finger flexor digitorum profundus from
zone 2 to zone 4.
7. Middle finger flexor digitorum profundus reconstruction
from zone 3 to zone 4 using tendon graft.
8. Open carpal tunnel release.
9. Allograft nerve reconstruction of middle finger radial
digital nerve.
10.Primary repair of superficial palmar arch under
operating microscope.
11.Skin graft reconstruction of middle finger volar radial
defect (1 x 2 cm).
12.Complex repair of volar skin and dorsal index finger
wound (combined length of 8 cm).
History of Present Illness:
___ RHD M ___ speaking, who was ___ around 11am
this morning. Patient put hand on table by accident in the area
of the saw blade while picking up a piece of wood. Patient was
transferred from ___. Patient is accompanied by
his daughter. At the OSH patient had hand x rays which revealed
fractures of the long metarcarpal head, as well as digital
fracture of index and long finger. Patient has multiple full
thickness lacerations with exposed tendons and partial
amputation
of distal index finger. Currently patient only had some moderate
pain to right hand. Overall he states he doing well. Denies
f/c/n/v
Past Medical History:
Hemochromatosis
HTN
HLD
Pancreatic Cancer (s/p whipple)
Social History:
___
Family History:
There is no family history of pancreas cancer
Physical Exam:
NAD
AOx3
R hand brisk capillary refills digits ___, revision amp of R
index finger
Pertinent Results:
___ 06:49AM BLOOD WBC-7.7 RBC-2.91*# Hgb-8.7*# Hct-26.3*#
MCV-90 MCH-29.9 MCHC-33.1 RDW-12.8 RDWSD-42.1 Plt ___
Radiology Report
INDICATION: ___ man with trauma, preoperative evaluation.
TECHNIQUE: PA and lateral chest radiograph.
COMPARISON: Chest x-ray ___.
FINDINGS:
EKG leads overlie the chest. There are low lung volumes with crowding of the
normal bronchovascular structures. Allowing for changes due to low lung
volumes, the cardiomediastinal silhouette within normal limits. The hila are
unremarkable. The lungs are clear without focal consolidation. There is no
pulmonary vascular congestion or pulmonary edema. There is no pneumothorax or
sizable pleural effusion.
IMPRESSION:
Low lung volumes. No acute cardiopulmonary process.
Gender: M
Race: PORTUGUESE
Arrive by AMBULANCE
Chief complaint: Hand laceration, Transfer
Diagnosed with Partial traumatic trnsphal amputation of r idx fngr, init, Contact w powered woodworking and forming machines, init
temperature: 98.0
heartrate: 53.0
resprate: 16.0
o2sat: 98.0
sbp: 133.0
dbp: 73.0
level of pain: 8
level of acuity: 2.0 | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have right hand table saw injury and was admitted to the hand
surgery service. The patient was taken to the operating room on
___ for fixation of hand fractures and revascularization,
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 OT was appropriate. The hospital course
is notable for:
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
nonweight bearing in the right extremity, and will be discharged
on aspirin 121.5mg daily for DVT prophylaxis. The patient will
follow up with Dr. ___ per routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cephalosporins
Attending: ___.
Chief Complaint:
Urinary and bowel incontinence, fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F with PMHx notable for osteopenia,
HTN, CKD stage III, multiple recent falls with cognitive decline
per family who presents as transfer from OSH for evaluation of
bowel and urinary incontinence over past ___ days.
Pt is unable to provide significant history due to mental
status. When asked why she was in the hospital she reports "I
work here." Per patient's Niece and HCP ___, patient has been
living independently but has had several falls at home over past
weeks. She has had progressive cognitive decline over last year
with short-term memory problems and has stopped working/driving.
She complained of back pain last week and went to ___
___ where she was given tylenol #3 that she took at home.
She represented to ___ and was found to have
compression fracture in spine with retropulsion of L1 vertebral
body. A foley was placed that returned 250cc clear urine and
neuro exam was intact aside from somewhat decreased rectal tone.
She was then transferred to ___ for further work-up of
possible cord compression due to fractures.
ED Course: On arrival to ___, pt was seen by Ortho team and
had CT and MRI of L-spine that revealed compression fracture of
L1, with retropulsion of the superior endplate of L1 causing
severe kinking and indentation of the thecal sac at this level.
No evidence of acute cord compression or need for acute surgical
intervention. Exam was notable for ___ strength, normal rectal
tone. Following these scans, pt reportedly had alteration of
mental status, wandering into triage oriented only to person.
She received Zyprexa 5mg IM x 2. UA neg, labs unremarkable. Head
CT and Chest X-RAY negative for acute process.
On the floor, pt denies any pain. She states she feels well and
wants to get dressed. Thinks she is in an apartment, went to
"Toys R' Us" to get gifts for the children. Describes she has
been urinating normally and moving bowels regularly. Unable to
provide additional history as above.
Past Medical History:
-CKD Stage 3
-Glaucoma
-In situ adenocarcinoma right colon polyp ___, node neg
-HTN
-obesity
-osteopenia
-hx memory loss per family, has not had work-up yet
Social History:
___
Family History:
Mother deceased during childbirth with pt's brother. Father
deceased from ___ in elderly years. 10 siblings, 4 of which
passed away from cancer (pancreatic, lung).
Physical Exam:
EXAM ON ADMISSION:
Vitals: T:97.6 BP:141/111 P:64 R:18 O2:97% RA
General: Elderly female oriented to person only, attempting to
get out of bed and pull out IV, temporarily redirectable
HEENT: Sclera anicteric, PERRLA, limited visual fields, MMM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Back: Tender to palpation in bilateral lumbar paraspinous
muscles
Skin: No rashes
Neuro: Oriented to person, not to place or time. Unable to state
days of week backwards or other attention tasks. Often answering
questions with nonsensical answers. CN II-XII grossly intact
although exam somewhat limited due to pt participation, motor
strength and sensation intact. No asterixis.
EXAM ON DISCHARGE:
Vitals: T:98.2 BP:100-115/50-65 P:66-68 ___ O2:97-98% RA
General: A&Ox3, elderly female sitting calmly eating breakfast
HEENT: Sclera anicteric, PERRLA, improved tracking with ocular
muscles, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Skin: Right lower abdomen near groin mildly erythematous plaque
with scale
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Oriented as above. Able to state days of the week forward
and backwards, list months of year, complete simple pattern. CN
II-XII, motor strength and sensation grossly intact.
Pertinent Results:
LABS ON ADMISSION:
___ 07:30PM BLOOD WBC-5.0 RBC-4.16* Hgb-12.1 Hct-36.8
MCV-89 MCH-29.0 MCHC-32.8 RDW-12.8 Plt ___
___ 07:30PM BLOOD Neuts-61.7 ___ Monos-6.3 Eos-2.9
Baso-1.1
___ 07:30PM BLOOD Glucose-84 UreaN-16 Creat-1.0 Na-143
K-3.8 Cl-106 HCO3-25 AnGap-16
.
URINALYSIS:
___ 07:30PM URINE Color-Straw Appear-Clear Sp ___
___ 07:30PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:30PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
.
URINE TOX:
___ 07:30PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
KEY RESULTS:
___ 12:46PM BLOOD VitB___* Folate-GREATER TH
___ 12:46PM BLOOD TSH-0.87
___ 05:35AM BLOOD PTH-21
___ 12:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
STUDIES:
MRI LUMBAR SPINE (___):
1. Acute to subacute compression fracture of the L1 vertebral
body with near complete loss of vertebral body height and
retropulsion resulting in mild to moderate spinal canal stenosis
at T12-L1 and deformity of the distal spinal cord. No cord
signal abnormality.
2. Edema in the anterior longitudinal ligament at L2 and
questionably at L1. There is a wavy contour of the anterior
longitudinal ligament at T12-L1, although it appears to be
grossly intact. Edema within the L1-2 disc space. Subtle injury
cannot be excluded.
3. Acute to subacute compression fracture of the L2 vertebral
body with mild height loss but no retropulsion.
4. Chronic compression fracture of the L4 superior endplate.
Follow-up recommended as clinically indicated to assess for
interval healing
and exclude less likely pathologic component.
5. Multilevel disc herniations and facet arthropathy resulting
in spinal
canal and bilateral neural foraminal stenosis that is most
severe at L3-4 and L4-5.
.
CT LUMBAR SPINE (___):
1. Near complete compression fracture of the L1 vertebral body
with a
combination of posterior osteophytosis and bony retropulsion
into the canal at this level, causing moderate-severe canal
narrowing.
2. Comminuted fracture of the superior endplate of the L2
vertebral body.
3. Moderate-severe multilevel degenerative changes of the lumbar
spine, most significant at L4-5 with severe spinal canal and
bilateral neural foraminal narrowing.
.
CT HEAD W/O CONTRAST (___): No acute intracranial
hemorrhage or large vascular territory infarction.
.
CXR (___): No evidence of acute cardiopulmonary process.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Aspirin 81 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Nystatin Cream 1 Appl TP BID Duration: 14 Days
11. Acetaminophen 650 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Acute toxic metabolic encephalopathy
L1 spinal compression fracture with retropulsion
Secondary:
Hypertension
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with AMS // r/o PNA
TECHNIQUE: SINGLE, AP, PORTABLE VIEW OF THE CHEST.
COMPARISON: None available.
FINDINGS:
Minimal bibasilar atelectasis is present. There is no evidence of focal
consolidation, pleural effusion, pneumothorax, or frank pulmonary edema. A
right hilar opacity is likely exaggerated secondary to patient rotation and
overlap with the mediastinum. The cardiac silhouette is within normal limits.
The descending thoracic aorta is noted to be somewhat tortuous. A chronic,
left humeral fracture is incidentally noted.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT ___ W/O CONTRAST
INDICATION: ___ with L1 compression fx // Please further eval for bony
lesions in lower spine
TECHNIQUE: Ataxial, 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: 32.05 mGy
DLP: 916.38 mGy-cm
COMPARISON: MR ___ dated ___.
FINDINGS:
There is a severe compression fracture of the L1 vertebral body with nearly
complete loss of vertebral body height. There is osseous extension posteriorly
into the canal, likely due to a combination of retropulsed fragmentation and
posterior osteophytosis, contacting the cord and causing moderate-severe canal
narrowing at this level (2:23). Additionally, there is a comminuted fracture
involving the superior endplate of the L2 vertebral body without significant
bony retropulsion.
Moderate-severe, multilevel degenerative changes are also seen throughout the
lumbar spine, most significant at the level of L4-L5 with a large posterior
disc-osteophyte complex, bilateral facet hypertrophy, and ligamentum flavum
hypertrophy resulting in severe spinal canal and bilateral neural foraminal
narrowing.
IMPRESSION:
1. Near complete compression fracture of the L1 vertebral body with a
combination of posterior osteophytosis and bony retropulsion into the canal at
this level, causing moderate-severe canal narrowing.
2. Comminuted fracture of the superior endplate of the L2 vertebral body.
3. Moderate-severe multilevel degenerative changes of the lumbar spine, most
significant at L4-5 with severe spinal canal and bilateral neural foraminal
narrowing.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with AMS // r/o head bleed
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDI vol: 50.93 mGy
DLP: 891.93 mGy-cm
COMPARISON: None available.
FINDINGS:
This is a partially limited examination due to patient motion. There is no
evidence of acute intracranial hemorrhage, edema, mass effect, or large
territorial infarction. Prominent ventricles and sulci suggest age-related
involutional changes or atrophy. Subcortical and periventricular white matter
hypodensities are consistent with chronic small vessel ischemic disease. The
basal cisterns appear patent and there is preservation of gray-white matter
differentiation.
The visualized bony structures are grossly unremarkable. The paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. Atherosclerotic
mural calcification of the bilateral internal carotid arteries is noted. The
globes are unremarkable.
IMPRESSION:
No acute intracranial hemorrhage or large vascular territory infarction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with FX LUMBAR VERTEBRA-CLOSE, UNSPECIFIED FALL, BACKACHE NOS, URINARY INCONTINENCE
temperature: 98.7
heartrate: 70.0
resprate: 16.0
o2sat: 99.0
sbp: 174.0
dbp: 73.0
level of pain: 5
level of acuity: 1.0 | Ms. ___ is a ___ F with PMHx notable for osteopenia,
HTN, CKD stage III, multiple recent falls with cognitive decline
per family who presented as transfer from OSH for evaluation of
bowel and urinary incontinence over ___ days after a fall, found
to have L1 compression fracture on MRI being managed
non-operatively, subsequently developed AMS.
# L1 compression fracture with retropulsion: Circumstances
around fall, including exact timing, remain unclear. Per family
patient lives alone and has been falling frequently lately. Pt
did not seek care immediately, likely due to baseline cognitive
dysfunction. Pt initially sought care at ___ for symptoms of
bowel and bladder incontinence. She was transferred to ___
given concern for cord compression. Initial exam did not reveal
any acute neurological changes. MRI here revealed acute on
chronic L1 compression fracture without evidence of compression
of cord to explain her symptoms. Pt has history of osteopenia,
which likely predisposed her to fracture. She was evaluated by
the Orthopedic Spine team, who recommended non-operative
management. She was fitted with a Jewitt brace for spine
stabilization to wear with ambulation. She was evaluated by ___
and OT, who recommended SNF for further recovery. If medication
is needed for pain prefer tylenol given AMS likely caused by
narcotic pain medication. Pt will need to follow up with Ortho
Spine clinic ___ weeks after discharge. Vitamin D and
multivitamin should be continued.
# Toxic metabolic encephalopathy: Pt's family reports
progressive cognitive decline over the past year. She continues
to lives alone, however has had several recent falls as above.
Initial exam after admission to medicine was consistent with
acute delirium given lack of orientation, attention and
concentration. Her symptoms were most likely caused by narcotic
pain medication given urine tox positive for opiates and/or
hospital setting on baseline dementia. Infectious work-up
negative. CT head revealed no acute intracranial abnormality.
She was found to be Vitamin B12 deficit, however this is not
likely to explain the acute change. TSH was normal. She required
Zyprexa in ED and additional 5mg PO on AM of ___ for
agitation, none thereafter. Over the next several days pt's
mental status gradually cleared. Prior to discharge she was
alert and oriented x 3 and able to form concentration tasks, per
family approaching her baseline. Will need to continue
environmental measures to reduce delirium, especially while at
___, and continue vitamin B12 supplementation.
# Candidal intertrigo: Rash noted in right groin area during
admission. It was not itchy, painful or otherwise bothersome to
patient. She was started on nystatin cream with some improvement
prior to discharge. She should continue a 2 week course. To
prevent infection from recurring, make sure to pat area dry
after showers.
# Bowel/bladder incontinence: Resolved. Reported by pt over
several days prior to admission to ___. Initial
evaluation in ED revealed normal rectal tone. MRI was negative
for acute cord compression as above. Pt voided urine
spontaneously and had normal bowel movements during admission
without incontinence.
# Hypercalcemia: Noted to have elevated Ca to 10.6 on ___ that
quickly returned to normal. Albumin and PTH were normal.
Encouraged PO intake, likely dry.
# HTN: Remained well-controlled. Home lisinopril was continued.
# CKD: Cr stable at 1.0-1.1. CKD stage III per records, likely
due to chronic HTN. Medications were renally dosed.
# Glaucoma: Continued home eyedrops.
# Primary prevention CAD: Continue home ASA 81mg. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ibuprofen / naproxen / Cytotec / Prednisone
Attending: ___.
Chief Complaint:
Abdominal and back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with history of Rheumatoid
Arthritis (wheelchair bound, was was seen in the ___ ED 4 days
PTA for left flank pain and subsequently had a negative CT scan.
Patient was given a prescription for bactrim for a UTI. She
re-presents with with bilateral flank pain, lower back pain, and
abdominal pain that has been present for the last 8 days and
progressively getting worse.
.
In the ED, initial vs were: 98.2 90 143/58 16 94%. Patient was
given 1 dose of azithromycin, 1LNS, and benadryll. Patient had a
CXR that demonstrated bibasilar minimilar atelectasis (less
concern for PNA), and mild cardiomegaly. Her labs were notable
for hyponatremia 125, trop neg x1, Hb 10.4.
.
Prior to transfer vitals were 99.0, 80, 147/74, 18, 94%RA.
.
On the floor, patient's vitals were 98.4 83 143/60 18 93%RA. She
is a difficult historian. On further history, patient reports
that she has had progress worsening pain that starts at her
lower breasts bilaterally and goes down into her abdomen that
has been going on for 8 days. She says that she also has back
pain associated with this, which is also bilateral, mainly
located in her lower back but also at times closer to her spinal
column. She denies any recent trauma or falls. She denies any
recent illnesses, fevers/chills. She qualifies the pain as being
constant, located all around her abdomen at times, only
alleviated by laying still, and aggravated with movement. She
also reports a decrease in her appetite, and associated nausea.
She was able to tolerate a meal last night, beans with
vegetables, she ate half her plate and did not have any emesis.
She also reports constipation, as she had a suppository placed
yesterday with small BM, but previously had not had BM since
seeing her PCP last ___. Patient also reports small cough,
clear sputum production, but no sore throat or rhinorrhea.
Patient denies dysuria, increased frequency, change in
color/odor of her urine (she was recently seen in ED with UTI
and given bactrim).
.
Of note, patient had CXR at outside facility demonstrating
subtle minimally displaced fractures of left ___ and 9th ribs on
___.
.
In addition patient reports numbness/cramping in her hands, this
has been present for quite some time ___ year) with also
weakness in her legs that has also been more chronic. She is
wheelchair bound. Patient reports that she has been dropping
objects more recently in the last 3 weeks and has difficulty
holding them in her hands. She has had urinary incontinence,
which is not new, and denies any bowel incontinence.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Has cough at times, clear sputum production. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied vomiting, diarrhea.
Past Medical History:
-Rheumatoid Arthritis (not on DMARDS, takes aspirin for pain at
home)
-Hypertension
-Ovarian Cancer Surgery ___ ___? Patient reports that she had a
surgery for fibroma
-s/p Ovarian CA hysterectomy and bilateral oophorectomy ___
Social History:
___
Family History:
Mother- diabetes, died in her ___, questionable Heart disease
Father - died at age ___, old age
Physical Exam:
Vitals: T: 98.4 BP: 83 P: 143/60 R: 18 O2: 93%RA
General: Alert, oriented, tearful at times, mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Mild wheezes bilaterally, crackles at the bases
CV: Regular rate and rhythm, normal S1 + S2, holosystolic murmur
heard throughout precordium, loudest at apex, with radiation to
axillae, ___. No carotid bruits.
Abdomen: soft, ttp in LUQ and epigastric area, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
MS: TTP over lower lumbar spine
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Left hand and right hand with subluxation of PIP and MCP
c/w with severe rheumatoid arthritis
Neuro: CNs2-12 intact, upper extremity ___ strength, lower
extremity ___, no paresthesias identified
Pertinent Results:
Admission labs ___:
.
___ 12:56AM BLOOD WBC-8.1 RBC-4.21 Hgb-10.4* Hct-31.5*
MCV-75* MCH-24.7* MCHC-32.9 RDW-17.2* Plt ___
___ 12:56AM BLOOD Neuts-74.4* ___ Monos-4.4 Eos-1.0
Baso-0.3
___ 12:56AM BLOOD Glucose-101* UreaN-10 Creat-0.8 Na-125*
K-4.1 Cl-93* HCO3-23 AnGap-13
___ 01:30PM BLOOD Calcium-8.7 Phos-2.7 Mg-2.0
___ 01:30PM BLOOD Osmolal-281
___ 01:05AM BLOOD Lactate-1.3
.
Other notable labs:
.
___ 12:56AM BLOOD Lipase-25
___ 06:30AM BLOOD VitB___-___
___ 01:30PM BLOOD TSH-1.2
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
.
Microbiology:
___ Urine culture negative
___ Urine legionella antigen negative
___ Blood culture pending (negative to date)
.
Imaging:
___ EKG: Normal sinus rhythm. Normal tracing. Compared to the
previous tracing of ___ there is no significant change.
.
___ CXR:
FINDINGS: Aside from minimal bibasilar atelectasis, the lungs
are clear.
Moderate cardiomegaly has increased and lung vasculature is more
engorged, and there is probably a new small, right pleural
effusion, but there is no
pulmonary edema. Contours of the tortuous aorta are unchanged.
There are no pleural abnormalities. Despite severe, erosive
degenerative deformities of the humeral heads, the shoulders are
not dislocated. It is not possible to say whether there has been
progression of multiple wedge deformities of the thoracic
vertebra.
.
IMPRESSION:
1. Mild congestive heart failure.
Medications on Admission:
Patient is unsure of medications that she is taking at home. Per
PCP's office records she takes:
-Amlodipine Besylate 5mg QD
-Famotidine 20mg QD
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Rheumatoid Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Flank pain, evaluate for pneumonia.
COMPARISON: Chest radiograph from ___.
FINDINGS: Aside from minimal bibasilar atelectasis, the lungs are clear.
Moderate cardiomegaly has increased and lung vasculature is more engorged, and
there is probably a new small, right pleural effusion, but there is no
pulmonary edema. Contours of the tortuous aorta are unchanged. There are no
pleural abnormalities. Despite severe, erosive degenerative deformities of
the humeral heads, the shoulders are not dislocated. It is not possible to say
whether there has been progression of multiple wedge deformities of the
thoracic vertebra.
IMPRESSION:
1. Mild congestive heart failure.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: BILAT FLANK PAIN
Diagnosed with HYPOSMOLALITY/HYPONATREMIA, ABDOMINAL PAIN OTHER SPECIED
temperature: 98.2
heartrate: 90.0
resprate: 16.0
o2sat: 94.0
sbp: 143.0
dbp: 58.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with hx of Rheumatoid
Arthritis and HTN who presented with abdominal and bilateral
flank pain of 8 days duration, with no other GI symptoms apart
from her progressively worsening pain. In summary, she had a
negative CT on ___ and workup was otherwise negative. She
continues to have a chronic left otitis, for which ENT follow up
is recommended.
# Flank/Back Pain/Abdominal Pain: Pt had normal lipase, LFTs,
clean UA, negative urine cultures and legionella antigen,
negative blood cultures, no leukocytosis; as such, UTI/pyelo or
other infection as well pancreatitis both seemed unlikely. Her
CT showed no evidence of compression fracture. Her pain was
unchanged throughout her admission; she took acetaminophen and
reported some small pain relief, but refused any narcotic pain
medication.
.
# Wheezing: Pt had some wheezing on admission, with no SOB or
respiratory distress, adequate O2 sat, and normal resp rate. She
received an albuterol nebulizer treatment on ___, and had
resolution of her wheezing. Her lungs were clear at the time of
discharge on ___.
.
# L ear discharge: The presentation of the ear is concerning for
otitis media or externa; unable to adequately visualize TM due
to purulent discharge. As such, perforated TM could not be ruled
out, which led team to hold off on antibiotic drops. This otitis
is likely chronic and was seen by her PCP, who obtained a cx
sample on ___ (grew S aureus). It is unclear where exactly this
sample was obtained from. Pt was discussed with ENT, who felt
that pt should be seen for outpatient f/u for repeat culture
from within ear canal and appropriate therapy.
.
# Social: Patient was seen by SW to follow up on issues that
came up, including that her husband is her sole caretaker but
also works; therefore, the patient spends the majority of her
time alone. She pays for some private home help. Patient also
reports verbal abuse, but denies phsyical abuse from husband. ___
provided support and also contacted Ethos Elder Services on her
behalf given her isolation, to discuss further resource
availability.
.
# Psych: Psychiatry was consulted given the patient's numerous
psychosocial stressors and question of difficulty coping and
safety going home, as well as some mention in previous PCP notes
about pt seeing demons. Psychiatry corraborated some possible
delusional aspect to her thinking as well as prominent mood
symptoms (though the patient firmly opposed the label of
depression), but psychiatry felt that her primary treatment
concerned her underlying delusional disorder with psychotic
symptoms. They recommended some additional laboratory workup
that is detailed elsewhere for possible organic causes of her
symptoms(negative RPR); brain MRI was not obtained. Pt declined
any treatment for mood symptoms.
.
# Hyponatremia: Pt's Na was 125 on presentation, but resolved
overnight with NS and remained normal throughout her admission.
Previous treatment with bactrim may have contributed to her
hyponatremia, though this is unclear.
.
# HTN - Patient was continued on her home amlodipine 5 mg with
good effect.
.
# Rheumatoid Arthritis: Patient is not currently on and has
never taken DMARDS, and does not like to take muliple
medications at home. She refused pain medication stronger than
acetaminophen, which she reported provided only a small amount
of pain relief.
.
.
.
1. Left-sided otitis: for ENT follow up.
2. Patient will go to rehab following discharge to receive
physical therapy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
left periprosthetic hip fracture ORIF on ___ ___
___ of Present Illness:
___ s/p R THA ___ years ago but without other significant
PMH, transferred from OSH with right hip pain and reported
periprosthetic hip fracture following slip and fall. Patient was
clearing ice out of his drive way at ~3pm on day prior to
presentation, when he slipped and fell, landing on right hip.
Denies prodromal symptoms; denies HS or LOC. Immediate right hip
pain but no other injuries/complaints. Unable to weight-bear
subsequently; brought by ambulance to ___, with noted right
periprosthetic hip fracture. Transferred to ___ ED for further
management.
At time of interview, endorses only right hip pain. No headache,
neck pain, chest pain, dyspnea, abd pain. No new urinary
symptoms; foley placed at OSH.
Past Medical History:
Urinary hesitancy
Cervical radiculopathy
S/p R THA ___ years ago - ___
S/p L THA ___ years ago - ___
Diverticulosis - occasional blood in stools
Social History:
___
Family History:
NC
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Incision clean/dry/intact with no erythema or discharge, minimal
ecchymosis
Left lower extremity fires ___
Left lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Left lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Pertinent Results:
___ 04:10AM BLOOD WBC-10.4 RBC-2.77* Hgb-9.0* Hct-26.4*
MCV-95 MCH-32.3* MCHC-33.9 RDW-13.6 Plt ___
___ 01:25AM BLOOD WBC-12.1* RBC-3.68* Hgb-11.7* Hct-34.6*
MCV-94 MCH-31.7 MCHC-33.7 RDW-13.6 Plt ___
___ 01:25AM BLOOD Neuts-84.7* Lymphs-8.3* Monos-6.3 Eos-0.7
Baso-0
___ 04:10AM BLOOD Glucose-123* UreaN-25* Creat-1.2 Na-136
K-4.3 Cl-103 HCO3-25 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H
3. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN
Dyspepsia
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
6. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H Disp #*60
Tablet Refills:*0
7. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left hip periprosthetic fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX HIP AND FEMUR
INDICATION: History: ___ with fall r hip pain // fracture
TECHNIQUE: Single AP view of the pelvis, and frontal and lateral radiographs
of the right femur.
COMPARISON: None available.
FINDINGS:
The patient is status post bilateral total hip arthroplasty.
There is a fracture through the proximal right femur shaft, in the region of
the shaft of the femoral arthroplasty hardware. There is approximately 1.7 cm
of posterior displacement of the distal fracture fragment. No additional
fractures are identified. Degenerative changes are seen in the included
portion of the lumbar spine and right knee. Heterotopic ossification is seen
about the greater trochanter on the right.
IMPRESSION:
Periprosthetic fracture of the proximal right femur shaft with 1.7 cm of
dorsal displacement of the distal fracture fragment.
Radiology Report
INDICATION: History: ___ with pain s/p fall // acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
Frontal chest radiographs demonstrates well expanded, clear lungs. A rounded
area of increased density is seen projecting over the medial left lung base.
The contour of the descending thoracic aorta is seen running through this
area. This finding is most consistent with a hiatal hernia, or much less
likely an atypical appearing aortic aneurysm. The cardiomediastinal and hilar
contours are unremarkable. There is no pneumothorax, pleural effusion, or
consolidation. No acute displaced rib fracture identified.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Although no acute fracture or other chest wall lesion is seen, conventional
chest radiographs are not sufficient for detection or characterization of such
abnormalities. If the demonstration of a fracture or other trauma is
clinically warranted, the location where there are focal findings should be
clearly marked and imaged with either bone detail views or CT scanning.
3. A rounded area of increased density is seen projecting over the medial
left lung base. This finding is most consistent with a hiatal hernia.
NOTIFICATION:
Updated impression was discussed with Dr. ___ by Dr. ___ telephone
at 9:20am on ___, 90 minutes after discovery.
Radiology Report
EXAMINATION: Intraoperative radiographs for surgical guidance.
INDICATION: Periprosthetic fracture of the right proximal femur.
TECHNIQUE: 8 fluoroscopic views of the right hip provided for a total of 64.7
seconds of fluoro time.
COMPARISON: Prior exam performed earlier same day.
FINDINGS:
8 intraoperative images were acquired without a radiologist present.
Images show lateral plate and screw fixation of the right proximal femur with
cerclage wires supporting the proximal femoral shaft..
IMPRESSION:
Intraoperative images were obtained during operative fixation of right femoral
fracture. Please refer to the operative note for details of the procedure.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, R Hip pain
Diagnosed with FX FEMUR SHAFT-CLOSED, JOINT REPLACEMENT-HIP, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING
temperature: 98.4
heartrate: 67.0
resprate: 18.0
o2sat: 95.0
sbp: 154.0
dbp: 80.0
level of pain: 6
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 left hip periprosthetic hip fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of the left hip periprosthetic
hip fracture which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. On POD3, patient had a
bloody bowel movement, with another one the folowing day. His
lovenox dvt prophylaxis was held for two days. He received
1uPRBC for a hct of 23, which bumped up appropriately to 27 and
remained stable prior to discharge. Gastroenterology was
consulted who recommended a colonoscopy, which he underwent on
___ which revealed diverticulosis without any other
concerning masses. They cleared him for discharge on ___.
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
TDWB in the LLE, and will be discharged on lovenox x 2 weeks for
DVT prophylaxis. The patient will follow up in two weeks with
Dr. ___ team in 2 weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Proton Pump Inhibitors / Aspirin
Attending: ___
Chief Complaint:
Diplopia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old man with a history of recurrent PE on
coumadin, HTN, and hyperlipidemia who presents with head
pressure/ache and diplopia.
The patient reports that he first had a severe headache about 2
weeks ago. He is not someone who usually gets headaches. This is
a sharp pain in the back of the head. This went away after a
day.
For the past 3 days he has been feeling a "fullness" in his head
and especially behind his eyes as well as the same occipital
headache. Last night the patient was reading his book and had
trouble focusing. This morning around 10:30 he was walking
outside when he noted that he was seeing double. This was
present
on primary gaze but worse with looking left.
The headache/fullness he's been having over the past 3 days is
noticeably worse when he wakes up and worse when he changes
position from bending over to sitting up. It's not worse with
lying flat.
There have been no falls, head injuries, vision loss, weakness,
numbness, vertigo or difficulty walking.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
recurrent PE, on coumadin (frequent subtherapeutic INRs)
hypertension
hyperlipidemia
OSA
Depression/anxiety
restless legs syndrome
sickle cell trait
GERD
Social History:
___
Family History:
Significant for an Aunt who had PE's, and uncle who had blood
clots, also diabetes in his siblings. DM in siblings, bipolar in
sister.
Physical Exam:
Admission Physical Exam:
Vitals: 98.3 94 157/100 18 95%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Cardiac: RRR, nl. S1S2
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
II: PERRL 1mm and minimally reactive. VFF to confrontation.
Funduscopic exam unable to be done due to small pupils.
III, IV, VI: Eye movements appear full with no nystagmus. No
phoria. Normal saccades. The patient reports diplopia only with
left gaze and when looking at a distance.
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 with normal strength
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ ___ 5
R ___ ___ ___ ___ 5
-Sensory: No deficits to light touch, cold sensation. No
extinction to DSS.
-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: defered
#############################
Discharge Physical Exam:
Gen- Awake, NAD
Resp- Breathing comfortably on room air
Abd- Soft, NTND
Extr- No swelling
Neuro- Slight left head tilt. Fundoscopic exam with sharp discs.
PERRL with no RAPD. Right eye hypertropia worsened with looking
to the left. Diplopia worsened with looking to the left. Motor
with full strength in bilat upper and lower extremities.
Normal-based gait.
Pertinent Results:
___ 01:20PM BLOOD WBC-4.8 RBC-5.01 Hgb-13.7* Hct-39.8*
MCV-79* MCH-27.4 MCHC-34.5 RDW-14.7 Plt ___
___ 01:20PM BLOOD Neuts-46.5* Lymphs-43.3* Monos-6.7
Eos-2.4 Baso-1.1
___ 01:59PM BLOOD ___ PTT-40.3* ___
___ 01:20PM BLOOD Glucose-109* UreaN-10 Creat-1.0 Na-136
K-3.3 Cl-102 HCO3-27 AnGap-10
___ 03:04PM BLOOD TSH-1.1
___ 03:04PM BLOOD Free T4-1.3
___ 03:04PM BLOOD VITAMIN B1- 83 (78-185)
___ 03:04PM BLOOD THYROID STIMULATING IMMUNOGLOBULIN (TSI)-
22 (WNL)
free T3 3.5 (2.3-4.2)
AchR receptor antibody neg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 25 mg PO DAILY
2. Morphine SR (MS ___ 30 mg PO DAILY 6PM restless leg
syndrome
3. Warfarin 7.5 mg PO DAILY16
4. OxycoDONE (Immediate Release) 10 mg PO BEDTIME breakthrough
pain
Discharge Medications:
1. Chlorthalidone 25 mg PO DAILY
2. Morphine SR (MS ___ 30 mg PO DAILY 6PM restless leg
syndrome
3. OxycoDONE (Immediate Release) 10 mg PO BEDTIME breakthrough
pain
4. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: idiopathic headache, diplopia
Secondary: hypertension, pulmonary embolisms on coumadin,
hyperlipidemia
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 ___ nerve palsy, increased ICP // ? cause
of increased ICP and ___ nerve palsy
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
Phase-contrast MR venography of the head was acquired.
COMPARISON: None
FINDINGS:
The ventricles and extra-axial spaces are normal in size. There is no evidence
of midline shift, mass effect or hydrocephalus. There are no acute infarcts.
There is no evidence of focal abnormalities. The vascular flow voids are
maintained. The visualized paranasal sinuses are clear. Following gadolinium
administration there is no evidence of abnormal parenchymal, vascular and
meningeal enhancement seen.
MR venogram 3 of the head shows patency of the superior sagittal and straight
sinuses. Deep venous system is also patent. No evidence of venous sinus
thrombosis.
IMPRESSION:
No significant abnormalities are seen on MRI of the brain with and without
gadolinium. No evidence of venous sinus thrombosis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Headache, Diplopia
Diagnosed with DIPLOPIA, HEADACHE, PERSONAL HISTORY OF PULMONARY EMBOLISM, LONG TERM USE ANTIGOAGULANT
temperature: 98.3
heartrate: 94.0
resprate: 18.0
o2sat: 95.0
sbp: 157.0
dbp: 100.0
level of pain: 7
level of acuity: 2.0 | ___ M w diplopia and headaches. Headaches described as
"fullness". Fundoscopic exam w/o e/o papilledema. Diplopia on
far lateral gaze bilaterally - appear to be consistent w mild
bilateral ___ nerve palsies. CT head benign. MRI+/MRV benign.
Will follow closely in neurology and neuro-ophtho clinics.
Will follow in ___ clinic on ___. |
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, hypoxia, cought
Major Surgical or Invasive Procedure:
___ Line placement
History of Present Illness:
Patient is a ___ M with history of severe COPD (per pulmonary
note dated ___ baseline FEV1 has been 0.8-1.0L for the past
___, s/p LVRS in ___, who was treated for pneumonia one
month ago with levaquin and high-dose steroids, sent to the ED
from pulmonary clinic with worsening cough, dyspnea, weight
loss, and exertional hypoxia over the past month.
The patient presented to his pulmonologist in ___ with
worsening shortness of breath and was treated with a course of
prednisone and 7 days of levofloxacin for bacterial pneumonia.
He felt his symptoms improved briefly but then have
progressively worsened over the past month. Specifically, he
complains of shortness of breath, made especially worse with
exertion. Patient also reports a non-productive cough that began
two weeks ago. He says that usually he can walk up a flight of
stairs but now he would only be able to make it up two stairs
before having to stop. He says if he walks 20 feet, now his O2
sats would drop to the mid-80s, even on 3L O2. Also of note, the
patient reports he has lost 25-lbs over the past month and that
this has been at least partially intentional (with changes in
his diet and cutting out alcohol).
At baseline the patient uses home O2 only with exertion; however
for the past month, he has required 3L during the day and 2L at
night. He says he usually has one COPD exacerbation per year and
that his current symptoms are the worst he has experienced.
He denies any fevers or chills, chest pain, palpitations,
swelling of the lower extremities, or recent
travel/immobilization. He denies travel to TB-endemic areas. No
recent hospitalizations.
In the ED, initial vitals were: T 97.7 P 66 BP 127/83 RR 22 SpO2
98% on 3L Nasal Cannula. In the ED, CXR was obtained which
showed increased lingular and left lower lobe opacities
consistent with worsened infection. The patient was given 60mg
prednisone, cefepime, azithromycin, albuterol and ipratroprium
nebulizers.
Upon arrival to the floor, the patient has no complaints and is
requesting lozenges.
Past Medical History:
--COPD
--Childhood asthma
--H/o gout
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Admission physical exam:
VS - Temp 98.2F, BP 137/71, HR 68, R 20, O2-sat 93% RA
GENERAL - Pale, ill-appearing patient in NAD, speaking in full
sentences with frequent coughing
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - Expiratory wheezes at lung apices L>R, good air
movement, slightly labored breathing after coughing but no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no erythema or warmth of the ___ bilaterally.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
Discharge physical exam:
VS - Tm 98.3 Tc 98.3, BP 110s-130s/40-60s (116/65), HR ___
(70), R 20, O2-sat 95% RA
GENERAL - Resting comfortably in bed, pale, able to speak in
complete sentences without difficulty
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no crackles, good air movement, no accessory
muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, no erythema or warmth of the ___
bilaterally.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3
Pertinent Results:
Admission labs:
___ 02:54PM COMMENTS-ADDED TO G
___ 02:54PM K+-5.4*
___ 01:32PM GLUCOSE-164* UREA N-21* CREAT-1.2 SODIUM-132*
POTASSIUM-7.0* CHLORIDE-98 TOTAL CO2-27 ANION GAP-14
___ 01:32PM estGFR-Using this
___ 01:32PM CK(CPK)-178
___ 01:32PM CK-MB-3 cTropnT-0.02*
___ 01:32PM D-DIMER-1039*
___ 01:32PM WBC-11.7* RBC-4.02* HGB-12.2* HCT-37.8*
MCV-94 MCH-30.4 MCHC-32.3 RDW-13.3
___ 01:32PM NEUTS-81.5* LYMPHS-10.0* MONOS-6.8 EOS-1.2
BASOS-0.4
___ 01:32PM PLT COUNT-566*#
___ 01:32PM ___ PTT-29.5 ___
___ Chest CT with contrast:
FINDINGS: Heterogeneous opacities overlying the left mid lung
field and
silhouetting the left heart border are increased since ___. The patient is status post left lower lobectomy for
volume reduction with stable mild leftward shift of the
mediastinum. Blunting of the left costophrenic angle is
compatible with a small pleural effusion. The right lung is
grossly clear. No pneumothorax. The heart size appears normal.
No radiopaque foreign body.
IMPRESSION: Increased lingular and left lower lung opacities,
compatible with worsened infection since ___. Small
left pleural effusion.
Discharge labs:
___ 04:50AM BLOOD WBC-12.3* RBC-3.91* Hgb-11.9* Hct-35.8*
MCV-92 MCH-30.4 MCHC-33.1 RDW-13.5 Plt ___
___ 04:50AM BLOOD Glucose-144* UreaN-23* Creat-1.3* Na-135
K-4.2 Cl-99 HCO3-27 AnGap-13
Microbioogy:
___ 01:20PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
Negative
___ 01:20PM BLOOD B-GLUCAN-Test Negative
___ 6:40 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
Medications on Admission:
--albuterol sulfate q6-8hours PRN SOB
--albuterol sulfate [ProAir HFA] 90 mcg/actuation Aerosol
Inhaler
2 puffs(s) inhaled every ___ hours as needed for shortness of
breath
--allopurinol uncertain dose
--fluticasone 50 mcg/actuation Nasal Spray, 2 squirts(s) nasally
once daily
--montelukast [Singulair] 10 mg tablet in the evening
--Home oxygen
--salmeterol [Serevent Diskus] 50 mcg/dose for Inhalation 1 puff
inhaled Twice daily
--tacrolimus [Protopic] 0.1 % Ointment apply to eczema twice a
day
--tiotropium bromide [Spiriva with HandiHaler] 18 mcg &
inhalation capsules- One capsule inhaled daily
--guaifenesin [Mucinex] 600 mg tablet,extended release 2
Tablet(s) by mouth daily (OTC)
--Multivitamin
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheezing
4. Montelukast Sodium 10 mg PO DAILY
5. Guaifenesin ER 600 mg PO Q12H
6. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
7. Tiotropium Bromide 1 CAP IH DAILY
8. CefePIME 2 g IV Q12H
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
with spacer
10. Vancomycin 1000 mg IV Q 12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Multilobar Pneumonia
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath and dyspnea on exertion. History of alpha 1
antitrypsin disease.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: Multiple prior radiographs, most recently ___.
Chest CT of ___.
FINDINGS: Heterogeneous opacities overlying the left mid lung field and
silhouetting the left heart border are increased since ___. The
patient is status post left lower lobectomy for volume reduction with stable
mild leftward shift of the mediastinum. Blunting of the left costophrenic
angle is compatible with a small pleural effusion. The right lung is grossly
clear. No pneumothorax. The heart size appears normal. No radiopaque
foreign body.
IMPRESSION: Increased lingular and left lower lung opacities, compatible with
worsened infection since ___. Small left pleural effusion.
Radiology Report
INDICATION: Severe COPD with known alpha-1 antitrypsin disorder. Worsening
dyspnea and hypoxia.
COMPARISONS: Chest CT, ___. CT Chest, ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the chest after
the administration of IV contrast. Sagittal, coronal, and thin-slice images
were obtained and reviewed.
FINDINGS: The thyroid is unremarkable. There is no supraclavicular or
axillary lymphadenopathy. Gynecomastia is noted bilaterally. Small
mediastinal and hilar lymph nodes are not significantly changed from the prior
exam and likely reactive. The largest is in the left hila and measures 15 mm
in short axis (4, 107). There are no new lymph nodes. The heart is
unremarkable. There is no pericardial effusion. Atherosclerotic disease is
noted in the coronary arteries. Although this exam is not timed for detection
of pulmonary embolism, there is no large filling defect in the main or
segmental pulmonary arteries.
The airways are patent to the subsegmental levels. There are no filling
defects or bronchial masses. There is severe pan-lobular emphysema, most
prominent in the right lower lobe, but not significantly changed from the
prior exam. The patient is status post left lower lobe lobectomy.
Since the prior exam, the areas of ill-defined bronchiolar ground-glass and
alveolar opacities in the residual lingula and left upper lobe have worsened.
There are also areas of denser consolidation, particularly anteriorly (4,
141). This is most concerning for an infectious process. No areas of large
mucus impaction are noted. There is no bronchiectasis.
Multiple pleural-based nodules are not significantly changed from the prior
exam. Two pleural-based nodules in the right lower lobe are stable. One
measures 6 mm and one measures 7 mm (4, 48 and 167). A smaller subpleural
nodule in the right middle lobe is stable (4, 93). Finally, the previously
seen tiny nodule in the left upper lobe is not well evaluated on today's exam
due to the surrounding ground-glass opacification. No new nodules are
identified. There is no pleural effusion or pneumothorax.
The exam was not tailored for subdiaphragmatic evaluation. Within this
limitation, the visualized portions of the liver, spleen, adrenal glands, and
kidneys are unremarkable.
There are no suspicious lytic or sclerotic bony lesions. There are no
significant degenerative changes.
IMPRESSION:
1. Increasing consolidation and ground-glass opacification in the residual
left lingula and left upper lobe. This is most concerning for a worsening
infectious process.
2. Stable mildly enlarged left hilar and mediastinal lymph nodes are likely
reactive.
3. Stable severe pan-lobular emphysema.
4. Multiple stable pulmonary nodules. These are unchanged dating to ___.
Radiology Report
INDICATION: PICC line placement.
COMPARISON: Comparison is made to radiograph of the chest from ___.
FINDINGS: Frontal radiograph of the chest demonstrates right PICC with distal
tip terminating in the upper SVC. The previously seen left lingular and lower
lobe opacities are more prominent on this study, however this is likely
secondary to decreased lung volumes compared to the prior exam. The
cardiomediastinal silhouette is unremarkable. The remainder of the study is
unchanged from the prior.
IMPRESSION: Right PICC terminating in upper SVC. Left lingular and lower
lobe opacification more prominent on this exam due to lower lung volumes
compared to prior. Otherwise, stable chest radiograph.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: COUGH/CONGESTION
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.7
heartrate: 66.0
resprate: 22.0
o2sat: 98.0
sbp: 127.0
dbp: 83.0
level of pain: 0
level of acuity: 3.0 | ___ with history of severe COPD who was treated for bacterial
pneumonia one month ago with levofloxacin and PO steroids, sent
to the ED from pulmonary clinic with worsening cough, dyspnea,
and exertional hypoxia over the past month.
HOSPITAL COURSE BY PROBLEM
#. Dyspnea, cough, and hypoxia.
Given his risk factors of older age, severe obstructive disease,
and failure of recent antimicrobial therapy, the patient was
started on vancomycin and cefepime for pneumonia. PE was felt to
be less likely given that the patient had no other signs or
symptoms suggesting this (no chest pain, not tachycardia, no
history of immobilization, Wells score of zero). A chest CT was
obtained which showed increasing consolidation in the lingula
and left upper lobe compared to prior CT, concerning for a
worsening infection. The patient was continued on his home
impratroprium and albuterol nebulizers. A cardiac etiology of
his dyspnea was thought to be less likely given that he had no
cardiac history, did not appear volume overloaded on exam, and
recent normal LV and RV function on TTE from ___. His EKG on
arrival was negative for acute ischemic changes, though troponin
in ED slightly elevated to 0.02. His subsequent cardiac markers
were negative and an AM EKG showed no acute changes. A urine
legionella antigen was obtained and found to be negative.
Beta-glucan and galactomannan were also checked and were found
to be negative. Alpha-1 antitrypsin levels were also checked and
were also pending at the time of discharge. The inpatient
pulmonology team was consulted and recommended that he be
discharged on IV vancomycin and cefepime and that he begin
taking fluticasone with a spacer. The patient was discharged on
IV vancomycin and cefepime; follow-up with his outpatient
pulmonologist was being arranged by Dr. ___.
#. Elevated troponin.
The patient's troponin was elevated in the ED to 0.02, which was
attributed to a hemolyzed specimen. His EKG showed no acute
ischemic changes, and his cardiac markers were cycled and found
to be negative x2. He was placed on telemetry overnight, which
was discontinued the morning after a morning EKG showed no acute
ischemic changes. The patient denied any chest pain throughout
his admission.
#Creatinine bump.
On day four of his admission, the patient's serum creatinine
bumped from 1.1 to 1.4. Urine electrolytes were consistent with
an intrinsic renal process, likely contrast-induced (as he
received a chest CT with contrast) vs. antibiotic-induced. The
patient's AM and ___ doses of vancomycin were held for one day.
His serum creatinine was monitored and remained stably elevated
on the day of discharge. Upon discharge, the patient will have a
serum creatinine check along with Vancomcyin trough checked upon
discharge by ___ services; patient was provided with presciption
for outpatient lab check.
#. Hyperkalemia.
On admission the patient was found to be hyperkalemic, withou
acute EKG changes. An AM K was checked and found to be within
normal limits.
#. Hyponatremia
Mild, asymptomatic. Thought to be secondary to poor PO intake
versus SIADH in light of the patient's history of lung disease.
Urine electrolytes were checked and found to be consistent with
SIADH. The patient was initially fluid restricted; however this
was discontinued per the patient's request. His sodium was
trended and his hyponatremia resolved.
#. Urinary symptoms: Patient with PSA of 9 as an outpatient; he
is awaiting Urology follow-up at ___. Tamsulosin was started.
Patient tolerated this well, denying symptoms of orthostatics.
The patient was provided with prescription for this medication
and encouraged to follow-up with Urology as an outpatient as per
plan prior to admission.
Transition of care issues:
- follow-up alpha 1 antitripsin level (pending at time of
discharge)
- continuation of IV antiboitics through ___ line
- outpatient pulmonology follow-up |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Cephalexin / Tetracycline / morphine / Toradol /
clarithromycin / Penicillins / vancomycin / Suboxone
Attending: ___
Chief Complaint:
patient presented to the hospital with left eye pain swelling
and erythema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
presented with left eye pain and swelling after she manually
lanced it and the pain/swelling has been getting and she came to
the ED where ophthalmo Fellow saw her and he stated that it is
not orbital cellulitis but it is pre-septal cellulitis. Patient
was hard to establish IV access and picc line was placed for
her. Patient is very eager to leave although her cellulitis was
not completely resolved. I discussed with her the risk of
leaving AMA including worsening of her infection to extend to
her neurological system or the risk of losing her eye but she
insisted on leaving and she does not want to stay in the
hospital. I informed her that her abscess around her eye need to
be drained and she refused any further treatment and she does
not want to stay, a prescription of Bactrim has been given and
she was informed that it is not full treatment for her eye
infection and she is aware and understands the risks
Past Medical History:
Chronic pancreatitis
Drug abuse
Social History:
IV drug user
smoker
Pertinent Results:
___ 05:20AM BLOOD WBC-11.2* RBC-4.26 Hgb-12.7 Hct-38.0
MCV-89 MCH-29.8 MCHC-33.4 RDW-12.7 RDWSD-41.3 Plt ___
___ 10:00AM BLOOD Neuts-65.2 ___ Monos-9.9 Eos-4.9
Baso-0.3 Im ___ AbsNeut-7.68* AbsLymp-2.27 AbsMono-1.17*
AbsEos-0.58* AbsBaso-0.04
___ 05:20AM BLOOD Plt ___
___ 11:18AM BLOOD ___ PTT-30.3 ___
___ 05:20AM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-139
K-3.8 Cl-97 HCO3-27 AnGap-15
___ 05:20AM BLOOD Calcium-8.8 Mg-1.9
___ 04:45PM BLOOD ___ pO2-41* pCO2-49* pH-7.38
calTCO2-30 Base XS-2
Radiology Report
EXAMINATION: CT ORBITS, SELLA AND IAC W/ AND W/O CONTRAST Q1216 CT HEADSUB
INDICATION: ___ year old woman with swelling erythema of the left eye// Ruling
out orbital cellulitis
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 15.0 cm; CTDIvol = 35.9 mGy (Head) DLP = 515.4
mGy-cm.
Total DLP (Head) = 515 mGy-cm.
COMPARISON: Reference made to the prior CT orbits dated ___ from
outside facility.
FINDINGS:
There is extensive swelling involving the soft tissues of the left orbit
extending superiorly over the left frontal bone. This orbital soft tissue
swelling is in a preseptal distribution. The left retrobulbar fat appears
normal without evidence of stranding. The left globe, extraocular muscles and
optic nerve are within normal limits. In comparison to the prior CT dated ___, the degree of left preseptal swelling appears reduced. The right
globe, extraocular muscles, optic nerves and retrobulbar fat are within normal
limits.
The partially visualized upper aerodigestive tract is within normal limits.
The mandible and temporomandibular joints are within normal limits. There is
extensive thickening of the anterior ethmoidal air cells and frontal sinuses.
There is mucosal thickening involving the right greater than left maxillary
sinuses. Trace thickening is noted in the sphenoid sinus. The partially
visualized mastoid air cells appear clear. There is no evidence of fracture.
IMPRESSION:
1. Preseptal soft tissue swelling and edema of the medial and lateral left
orbit. The appearance appears somewhat improved in comparison to the prior
exam. However, post-septal orbital cellulitis remains a clinical diagnosis.
2. Paranasal sinus disease as described above.
Radiology Report
INDICATION: ___ year old woman with IV drug abuse, here for pre-septal orbital
cellulitis// PICC line placement (failed attempt on the floor to get the PICC)
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology
Attending, performed the procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: Lidocaine
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.23 min, 234 mGy
PROCEDURE:
1. Single lumen PICC placement
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the vein was
punctured under direct ultrasound guidance using a micropuncture set.
Permanent ultrasound images were obtained before and after intravenous access,
which confirmed vein patency. A peel-away sheath was then placed over a
guidewire. The guidewire was then advanced into the superior vena cava using
fluoroscopic guidance. A PIC line was then placed through the peel-away sheath
with its tip positioned in the distal SVC under fluoroscopic guidance.
Position of the catheter was confirmed by a fluoroscopic spot film of the
chest. The peel-away sheath and guidewire were then removed. The catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Brachialvein approach single lumen PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a right 37 cm brachial approach single lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Facial cellulitis, Transfer
Diagnosed with Periorbital cellulitis
temperature: 97.2
heartrate: 81.0
resprate: 16.0
o2sat: 98.0
sbp: 114.0
dbp: 71.0
level of pain: 5
level of acuity: 2.0 | presented with left eye pain and swelling after she manually
lanced it and the pain/swelling has been getting and she came to
the ED where ophthalmo Fellow saw her and he stated that it is
not orbital cellulitis but it is pre-septal cellulitis. Patient
was hard to establish IV access and picc line was placed for
her. Patient is very eager to leave although her cellulitis was
not completely resolved. I discussed with her the risk of
leaving AMA including worsening of her infection to extend to
her neurological system or the risk of losing her eye but she
insisted on leaving and she does not want to stay in the
hospital. I informed her that her abscess around her eye need to
be drained and she refused any further treatment and she does
not want to stay, a prescription of Bactrim has been given and
she was informed that it is not full treatment for her eye
infection and she is aware and understands the risks |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tramadol / latex / shellfish derived / aspirin / peanut
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
ADMISSION LABS
==================
___ 12:50PM BLOOD WBC-10.3* RBC-4.98 Hgb-15.4 Hct-44.2
MCV-89 MCH-30.9 MCHC-34.8 RDW-14.5 RDWSD-46.0 Plt ___
___ 12:50PM BLOOD Neuts-85.4* Lymphs-7.6* Monos-5.9
Eos-0.0* Baso-0.5 Im ___ AbsNeut-8.80* AbsLymp-0.78*
AbsMono-0.61 AbsEos-0.00* AbsBaso-0.05
___ 12:50PM BLOOD Plt ___
___ 04:00PM BLOOD ___ PTT-31.7 ___
___ 12:50PM BLOOD Glucose-248* UreaN-13 Creat-0.8 Na-133*
K-3.6 Cl-89* HCO3-26 AnGap-18
___ 12:50PM BLOOD ALT-122* AST-226* AlkPhos-293*
TotBili-1.6*
___ 12:50PM BLOOD Lipase-179*
___ 12:50PM BLOOD Albumin-3.9 Calcium-8.6 Phos-3.3 Mg-1.2*
___ 01:02PM BLOOD Lactate-3.7*
___ 04:04PM BLOOD Lactate-2.1*
MICROBIOLOGY
================
___ 4:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
================
___ CTA/P
IMPRESSION:
1. Findings consistent with acute interstitial edematous
pancreatitis. The pancreas appears to enhance homogeneously.
No peripancreatic fluid
collections are identified.
2. Peripancreatic fat stranding extends into the lesser sac
abuts the lesser curvature of the stomach and duodenum with
reactive lymphadenopathy as described above.
3. Hepatic steatosis.
Discharge labs:
___ 04:37AM BLOOD WBC-10.6* RBC-3.64* Hgb-11.2 Hct-35.0
MCV-96 MCH-30.8 MCHC-32.0 RDW-14.7 RDWSD-51.0* Plt ___
___ 04:37AM BLOOD Glucose-221* UreaN-11 Creat-0.6 Na-139
K-4.6 Cl-97 HCO3-28 AnGap-14
___ 04:37AM BLOOD ALT-28 AST-34 AlkPhos-133* TotBili-0.4
___ 04:37AM BLOOD Calcium-9.5 Phos-5.4* Mg-1.7
___ 06:35AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS*
___ 12:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:35AM BLOOD HIV Ab-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Gabapentin 800 mg PO TID
3. Multivitamins 1 TAB PO DAILY
4. amLODIPine 5 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. Glargine 40 Units Dinner
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 4
hours as needed Disp #*20 Tablet Refills:*0
2. Gabapentin 1200 mg PO TID
RX *gabapentin 600 mg 2 capsule(s) by mouth three times a day
Disp #*45 Tablet Refills:*0
3. Glargine 40 Units Dinner
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Acetaminophen 1000 mg PO Q8H
5. amLODIPine 5 mg PO DAILY
6. Citalopram 30 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Prazosin 5 mg PO BID
10. Prazosin 2 mg PO DAILY
11. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ yo woman with hx of HCV, EtOH use disorder c/b withdrawal
seizures, multiple prior ICU admissions for alcohol withdrawal including need
for Phenobarbital, prior opioid use disorder on suboxone, recurrent
pancreatitis, T2DM Who presents with abdominal pain.NO_PO contrast //
etiology of abd pain, ?pancreatitis, ?biliary obstruction
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 7.0 s, 55.1 cm; CTDIvol = 27.8 mGy (Body) DLP =
1,529.3 mGy-cm.
Total DLP (Body) = 1,545 mGy-cm.
COMPARISON: MRCP ___. CT abdomen/pelvis ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is diffusely hypoattenuating consistent with hepatic
steatosis. There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: Diffuse fat stranding surrounding the pancreatic body, head and
uncinate process consistent with acute pancreatitis. No evidence of main
ductal dilatation. Pancreas appears to enhance homogeneously without definite
evidence of necrosis. No peripancreatic fluid collection is identified.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. Bilateral
simple cysts and subcentimeter hypodensities too small to characterize are
unchanged. Cortical irregularity in the interpolar region of the left kidney
may reflect prior infection (2:38). There is no perinephric abnormality.
GASTROINTESTINAL: Stranding in the lesser sac abuts the lesser curvature of
the stomach. Peripancreatic stranding also abuts the proximal, second and
third portions of the duodenum. No small bowel obstruction. The colon rectum
are unremarkable in appearance. Submucosal fat deposition in the ascending
colon at the hepatic flexure may reflect sequelae of prior inflammation or
infection. The appendix is unremarkable. No free fluid in the abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Visualized uterus is unremarkable. A small amount of air
is seen within the vagina, nonspecific. No adnexal abnormality.
LYMPH NODES: Peripancreatic and porta hepatic lymph nodes are noted measuring
up to 1.0 cm in axial diameter, likely reactive (2:31). No pelvic or inguinal
lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. There is mild atherosclerotic
disease. Soft tissue stranding the lesser sac abuts the celiac trunk and
proximal SMA although no associated vascular abnormalities identified. The
splenic vein is patent.
BONES: The patient is status post right hip arthroplasty and placement of a
gamma nail through the left femoral head.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Findings consistent with acute interstitial edematous pancreatitis. The
pancreas appears to enhance homogeneously. No peripancreatic fluid
collections are identified.
2. Peripancreatic fat stranding extends into the lesser sac abuts the lesser
curvature of the stomach and duodenum with reactive lymphadenopathy as
described above.
3. Hepatic steatosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Alcohol withdrawal, n/v/d
Diagnosed with Other chronic pancreatitis
temperature: 97.6
heartrate: 105.0
resprate: 18.0
o2sat: 99.0
sbp: 141.0
dbp: 99.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ female with h/o alcohol use
disorder, previous admissions for alcohol withdrawal requiring
IV phenobarbital as well as previous admissions for necrotizing
pancreatitis presents with alcohol withdrawal,
alcoholic hepatitis, and acute pancreatitis. |
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, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a history of hypertension, GERD,
dyslipidemia, remote bowel resection for colonic lipoma and
peptic ulcer disease s/p vagotomy (in ___ who presents with
abdominal pain. 2 weeks ago, the patient developed gradual
onset
abdominal pain which is been waxing and waning but overall
constant per report. He says it is been nonradiating. The pain
is intermittently on the left, right and center, but typically
is
around the umbilical level. The pain is not associated with
p.o.
intake or improved by p.o. The pain is not improved or worsened
by movement or exercise. The pain is typically dull but gets
sharp when he presses and he occasionally has sharp pains that
have woken him from sleep. He has had nausea without vomiting.
He intermittently has small bowel movements which are at his
baseline and he denies any hematochezia or melena. He has also
had intermittent fevers for the past 3 days up to 38.5 °C
yesterday. He has had no difficulty with urination or blood in
his urine. Denies chest pain, shortness of breath,
palpitations,
cough, or lightheadedness. He denies any headache or double
vision. He denies any testicular pain or penile discharge. No
recent travel and no sick contacts. He has been taking Aleve
for
the pain, which is mildly effective.
His prior encounters at ___ are notable for an admission to
general surgery in ___ for abdominal cramping and blood per
rectum for 6 weeks. He had a laparoscopy sigmoid colectomy with
removal of sigmoid mass. Pathology revealed that the mass was a
lipoma. He also presented to ___ ED in ___ with rectal
bleeding. His evaluation was benign and he was discharged to the
care of his PCP.
- In the ED, initial vitals were:
T 95.8F HR 104 BP 142/83 RR 20 100% RA
- Exam was notable for:
"Diffuse abd ttp wo peritonitic signs, worse on R."
- Labs were notable for:
WBC 18 Hgb 12.9 Plt 355
BMP overall unremarkable
ALT 59 Alk phos 156 AST 37 T bili 0.4
INR 1.3
UA w/ small ketones, urobil, and RBCs
- Studies were notable for:
CT Abd/Pelv w/ contrast:
Significant wall thickening of the terminal ileum, cecum, and
proximal
ascending: With surrounding fat stranding and prominent
ileocolic
lymph nodes, suggestive of terminal ileitis; however, an
underlying mass cannot be excluded. The appendix is normal.
Recommend follow-up CT or colonoscopy once the acute process
resides to ensure resolution and exclude an underlying mass.
- The patient was given:
3L LR
IV Morphine Sulfate 4 mg
IV Ampicillin-Sulbactam 3 g
PO Acetaminophen 1000 mg
On arrival to the floor, he reports some continued abdominal
pain
around his umbilicus and in the right lower quadrant. There is
some radiation to the back from this. He thinks that some of
his
nausea was attributable to the NSAIDs and Tylenol he was taking.
He otherwise does not have any current symptoms.
Past Medical History:
Hypertension
GERD
Peptic ulcer disease s/p vagotomy
Sigmoid lipoma s/p partial sigmoid colectomy (___)
Dyslipidemia
Social History:
___
Family History:
CAD, HTN
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VITALS:
___ 2335 Temp: 98.1 PO BP: 134/82 HR: 89 RR: 18 O2 sat: 92%
O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Somewhat hyperactive bowel sounds, non distended,
mildly
tender to deep palpation throughout, more so in the right lower
quadrant. No peritoneal signs.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM
==========================
VITALS:
24 HR Data (last updated ___ @ 1855)
Temp: 99.5 (Tm 99.5), BP: 137/90 (125-139/87-90), HR: 88
(84-94), RR: 18 (___), O2 sat: 97% (95-97), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowel sounds, non distended, mildly tender to
deep palpation throughout, more so in the right lower quadrant.
No peritoneal signs.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS
=================
___ 12:00PM BLOOD WBC-18.0* RBC-4.59* Hgb-12.9* Hct-39.7*
MCV-87 MCH-28.1 MCHC-32.5 RDW-14.0 RDWSD-44.5 Plt ___
___ 12:00PM BLOOD Neuts-84.9* Lymphs-4.7* Monos-9.6
Eos-0.2* Baso-0.2 Im ___ AbsNeut-15.24* AbsLymp-0.85*
AbsMono-1.73* AbsEos-0.04 AbsBaso-0.03
___ 12:00PM BLOOD ___ PTT-41.0* ___
___ 12:00PM BLOOD Glucose-111* UreaN-14 Creat-0.9 Na-142
K-4.8 Cl-103 HCO3-25 AnGap-14
___ 12:00PM BLOOD ALT-59* AST-37 AlkPhos-156* TotBili-0.4
___ 12:00PM BLOOD Albumin-3.7
___ 12:00PM BLOOD CRP-179.0*
PERTINENT LABS
=================
___ 05:10AM BLOOD ALT-88* AST-91* AlkPhos-176* TotBili-0.6
___ 05:02AM BLOOD ALT-61* AST-31 LD(LDH)-189 AlkPhos-152*
TotBili-0.3
___ 05:10AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8 Iron-20*
___ 05:10AM BLOOD calTIBC-264 Ferritn-477* TRF-203
___ 05:02AM BLOOD Hapto-510*
___ 05:10AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG IgM HAV-NEG
___ 08:10PM BLOOD CMV IgG-POS* CMV IgM-POS* CMVI-In the app
EBV IgG-POS* EBNA-POS* EBV IgM-PND EBVI-PND
___ 08:10PM BLOOD CMV VL-NOT DETECT
___ 08:10PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-PND
___ 08:10PM BLOOD YERSINIA ENTERCOLITICA ANTIBODIES
(IGG,IGA)-PND
DISCHARGE LABS
=================
___ 06:43AM BLOOD WBC-10.2* RBC-4.33* Hgb-12.2* Hct-37.8*
MCV-87 MCH-28.2 MCHC-32.3 RDW-14.3 RDWSD-46.3 Plt ___
___ 06:43AM BLOOD Glucose-106* UreaN-13 Creat-1.0 Na-142
K-5.4 Cl-102 HCO3-25 AnGap-15
IMAGING
=================
CT A/P ___
IMPRESSION:
1. Marked wall thickening of the terminal ileum in very distal
ileum and wall
thickening to a lesser extent involving the cecum and proximal
ascending
colon. 5 x 4.0 cm region of likely phlegmon superior to the
thickened
terminal ileum. Numerous associated mildly prominent likely
reactive right
abdominal ileocolic lymph nodes. Consultation of findings most
compatible
with terminal ileitis and associated phlegmonous change.
Differential
diagnosis includes inflammatory bowel disease, including Crohn's
disease,
other inflammatory process, versus infectious ileitis. No free
air or
extraluminal oral contrast seen. No drainable collection.
2. Normal caliber appendix.
RECOMMENDATION(S): Recommend follow-up CT or colonoscopy once
the acute
process resides to ensure resolution and exclude an underlying
mass.
RUQUS ___
IMPRESSION:
1. Normal appearance of the liver parenchyma. No focal liver
lesions are
identified.
2. Nondistended gallbladder with trace wall edema versus
pericholecystic
fluid. Findings may be related to third spacing. No other
sonographic
findings to suggest cholecystitis.
MICROBIOLOGY
================
___ 10:26 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
Medications on Admission:
None
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID Duration: 7 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*14 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
Terminal Ileitis
SECONDARY DIAGNOSIS
======================
Peptic Ulcer Disease
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: ___ with hx bowel resection here w fevers, diffuse abdominal pain
worst on RLQ/RUQ.//eval bowel obstruction vs appy vs biliary infection vs
other infectious process
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 6.4 s, 50.1 cm; CTDIvol = 10.7 mGy (Body) DLP = 537.5
mGy-cm.
Total DLP (Body) = 546 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: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There is marked wall
thickening of the terminal and very distal ileum and wall thickening to a
lesser extent involving the cecum and proximal ascending colon. A 5 x 4.0 cm
region likely phlegmonous changes seen superior to the thickened terminal
ileum, series 601, image 28. Numerous associated mildly prominent and likely
reactive right lower quadrant ileocolic lymph nodes are seen. No free air or
drainable fluid collection is seen. The appendix is normal in caliber.
Patient is status post partial sigmoid resection, with anastomosis seen.
PELVIS: The urinary bladder and distal ureters are unremarkable.
LYMPH NODES: Prominent right ileocolic lymph nodes, likely reactive.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Bilateral fat containing inguinal hernias are seen.
IMPRESSION:
1. Marked wall thickening of the terminal ileum in very distal ileum and wall
thickening to a lesser extent involving the cecum and proximal ascending
colon. 5 x 4.0 cm region of likely phlegmon superior to the thickened
terminal ileum. Numerous associated mildly prominent likely reactive right
abdominal ileocolic lymph nodes. Consultation of findings most compatible
with terminal ileitis and associated phlegmonous change. Differential
diagnosis includes inflammatory bowel disease, including Crohn's disease,
other inflammatory process, versus infectious ileitis. No free air or
extraluminal oral contrast seen. No drainable collection.
2. Normal caliber appendix.
RECOMMENDATION(S): Recommend follow-up CT or colonoscopy once the acute
process resides to ensure resolution and exclude an underlying mass.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with transaminitis and abdominal pain of unclear
etiology// eval for cause of transaminitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis performed ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: The gallbladder is not distended. There is trace wall edema
versus pericholecystic fluid, possibly related to third spacing.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 9.2 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 11.2 cm
Left kidney: 11.2 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Normal appearance of the liver parenchyma. No focal liver lesions are
identified.
2. Nondistended gallbladder with trace wall edema versus pericholecystic
fluid. Findings may be related to third spacing. No other sonographic
findings to suggest cholecystitis.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Abd pain, Fever
Diagnosed with Crohn's disease of small intestine without complications
temperature: 95.8
heartrate: 104.0
resprate: 20.0
o2sat: 100.0
sbp: 142.0
dbp: 83.0
level of pain: 4
level of acuity: 3.0 | SUMMARY
===============
___ male with a history of GERD, peptic ulcer s/p vagotomy, and
sigmoid lipoma s/p partial sigmoid colectomy (___) who
presented with fevers and abdominal pain with features of
enterocolitis noted on imaging. He was started on ciprofloxacin
and flagyl with improvement in his symptoms. He was seen by
gastroenterology, who recommended outpatient colonoscopy for
further follow up.
TRANSITIONAL ISSUES
=====================
[] At time of discharge, patient did not have an outpatient
colonoscopy scheduled but had been ordered. Please confirm with
patient that this has been scheduled for the next few weeks
after he completes course of antibiotics.
[] Patient with " Marked wall thickening of the terminal ileum
in very distal ileum and wall thickening to a lesser extent
involving the cecum and proximal ascending
colon. 5 x 4.0 cm region of likely phlegmon superior to the
thickened terminal ileum." found on CT A/P. Recommend that
patient has a follow up CT or colonoscopy once the acute process
resides to ensure resolution and exclude underlying mass.
[] Patient discharged on ciprofloxacin and flagyl for a 10 day
course scheduled to end ___.
[] Patient found to be CMV IGM and IGG positive. Per GI, there
was no indication for antiviral treatment or colonoscopy at this
time because patient is immunocompetant. GI will follow with
outpatient colonoscopy.
[] Recommend outpatient vaccination for hepatitis.
ACUTE ISSUES
=================
# Terminal ileitis
He presented with 2 weeks of abdominal pain and intermittent
fevers and was found on imaging to have findings consistent with
terminal ileitis. This is typically associated with Crohn's
disease although there are other associated conditions such as
ulcerative colitis, infection or less likely NSAID ileitis. CRP
at admission was elevated to 179. He was started on cipro and
flagyl with improvement in his abdominal pain. GI was consulted
and recommended sending off serologies. At the time of
discharge, patient was noted to be CMV IgM positive, IgG
positive, EBV IgG positive. Per GI, since patient was
immunocompetant, they believed this was likely infectious and
recommended continuing antibiotics and setting up an outpatient
colonoscopy once the infection resolved.
# Mild normocytic anemia
Suspect reactive from illness however pt has prior hx of BRBPR
iso lipoma. Low iron. Hemolysis labs negative. No evidence of
active bleeding.
# Mild transaminitis
Initially presented with transaminitis that improved by
discharge. RUQUS negative for biliary process. Likely secondary
to infection as above. Hepatitis panels negative. |
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 fractures
Major Surgical or Invasive Procedure:
ORIF of facial fractures
History of Present Illness:
Mr. ___ is a ___ year old male who presented as a trauma
patient after a syncopal episode. He had been on a prolonged
bikycle ride with his wife. Per report, he was standing and
talking in the driveway after the ride when he suddenly lost
consciousness and fell forward, striking his face. He had no
prodromal symptoms. He has not had prior syncope. At the time of
presentation, he complained of pain and bleeding and loss of
multiple teeth. Patient denies any medical history however he
has not seen a physician in several decades by his estimate.
Past Medical History:
PMH: Denies
PSH: Denies
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On admission:
Temp: 97.8 HR: 81 BP: 162/93 Resp: 18 O(2)Sat: 97
Constitutional: Comfortable
HEENT: Bleeding from the mouth and nose
Multiple fractured and avulsed teeth the maxilla and
mandible, he has malocclusion, he is bleeding from his
inferior mandible as well, midface is mobile, no midline
C-spine tenderness
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
On discharge:
VS: 97.7, 95, 139/77, 18, 97% RA
Gen: NAD, AAOx3, pleasant
HEENT: PERRL, EOMI, no active epistaxis, packing removed by
OMFS. Mild soft tissue swelling on the right and left side of
the face consistent with the surgery, abrasions on the right
forehead and left cheek and tip of the nose, soft tissue
swelling consistent with the procedure
CV: RRR no m/r/g
Pulm: CTAB no w/r/r
Abd: Soft, NT/ND
Pertinent Results:
___ 05:40PM BLOOD WBC-19.8* RBC-5.30 Hgb-15.4 Hct-47.5
MCV-90 MCH-29.2 MCHC-32.5 RDW-13.8 Plt ___
___ 06:05AM BLOOD WBC-15.2* RBC-4.89 Hgb-13.9* Hct-43.8
MCV-90 MCH-28.4 MCHC-31.7 RDW-13.4 Plt ___
___ 01:42AM BLOOD WBC-10.6 RBC-4.78 Hgb-13.9* Hct-42.7
MCV-90 MCH-29.1 MCHC-32.5 RDW-13.5 Plt ___
___ 05:40AM BLOOD WBC-7.2 RBC-4.76 Hgb-13.6* Hct-42.5
MCV-89 MCH-28.6 MCHC-32.0 RDW-13.2 Plt ___
___ 02:06AM BLOOD WBC-9.2 RBC-4.21* Hgb-12.6* Hct-37.8*
MCV-90 MCH-30.0 MCHC-33.5 RDW-13.3 Plt ___
___ 06:50AM BLOOD WBC-7.8 RBC-4.09* Hgb-12.0* Hct-37.1*
MCV-91 MCH-29.3 MCHC-32.3 RDW-13.7 Plt ___
CT maxillofacial ___:
IMPRESSION:
1. Bilateral ___ Fort I, right ___ ___ and left ___ ___
fractures as
described above with involvement of the bilateral cribriform
plates, the
lacrimal duct on the left and the lacrimal fossa on the right.
2. Comminuted fractures through the hard palate with teeth 9
and 11 missing and fractures involving the roots of multiple
left maxillary teeth.
3. Vertically oriented mandibular fractures in the
parasymphyseal region on the right and the left with a
horizontally oriented fracture extending through the body of the
mandible on the right paralleling the course of the inferior
alveolar canal.
CT maxillofacial ___:
IMPRESSION:
1. Numerous facial fractures, status post repair.
2. Persistent comminuted fracture of the lateral wall of the
right maxillary sinus with now an angulated linear fracture
fragment present inside the sinus cavity surrounded by increased
hematoma. There is also increased hemorrhagic opacification of
the right maxillary sinus and ethmoid air cells.
3. Persistent subluxation of the right temporomandibular joint.
RUE DVT scan ___:
Focal thrombosis of the right cephalic vein at the prior line
insertion site.
No deep vein thrombosis identified in the right upper extremity.
CAROTID SERIES COMPLETE ___:
Impression:
Right ICA with <40% stenosis.
Left ICA with no stenosis.
Echo (TTE) ___:
IMPRESSION: No structural cardiac cause of syncope identified.
Normal biventricular cavity size and regional/global systolic
function. Mild aortic regurgitation.
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
RX *acetaminophen 160 mg/5 mL (5 mL) 15 ml by mouth every six
(6) hours Disp #*300 Milliliter Refills:*0
2. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
Do not drive or operate other machinery while using
RX *oxycodone 5 mg/5 mL ___ ml by mouth every four (4) hours
Refills:*0
3. Ibuprofen Suspension 600 mg PO Q6H:PRN pain
RX *ibuprofen 100 mg/5 mL 30 ml by mouth every six (6) hours
Refills:*0
4. Sodium Chloride Nasal ___ SPRY NU QID:PRN nose dryness
RX *sodium chloride [Ocean Nasal] 0.65 % ___ spray Both nostrils
four times a day Disp #*50 Spray Refills:*0
5. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % Swich and spit twice a day
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral LeFort I fractures, right LeFort II fracture, and left
LeFort III fracture
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 fall from standing, injury to mouth with teeth
knocked out.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest. Relatively low lung
volumes are noted. There is a hazy opacity at the left lung base, both
laterally and posteriorly involving the costophrenic angles. Elsewhere, lungs
are clear. The cardiomediastinal silhouette is within normal limits. No
definite acute osseous abnormality identified.
IMPRESSION: Low lung volumes. Left basilar opacity may be secondary to
atelectasis. Consider repeat with improved inspiratory effort to further
assess.
Radiology Report
PANOREX FILM OF THE MANDIBLE: ___.
HISTORY: ___ male with fall from standing with a mandible deformity.
COMPARISON: CT sinuses performed the same day.
FINDINGS: Single Panorex film of the mandible. The known comminuted
mandibular fracture involving the parasymphyseal region extending to the body
on the right is not clearly seen on this Panorex film. Unusual configuration
___ tooth #26 is due to its relative anterior-posterior
projection/angulation, better depicted on CT scan. Multiple other facial
fractures involving the maxilla are better characterized by CT scan.
Radiology Report
HISTORY: Fall from standing with head strike and pain
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Multiplanar reformatted images in
coronal and sagittal axes and thin-section bone algorithm reconstructed images
were acquired.
DLP: 892 mGy-cm
CTDIvol: 54 mGy
COMPARISON: None available
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect or acute infarction.
Mild prominence of the ventricles and sulci is consistent with age-related
atrophy. The basal cisterns appear patent and there is preservation of
gray-white differentiation.
For details regarding the extensive facial fractures, please see dedicated
facial bone CT. The mastoid air cells are clear. Blood is seen layering
within the bilateral maxillary sinuses, the frontal sinuses and the ethmoid
air cells. A mucous retention cyst is noted in the right sphenoid sinus. The
left sphenoid sinus is clear. The globes are intact.
IMPRESSION:
1. No evidence of acute intracranial process.
2. For details regarding the extensive facial fractures, please see dedicated
facial bone CT
Radiology Report
STUDY: Facial bones CT.
INDICATION: Fall from standing with head strike and concern for ___ Fort
fracture.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained through the facial bones
without administration of IV contrast. Multiplanar reformatted images in
coronal and sagittal axes were generated.
DLP: 607 mGy-cm.
FINDINGS: There are fractures of the bilateral medial and lateral pterygoid
processes. There are fractures through the bilateral medial orbital walls and
ethmoid air cells with fractures involving the bilateral cribriform plates.
The fracture extends through the left lacrimal duct. Fracture lines also seen
in the region of the right lacrimal fossa. There is a fracture of the right
orbital floor involving the inferior orbital canal, extending to the rim as
well as a fracture of the left orbital floor and left lateral orbital wall.
The left zygomatic arch is fractured. There are comminuted fractures of the
bilateral nasal bones as well as comminuted angulated fractures of the nasal
septum. There are fractures involving the frontal process of the maxilla on
the right with a right pyriform aperture fracture. There are comminuted
fractures of the medial, lateral and anterior walls of the maxillary sinuses.
On the left, the horizonatlly oriented fracture through the maxilla extends
through the alveolar process and through the hard palate posteriorly without
involvement of the piriform aperture. The fracture involves the roots of
multiple maxillary teeth on the lef. ___ teeth 9 and 11 are missing.
There are two vertically oriented fractures in the parasymphyseal region of
the mandible on the right and the left with a more horizontally oriented
fracture line extending through the body on the right, which parallels the
course of the inferior alveolar canal and may involve the canal.
Temporomandibular joints are antaomically aligned.
The globes appear intact. There is no radiographic evidence of extraocular
muscle entrapment. There is no large retrobulbar hematoma. Air-fluid levels
are seen within the bilateral maxillary sinuses and frontal sinuses with
opacification of the ethmoid air cells, all consistent with hemorrhage. A
mucus retention cyst is noted on the right sphenoid sinus. The left sphenoid
sinus is clear. The visualized mastoid air cells are clear. Extensive soft
tissue edema of the face with subcutaneous emphysema is noted.
IMPRESSION:
1. Bilateral ___ Fort I, right ___ ___ and left ___ ___ fractures as
described above with involvement of the bilateral cribriform plates, the
lacrimal duct on the left and the lacrimal fossa on the right.
2. Comminuted fractures through the hard palate with teeth 9 and 11 missing
and fractures involving the roots of multiple left maxillary teeth.
3. Vertically oriented mandibular fractures in the parasymphyseal region on
the right and the left with a horizontally oriented fracture extending through
the body of the mandible on the right paralleling the course of the inferior
alveolar canal.
Findings were discussed with Dr. ___ by Dr. ___ in person at 8:30 p.m.
on ___, 20 minutes after review of the study.
Radiology Report
HISTORY: Following and history, evaluate for injury
TECHNIQUE: Helical axial MDCT sections were obtained from the skullbase
through the T2 level. Reformatted images in sagittal and coronal axes were
obtained.
DLP: 790 mGy-cm
COMPARISON: None available
FINDINGS:
There is no evidence of acute fracture or traumatic malalignment in the
cervical spine. Old well corticated T1 spinous process fracture is noted.
There is no prevertebral soft tissue swelling. Mild multilevel degenerative
changes are noted. CT is not able to provide intrathecal detailed comparable
to MRI, but the visualized outline of the thecal sac appears unremarkable. No
lymphadenopathy is present by CT size criteria. The lung apices are clear.
For details regarding the facial fractures see facial bone CT.
IMPRESSION:
No evidence of acute fracture or traumatic malalignment in the cervical spine.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with worsening SOB after facial trauma //
presence of ptx, infiltrate, other acute process presence of ptx,
infiltrate, other acute process
IMPRESSION:
In comparison with the study ___, the lung volumes have slightly
improved. Opacification at the left base most likely represents the
combination of a small effusion and compressive atelectasis.
Radiology Report
___
Department of Radiology
Standard Report- Carotid Series Complete
Reason: ___ year old man with syncope.
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is mild homogeneous plaque in the ICA. On the left there is no
plaque in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 69/28, 57/21, 63/28, cm/sec. CCA peak systolic
velocity is 75 cm/sec. ECA peak systolic velocity is 78 cm/sec. The ICA/CCA
ratio is .92. These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 55/23, 69/25, 53/23 cm/sec. CCA peak systolic velocity
is 83 cm/sec. ECA peak systolic velocity is 78 cm/sec. The ICA/CCA ratio is
.83. These findings are consistent with no stenosis.
There is right antegrade vertebral artery flow.
There is left antegrade vertebral artery flow.
Impression: Right ICA with <40% stenosis.
Left ICA with no stenosis.
Radiology Report
EXAMINATION: 3D reconstructions of facial bone CT
INDICATION: ___ year old man with facial traumamultiple facial FX // ___
need the 3D reconstruct
TECHNIQUE: 3D reconstructions were processed on a separate workstation for
surgical planning.
COMPARISON: CT sinus, ___.
FINDINGS:
Please see report under clip ___.
IMPRESSION:
Please see report under clip ___.
Radiology Report
INDICATION: ___ man with syncopal event while biking, sustaining
multiple facial fractures, status post repair.
COMPARISON: CT facial bones from ___.
TECHNIQUE: Non-contrast axial multidetector CT images were obtained from the
frontal sinuses through the mandible with coronal and sagittal reformats.
DLP: 877 mGy-cm.
CTDIvol: 37 mGy.
FINDINGS:
There is interval fixation of numerous facial fractures as described in detail
in the facial bone CT report dated ___. There remains a comminuted
fracture of the lateral wall of the right maxillary sinus with the bone
fragment now angulated medially and located in size inside the right maxillary
sinus cavity which is opacified by a large hemorrhagic collection, increased
compared to the prior study. There is also increased hemorrhagic
opacification of the left maxillary sinus. The mastoid air cells remain
clear. The sphenoid sinuses are clear except for a stable appearance of a
mucus retention cyst on the right. Diffuse opacification of the ethmoid air
cells is increased. Packing surgical material is now present in bilateral
nasal cavities with likely hemorrhagic opacification of the posterior right
nasal passage. The right temporomandibular joint remains subluxed. The
visualized portion of the cervical spine is unremarkable. No gross
abnormality is identified. Bilateral periorbital hematomas are again noted.
Extensive diffuse facial swelling is again noted.
IMPRESSION:
1. Numerous facial fractures, status post repair.
2. Persistent comminuted fracture of the lateral wall of the right maxillary
sinus with now an angulated linear fracture fragment present inside the sinus
cavity surrounded by increased hematoma. There is also increased hemorrhagic
opacification of the right maxillary sinus and ethmoid air cells.
3. Persistent subluxation of the right temporomandibular joint.
NOTE ADDED AT ATTENDING REVIEW: Unchanged comminuted mandibular fractures.
Radiology Report
INDICATION: ___ year old man with RUE induration/erythema at old IV site //
Please rule out DVT
TECHNIQUE: Grayscale, color, and spectral Doppler evaluation was performed of
the right upper extremity veins.
COMPARISON: None.
FINDINGS:
There is normal phasicity of the subclavian veins bilaterally. There is normal
compression and augmentation of the right internal jugular, axillary, paired
brachial, and basilic veins. There is focal thrombosis of the right cephalic
vein at the prior line insertion site. More proximal and more distal portions
of the cephalic vein are patent.
IMPRESSION:
Focal thrombosis of the right cephalic vein at the prior line insertion site.
No deep vein thrombosis identified in the right upper extremity.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope, ORAL TRAUMA
Diagnosed with FX MALAR/MAXILLARY-CLOSE, MULT FX MANDIBLE-CLOSED, TOOTH (BROKEN) (FRACTURED) (DUE TO TRAUMA), WITHOUT MENTION OF COMPLICATION, OPEN WOUND OF LIP, SYNCOPE AND COLLAPSE, OTHER FALL
temperature: 97.8
heartrate: 81.0
resprate: 18.0
o2sat: 97.0
sbp: 162.0
dbp: 93.0
level of pain: 4
level of acuity: 1.0 | Mr. ___ was admitted to the ACS service with HPI as
stated above. He underwent imaging which revealed bilateral
___ I fractures, right LeFort II fracture, and left LeFort
III fracture. OMFS and ophthalmology were consulted. OMFS
determined that operative repair would require a substantial
block of OR time and so scheduled the case for ___.
Ophthalmology evaluated the patient and determined that no acute
ophthalmologic operative intervention was indicated but that the
patient should follow up with the Mass Eye and Ear Institute
department of occuloplastics. He was given a full liquid diet
as he was not expected to go to the OR immediately.
On ___, the patient was noted to have substantial facial
swelling secondary to his injuries and so he was placed on
continuous O2 saturation monitoring and transferred to the SICU;
his condition did not worsen and he required no additional
interventions. A tertiary survey on that day did not reveal any
new injuries. He returned to the floor on ___ and was kept on
full liquids.
On ___, a syncope workup was initiated. EKG and CXR on
___ were not acutely concerning for evidence of a cause for his
syncopal episode. A carotid ultrasound was similarly
non-concerning. Ancef was initiated on that day per ___
recommendations. A TTE on ___ did not reveal any clear cause
of his syncope but was reassuring for his appropriateness as an
operative candidate.
Mr. ___ went to the OR on ___ and underwent ORIF of
facial fractures of his facial fractures and he tolerated the
procedure well; for full details please see the operative
report. He remained intubated for airway protection in the
context of edema and went to the ICU post-op; he was extubated
on POD#1, went to the floor in good condition, and was resumed
on a full liquid diet.
He initially was unable to tolerate the liquid diet due to
difficulty swallowing as a consequence of the packing in his
nose. He remained on IV fluids for hydration. ___ was
involved in discussion of disposition and it was decided to keep
Mr. ___ in the hospital for the time being. Ultimately,
packing was discontinued by ___ on ___ in the early afternoon
and the patient tolerated a full liquid diet very well after
this action.
On the day of his discharge, foley was removed and the patient
voided multiple times successfully. It was noted that his right
antecubital fossa was inflamed and indurated at his former IV
site and so an ultrasound was ordered which revealed superficial
clot but no DVT; he was advised to apply moderate comfortable
heat to the area.
Discharge meds were prescribed and follow-up with ___ and
ophthalmology services in accordance with the recommendations of
these services. He will remain on chlorhexadine mouth rinse and
PO Keflex for 1 week.
Mr. ___ was discharged to home on ___ with
appropriate information, warnings, prescriptions, and follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
ERCP ___
EGD ___
History of Present Illness:
Mr. ___ is a ___ with history of presumed ETOH cirrhosis,
GERD, BPH, biliary colic s/p ERCP in ___ who presents with
right upper quadrant pain. Records suggest that he has had
several previous admissions with similar complaints, including
in ___, and most recently, he was admitted to ___
___ in late ___ for RUQ pain and was thought to
have cholecystitis, so he underwent ERCP with balloon sweep,
which did not reveal further stones. He was ultimately
discharged to rehab with outpatient surgical follow up.
He continues to have intermittent episodes of right upper
quadrant pain which he reports can be related to food however
not always. Has some nausea but no vomiting. No changes in bowel
habits. No hematemesis, melena, or hematochezia. Other than an
ERCP has never had an EGD or colonoscopy.
On day of presentation he complained of ongoing abdominal pain
and was sent to an OSH where he underwent an RUQ ultrasound
showed a thickened gallbladder wall with sludge and stones in
its neck,
CBD of 5mm, negative sonographic ___ sign and a small
amount
of ascites around the liver. He was started on
piperacillin/tazobactam and was transferred to ___ for
definitive care and presumed diagnosis of acute cholecystitis
where he was ultimately admitted to hepaticobiliary surgery.
Here at ___, he was started on ampicillin/sulbactam. Surgery
recommended medical management, so he is being transferred to
the liver service.
With regards to his cirrhosis, he reports that was told by about
___ years ago that he had 'liver problems' and stopped drinking.
Prior to this he admits to drink 0.5pint of Brandy per day for
several days. His outpatient gastroenterologist is Dr. ___.
He reports having paracenteses in the past.
Currently he reports ongoing abdominal pain, making it difficult
for him to breathe, without nausea or appetite.
Review of Systems:
(-) Denies fever, chills. Denies chest pain or tightness,
palpitations, lower extremity edema. Denies cough, shortness of
breath, or wheezes. 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:
- Cirrhosis - presumed ___ ETOH
- GERD
- HTN
- BPH
- Anxiety
- Cholelithiasis
- L shoulder surgery after trauma
- ORIF of RLE
Social History:
___
Family History:
Mother died of MI at age ___. Otherwise non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Tm 99.0 Tc 98.5 127/69 P 87 R 18 Sat 93%RA
Gen: Uncomfortable appearing, moaning quietly, moving around in
bed
HEENT: Scleral icterus, EOMI, +mild thrush, poor dentition
Neck: Supple. No lymphadenopathy
CV: RRR, no m/r/g
Lungs: CTAB, no w/r/c
Abdomen: +BS, ND, soft, TTP in RUQ with ___ sign, no
rebound/guarding
Ext: wwp, no ___ edema, +palmar erythema
Neuro: AAOx3. No asterixis
Skin: jaundiced, +spider angiomata
DISCHARGE EXAM:
VS: 98.2 91/60 (91-102 SBP) 70 18 98%RA
Gen: Comfortable appearing adult male lying in bed in NAD
HEENT: Scleral icterus, EOMI, poor dentition
Neck: Supple. No lymphadenopathy
CV: RRR, no m/r/g
Lungs: +scattered wheezes R > L, poor air entry bilaterally
Abdomen: +BS, ND, soft, no TTP throughout abd, no
rebound/guarding, Ext: wwp, no ___ edema, +palmar erythema
Neuro: AAOx3. No asterixis
Skin: jaundiced, +spider angiomata
Pertinent Results:
ADMISSION LABS:
=======================
___ 06:20PM BLOOD WBC-11.1* RBC-4.18* Hgb-15.9 Hct-47.9
MCV-114* MCH-37.9* MCHC-33.1 RDW-13.5 Plt Ct-78*
___ 06:20PM BLOOD Neuts-73.4* Lymphs-17.7* Monos-5.2
Eos-2.8 Baso-0.9
___ 06:20PM BLOOD Plt Smr-VERY LOW Plt Ct-78*
___ 06:10AM BLOOD ___ PTT-33.4 ___
___ 06:20PM BLOOD Glucose-115* UreaN-15 Creat-0.7 Na-139
K-4.6 Cl-103 HCO3-26 AnGap-15
___ 06:20PM BLOOD ALT-26 AST-40 AlkPhos-106 TotBili-5.5*
___ 06:20PM BLOOD Albumin-3.6
___ 03:00PM BLOOD calTIBC-174* Ferritn-802* TRF-134*
RELEVANT LABS:
====================
___ 06:10AM BLOOD WBC-12.2* RBC-3.50* Hgb-13.2* Hct-40.1
MCV-115* MCH-37.7* MCHC-32.9 RDW-13.5 Plt Ct-62*
___ 06:20AM BLOOD ___ PTT-45.4* ___
___ 06:10AM BLOOD ALT-20 AST-26 AlkPhos-88 TotBili-5.3*
___ 08:00AM BLOOD ALT-17 AST-25 AlkPhos-85 Amylase-42
TotBili-5.1* DirBili-2.0* IndBili-3.1
___ 06:25AM BLOOD ALT-14 AST-22 LD(LDH)-147 AlkPhos-75
Amylase-24 TotBili-7.0* DirBili-2.6* IndBili-4.4
___ 06:20AM BLOOD ALT-16 AST-23 AlkPhos-80 TotBili-5.2*
___ 06:20AM BLOOD ALT-14 AST-22 AlkPhos-79 TotBili-4.8*
___ 03:00PM BLOOD calTIBC-174* Ferritn-802* TRF-134*
___ 03:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
___ 03:00PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 03:00PM BLOOD ___
___ 03:00PM BLOOD AFP-9.4*
___ 03:00PM BLOOD IgG-1154 IgA-522* IgM-302*
___ 03:00PM BLOOD HCV Ab-NEGATIVE
DISCHARGE:
===================
___ 11:15AM BLOOD WBC-11.1* RBC-3.61* Hgb-13.8* Hct-42.9
MCV-119* MCH-38.1* MCHC-32.0 RDW-13.5 Plt ___
___ 11:15AM BLOOD ___ PTT-37.9* ___
___ 11:15AM BLOOD Glucose-207* UreaN-29* Creat-0.8 Na-137
K-4.4 Cl-106 HCO3-22 AnGap-13
___ 11:15AM BLOOD ALT-17 AST-27 AlkPhos-92 TotBili-5.1*
___ 11:15AM BLOOD Calcium-8.6 Phos-2.1* Mg-2.3
IMAGING / STUDIES:
=======================
___ RUQ U/S:
IMPRESSION:
1. Sludge in a nondistended gallbladder with a thickened wall.
Equivocal sonographic ___ sign. If concern for acute
cholecystitis remains high, a HIDA scan could be considered.
Findings may relate to adjacent liver disease.
2. Hepatic cirrhosis. Small amount of ___ ascites.
3. Splenomegaly.
___ CXR:
FINDINGS:
There is an area of consolidation at the left base which is more
suspicious for developing infiltrate or aspiration as opposed to
simply atelectasis. There is atelectasis at the right base.
The heart size is grossly within normal limits. There are no
pneumothoraces. There are no signs for pulmonary edema.
___ MRI SCREENING:
Preliminary Report IMPRESSION:
Morphologic appearance of the liver consistent with cirrhosis.
Nonspecific, subcentimeter focus of arterial hyperenhancement.
Particular attention to this lesion on future surveillance
imaging is recommended.
Evidence of portal hypertension based on ascites, splenomegaly,
and varices.
Given degree of motion degradation of this examination,
consideration may be given to acquiring future surveillance
imaging with multiphase CT.
Cholelithiasis, biliary sludge and likely fundal
adenomyomatosis.
Small pleural effusions and bibasilar atelectasis.
___ ERCP:
The scout film was normal.
Evidence of a previous sphincterotomy was noted in the major
papilla.
The bile duct was deeply cannulated with a sphincterotome.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree.
The CBD was 10mm in diameter. Two filling defects consistent
with stones were identified in the mid and distal CBD.
Opacification of the gallbladder was incomplete.
The left and right hepatic ducts and all intrahepatic branches
were incompletely visualized.
Given the presence of a previous sphincterotomy, to facilitate
stone extraction, balloon sphincteroplasty was performed from
10mm to12mm.
The biliary tree was swept with a 9-12mm balloon starting at the
bifurcation. Two stones were removed.
The CBD and CHD were swept repeatedly until no further stones
were seen.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
___ EGD:
1 cord of grade II varix 2 cords of grade I varices were seen
starting at 28 cm from the incisors in the gastroesophageal
junction and lower third of the esophagus. The varices were not
bleeding.
Food in the stomach
Varices at the gastroesophageal junction and lower third of the
esophagus
Congestion and petechiae in the fundus and stomach body
compatible with portal hypertensive gastropathy
Otherwise normal EGD to third part of the duodenum
Recommendations: Patient can be started on nonselective
B-Blocker therapy for prophylaxis against bleeding if no
contraindications. I fnot started on B-blockers repeat upper
endoscopy in one year.
BLOOD CULTURES NEGATIVE.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Spironolactone 25 mg PO DAILY
3. Tamsulosin 0.4 mg PO HS
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 1 mg PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Metoclopramide 10 mg PO QIDACHS
9. Simethicone 160 mg PO TID:PRN GI distress
10. Omeprazole 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP BID:PRN
face rash
13. Acetaminophen 650 mg PO Q6H:PRN pain
14. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting
15. Milk of Magnesia 30 mL PO DAILY:PRN constipation
16. Bisacodyl 10 mg PR HS:PRN constipation
17. TraZODone 12.5 mg PO HS:PRN insomnia
18. Potassium Chloride 20 mEq PO BID
19. Lactulose 20 mL PO TID
20. Rifaximin 550 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Lactulose 20 mL PO TID
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Rifaximin 550 mg PO BID
6. Tamsulosin 0.4 mg PO HS
7. TraZODone 12.5 mg PO HS:PRN insomnia
8. Ciprofloxacin HCl 500 mg PO Q12H
to continue through end of ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*7 Tablet Refills:*0
9. Bisacodyl 10 mg PR HS:PRN constipation
10. Calcium Carbonate 500 mg PO DAILY
avoid giving at same time as ciprofloxacin.
11. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP BID:PRN
face rash
12. FoLIC Acid 1 mg PO DAILY
13. Metoclopramide 10 mg PO QIDACHS
14. Milk of Magnesia 30 mL PO DAILY:PRN constipation
avoid giving at same time as ciprofloxacin.
15. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
16. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting
17. Simethicone 160 mg PO TID:PRN GI distress
18. Thiamine 1 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Cholangitis
Biliary obstruction (choledocholithiasis)
Secondary Diagnosis:
Esophageal varices, grade I-II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: PA and lateral chest, ___.
CLINICAL HISTORY: ___ man with right upper quadrant pain. Evaluate
for acute chest process.
FINDINGS:
There is an area of consolidation at the left base which is more suspicious
for developing infiltrate or aspiration as opposed to simply atelectasis.
There is atelectasis at the right base. The heart size is grossly within
normal limits. There are no pneumothoraces. There are no signs for pulmonary
edema.
Radiology Report
INDICATION:
___ year old man with h/o ERCP and biliary colic. Confirm absence of clips
before MRI // ?clips or metal
COMPARISON: None available.
FINDINGS:
Single view plain film of the abdomen and pelvis demonstrates no visualized
metallic objects. Small densities noted in the right lower quadrant likely
represent ingested medication. Gallstones in the gallbladder. Non-obstructive
bowel gas pattern.
IMPRESSION:
No visualized metallic objects.
Radiology Report
EXAMINATION: MRI abdomen with and without contrast
INDICATION: ___ year old man with EtOH cirrhosis and elevated afp, please eval
for ___ // eval for ___
TECHNIQUE: MRI of the abdomen is obtained in a 1.5 Tesla per liver mass
protocol. Multiplanar T1 and T2 sequences are acquired both pre and post
uneventful administration of 6 mL of Gadavist. Multiple sequences are
significantly motion degraded.
COMPARISON: Right upper quadrant ultrasound dating ___
FINDINGS:
There are small bilateral pleural effusions, slightly greater on the left than
the right, with adjacent enhancing bibasilar consolidative changes.
The morphologic appearance of the liver is consistent with cirrhosis based on
nodular contour, segmental size discrepancies, and heterogeneous parenchyma
signal. There is a 8mm arterially enhancing lesion along the subcapsular
surface lateral to the falciform ligament. This is seen on series 11, image
40, likely is within segment 8, although the middle hepatic vein is not
definitively visualized. This is subtly T2 hypointense and T1 hyperintense,
but no wash out is definitively identified. No additional focal hepatic lesion
is seen.
Intrahepatic and extrahepatic bile ducts are normal caliber. There is
cholelithiasis and biliary sludge. The wall irregularity at the level of the
fundus is suggestive of focal adenomyomatosis, although poorly evaluated given
the motion artifact.
The main portal vein is somewhat attenuated but patent and contrast opacified.
The splenic vein, SMV and intrahepatic portal venous branches are also patent
and contrast opacified. There is evidence of portal hypertension, based on
mild splenomegaly (rounded contour and maximum dimension of 13cm), moderate
volume of ascites, and collateral vessel formation (paraesophageal varices and
patent paraumbilical vein).
Adrenal glands, kidneys and pancreas are unremarkable.
IMPRESSION:
Morphologic appearance of the liver consistent with cirrhosis. Non-specific,
sub-centimeter focus of arterial hyperenhancement. Particular attention to
this lesion on future surveillance imaging is recommended.
Evidence of portal hypertension based on ascites, splenomegaly, and varices.
Given degree of motion degradation of this examination, consideration may be
given to acquiring future surveillance imaging with multiphase CT.
Cholelithiasis, biliary sludge and likely fundal adenomyomatosis.
Small pleural effusions and bibasilar atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, CHOLECYSTITIS
Diagnosed with ABDOMINAL PAIN RUQ, ALCOHOL CIRRHOSIS LIVER
temperature: 98.9
heartrate: 88.0
resprate: 14.0
o2sat: 93.0
sbp: 118.0
dbp: 70.0
level of pain: 9
level of acuity: 3.0 | Brief Narrative (more details below):
___ with history of presumed ETOH cirrhosis, GERD, BPH,
biliary colic s/p ERCP in ___ with sphincterotomy admitted
___ for recurrent right upper quadrant abdominal pain with
initial concern for cholecystitis. Given his Child ___ Class C,
he was deemed a high-risk surgical candidate and was therefore
managed medically with IV antibiotics. His pain persisted and he
began to develop low-grade fevers with rising T bili, so he went
for ERCP which revealed 2 stones in the Common Bile Duct which
were successfully removed with good drainage. Given these
findings and his clinical presentation, he was diagnosed with
cholangitis. He improved significantly after ERCP and with IV
unasyn and was subsequently narrowed to po ciprofloxacin. He
should continue on this ciprofloxacin through ___.
His blood pressure while inpatient was in the 90-100 systolic
range after resolution of his infection - likely due to poor
nutritional intake while hospitalized and amidst his acute
illness. For this reason, though, his home lasix/spironolactone
regimen and his new nadolol were NOT CONTINUED on discharge -
these should be re-addressed and possibly restarted at his
upcoming appointment on ___ ___.
Of note, he also underwent routine screening EGD for varices
while inpatient which discovered Grade I-II varices, no
intervention needed, with recommendation for nadolol
prophylaxis. He also underwent routine MRI screening which was
negative for HCC.
** TRANSITIONAL ISSUES **:
- continue ciprofloxacin 500mg po q12h through end of ___.
- check full labs (CBC, basic chemistries, LFTs) on ___ ___ - ensure stable liver function and also renal
function.
- on ___ ___ blood pressure should be
assessed to determine whether he is safe to restart his normal
lasix 40mg daily and spironolactone 25mg daily, as these are
HELD on discharge. Nadolol prophylaxis can also be re-addressed
since this was NOT STARTED on discharge due to his BP
- his home potassium supplements were HELD since his lasix is
being held as above. re-evaluate with his labs and if restarting
lasix as above as outpatient
- initiated HBV vaccine series on ___ - should complete routine
initial vaccination series with 2 more administrations
- iron/TIBC ratio noted to be elevated (116/174) - hereditary
hemochromatosis panel was ordered and should be followed-up
================================================================
___ with history of presumed ETOH cirrhosis, GERD, BPH,
biliary colic s/p ERCP in ___ who presents with right upper
quadrant pain found to have radiographic evidence equivocal for
acute cholecystitis, initially admitted to surgery service but
subsequently transferred to the liver service given high
surgical risk with subsequent development of cholangitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / Latex / Lovenox
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___:
Laparoscopic appendectomy
History of Present Illness:
Ms. ___ is a ___ female with abdominal pain since
started last night (10 hours ago) which she describes as right
sided and crampy. She has associated nausea but denies emesis.
She had a bowel movement yesterday and continues to pass gas.
Past Medical History:
1. Gastroesophageal reflux disease.
2. Headaches.
.
PSH:
1. ACL reconstruction.
2. Right breast core biopsy ___ showing fibroadenoma.
Social History:
___
Family History:
1. Sister with breast cancer (age ___, negative BRCA:
2. History of breast cancer (age ___, negative BRCA.
3. Maternal cousin with breast cancer (age ___, negative BRCA.
4. Two maternal aunts with breast cancer, one diagnosed in age
___ and one in her ___.
5. Other cancers in the patient's family are stomach, colon,
kidney and prostate per her report.
Physical Exam:
PE: 98.5 84 134/84 16 95% RA
GEN: NAD, AAOx3
CV: RRR
RESP: CTA b/l
ABD: soft, nondistended, focally tender in RLQ with voluntary
guarding, no rebound
EXT: no peripheral edema or cyanosis
Discharge:
GEN: NAD, AAOx3
CV: RRR
RESP: CTA b/l
ABD: soft, non distended, post surgical TTP with voluntary
guarding, no rebound
EXT: no peripheral edema or cyanosis
Neuro: Left pupil dilated to 4mm compared to right 2mm, reactive
to direct light and consensual light. EOMI, facial sensation
intact, no facial drooping, CNXII intact, no palatal deviation,
CN XI ___ strength, tongue midline
Pertinent Results:
___ 02:25AM URINE UCG-NEGATIVE
___ 02:13AM LACTATE-1.6
___ 02:06AM GLUCOSE-152* UREA N-17 CREAT-0.9 SODIUM-136
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
___ 02:06AM WBC-15.4*# RBC-4.54# HGB-14.2# HCT-43.3
MCV-95 MCH-31.2 MCHC-32.7 RDW-12.4
___ 02:06AM PLT COUNT-194
Medications on Admission:
acyclovir 400', tamoxifen 20'
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not operate any vehicles or heavy machinery
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 6 hours or as
needed Disp #*20 Tablet Refills:*0
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
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ woman with periumbilical and right lower quadrant
pain. Recent history of invasive ductal carcinoma.
TECHNIQUE: Contiguous axial multidetector CT images through the abdomen and
pelvis with intravenous contrast. Multiplanar reformations.
Total DLP: 461 mGy-cm
COMPARISON: ___
FINDINGS:
Partially imaged lung bases are clear. There is no pleural effusion.
CT abdomen: A sub cm hypodensity in the right lobe of the liver is too small
to characterize. The liver enhances homogeneously without concerning lesions
or biliary dilatation. Gallbladder, spleen, pancreas, and adrenal glands are
within normal limits. Kidneys enhance and excrete in a symmetric without
concerning lesions or hydronephrosis.
Stomach is mildly distended with ingested material. Several loops of small
bowel are distended with fluid however there is no dilatation to suggest
obstruction. Appendix is fluid-filled and dilated to 1 cm demonstrating wall
thickening and adjacent fat stranding consistent with acute appendicitis
(601b:24). Reactive wall thickening is also seen along the cecum. There is no
extraluminal air; however, a small amount of free fluid along the distal
appendix may represent perforation (2:46). No drainable fluid collection or
abscess. There is no mesenteric or retroperitoneal lymphadenopathy. Abdominal
aorta is of normal caliber throughout.
CT pelvis: Bladder, terminal ureters, and uterus are within normal limits.
Well-circumscribed bilateral intermediate density ___ Hounsfield units)
adnexal masses, likely represent mildly complex ovarian cysts, and measure up
to 3.5 cm on the left and 3.3 cm on the right. There is no pelvic free fluid
or lymphadenopathy.
Bone window: Degenerative changes are present throughout the mid to spine
without evidence for concerning osteolytic or sclerotic lesions. A focus of
sclerosis in the posterior body of L4, unchanged, likely represents a bone
island.
Surgical clips are present along the anterior abdominal wall.
IMPRESSION:
Appendix is fluid-filled and dilated to 1 cm demonstrating wall thickening and
adjacent fat stranding consistent with acute appendicitis (601b:24). There is
no extraluminal air; however, a small amount of free fluid along the distal
appendix may represent early changes after perforation (2:46). No drainable
fluid collection or abscess.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ACUTE APPENDICITIS NOS, HX OF BREAST MALIGNANCY
temperature: 98.5
heartrate: 84.0
resprate: 16.0
o2sat: 95.0
sbp: 134.0
dbp: 84.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ was admitted to ___ for abdominal pain. At CT
scan showed Appendix is fluid-filled and dilated to 1 cm
demonstrating wall thickening and adjacent fat stranding
consistent with acute appendicitis. She was taken to the
operating room that night for a laparoscopic appendectomy. She
improved through out the night. By morning she was able to
tolerate a regular diet. Her pain was well controlled. Upon
discussion with the pt concerning discharge it was noted the her
left pupil was dilated compared to the right. She had no visual
complaints at the time. A cranial nerve exam showed that both
pupils were reactive to light, with the left less so than the
right. Neurology was notified, and she was scheduled to visit
the neurology clinic as an outpatient. At the time of discharge
she was doing well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Polysporin / Latex / Hydrochlorothiazide
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ dementia who presents from home because patient has been
less willing to walk, eat, drink, or take meds. Patient has had
subacute decline over the past several months with increased
fatigue, weight loss, decreased appetite, refusal to take
certain medications, and unwillingness to get out of bed. Also
newly incontinent of urine. On day of admission, pt complained
of neck and shoulder pain, which is chronic, but was unwilling
to take tylenol. Daughter, ___, who lives with patient feels
she has become deconditioned and needs a higher level of care,
at least temporarily.
Initial VS in the ED: 98.6 94 181/68 18 98% Labs notable for K
2.7, Mg 1.6, P 2.2, normal creatinine. Patient was given 800mg
MgOxide, 40mEq PO K, 40mEq IV K, 2 packets neutraphos, 1L IVF.
Past Medical History:
1. Hypertension
2. Mild diastolic dysfunction
3. Reflux esophagitis (GERD) and dyspepsia
4. History of asbestos exposure, chronic interstitial lung
disease
5. Cataracts
6. Migraine headaches
7. History of rheumatic fever
8. Carpal tunnel
9. Osteoarthritis
10. Chronic kidney disease
11. Spinal stenosis
12. Myelodysplastic syndrome
Social History:
___
Family History:
Mother, Father passes away in ___ from stroke.
Physical Exam:
ADMISSION/DISCHARGE Physical Exam:
98.4 ___ 18 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Good air movement bilaterally, +dry crackles at bases b/l
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non ttp, nondistended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 05:15PM BLOOD WBC-7.4 RBC-3.97* Hgb-9.9* Hct-32.5*
MCV-82# MCH-24.9*# MCHC-30.5* RDW-16.4* Plt ___
___ 05:15PM BLOOD Glucose-157* UreaN-14 Creat-0.8 Na-142
K-2.7* Cl-96 HCO3-31 AnGap-18
___ 05:15PM BLOOD ALT-6 AST-17 LD(LDH)-181 CK(CPK)-37
AlkPhos-82 TotBili-0.3
___ 05:15PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:15PM BLOOD Albumin-3.4* Calcium-9.1 Phos-2.2* Mg-1.6
___ 07:45AM BLOOD WBC-5.5 RBC-3.72* Hgb-9.4* Hct-30.7*
MCV-82 MCH-25.2* MCHC-30.6* RDW-16.5* Plt ___
___ 07:45AM BLOOD Glucose-83 UreaN-8 Creat-0.6 Na-140 K-4.0
Cl-102 HCO3-27 AnGap-15
___ 07:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:45AM BLOOD Calcium-8.5 Phos-1.8* Mg-1.6 Iron-___ 07:45AM BLOOD calTIBC-146* Ferritn-190* TRF-112*
CXR: IMPRESSION:
Chronic fibrotic changes with bilateral calcified pleural
plaques compatible with asbestosis, similar compared to the
prior exam. No new areas of focal consolidation identified.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Moexipril 15 mg PO BID
hold for sbp<100
3. Calcium Carbonate 500 mg PO TID
4. Atenolol 50 mg PO BID
hold for sbp<100, hr<55
5. Amlodipine 10 mg PO DAILY
hold for sbp<100
6. cycloSPORINE *NF* 0.05 % ___ BID
7. Ranitidine 150 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Sucralfate 1 gm PO QID
10. Pantoprazole 40 mg PO Q12H
11. Aspirin 81 mg PO DAILY
12. Citalopram 30 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO BID
5. Calcium Carbonate 500 mg PO TID
6. Citalopram 30 mg PO DAILY
7. Moexipril 15 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Vitamin D ___ UNIT PO DAILY
11. cycloSPORINE *NF* 0.05 % ___ BID
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
advancing dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Generalized malaise.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest CTA ___ and chest radiograph ___.
FINDINGS:
Heart size is borderline enlarged. The aorta remains tortuous with marked
calcifications of the aortic knob. There is no pulmonary vascular congestion.
Bilateral calcified pleural plaques are re- demonstrated, with evidence of
honeycombing, bronchiectasis and fibrosis within the lung bases, similar
compared to the prior exam. No new focal consolidation, pleural effusion or
pneumothorax is visualized. There are no acute osseous abnormalities.
IMPRESSION:
Chronic fibrotic changes with bilateral calcified pleural plaques compatible
with asbestosis, similar compared to the prior exam. No new areas of focal
consolidation identified.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: BACK/NECK PAIN
Diagnosed with HYPOKALEMIA, FAILURE TO THRIVE,ADULT, HYPERTENSION NOS
temperature: 98.6
heartrate: 94.0
resprate: 18.0
o2sat: 98.0
sbp: 181.0
dbp: 68.0
level of pain: 0
level of acuity: 3.0 | ___ with dementia here with FTT and hypokalemia. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Erythromycin Base / Codeine / Tetracycline / magnesium /
Cholestyramine / Bactrim
Attending: ___.
Chief Complaint:
left sided sensory changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Stroke Scale - Total [1]
1a. Level of Consciousness -0
1b. LOC Questions -0
1c. LOC Commands -0
2. Best Gaze -0
3. Visual Fields -0
4. Facial Palsy - 0
5a. Motor arm, left -0
5b. Motor arm, right -0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory -1
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not given/considered: Low stroke scale
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
HPI: Mrs. ___ is a ___ woman with a past medical
history of hypertension, breast cancer in remission,
nonalcoholic stat oh hepatitis, hypothyroidism on Synthroid, and
recent workup for dyspnea on exertion and chest pressure, as
well as macular degeneration and prior workups in the past for
TIA who presented to the ED with complaints of generalized
weakness and paresthesias of the left hemibody.
Patient states that she was feeling restless last night and had
difficulty sleeping. At 4 AM the patient awoke and walked
downstairs to make herself a cup of tea. At this time she felt
well and was able to ambulate on her own. The patient went back
to sleep and woke up at 730 when she noted a dull ache in the
posterior aspect of her skull. The patient then decided to
sleep again from 8:30 AM to 11:30 AM. When the patient awoke
for the second time, she noted to feel lightheaded and
generalized weakness. Because she was feeling off she asked her
husband to take her blood pressure which was 148/110 using a
manual blood pressure cuff. As her symptoms did not subside
they decided to call EMS for further evaluation. In the
ambulance, the patient started to develop left V2 to V3
distribution paresthesias and a few minutes later had
paresthesias in her left leg. The paresthesias transitioned to
a feeling of numbness that she describes as a Novocain sensation
in her left face and left hemibody. She denies any difficulty
with language, no facial droop (confirmed with her husband who
has been at her side), no weakness, no seizure-like activity, or
any other neurologic complaints.
Of note, the patient has been suffering from palpitations and
was recently placed on a Holter monitor for further arrhythmia
characterization.
On review of systems, the patient endorses: Feeling continued
dyspnea on exertion, generalized weakness, and nausea. Her
headache has resolved.
On review of systems, the patient denies the following:
- Neurologic: confusion, difficulty producing speech,
difficulty understanding speech, vision loss, diplopia, vertigo,
dysarthria, dysphagia, focal limb weakness, gait imbalance.
- Constitutional: fever, rigors, night sweats, unintentional
weight loss.
- Cardiovascular: chest pain, palpitations, lightheadedness.
- Gastrointestinal: nausea, emesis, diarrhea, constipation.
- Genitourinary: dysuria, urinary urgency, urinary
incontinence.
- Ear, Nose, Throat: tinnitus, hearing loss, rhinorrhea,
odynophagia.
- Hematologic: bleeding, easy bruising.
- Musculoskeletal: arthralgia, myalgia.
- Psychiatric: anxiety, depression.
- Respiratory: dyspnea, cough, hematemesis.
- Skin: rash, new skin lesions.
Past Medical History:
Past Medical:
HTN
Breast Cancer
Obesity
Cholecystectomy
Asthma
Knee pain
GERD
Hysterectomy
Social History:
___
Family History:
- dad died at ___ yo of esophageal ca, also had CVA
- sister died at ___ yo of salivary gland adenocarcinoma of neck
- mother died of cancer at ___ yo stomach adenoca
Physical Exam:
Physical Examination on admission :
VS T: 98.8 HR: 104-115 BP: 150/87 RR: 18 SaO2: 98% on room air
- General/Constitutional: Lying in bed comfortably,
well-appearing, slightly anxious
- Eyes: Round, regular pupils. No conjunctival icterus, no
injection.
- Ear, Nose, Throat: No oropharyngeal lesions. Normal
appearance of the tongue.
- Neck: No meningismus. No carotid, vertebral, or subclavian
bruits appreciated. No lymphadenopathy.
- Musculoskeletal: Range of motion with neck rotation full
bilaterally. No focal spinal tenderness.
- Skin: No rashes. No concerning lesions appreciated.
- Cardiovascular: Regular rate. Regular rhythm. No murmurs,
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily attained and maintained. Concentration
maintained when recalling months backwards. Recalls a coherent
history. Structure of speech demonstrates fluency with full
sentences, intact repetition, and intact verbal comprehension.
Content of speech demonstrates intact naming (high and low
frequency) and no paraphasias. Normal prosody. No dysarthria.
Verbal registration and recall ___. No apraxia. No evidence of
hemineglect. No left-right agnosia.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number
counting. Funduscopy shows crisp disc margins, no papilledema.
[III, IV, VI] EOMI, no nystagmus. [V] V2-V3 50% decrease to
light touch on L. [VII] No facial movement asymmetry with forced
eyelid closure or volitional smile. [VIII] Hearing intact to
finger rub bilaterally. [IX, X] Palate elevation symmetric. [XI]
SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
orbiting with arm roll. No tremor or asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
L ___ 5 5
R ___ 5 5
- Sensory : Patient describes 50% decrease to light touch,
temperature, and pinprick in the V2 to V3 distribution as well
as left torso arm and leg. No extinction to double simultaneous
tactile stimulation.
Reflexes
[Bic] [Tri] [___] [Quad] [Gastroc]
L ___ 2 2
R ___ 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose or heel-shin
testing. Good speed and intact cadence with rapid alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and arm swing. Stable without sway. No Romberg.
Laboratory and Imaging Data: Creatinine 0.7, INR 1.0, WBC 7.3,
hemoglobin 12.8, hematocrit 30.7, platelets 166
NC Head CT: No acute intracranial process.
_____________________________________________________________
Physical Examination:
VS T: 97.6-98.3, HR: ___ BP: ___ RR: ___ SaO2:
94-96% on room air
- General/Constitutional: Lying in bed comfortably,
well-appearing, slightly anxious
- Eyes: Round, regular pupils. No conjunctival icterus, no
injection.
- Ear, Nose, Throat: No oropharyngeal lesions. Normal
appearance of the tongue.
- Neck: No meningismus. No carotid, vertebral, or subclavian
bruits appreciated. No lymphadenopathy.
- Musculoskeletal: Range of motion with neck rotation full
bilaterally. No focal spinal tenderness.
- Skin: No rashes. No concerning lesions appreciated.
- Cardiovascular: Regular rate. Regular rhythm. No murmurs,
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily attained and maintained. Concentration
maintained when recalling months backwards. Recalls a coherent
history. Structure of speech demonstrates fluency with full
sentences, intact repetition, and intact verbal comprehension.
Content of speech demonstrates intact naming (high and low
frequency) and no paraphasias. Normal prosody. No dysarthria.
Verbal registration and recall ___. No apraxia. No evidence of
hemineglect. No left-right agnosia.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number
counting. Funduscopy shows crisp disc margins, no papilledema.
[III, IV, VI] EOMI, no nystagmus. [V] intact to light touch with
no defecits. [VII] No facial movement asymmetry with forced
eyelid closure or volitional smile. [VIII] Hearing intact to
finger rub bilaterally. [IX, X] Palate elevation symmetric. [XI]
SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
orbiting with arm roll. No tremor or asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
L 5 5 5 ___ 5 5 5 5 5
R 5 5 5 ___ 5 5 5 5 5
- Sensory : intact light touch, temperature, and pinprick in
the V2 to V3 distribution as well as arm and leg. No extinction
to double simultaneous tactile stimulation.
Reflexes
[Bic] [Tri] [___] [Quad] [Gastroc]
L ___ 2 2
R ___ 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose or heel-shin
testing. Good speed and intact cadence with rapid alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and arm swing. Stable without sway. No Romberg.
Pertinent Results:
___ 02:50PM BLOOD WBC-7.3 RBC-5.62* Hgb-12.8 Hct-38.7
MCV-69* MCH-22.8* MCHC-33.1 RDW-18.0* RDWSD-39.2 Plt ___
___ 05:15AM BLOOD WBC-8.4 RBC-5.43* Hgb-11.6 Hct-38.0
MCV-70* MCH-21.4* MCHC-30.5* RDW-17.0* RDWSD-40.8 Plt ___
___ 02:50PM BLOOD Neuts-55.8 ___ Monos-9.1 Eos-1.7
Baso-0.9 Im ___ AbsNeut-4.17 AbsLymp-2.31 AbsMono-0.68
AbsEos-0.13 AbsBaso-0.07
___ 05:15AM BLOOD Neuts-60.2 ___ Monos-8.3 Eos-1.5
Baso-0.7 Im ___ AbsNeut-5.05 AbsLymp-2.43 AbsMono-0.70
AbsEos-0.13 AbsBaso-0.06
___ 02:50PM BLOOD ___ PTT-25.5 ___
___ 05:15AM BLOOD Plt ___
___ 02:50PM BLOOD Glucose-126* UreaN-13 Creat-0.7 Na-139
K-4.1 Cl-105 HCO3-17* AnGap-21*
___ 05:15AM BLOOD Glucose-86 UreaN-14 Creat-0.7 Na-141
K-4.4 Cl-104 HCO3-22 AnGap-19
___ 02:50PM BLOOD ALT-19 AST-36 AlkPhos-57 TotBili-0.9
___ 05:15AM BLOOD ALT-20 AST-22 LD(LDH)-159 AlkPhos-49
TotBili-0.9
___ 02:50PM BLOOD cTropnT-<0.01
___ 02:50PM BLOOD Lipase-48
___ 02:50PM BLOOD Albumin-4.1
___ 05:15AM BLOOD Albumin-3.7 Calcium-9.4 Phos-3.8 Mg-2.2
Cholest-168
___ 03:06PM BLOOD D-Dimer-330
___ 05:15AM BLOOD %HbA1c-4.8 eAG-91
___ 05:15AM BLOOD Triglyc-124 HDL-57 CHOL/HD-2.9 LDLcalc-86
___ 05:15AM BLOOD TSH-1.2
___ 02:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MRI/MRA:
IMPRESSION:
1. No evidence of hemorrhage, infarction, or edema.
2. No evidence of stenosis, occlusion, or aneurysm formation.
CT head
IMPRESSION:
No evidence of acute hemorrhage or fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 100 mcg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 100 mcg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Levoxyl (levothyroxine) 75 mcg oral DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1)Left lumbar radiculopathy
2) Meralgia paresthetica or lateral femoral cutaneous neuropathy
is numbness or pain in the outer thigh caused by injury or
irritation to a nerve that extends from the spinal column to the
thigh.
Patient did not have a TIA or STROKE
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 sudden onset left sided numbness// eval for ICH
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
There is a calcific density abutting the left humeral head in the subacromial
space likely representing rotator cuff tendinopathy. No free air below the
right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with sudden onset left sided numbness// eval for ICH
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CTA head and neck ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Mild periventricular white matter hypodensities are nonspecific,
but likely reflect sequelae of chronic small vessel ischemic disease.
Prominence of the ventricles and sulci suggest involutional changes. The
imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities
are well aerated. The bony calvarium is intact.
IMPRESSION:
No evidence of acute hemorrhage or fracture.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: Left hemibody numbness and trigeminal 2 and 3 numbness. Evaluate
for stroke.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 18 mL of
Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: ___ head CT
FINDINGS:
MRI BRAIN:
There is no evidence of hemorrhage, infarction, edema, or midline shift. The
ventricles, sulci, and cisterns are age appropriate. There is minimal
nonspecific FLAIR hyperintensity, along the left frontal centrum semiovale,
likely a sequela of chronic small vessel microangiopathy or prior stroke. The
paranasal sinuses appear clear. There is trace nonspecific fluid
opacification within the left mastoid air cells, possibly reactive or
inflammatory.
MRA BRAIN:
The intracranial vertebral and internal carotid arteries and their major
branches appear normal without evidence of stenosis, occlusion, or aneurysm
formation.
MRA NECK:
The common, internal and external carotid arteries appear normal. There is no
evidence of internal carotid artery stenosis by NASCET criteria. The origins
of the great vessels, subclavian and vertebral arteries appear normal
bilaterally.
IMPRESSION:
1. No evidence of hemorrhage, infarction, or edema.
2. No evidence of stenosis, occlusion, or aneurysm formation.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Facial numbness, L Numbness
Diagnosed with Transient cerebral ischemic attack, unspecified
temperature: 98.8
heartrate: 115.0
resprate: 18.0
o2sat: 98.0
sbp: 150.0
dbp: 87.0
level of pain: 0
level of acuity: 1.0 | Mrs. ___ is a ___ woman with a past medical
history and recent admission for dyspnea and chest pain, who
presents with a generalized feeling of being unwell, some
dyspnea on exertion, and acute onset of left V2 to V3 facial and
hemibody paresthesias that progressed into 50% decrease in
sensation. NIHSS was 1 for her sensory changes, otherwise
patient demonstrated good strength, no language deficits, no
dysarthria, and no cortical signs such as extinction or neglect.
Patient also has full visual fields and no asymmetry in her
smile.
Given the acute onset of paresthesias and numbness in the
hemibody distribution, she was worked up for TIA versus stroke
which was negative. No concern for metastasis to the brain.
There was no other evidence to suggest that the patient was
experiencing a seizure as there was no alteration in
consciousness nor any abnormal movements. The patient denied
paresthesias at the time of discharge.
Patient's left iliopsoas was slightly weak with signs of left
lumbar radiculopathy. There was numbness of the left lateral
thigh concerning for left lateral cutaneous neuropathy of the
thigh (otherwise known as meralgia paresthetica).
Hospital course by system |
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 is an otherwise healthy ___ year-old female with a one-day
history of abdominal pain. Patient reports having felt mild
periumbilical discomfort last night that migrated to the right
lower quadrant earlier this morning and became sharp, of
moderate
intensity (___), non-radiated, with no known alleviating
factors, worsened with movements. Concomitantly, she endorsed
intermittent nausea but no emesis, as well as headache. She
denies fever, chills.
Past Medical History:
Migraines
Social History:
___
Family History:
NC
Physical Exam:
Physical examination: ___: upon admission:
Vital signs - 98.8 102 151/82 18 100%RA
Constitutional - Well appearing, in no distress
Cardiopulmonary - RRR, normal S1 and S2. No murmurs
Abdomen - Soft, non-distended, tender to palpation over right
lower quadrant. No rebound or guarding. Negative Rovsing's
Extremities - Well perfused. No clubbing, cyanosis or edema
Neurologic - Grossly intact. Appears alert and oriented x 3
Physical examination upon discharge: ___:
vital signs: 98.4, hr=67, bp=137/59, rr=18, oxygen sat 94% room
air
General: NAD
CV: ns1, s2, -s3, -s4
LUNGS: diminshed bases bil.
ABDOMEN: soft, tender, port sites clean and dry
EXT: no pedal edema bil., no calf tenderenss bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 10:35AM BLOOD WBC-9.2 RBC-4.67 Hgb-13.8 Hct-40.3 MCV-86
MCH-29.6 MCHC-34.3 RDW-11.9 Plt ___
___ 10:35AM BLOOD Neuts-67.2 ___ Monos-3.5 Eos-2.3
Baso-0.4
___ 05:30PM BLOOD ___ PTT-29.6 ___
___ 11:56PM BLOOD Glucose-93 UreaN-12 Creat-0.7 Na-140
K-3.7 Cl-105 HCO3-22 AnGap-17
___ 10:35AM BLOOD ALT-23 AST-22 AlkPhos-63 TotBili-0.3
___ 11:56PM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8
___: US of appendix:
The appendix was not reliably identified. If there is concern
for
appendicitis, a CT should be performed.
___: abdomen and pelvis:
Normal pelvic ultrasound.
___: cat scan of abdomen and pelvis:
Slightly prominent size of the appendix up to 7 mm with slight
wall thickening and mild surrounding stranding. In the proper
clinical setting this may represent acute appendicitis.
Medications on Admission:
Excedrin prn, OCP
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipaton
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
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: ___ with no PMH presenting with LRQ pain // ?ovarian
cyst/torsion?
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: None
FINDINGS:
The uterus is anteverted and measures 6.2 x 2.3 x 3.3 cm. The endometrium is
homogenous and measures 4 mm. The ovaries are normal with appropriate
arterial and venous waveforms. There is no free fluid.
IMPRESSION:
Normal pelvic ultrasound.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ woman with right lower quadrant pain, evaluate for
appendicitis.
TECHNIQUE: Contiguous axial multidetector CT images through the abdomen and
pelvis with intravenous contrast. Multiplanar reformations.
Total DLP: 425 mGy-cm
COMPARISON: None
FINDINGS:
Lung bases: Partially imaged lung bases are notable for minimal atelectasis;
otherwise clear. There is no pleural effusion. The cardiac apex is
unremarkable.
CT abdomen: The liver enhances homogeneously without concerning lesions or
biliary dilatation. The gallbladder, spleen, pancreas, and adrenal glands are
within normal limits. The kidneys enhance and excrete symmetrically without
concerning lesions or hydronephrosis.
Stomach and loops of small bowel are largely decompressed. Colon is
unremarkable. The appendix is fluid-filled measures up to 7 mm and
demonstrates mild wall thickening and mild adjacent fat stranding (2:50,
601b:23). There is no extraluminal fluid or gas. There is no mesenteric or
retroperitoneal lymphadenopathy.
The abdominal aorta is of normal caliber throughout. Portal vein, splenic
vein, and SMV are well opacified.
CT pelvis: Partially distended bladder and uterus are within normal limits.
There are no adnexal masses. There is no pelvic free fluid or
lymphadenopathy.
Bone windows: No suspicious lytic or sclerotic osseous lesion is identified.
IMPRESSION:
Slightly prominent size of the appendix up to 7 mm with slight wall thickening
and mild surrounding stranding. In the proper clinical setting this may
represent acute appendicitis.
Radiology Report
EXAMINATION: US APPENDIX
INDICATION: History: ___ with no PMH presenting with acute onset of
tenderness in RLQ // question apendicitis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None
FINDINGS:
Targeted ultrasound evaluation of the right lower quadrant, failed to reveal
of the appendix.
IMPRESSION:
The appendix was not reliably identified. If there is concern for
appendicitis, a CT should be performed.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain, Nausea
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 98.8
heartrate: 102.0
resprate: 18.0
o2sat: 100.0
sbp: 151.0
dbp: 82.0
level of pain: 6
level of acuity: 3.0 | The patient was admitted to the hospital with abdominal pain.
Upon admission, the patient was made NPO, given intravenous
fluids, and underwent imaging. A cat scan of the abdomen was
done which showed a 7 mm appendix with slight wall thickening
and mild surrounding stranding. These findings were suggestive
of acute appendicitis. The patient was taken to the operating
room where she underwent an appendectomy. The operative course
was stable with minimal blood loss. The patient was extubated
after the procedure and monitored in the recovery room
The post-operative course was stable. The patient was started
on clear liquids and advanced to a regular diet. Her vital
signs remained stable and she was afebrile. She was
transitioned to oral analgesia for management of her incisional
pain. The patient was discharged home on POD # 1 in stable
condition. Follow-up appointments were made with the acute care
service. |
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:
Incision and drainage of abscess
History of Present Illness:
___ male with IDDM, HTN, right BKA presenting with
abdominal pain x 1 week. Pain is not related to eating or to
bowel movements. Has had a poor appetite. Denies fevers/chills.
Denies N/V or diarrhea/constipation. Last BM was on morning
prior to presentation to ED and normal in appearance. He has
been taking pepcid at the advice of his PCP but this has not
improved symptoms. He states that several people he knows are
sick with N/V and diarrhea.
.
In the ED, initial VS: 98 90 158/96 16 100% RA. CT
abdomen/pelvis was performed that showed mild mesenteric
stranding between the uncinate process and third part of the
duodenum is nonspecific and could represent a focal pancreatitis
or duodenitis. He was given IV cipro and IV flagyl, 1 tab
percocet, as well as 1L normal saline. He was also found to have
an abscess in his right lower quadrant that was drained at the
ED. However, cultures were not sent.
Past Medical History:
-Insulin dependent diabetes diagnosed age ___
-HTN
-History of multiple stump infections
-Bilateral Charcot foot deformities which along with damage from
a motor vehicle accident in ___ and multiple infections led to
right BKA in ___
-s/p R BKA stump revision in ___
Social History:
___
Family History:
Notable for DM in his mother and one younger brother.
Physical Exam:
admission exam
VS - 97.9 124/76 77 18 100%RA ___ 130
GENERAL - obese male, comfortable, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, tender on palpation of RUQ, no
rebound/guarding, area of erythema at RLQ s/p drainage with
packing in place, no active drainage
EXTREMITIES - right BKA, left foot charcot deformity, moving all
extremities
BACK - mild tenderness to palpation of lumbar spine and
paraspinal lumbar region towards right
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
.
discharge exam
VS - 97.9 124/76 77 18 100%RA ___ 130
GENERAL - obese male, comfortable, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, tender on palpation of predominately
epigastric area to umbilicus. no rebound/guarding, area of
erythema at RLQ s/p drainage with packing in place, no active
drainage
EXTREMITIES - right BKA, left foot charcot deformity, moving all
extremities
BACK - mild tenderness to palpation of lumbar spine
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
admission labs
___ 11:05PM BLOOD WBC-10.5# RBC-4.82 Hgb-15.4 Hct-42.2
MCV-88 MCH-32.0 MCHC-36.5* RDW-13.0 Plt ___
___ 11:05PM BLOOD Neuts-75.4* Lymphs-17.4* Monos-3.9
Eos-2.9 Baso-0.5
___ 11:05PM BLOOD Glucose-183* UreaN-16 Creat-1.1 Na-136
K-4.5 Cl-101 HCO3-26 AnGap-14
___ 11:05PM BLOOD ALT-20 AST-18 AlkPhos-116 TotBili-0.6
___ 11:05PM BLOOD Lipase-58
___ 11:05PM BLOOD Albumin-4.2
___ 11:05PM BLOOD Lactate-2.4*
.
discharge labs:
___ 06:50AM BLOOD WBC-7.3 RBC-4.42* Hgb-14.3 Hct-38.9*
MCV-88 MCH-32.3* MCHC-36.6* RDW-12.9 Plt ___
___ 06:50AM BLOOD Glucose-99 UreaN-15 Creat-1.2 Na-137
K-4.1 Cl-102 HCO3-26 AnGap-13
___ 06:50AM BLOOD Calcium-8.7 Phos-3.8# Mg-2.0
___ 08:05AM BLOOD Lactate-1.4
.
urine
___ 12:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:00PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 12:00PM URINE Mucous-RARE
.
micro
urine culture - no growth
blood culutre x 2 pending at time of discharge
h. pylori antibody pending
.
studies
CXR: IMPRESSION: No pneumonia, edema or effusion.
.
CT abdomen and pelvis:
1. Mild mesenteric mistiness between the uncinate process and
the third part of the duodenum is nonspecific but may represent
a focal pancreatitis or duodenitis in the appropriate clinical
setting. An adjacent borderline enlarged lymph node is likely
reactive.
2. Mild diverticulosis without diverticulitis.
Radiology Report
CLINICAL HISTORY: ___ man with abdominal pain. Evaluate for
pneumonia.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. Low lung
volumes result in bronchovascular crowding. There is no focal consolidation,
pleural effusion, or pneumothorax. Heart size is within normal limits
allowing for lung volumes. The mediastinal silhouette and hilar contours are
normal. There is no free air under the diaphragm.
IMPRESSION: No pneumonia, edema or effusion.
Radiology Report
CLINICAL HISTORY: ___ male with abdominal pain for one week.
COMPARISON: AXR ___ and CT abdomen ___.
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness with 130 mL Omnipaque
intravenous contrast. Coronal and sagittal reformats were displayed with 5-mm
slice thickness.
CT ABDOMEN: The visualized lung bases are clear. A bleb in the right middle
lobe is new from ___. There is no pleural or pericardial effusion.
The liver, gallbladder, spleen, bilateral adrenal glands are normal. Mild
mesenteric mistiness between the pancreatic uncinate process and the third
portion of the duodenum is nonspecific but may be related to mild pancreatitis
or duodenitis in the appropriate clinical setting. The kidneys enhance
symmetrically and excrete contrast promptly without hydronephrosis.
The small and large bowel are normal in course and caliber without
obstruction. The appendix is normal. There is no free fluid and no free air.
The aorta is of normal caliber throughout with mild atherosclerotic
calcifications. The main portal vein, splenic vein and SMV are patent. No
pathologically enlarged mesenteric or retroperitoneal lymph nodes are
identified. A borderline enlarged retroperitoneal lymph node (2:45) measuring
11 mm is slightly enlarged compared to ___ when it measured 8 mm and may be
reactive.
CT PELVIS: The rectum is normal. Scattered diverticula are seen in the
sigmoid colon without inflammatory changes. The bladder and prostate are
normal. Calcifications are seen in the vas deferens bilaterally. The prostate
and bladder are normal. There is no free fluid and no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
A sclerotic focus at the inferior endplate of T12 is unchanged from ___ and
likely represents a bone island. Healed rib fractures of left lateral fifth
through seventh and maybe the eighth ribs are noted.
IMPRESSION:
1. Mild mesenteric mistiness between the uncinate process and the third part
of the duodenum is nonspecific but may represent a focal pancreatitis or
duodenitis in the appropriate clinical setting. An adjacent borderline
enlarged lymph node is likely reactive.
2. Mild diverticulosis without diverticulitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN, LBP
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, LUMBAGO, DIAB W MANIF NEC ADULT, CELLULITIS/ABSCESS OF TRUNK, HYPERTENSION NOS
temperature: 98.0
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 158.0
dbp: 96.0
level of pain: 7
level of acuity: 3.0 | ___ yo M with hx of HTN, IDDM, and R. BKA who presents with
abdominal pain x ___bdomen only showing mild
mesenteric stranding.
.
# Abdominal pain: Patient presented with abodminal pain x 1 week
with no associated n/v/d. In the emergency department, he
underwent CT abdomen which showed mild mesenteric stranding and
was given a dose of intravenous cipro and flagyl. Patient
remained afebrile without leukocytosis. Other labs including
lipase and liver function tests were within normal limits. Upon
arrival to the flood antibiotics were discontinued. Abdominal
pain thought to be due to viral etiology given known sick
contacts with GI symptoms. Also given the location and nature of
the pain, PUD vs gastritis was considered. He was treated with
IVF on the floor and his lactate improved. He was given a GI
cocktail and percocet for pain. H. pylori antibody was sent. At
time of discharge pain improved and he was able to tolerate
diet. He was discharged with maalox and omeprazole with plans to
follow up with his primary care physician.
.
# Cellulitis - Patient found to have small abscess on his RLQ
that was drained in ED, however cultures were not sent. The
surrounding skin was erythematous and warm. Given that patient
is a diabetic and that there was purulent drainage, clindamycin
was started for MRSA coverage. He was discharged with plans to
complete a ___nd follow up with his PCP.
.
# back pain - Patient with known chronic back pain. There were
no concerning symptoms for acute process on presentation. He was
continued on his home percocet.
.
# Hypertension - Patient remained normotensive during admission.
He was continued on his home lisinopril and amlodipine.
.
# IDDM - Blood sugars were controlled with sliding scale during
admission.
.
Transitional Issues
- H. pylori and blood cultures pending at time of discharge
- patient was full code on this admission
- contact: ___ (brother, HCP) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
clindamycin / Depakote
Attending: ___
Chief Complaint:
N/V
Major Surgical or Invasive Procedure:
Kidney biopsy
Bronchoscopy
Plasmapheresis
Tunnelled HD Line Placmeent
History of Present Illness:
Mr. ___ is a ___ year-old man with a PMH significant for
ESRD ___ Alport syndrome s/p LURT in ___ from his wife
complicated by BK viremia, proteinuria and biopsy showing both
BK viral inclusions as well as evidence of chronic humoral
rejection who presents with nausea and vomiting.
Of note, the patient was recently admitted ___ for
N/V and diarrhea after recently starting MMF, found to have
severe C.diff infection for which he was discharged on PO vanco,
with the rest of w/u for infectous causes of diarrhea
unrevealing (including stool cultures, CMV, adenovirus and
norovirus).
Patient went in for routine labs yesterday, which returned with
Cr up to 2.9 (from 1.7 on discharge), so he was referred into
___ ED. He also reports 2 episodes of vomiting this morning.
In general, however, he feels overall significant improved
compared to his last hospitalization. Diarrhea as resolved
(currently only 1 formed stool per day), and N/V significant
improved as well. Denies fevers, chills, abdominal pain, chest
pain, SOB.
In the ED, initial vitals were 99.8 89 168/104 16 100%. Labs
notalbe for Chem-7 with Cr 2.8 (Cr 1.7 baseline, 2.7 on last
discharge), CBC with WBC 3.3 H/H 9.1/27.3 plts 117, lactate
normal. Renal US showed a normal transplant. Transplant
Nephrology team recommended admission for IVF overnight. VS on
transfer 98.7 88 180/120 16 100% RA.
On arrival to the floor, VS 98.8 108/54 91 18 99%RA, The patient
is well-appearing and without complaints.
Past Medical History:
1. Alport syndrome c/b renal failure now s/p transplant.
2. Anxiety.
3. Renal transplant ___.
4. Hypertension.
5. Gout.
6. Dyslipidemia.
7. Migraines.
8. BK viremia.
9. OSA, on home CPAP.
Social History:
___
Family History:
He has a history of hereditary nephritis in his twin brother,
three cousins, and one uncle. His father has ___ disease
and spastic paraplegia. His mother has a history of thyroid
cancer.
Physical Exam:
>> Admission Physical Exam:
VS: 98.8 108/54 91 18 99%RA
General: Thin and tall looking gentleman in street clothes,
pacing in room, NAD
HEENT: MMM, PERRL, anicteric, oropharynx clear with dry MM
Neck: Supple, no JVD
CV: RRR, +S1/S2, no m/r/g
Lungs: CTAB
Abdomen: Soft, no tenderness in all qaudarnts, no r/g,
nondistended
GU: No foley
Ext: No c/c/e
Neuro: CN2-12 grossly in tact, AAOx3
.
>> Discharge Physical Exam:
Vitals: T 97.9 167- 152 / 97-104 18 70s 98 RA
General: NAD, sitting in bed. Conversing well.
Neck: Supple, no JVD.
CV: RRR, +S1/S2, no m/r/g
Right Dialysis Line: Tender along clavicle bone. Mildly
indurated. No erythema seen.
Lungs: clearer to auscutlation bilaterally.
Abdomen: Soft, nontender
Ext: No c/c/e
Neuro: CN2-12 grossly in tact, AAOx3
Pertinent Results:
>> Admission Labs:
___ 03:00PM BLOOD WBC-5.6 RBC-3.56* Hgb-10.6* Hct-30.6*
MCV-86 MCH-29.7 MCHC-34.5 RDW-15.2 Plt ___
___ 05:48PM BLOOD Neuts-73.8* Lymphs-16.5* Monos-5.8
Eos-3.3 Baso-0.6
___ 06:50AM BLOOD ___ PTT-30.1 ___
___ 05:17AM BLOOD Ret Aut-2.9
___ 03:00PM BLOOD UreaN-23* Creat-2.9*# Na-143 K-4.5
Cl-111* HCO3-24 AnGap-13
___ 03:00PM BLOOD Albumin-4.3 Calcium-8.9 Phos-3.5
___ 05:17AM BLOOD Hapto-<5*
___ 03:00PM BLOOD tacroFK-7.7
___ 06:02PM BLOOD Lactate-0.6
___ 09:39AM BLOOD freeCa-0.93*
.
>> Pertinent Reports:
MICRO:
___: Urine legionalla negative
___: Cyrotpococcal: CRYPTOCOCCAL ANTIGEN NOT DETECTED.
___
Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal aspirate.
Respiratory Viral Culture (Pending):
Respiratory Viral Antigen Screen (Pending):
BK VIremia: BK VIRUS DNA, QN PCR 9438 H
___: B glucan
Galactomannan: negativem 0.18
___:
Bronch Results: Pending
Bronch Washings: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
Studies:
GLOMERULAR BASEMENT MEMBRANE <1.0 NEGATIVE
Imaging:
___ V/Q SCAN
Very low likelihood ratio for acute pulmonary embolism.
Decreased
ventilation at the left base posteriorly.
___ CT ab/p
1. Bilateral atrophic kidneys with a right pelvic renal
transplant
identified. While there is no perinephric fluid or fluid
collection, there is trace pelvic free fluid noted. No
hydronephrosis or perinephric stranding.
2. No evidence of retroperitoneal bleed.
3. Mild diverticular disease without evidence of diverticulitis.
4. Diffusely dense liver, presumably hemosiderosis.
___ CT Chest
Bibasilar consolidations have increased in size and become more
consolidated within the left lower lobe concerning for
aspiration or alternatively pneumonia in the correct clinical
setting.
Several bronchiolar nodules within the right lower lobe are
thought likely infectious or inflammatory, stable when compared
to prior CT 3 days prior, though deserve followup chest CT up on
termination of treatment.
Small bilateral nonhemorrhagic and layering pleural effusions
have increased since prior study.
Trace pericardial effusion is unchanged.
Renal ultrasound ___: In the lower pole of the transplant
kidney, likely in similar location to recent biopsy, vascular
aliasing and turbulent flow with increased peak systolic
velocity worrisome for AV fistula.
CT Chest ___:
INTERVAL RESOLUTION OF THE CAVITATED LESION IN THE LEFT LOWER
LOBE.
INTERVAL INCREASE IN BILATERAL CURRENTLY MODERATE PLEURAL
EFFUSIONS
EVIDENCE OF ANEMIA.
SMALL PERICARDIAL EFFUSION, UNCHANGED
Pertussis: Negative
___: Anti-GBM : Negative for antibody to the Goodpasture antigen
(NC1 domain of the alpha 3 chain of type IV collagen) by western
blot analysis.
___: BK virus urine: pending
___: BK Virus blood: 4427 H
.
>> Discharge Labs:
___ 05:00AM BLOOD WBC-6.3 RBC-2.78* Hgb-8.5* Hct-24.2*
MCV-87 MCH-30.7 MCHC-35.3* RDW-18.5* Plt Ct-92*
___ 05:00AM BLOOD Plt Smr-LOW Plt Ct-92*
___ 05:00AM BLOOD Glucose-88 UreaN-21* Creat-3.7*# Na-140
K-3.7 Cl-104 HCO3-30 AnGap-10
___ 06:18AM BLOOD ALT-29 AST-30 LD(LDH)-300* AlkPhos-37*
TotBili-0.3
___ 05:00AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.8
___ 05:45AM BLOOD tacroFK-LESS THAN
___ 05:50AM BLOOD tacroFK-4.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO BID
2. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
3. Amitriptyline 50 mg PO QHS
4. Amlodipine 10 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Citalopram 40 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Gabapentin 800 mg PO BID
9. Labetalol 100 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO BID
12. Tacrolimus 2.5 mg PO Q12H
13. Vitamin D 1000 UNIT PO DAILY
14. Mycophenolate Sodium ___ 360 mg PO BID
15. Vancomycin Oral Liquid ___ mg PO Q6H
16. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral daily
17. trospium 20 mg oral Daily
18. Ondansetron 4 mg PO Q8H:PRN Nausea
Discharge Medications:
1. Amitriptyline 50 mg PO QHS
2. Amlodipine 10 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Gabapentin 400 mg PO BID
RX *gabapentin 400 mg 1 capsule(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
6. Labetalol 200 mg PO TID
RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. Mycophenolate Sodium ___ 360 mg PO BID
RX *mycophenolate sodium 360 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
9. Omeprazole 40 mg PO BID
10. Ondansetron 4 mg PO Q8H:PRN Nausea
11. Vitamin D 1000 UNIT PO DAILY
12. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
13. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
14. Atorvastatin 10 mg PO QPM
15. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral daily
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
17. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
18. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
RX *albuterol ___ puff IH every 6 hours Disp #*1 Inhaler
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS 1. Acute Kidney Rejection 2. BK nephropathy
and viremia
SECONDARY DIAGNOSIS: 1. Alport Syndrome
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: ___ with hx renal transplant, present with ___, evaluate for
rejection.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal ultrasound from ___.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis. There is a small amount of simple fluid around the transplant
kidney.
The resistive index of intrarenal arteries ranges from 0.56 to 0.69, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow. Peak systolic
velocities in the main renal artery are less elevated compared to prior study,
now ranging from 90 to 281cm/sec, again likely reflecting the tortuosity of
this vessel. Vascularity is symmetric throughout transplant. The transplant
renal vein is patent and shows normal waveform.
IMPRESSION:
Normal appearance and vascularity of the transplant kidney. Less elevated peak
systolic velocities in the remaining renal artery continue to reflect the
tortuosity of this vessel. Small amount of perinephric simple fluid.
Radiology Report
EXAMINATION: Ultrasound guidance for percutaneous kidney biopsy by nephrology
INDICATION: ___ year old man with h/o of kidney transplant, with ?chrnoic
rejection vs. bk nephropathy // rejection vs. bk nephropathy. Please schedule
for late am on ___.
TECHNIQUE: Real-time grayscale ultrasound imaging for biopsy guidance.
COMPARISON: ___
FINDINGS:
This procedure was performed by the Nephrology team; please see Nephrology
procedure note for further details.
Real-time ultrasound guidance for percutaneous renal biopsy was provided by
radiologist. The lower pole of the transplant kidney was targeted and 2 biopsy
passes performed.
SEDATION: Moderate sedation was provided by administering divided doses of
Fentanyl and Versed throughout the total intra-service time during which the
patient's hemodynamic parameters were continuously monitored by an
independent, trained radiology nurse.
IMPRESSION:
Ultrasound guidance for percutaneous transplant kidney biopsy.
Radiology Report
INDICATION: ___ year old man with h/o of Alports, on immunosup, BK, elevated
Cr, worsened dry cough overnight. // immunosup, eval acute process
EXAMINATION: CHEST (PA AND LAT)
TECHNIQUE: Chest radiograph, PA and lateral views
COMPARISON: Chest radiograph ___
FINDINGS:
There is a new small left pleural effusion. There is a new irregular opacity
at the left lung base laterally, which could be an infectious process or
atelectasis. A calcified granuloma in the left mid to upper lung is unchanged.
Cardiomediastinal silhouette is normal size.
IMPRESSION:
New small left pleural effusion and left lung base opacity could be an
infectious process or atelectasis. If clinically indicated, CT is recommended
for further evaluation.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with h/o of ___, s/p kidney transplant, with
acute rejection on immunosuppresion, new cough, and abnormal chest imaging.
// please further eval ?infectious process.
TECHNIQUE: Non-contrast chest CT was performed acquiring sequential axial
images from the thoracic inlet through the adrenal glands. Thin section axial,
coronal, sagittal and axial MIP's were also obtained.
DOSE: Total DLP = 357mGy-cm
COMPARISON: No prior chest CT available for comparison. Correlation made to
CT abdomen/pelvis dated ___.
FINDINGS:
The thyroid gland appears somewhat heterogeneous and edematous without
identification of a discrete nodule. There are no pathologically enlarged
supraclavicular, mediastinal, hilar or axillary lymph nodes.
Heart size is normal with a trace pericardial effusion. Diffuse low
attenuation of the blood in the heart suggests anemia. Mild focal
calcification of the proximal left anterior descending coronary artery is
atypical in a young patient (3, 37). The main pulmonary artery and thoracic
aorta are normal caliber.
A small layering nonhemorrhagic left pleural effusion contributes to mild
adjacent passive atelectasis of the left lower lobe. However, there is likely
superimposed consolidation at the dependent aspect of the left lower lobe.
There is also a trace right pleural effusion. Mild interlobular septal
thickening and mild bronchial wall thickening is most extensive in the lower
lobes. Multiple bilateral lower lobe bronchiolar nodules, some of which are
clustered, measure up to 7 mm in the dependent aspect of the right lower lobe
(5, 245). Airways are patent to the subsegmental level.
There is marked cortical atrophy of the partially imaged kidneys with presence
of a punctate left renal parenchymal calcification.
The bones are unremarkable.
IMPRESSION:
Suspected aspiration or pneumonia involving the dependent aspect of both lower
lobes. Given the history of immunosuppression, invasive aspergillosis cannot
be excluded. Although the bronchiolar nodules measuring up to 7 mm in the
dependent right lower lobe are likely infectious or inflammatory, a short-term
followup chest CT following appropriate antibiotic treatment is advised.
Mild pulmonary edema.
Small layering nonhemorrhagic left pleural effusion with mild associated
partial passive atelectasis of the left lower lobe. Trace right pleural
effusion.
Mild coronary artery calcification involving the proximal LAD is atypical in a
young patient. However, this patient may be at increased risk of coronary
artery disease given the history of chronic renal disease in the setting of
Alport syndrome.
Anemia.
Radiology Report
INDICATION: ___ male with a transplant kidney with elevated
creatinine.
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow), Dr. ___
___ resident) and Dr. ___ radiology attending)
performed the procedure. The attending, Dr. ___ was present and
supervising throughout the procedure. Dr. ___ radiologist,
personally supervised the trainee during the key components of the procedure
and reviewed and agreed with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
25mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service
time of 10 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, midazolam.
CONTRAST: None.
FLUOROSCOPY TIME AND DOSE: 1 minute, 2 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right neck and upper chest were prepped and
draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent internal jugular vein on the
right was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The
catheter was tunneled from the entry site towards the venotomy site from where
it was brought out using a tunneling device. The venotomy tract was dilated
using the introducer of the peel-away sheath supplied. Following this, the
peel-away sheath was placed over the ___ wire through which the catheter was
threaded into the right side of the heart with the tip in the right atrium.
The sheath was then peeled away. The catheter was sutured in place with 0 silk
sutures. Steri-strips were also used to close the venotomy incision site.
Final spot fluoroscopic image demonstrating good alignment of the catheter and
no kinking. The tip is in the right atrium. The catheter was flushed and both
lumens were capped. Sterile dressings were applied. The patient tolerated the
procedure well.
FINDINGS:
Patent internal jugular vein on the right. Final fluoroscopic image showing 23
cm tip to cuff length catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The
tip of the catheter terminates in the right atrium. The catheter is ready for
use.
Radiology Report
EXAMINATION: Fluoroscopy
INDICATION: Bronchoscopy
TECHNIQUE: Fluoroscopy
COMPARISON: None.
FINDINGS:
One intraoperative image was acquired without a radiologist present.
IMPRESSION:
Intraoperative images were obtained during left bronchoscopy. Please refer to
the operative note for details of the procedure.
Total fluoroscopic time is 161.8 seconds and total dose is 25 mGy
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pneumonia, now s/p tbbx on the left. // ptx
ptx
IMPRESSION:
In comparison with the study of ___, there has been placement of a
hemodialysis catheter that extends to the cavoatrial junction or right atrium.
Otherwise, little change. Specifically, no evidence of pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ y.o male with ESRD ___ alport's syndrome s/p LURT now with
acute rejection found to have pulmonary nodules s/p bronch and biopsy today
// pneumothorax pneumothorax
IMPRESSION:
In comparison with the study of ___, there is no evidence of
post-procedure pneumothorax or other change.
Radiology Report
INDICATION: ___ year old man with h/of acute kidney rejection, plamapheresis
and IVIG, recent renal biopsy, and recent bronchosopy, with chest pressure. RP
bleed vs. bleed chest.
TECHNIQUE: Multi detector CT images through the abdomen and pelvis were
obtained in the absence of intravenous and oral contrast. Coronal and sagittal
reformations were generated and reviewed.
DOSE: 584 mGy-cm.
COMPARISON: CT chest dated ___ as well as CT abdomen dated ___.
FINDINGS:
Chest: Please refer to CT chest obtained on the same day for complete intra
thoracic findings.
Abdomen: Evaluation is limited in the absence of intravenous and oral
contrast. Allowing for this, the liver appears homogeneously dense in
attenuation. There is no intrahepatic ductal dilatation. The gallbladder
appears distended the without gallbladder wall thickening or peripancreatic
fluid. There is no radiopaque cholelithiasis. The spleen is normal in size
measuring 10 cm in coronal dimension. Unenhanced images of the pancreas are
unremarkable. There is no pancreatic ductal dilatation. Bilateral adrenal
glands are without nodularity.
The kidneys are symmetrically severely atrophic. A kidney transplant within
the right lower quadrant is noted. Within the limits of an unenhanced
examination, the transplanted kidney appears without a focal lesion. There is
no surrounding fluid collection. There is no evidence of hydronephrosis.
The stomach, duodenum, and loops of small bowel are grossly unremarkable. The
appendix is visualized, within normal limits. Moderate fecal loading is noted.
The aorta is non aneurysmal. Scattered retroperitoneal nodes do not meet CT
size criteria for pathology.
The bladder is moderately well distended and grossly unremarkable. Prostate
gland and seminal vesicles are within normal limits. A trace amount of pelvic
free fluid is noted (3:114), low in density measuring 6.4 in ___ units,
suggestive of serous fluid. There is no inguinal or pelvic adenopathy.
Osseous structures: No suspicious lesion is identified. A lucency within the
right iliac bone (3:101) appears to have been present on prior CT abdomen and
pelvis dated ___, stable, likely benign in etiology.
IMPRESSION:
1. Bilateral atrophic kidneys with a right pelvic renal transplant
identified. While there is no perinephric fluid or fluid collection, there is
trace pelvic free fluid noted. No hydronephrosis or perinephric stranding.
2. No evidence of retroperitoneal bleed.
3. Mild diverticular disease without evidence of diverticulitis.
4. Diffusely dense liver, presumably hemosiderosis.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ male with history of acute kidney rejection with
chest pressure.
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images.
DOSE: DLP: 584
COMPARISON: Chest CT dated ___.
FINDINGS:
The thyroid gland is unremarkable. There is no supraclavicular, axillary,
mediastinal or hilar adenopathy. Heart size within normal limits. A trace
pericardial effusion is stable in appearance. The aorta and pulmonary artery
are within normal limits in caliber. A right central line is identified, its
tip terminating at the cavoatrial junction. No appreciable coronary artery
calcifications are detected. Very minimal calcification of the left anterior
descending coronary artery is again identified. There is no hiatal hernia.
Small layering nonhemorrhagic pleural effusions are increased in size when
compared to prior study dated ___. Mild interlobular septal
thickening and mild bronchial wall thickening within the lower lobes is
essentially unchanged when compared to prior study. A consolidation within the
left lower lobe appears more contracted, focal and rounded (8:241) measuring
1.7 x 1.8 cm in dimension. Consolidation within the right lower lobe has
developed.
Multiple right lower lobe bronchial nodules are again identified and
unchanged. Airways are patent to the subsegmental level.
Osseous structures are without suspicious lytic or blastic lesions.
For complete subdiaphragmatic findings, please refer to dedicated CT abdomen
and pelvis performed on the same date, clip number ___.
IMPRESSION:
Bibasilar consolidations have increased in size and become more consolidated
within the left lower lobe concerning for aspiration or alternatively
pneumonia in the correct clinical setting.
Several bronchiolar nodules within the right lower lobe are thought likely
infectious or inflammatory, stable when compared to prior CT 3 days prior,
though deserve followup chest CT up on termination of treatment.
Small bilateral nonhemorrhagic and layering pleural effusions have increased
since prior study.
Trace pericardial effusion is unchanged.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with esrd s/p transplant, with recent bronch,
receiving plasmapheresis, with chest pressure and dyspnea. Evaluate 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, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Radiology Report
INDICATION: ___ year old man with LLL PNA // interval change
EXAMINATION: CHEST (PA AND LAT)
TECHNIQUE: Chest radiograph, PA and lateral views
COMPARISON: CT chest ___. Chest radiograph ___
FINDINGS:
There is small bilateral pleural effusions, left larger than right. The
opacification at the left lung base is possibly pneumonia in correct clinical
setting. Compared to the prior radiograph from ___, left lung base
opacification and pleural effusion is increased. There is no pneumothorax.
Cardiomediastinal and hilar silhouettes are normal size. Right-sided dialysis
catheter terminates in the right atrium, unchanged in position.
IMPRESSION:
Mild left lower lobe opacification is increased compared to ___. This may
represent progressive pneumonia in correct clinical setting.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old man with h/o of recent renal biopsy of renal
transplant, presenting with acute rejection, palpable ?hematoma. // c/f renal
bleed, ?hematoma, please doppler to eval for extravastation.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: ___ and ___
FINDINGS:
The right lower quadrant transplant renal morphology is normal. The transplant
kidney measures 12.3 cm in length. Specifically, the cortex is of normal
thickness. There is no hydronephrosis. A sliver of simple appearing
perinephric fluid is seen. No drainable fluid collection is seen.
The resistive index of intrarenal arteries ranges from 0.58 to 0.61, within
the normal range. On ___, the lower pole of the transplant kidney
was biopsied. Today, in the lower pole of the transplant kidney, there is a
subtlely echogenic area which demonstrates vascular aliasing with a high
resistance increased peak systolic velocity worrisome for AV fistula.
The main renal artery demonstrate prompt systolic upstroke and continuous
antegrade diastolic flow, with peak systolic velocity of 112 cm/s. . The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
In the lower pole of the transplant kidney, likely in similar location to
recent biopsy, vascular aliasing and turbulent flow with increased peak
systolic velocity worrisome for AV fistula.
Findings discussed with Dr. ___ on ___ at 7:35pm via
telephone.
Radiology Report
EXAMINATION: Chest CT
INDICATION: ___ year old man with h/o LLL lung findings (please compare to
prior), previously on vori, had bronchospy. // interval change.
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: ___.
FINDINGS:
RIGHT CENTRAL VENOUS LINE TIP IS TERMINATING IN LOW RIGHT ATRIUM/ IVC. HEART
SIZE IS NORMAL. EVIDENCE OF SEVERE ANEMIA IS PRESENT. SMALL PERICARDIAL
EFFUSION IS UNCHANGED. THERE IS INTERVAL INCREASE IN BILATERAL PLEURAL
EFFUSIONS, CURRENTLY MODERATE. NO DEFINITIVE LYMPHADENOPATHY IS PRESENT. IMAGE
PORTION OF THE UPPER ABDOMEN DEMONSTRATE HYPERDENSE LIVER AND A TROPHIC LEFT
KIDNEY.
AIRWAYS ARE PATENT TO THE SUBSEGMENTAL LEVEL BILATERALLY. PREVIOUSLY
DEMONSTRATED CAVITATED LESION IN THE LEFT LOWER LOBE THAT IS NOT PRESENT ON
CURRENT EXAMINATION. INSTEAD THERE ARE BIBASAL LEFT MORE THAN RIGHT A AREAS OF
SMALL ATELECTASIS. NO NEW MASSES ARE CONSOLIDATIONS DEMONSTRATED.
IMPRESSION:
INTERVAL RESOLUTION OF THE CAVITATED LESION IN THE LEFT LOWER LOBE.
INTERVAL INCREASE IN BILATERAL CURRENTLY MODERATE PLEURAL EFFUSIONS
EVIDENCE OF ANEMIA.
SMALL PERICARDIAL EFFUSION, UNCHANGED
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT BILATERAL
CLINICAL HISTORY ___ year old man with h/o kidney transplant s/p acute
rejection, on dialysis // vein mapping for AVF vein mapping for AVF
FINDINGS:
Duplex was performed of bilateral upper extremity veins and limited views of
the brachial and radial arteries were obtained also.
Right colon phasic flow is seen in the subclavian vein. The cephalic vein is
patent throughout with diameters ranging from 1-3 mm in the forearm and 3 mm
throughout the upper arm. The basilic vein is patent with diameters ranging
from 2-3 mm in the forearm from 3-4 mm in the upper arm. The brachial and
radial arteries are patent with triphasic waveforms no significant
calcification and diameters of 5 and 2 mm respectively.
Left colon phasic flow is seen in the subclavian vein. The cephalic vein is
patent throughout with diameters from 1-2 mm in the forearm and 3 mm
throughout the upper arm. The basilic vein is patent with diameters ranging
from 1-2 mm in the forearm pain from 5-6 mm in the upper arm. The brachial
radial arteries are patent with triphasic waveforms. No significant
calcification and diameters of 5 mm and 2 mm respectively.
IMPRESSION:
Pain bilateral cephalic and basilic veins with diameters as noted.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Vomiting, N/V
Diagnosed with NAUSEA WITH VOMITING, ABDOMINAL PAIN UNSPEC SITE, KIDNEY TRANSPLANT STATUS
temperature: 99.8
heartrate: 89.0
resprate: 16.0
o2sat: 100.0
sbp: 168.0
dbp: 104.0
level of pain: 0
level of acuity: 3.0 | ___ year old male, with a history of ESRD ___ Alport Syndrome,
s/p LURT in ___ (from his wife), presenting with ___. Hospital
course complicated by BK viremia, and biopsy proven acute
humoral rejection.
.
>> ACTIVE ISSUES:
# Acute Humoral Rejection: Patient initially presented with an
increased creatinine, and there was question of rejection given
outpatient testing which was significant for low titer of donor
specific antibodies. Patient underwent a renal biopsy, and
repeat donor specific antibody testing, which revealed a > test
MFI. Further, BK testing done at that time also showed an
increasing BK viremia in both the serum and urine. Biopsy
results included a multitude of findings, including an acute on
chronic humoral rejection, with multiple crescenteric glomeruli.
Further, in the background of his acute rejection was BK
positivity on biopsy (SV40) as well. After much discussion
regarding treatment options, it was thought that patient should
be placed on high dose immunosuppression with both tacrolimus
and MMF. With increasing immunosuppression, patient started to
have increased hemolysis as well and thought to be ___ to
tacrolimus microangiopathy. Peripheral smears did show ___
schistocytes/HPF. Per acute rejection guidelines, patient was
initially started on plasmapheresis to remove donor specific
antibodies, and was replaced full FFP instead of half albumin
because of risks of bleeding with renal biopsy. Patient also was
started on high dose steroids at that time, and during
plasmapheresis sessions patient started to develop a cough
(reported below). Given concerns for aspergillus, and the risk
for invasive disease with higher immunosuppression, patient
underwent plasmapheresis and was transitioned to an IVIG load of
2 grams, with lower immunosuppression. Tacrolimus was also
discontinued in the setting of increased TMA with severely
elevated levels ___ to initiation of voriconazole. Patient
started to undergo dialysis sessions ___ to increased volume,
although urine output consistently stayed between 500-1L per
day. Patient eventually was transitioned to permanent dialysis,
with loss of his graft function, and was transitioned to a
regimen including low dose prednisone and MM sodium.
.
#ESRD s/p LURT : As described above, patient was transitioned to
dialysis during hospital stay after acute humoral rejection.
Patient underwent transplant evaluation for AVF, with vein
mapping bilaterally, and scheduled to undergo AVF after hospital
discharge. Plans for patient include home hemodialysis set up as
well in the future. Patient was discharged with negative
Hepatitis Serologies, and pending quantiferon gold for dialysis
placement.
.
# Pneumonia: As indicated above, patient started to develop a
cough during his plasmapheresis sessions, and initial imaging
showed a possible cavitary lesion. Patient was started on broad
spectrum antibiotics, however given concerns for invasive
aspergillus in the setting of higher dosed immunosuppression for
acute rejection, confirmatory testing with bronchoscopy was
performed. Patient's BAL did not show any evidence, and no
serologic evidence of fungi either. Patient was originally
started on amphotericin given interactions of voriconazole with
immunosuppression, however this was discontinued as suspicion
was low after testing. Patient was continued on Zosyn for 7 day
course, with resolution of cough and CT imaging showed
resolution of cavitary lesion.
.
# Hypertension: Patient was up-titrated to labetolol 200 mg TID
for better control as started to have both elevated diastolic
and systolic pressures. Patient tolerated dose adjustment well.
.
# Chest Pain: Patient was found to have acute chest pain, with
respiratory difficulty after bronchoscopy. He described this
pain as chest pressure, and since no DVT prophylaxis as risk of
bleeding with renal biopsy, initial concerns for PE. ABGs at
that time were significant for a resppiratory alkalosis (pH 7.8,
CO2 15). Patient underwent V/Q scan which showed low likelihood,
and LENIs which were negative for DVT. Patient also started to
have resolution with anxyiolitic, thought to be more panic
attack with pain ___ bronchoscopy.
.
# Gout: Patient was continued on allopurinol renal dose without
flare.
.
# History of C. diff: Patient would be classified as severe C.
diff in the past, and was finishing a course of PO vancomycin to
prevent recurrence. His course was extended given antibiotics
while inpatient and higher dose immunosuppression, and was
continued until ___ per ID recommendations. Patient did not
have diarrhea while inpatient and reported resolution of
symptoms.
.
# Anemia: Patient was found to be anemic several times during
hospital stay, requiring multiple transfusions. Anemia was
thought to be ___ to TMA evidenced by hemolysis and peripheral
smear findings. Further, patient's renal biopsy also
demonstrated thrombi as well. Patient also encountered a
dialyzer reaction, and therefore had an acute blood loss as
well. Patient's renal biopsy site was ultrasounded given
increased pain, but not significant for bleeding as well.
Patient remained hemodynamically stable, and will require checks
as an outpatient.
.
>> TRANSITIONAL ISSUES:# Dialysis: Set up ___. Plan for
transition to home HD
# TMA?: Concerns while inpatient for hemolysis, stable H/H.
Continue to trend as outpatient.
# C. diff: Patient completed course with PO Vanc, CTM for
diarrhea.
# CT Chest Imaging: Several bronchiolar nodules, f/u in 3 months
for resultion and tracking to compare (___)
# AVF: Patient to have AVF on ___ for planned hemo-dialysis.
# HTN: Up-titrated Labetolol 200 TID.
# Dialysis Placement: Quantiferon Gold pending upon discharge.
# ? Dialysis Rxn: Possible Dialysis Rxn to optiflux 180, but not
definitive. Please monitor. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Percocet / Ultram / Hydrochlorothiazide
Attending: ___
Chief Complaint:
Struck by car while crossing crosswalk on motorized vehicle.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ y/o M crossing a crosswalk in a motorized wheelchair when
struck by a car, thrown 30ft. +LOC.
Past Medical History:
- H/o stroke with residual left-sided facial droop
- COPD on home O2 (2L NC)
- Lung nodule?
- CAD with prior anteroseptal MI on ECG
- Hypertension
- Mildly dilated ascending aorta (3.8 cm)
- Peripheral vascular disease s/p right SFA stent
- ETOH abuse
- Tobacco abuse
- H/o anxiety/panic attacks
- Hepatitis B
- PUD (H. pylori)
- Migraine headaches
- Seizure disorder
- S/p cholecystectomy
- S/p appendectomy
- S/p cataract surgery
Social History:
___
Family History:
His father died at age ___ of lung cancer. His mother is age ___
and apparently has a "hole" in her heart. She also sustained a
stroke. He is estranged from his one brother. There is no family
history notable for hypertension, hyperlipidemia, or diabetes.
He is unsure about any early coronary artery disease or sudden
cardiac death history in his family.
Physical Exam:
GEN: alert and oriented x 3, NAD
Patient refused full physical exam, as he left before his
official discharge planned time.
Pertinent Results:
___ 06:56PM GLUCOSE-105* UREA N-9 CREAT-0.8 SODIUM-142
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-30 ANION GAP-14
Radiology Report
HISTORY: Trauma, thrown from wheelchair.
TECHNIQUE: Portable chest radiograph.
___.
PROCEDURE:
FINDINGS:
Single frontal supine portable chest radiograph provided. Left CP angle as
well as the mid and lower left lateral chest wall excluded. Underlying trauma
board and overlying belt limits the evaluation. The patient is known to have
severe bullous emphysema. A nodular density in the right lung apex is better
assessed on the subsequent CT. Otherwise no gross pulmonary abnormalities.
Heart size is within normal limits and stable. No definite bony
abnormalities.
IMPRESSION:
Emphysema, subtle nodularity in the right upper lung better assessed on
subsequent CT. No definite traumatic injuries.
NOTIFICATION:
Radiology Report
INDICATION: Struck by car in wheelchair. Thrown ___ feet.
COMPARISONS: CT head ___ at ___, under the name ___
with a medical record ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin slice
bone image reformats were obtained and reviewed. Due to motion, the exam was
repeated multiple times.
FINDINGS: The exam is limited by motion. Within these limitations, there is
no evidence of large hemorrhage, edema, mass, mass effect, or new large
vascular territory infarction. The ventricles and sulci are normal in size
and configuration for the patient's age. Encephalomalacia in the bilateral
frontal horns, worse on the left than the right, is likely the sequelae of
prior trauma. It is unchanged from prior exams. The basal cisterns are
patent.
No fracture is identified. A slight deformity of the left maxillary sinus is
unchanged from prior exams. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The soft tissues are unremarkable.
IMPRESSION:
1. No evidence of a large hemorrhage or vascular territorial infarction,
although the exam is somewhat limited by motion.
2. Stable bifrontal encephalomalacia, worse on the left than the right.
Radiology Report
INDICATION: Pedestrian struck by a car while in wheelchair. Evaluate for
fracture.
COMPARISONS: CT ___.
TECHNIQUE: Helical axial MDCT images were obtained from the base of the skull
through the apices of the lungs without the administration of IV contrast.
Sagittal and coronal reformatted images were obtained and reviewed.
FINDINGS: The exam is very limited by patient motion, particularly at C2
through C4. Within these limitations, there is no evidence of prevertebral
soft tissue swelling. No fracture or malalignment is identified. A subtle
fracture in the region of the motion cannot be completely excluded.
Multilevel degenerative changes appear unchanged from the prior exam. A small
disc osteophyte complex at C3-4 is stable and causing mild spinal canal
narrowing.
There are severe bullous emphysematous changes at the apices of the lungs.
The thyroid is unremarkable. There is no lymphadenopathy. The visualized
portions of the brain are unremarkable.
IMPRESSION: Extremely limited by motion, but within the limitations, no
evidence of fracture or malalignment.
Radiology Report
INDICATION: Pedestrian struck by car while in wheelchair.
COMPARISONS: CT torso, ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the chest,
abdomen, and pelvis after the administration of IV contrast. Sagittal and
coronal reformatted images were obtained and reviewed.
FINDINGS:
CHEST: There are severe emphysematous bullous changes, particularly in the
upper lobes. These are not significantly changed from one year prior. In the
right upper lobe, there is a 3.6 x 2.5 cm irregular consolidation with
calcifications which is most concerning for a new mass (2, 15). Two nodules
in the left upper lobe which measure 0.9 x 0.8 cm and 0.6 x 0.6 cm (2, 24) are
unchanged in appearance from the prior exam. A third nodule in the left lower
lobe measures 0.7 x 0.7 cm (2, 42) and is also stable in appearance. There is
no pleural effusion or pneumothorax.
The aorta is unremarkable without evidence of dissection or intramural
hematoma. Atherosclerotic calcifications are noted. The heart size is
normal. There is no pericardial effusion. A prominent mediastinal lymph node
measures 11 mm in short axis (2, 25). This is unchanged from the prior exam.
No new lymphadenopathy is noted.
ABDOMEN: The liver is normal in shape and contour. There are no focal
hepatic lesions. The portal veins are patent. There is no intrahepatic
biliary duct dilation. The patient is status post a cholecystectomy with
clips in the gallbladder fossa. The common bile duct is unremarkable without
evidence of dilation. The spleen, pancreas, and adrenal glands are
unremarkable. In the left kidney, a cyst in the mid pole (2, 71) has
collapsed in comparison to the prior exam. There is mild amount of
surrounding stranding. This is likely a subacute finding. There is no
surrounding hematoma or evidence of a renal laceration. Multiple other stable
simple-appearing cysts are unchanged in appearance. No new renal masses are
identified. There is no evidence of hydronephrosis. The kidneys enhance and
excrete contrast appropriately. The stomach and small bowel are unremarkable,
other than a stable duodenal diverticulum. There is no evidence of
obstruction. There is no free air or free fluid in the abdomen. There is no
abdominal or mesenteric lymphadenopathy. Atherosclerotic calcifications are
noted in the descending aorta.
Overlying the flank of the left mid abdomen, there is a subcutaneous hematoma
which measures approximately 6.3 x 2.1 cm (2, 91). There is hyperdense
material within the hematoma suggesting active extravasation.
PELVIS: There is diverticulosis without diverticulitis. The large bowel is
otherwise unremarkable without evidence of mass or obstruction. The bladder
and prostate are unremarkable. There is no free air or free fluid in the
pelvis. There is no inguinal or pelvic lymphadenopathy. Atherosclerotic
calcifications are noted in the common iliac arteries. In the left common
iliac artery, there is a small aneurysmal dilation which measures 1.7 x 1.7 cm
(2, 102). This is stable from the prior exam.
OSSEOUS STRUCTURES: There is no evidence of fracture. Stable old deformities
are noted in the right anterior ribs, likely from prior fractures. Mild
degenerative changes are noted in the lower thoracic spine, also stable.
IMPRESSION:
1. Left flank subcutaneous hematoma with evidence of active extravasation.
2. Consolidation in the right upper lobe is new from ___ and has the
appearance of a mass. Recommend evaluation with PET-CT to exclude a
malignancy.
3. Stable pulmonary nodules in the left upper and left lower lobes. These
also can be further evaluated on PET-CT.
4. Collapsed left renal cyst, likely subacute.
5. Severe bullous emphysema.
6. No solid organs injury.
7. No acute fracture.
Results were communicated with the surgery resident, Dr. ___, at the
time of the wet read was updated at 2:30 p.m. on ___ via telephone by Dr.
___.
Radiology Report
INDICATION: ___ male with trauma. Evaluate for fracture.
COMPARISONS: None.
FINDINGS: Three views of the left knee were obtained. There is a minimally
displaced fracture of the left proximal fibular shaft. No evidence of
degenerative change. No focal lytic or sclerotic lesion. No joint effusion
or lipohemarthrosis. Small vascular calcifications and popliteal fossa. No
radiopaque foreign body.
IMPRESSION: Minimally displaced fracture of the proximal left fibular shaft.
Findings were communicated via phone call by Dr. ___ on ___
at 15:43 via phone call to ___, M.D.
Radiology Report
INDICATION: ___ male with trauma. Evaluate for fracture.
COMPARISONS: None.
FINDINGS: Three views of the left elbow were obtained. No fracture,
dislocation, or degenerative change. No lytic or sclerotic lesion. No joint
effusion. An IV catheter is seen in the antecubital fossa with mild adjacent
subcutaneous stranding.
IMPRESSION: Unremarkable left elbow radiographs.
Radiology Report
RADIOGRAPHS OF THE LEFT TIBIA, FIBULA, AND ANKLE
HISTORY: Trauma.
COMPARISONS: None.
TECHNIQUE: Left tibia and fibula, two views; also left ankle, three views.
FINDINGS: There is a complete non-displaced oblique fracture through the
proximal shaft of the left fibula with slight posterior displacement of the
distal fragment. However, no other fracture is identified. The ankle mortise
appears congruent. Bony demineralization is suspected.
IMPRESSION: Fracture of the proximal fibular shaft. Findings suggestive of
bony demineralization.
Radiology Report
INDICATION: ___ male for evaluation for C-spine injury.
COMPARISONS: Multiple prior cervical spine CTs, most recently of the same day
at 12:04.
TECHNIQUE: 2.5 mm helical axial MDCT sections were obtained from the skull
base through the inferior aspect of T1. Axial images were interpreted in
conjunction with coronal and sagittal reformats.
FINDINGS:
There is no evidence of fracture. Vertebral body heights are maintained.
Multilevel degenerative changes are unchanged since ___. C3-4
posterior osteophyte complex causes mild spinal canal narrowing, similar to
prior. Congenital incomplete fusion of C1 posterior arch. No acute alignment
abnormality is present.
No prevertebral soft tissue abnormality. The thyroid is unremarkable. Large
bullous emphysematous changes are again seen at the lung apices. No cervical
lymphadenopathy.
IMPRESSION: No evidence of fracture, acute alignment abnormality, or
prevertebral soft tissue abnormality.
Radiology Report
TYPE OF EXAMINATION: Chest, AP portable single view.
INDICATION: ___ male patient, status post trauma with aspiration,
assess for infiltrates.
FINDINGS: AP single view of the chest has been obtained with patient in
sitting semi-upright position. Comparison is made with the portable frontal
view of the trauma examination of ___. No significant new
abnormalities are seen. As before, there is evidence of rather advanced
emphysematous changes in the apical areas of both lungs. A torso CT, which
has been performed during the latest examination interval, demonstrated a mass
lesion in the right upper lobe. The latter cannot be seen with certainty on
this portable chest examination, but its further workup should be performed as
recommended on the CT.
IMPRESSION: No acute new abnormalities on portable chest examination 24 hours
followup.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PED STRUCK
Diagnosed with FX ANKLE NOS-CLOSED, OPEN WOUND OF FOREHEAD, MV COLL W PEDEST-PEDEST, POSTCONCUSSION SYNDROME, CHEST SWELLING/MASS/LUMP, CHRONIC AIRWAY OBSTRUCTION
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | He was monitored closely in the TSICU. He was alert and
responsive. He had a L flank hematoma and his hct was monitored
closely, it was stable. His diet was advanced but he had a
possible aspiration event. His o2 sats remained stable, however,
in the low ___. He was placed on metoprolol for his tachycardia.
He was restarted on his home anti-seizure medications. He had a
speech and swallow consult.
Patient was transferred to the floor once stable. He remained on
the floor and was doing well until the evening of ___ when he
began to become agitated, stating "I've had enough," and warning
that he would leave that night despite knowing that his primary
team did not think it was wise. Pt was also aware that he was
likely to be discharged to rehab the following day. The intern
on call had multiple conversations with him totaling about 30
minutes explaining the risks of leaving against the team's
advice in his condition (requiring 4L of oxygen d/t severe COPD
and incomplete transition to rehab). As patient was ambulatory
at this time, he proceeded to walk out of floor despite advice,
after all lines were d/c'd. He was directed towards the lobby at
this time and left hospital. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
CODE STROKE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Time (and date) the patient was last known well: 22:00 on
___ (24h clock)
___ Stroke Scale Score: 26
t-PA given: no bleed on repeat CT head
The NIHSS, ICH score, GCS below were performed: Date: ___
Time: 0430 (within 6 hours of patient presentation or neurology
consult)
___ Stroke Scale score was : 26 1a. Level of Consciousness: 2
1b. LOC Question: 2 1c. LOC Commands: 2 2. Best gaze: 2 3.
Visual fields: 3 4. Facial palsy: 0 5a. Motor arm, left: 3 5b.
Motor arm, right: 3 6a. Motor leg, left: 3 6b. Motor leg, right:
3 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 3 10. Dysarthria:
un 11. Extinction and Neglect: 0 GCS score at presentation to
our ED: 7 ICH volume by ABC/2 method: cc ICH Score: 2 Pre-ICH
mRS ___ social history for description):3 If SAH component:
___ and ___ score (clinical): 4
REASON FOR CONSULTATION: Code stroke HPI: ___ year old female
with PMH of diabetes, HTN, HLD who presented from ___
after she was found by her sister in the bathroom at 22: 00 on
___.
Initially a code stroke was called on the patient at ___
and a tele-stroke was performed. Per the stroke fellow patient
was noted to not to be moving the left side on exam, will no
speech output, not following commands, and a forced left gaze
deviation. She was then noted to have convulsions consistent
with what was described as a generalized tonic-clonic seizure.
She was given 2 mg of IV Ativan and these movements subsided.
She was loaded with fosphenytoin and given IV labetalol for
systolic blood pressure of 220. In addition patient was noted to
have a blood glucose greater than 500 which was eventually
corrected to around the high 200s before transport. Patient had
a CTA head and neck and a CT head that were negative for any
large vessel occlusion or hemorrhage.
Upon arrival to the ED the patient was noted to have her eyes
closed, would not open them to noxious stimulation though would
localize briskly with her right upper extremity. She would
localize with the left upper extremity antigravity though much
less briskly than the right. Bilateral lower extremities
withdrawal to noxious stimulation right brisker than left.
Pupils were around 2 mm and reactive. She no longer had a forced
left gaze deviation rather eyes were midline with a sluggish
subtle VOR possibly to the right. No blink to threat
bilaterally, bilateral corneals were intact. She was
subsequently intubated in the emergency room and taken for
repeat CT head which showed a new right subarachnoid hemorrhage.
Neurosurgery was consulted and reviewed the CTA from the outside
hospital without any evidence of aneurysm. They are considering
an angiogram this morning.
I spoke to the patient's sister on the phone earlier this
morning who tells me that she found her sister in the bathroom
last night. She went to check on her because she had the water
running for a very long period of time. Patient was noted to
have a dazed look was not responding, and could not talk. She
sat down on the toilet and then became more unresponsive per the
sister. She checked her blood glucose and it was around 480s.
She also noted that she was not moving her left arm at all
during this time so she took her to the emergency room. Over the
last week or so she is noticed that her sisters had periods of
time where she has this "dazed look
" In her eyes "almost looked like she did not know where she was
for a few seconds". Overall she has had a more subacute decline
in functioning over the last few months and years. Patient has
had worsening issues with her memory. In addition she is not
very active and really only goes out to locations very close to
her house.
She also says that her sister recently was complaining of some
indigestion and increased burping but otherwise had been her
typical self. ROS: Patient is unable to answer review of systems
questions but her sister tells me that she was not complaining
of any headaches, changes in vision, dysarthria, dysphasia,
lightheadedness lightheadedness, vertigo, tinnitus or hearing
difficulty. No bowel or bladder incontinence or retention.
Denies difficulty with gait. Her sister also denies that she has
had any fevers,, cough, chest pain, abdominal pain other than
mild indigestion noted above.
Past Medical History:
HTN
HLD
diabetes
Cervical spine stenosis
Breast cancer s/p radical mastectomy and chemo in ___ per
sister
was stage 4
Social History:
Lives at home with her sister who provides fair amount of care
for her ADLs. She is still driving but only very short distances
as she has gotten lost a few times. She does not use a walker or
a cane to ambulate
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[x] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
No family history of aneurysms, IPH
Grand mother had a stroke and her mother "towards the end of her
life"
Physical Exam:
ADMISSION:
Physical Exam:
Vitals: HR 79, BP 113/40, RR 20, 100% intubated
General: intubated, off sedation for ~3mins
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, ETT in place
Neck: Supple, no clear nucal rigidity
Pulmonary: intubated
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
*Exam prior to sedation: noted to have her eyes closed, would
not
open them to noxious stimulation though would localize briskly
with her right upper. She would localize with the left upper
extremity antigravity though much less briskly than the right.
Bilateral lower extremities withdrawal to noxious stimulation
right brisker than left. Pupils were 2 mm->1mm and reactive.
She no longer had a forced left gaze deviation rather eyes were
midline with a sluggish subtle VOR possibly to the right. No
blink to threat bilaterally, bilateral corneals were intact (R
brisker than L). Toes upgoing bilaterally, no clonus, possibly
slightly increased tone in LLE compared to RLE.
*Exam after intubated and sedation held for ~3mins
-Mental Status: upon initial assessment in ED patient was not
following commands, no speech output, not opening eyes to voice
or noxious stimulation
-Cranial Nerves: Pupils 1mm reactive, gaze midline, possibly
sluggish VOR to the right, no gaze deviation, face appears
symmetric, +corneal bilaterally (R brisker than left), +cough
+gag
-Motor: localizes briskly with right upper extremity to noxious,
localizes sluggishly to noxious with left, both antigravity,
withdraws in bilateral lower extremities to noxious right
brisker
than left.
-Sensory: reacts to noxious in all 4 extremities
-DTRs:
Bi ___ Pat Ach
L 3 3 2 1
R 3 3 2 1
Plantar response was flexor on the right, extension on the left
No clonus
-Coordination: unable to asses
-Gait: unable to asses
============
Discharge Exam:
Physical Exam:
Vitals:
BP: 125/57, HR: 73, RR: 16 SPo2: 94%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, NG in place
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: skin warm, well-perfused.
Abdomen: soft, ND
Neurologic:
-Mental Status: Alert, oriented x 3. Said she was in ___ at a
hospital getting rehab. Language is fluent no paraphasic
errors.
Able to follow both midline and appendicular commands.
Comprehension intact.
-Cranial Nerves: Face symmetric at rest and with activation.
Hearing intact to conversation. No dysarthria.
-Motor: Normal bulk, tone throughout. Bilateral pronation
without
downward drift, symmetric. No adventitious movements, such as
tremor, noted. No asterixis noted. Strength limited in lower
extremities bilaterally secondary to pain.
-Sensory: deferred
-reflexes: deferred
-Coordination: deferred
-gait: deferred
Pertinent Results:
___ 04:05AM BLOOD WBC-17.3* RBC-4.37 Hgb-13.3 Hct-42.0
MCV-96 MCH-30.4 MCHC-31.7* RDW-12.8 RDWSD-45.4 Plt ___
___ 04:05AM BLOOD ___ PTT-36.2 ___
___ 04:05AM BLOOD Glucose-424* UreaN-18 Creat-1.0 Na-139
K-4.3 Cl-100 HCO3-23 AnGap-16
___ 04:05AM BLOOD ALT-19 AST-20 AlkPhos-72 TotBili-0.2
DirBili-<0.2
___ 05:37PM BLOOD Calcium-8.1* Phos-2.6* Mg-1.6
___ 04:05AM BLOOD Albumin-3.9
___ 04:05AM BLOOD Phenyto-20.6*
___ 05:37PM BLOOD Osmolal-298
___ 05:06AM BLOOD Type-ART pO2-410* pCO2-39 pH-7.37
calTCO2-23 Base XS--2
___ 05:06AM BLOOD Lactate-2.0
CT head ___:
1. Acute subarachnoid hemorrhage is seen layering in the right
sylvian
fissure.
2. Incompletely imaged 2.4 cm soft tissue density lesion in the
left parotid gland, recommend further evaluation with nonurgent
dedicated cross-sectional study.
MR head:
1. Punctate, 1-2 mm areas of slow diffusion in the left
cerebellum likely
representing acute embolic strokes.
2. Focus of slow diffusion in the right frontal lobe in the
periphery could be due to subarachnoid blood or acute infarcts.
3. Trace amount of right sylvian fissure subarachnoid
hemorrhage. No new or enlarging hemorrhage.
4. 3.0 cm left parotid lesion, better seen on the neck CT from
___. Differential includes pleomorphic adenoma and
Warthin's tumor.
CT head:
Decreased conspicuity of the pre-existing right sylvian fissure
subarachnoid hemorrhage. No new hemorrhage. No evidence of
large territorial infarct, though detection is somewhat limited
on the noncontrast head CT.
Cerebro Angio:
Extradural origin left posterior inferior cerebellar artery
Negative cerebral angiogram for intracranial vascular lesion
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. GlipiZIDE 10 mg PO BID
3. Losartan Potassium 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. CARVedilol 3.125 mg PO BID
2. Glargine 24 Units Breakfast
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. LevETIRAcetam 750 mg PO BID
4. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7
Days
5. Losartan Potassium 100 mg PO DAILY
6. HELD- Atorvastatin 80 mg PO QPM This medication was held. Do
not restart Atorvastatin until your outpatient provider decides
to restart
7. HELD- GlipiZIDE 10 mg PO BID This medication was held. Do
not restart GlipiZIDE until outpatient provider decides to
restart
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid hemorrhage
Seizure
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: SECOND OPINION CT NEURO PSO1 CT
INDICATION: History: ___ with SAH, seizure// NS requesting repeat read to
determine if need for angiogram NS requesting repeat read to determine
if need for angiogram
TECHNIQUE: Contrast enhanced contiguous axial images of the brain were
obtained at an outside hospital and submitted for second opinion. Coronal,
sagittal reformats as well as axial and coronal maximal intensity projection
images were provided and reviewed.
DOSE: Total DLP: 344.3 mGy-cm
COMPARISON: CT from ___
FINDINGS:
Circle of ___ and its major tributaries are patent without stenosis,
occlusion or aneurysm formation. Calcification along the cavernous segment
bilateral ICA, no narrowing.
Dural venous sinuses are well opacified.
Evaluation for subarachnoid hemorrhage noted on the head CT from ___
is limited on the this study due to the presence of IV contrast. No infarct.
The imaged orbits are unremarkable with evidence of prior left lens
replacement. The imaged portion of the paranasal sinuses are overall patent
with minimal mucosal thickening of the left frontal and anterior ethmoid air
cells.
IMPRESSION:
1. Normal CTA head. No aneurysm.
2. Subarachnoid hemorrhage is not as well seen secondary to contrast.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with seizures, SAH// Remains intubated please
evaluate lung fields
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph from ___
FINDINGS:
The tip of an ETT is seen 2.3 cm above the carina. Enteric tube is seen
coursing into the stomach. Surgical clips project over the left axilla.
Lung volumes remain low. There is apparent enlargement of the mediastinum,
likely positional. No focal consolidation is seen. No pneumothorax,
pulmonary edema, or large pleural effusion.
IMPRESSION:
Hypoinflated lungs without acute cardiopulmonary process.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old woman with left hemiparesis seizures right SAH//
please assess for SAH. portable at 0730
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP: 1343.87 mGy-cm
COMPARISON: CT from ___
FINDINGS:
Pre-existing small subarachnoid hemorrhage along the right sylvian fissure is
less conspicuous on today's exam (02:19). No new hemorrhage is identified.
Extensive periventricular and subcortical white matter hypodensities are
nonspecific, however likely due to chronic small vessel ischemic disease in
the age group and somewhat limits detection of acute infarcts.
The visualized portion of the paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable. Enteric tube and ET tube are partially imaged.
IMPRESSION:
Decreased conspicuity of the pre-existing right sylvian fissure subarachnoid
hemorrhage. No new hemorrhage. No evidence of large territorial infarct,
though detection is somewhat limited on the noncontrast head CT.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC// R DL Power PICC 42CM OUT 1cm
___ ___ Contact name: ___: ___
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph from ___
FINDINGS:
Interval placement of a right PICC with the tip seen in the right atrium. No
new focal consolidation is seen. There is no pneumothorax, pulmonary edema,
or large pleural effusion. The tip of an ETT is in unchanged position
approximately 2.9 cm above the carina. The cardiac size is unchanged.
IMPRESSION:
Interval placement of a right PICC with the tip seen in the right atrium.
Otherwise, stable appearance of the heart and lungs
RECOMMENDATION(S): Recommend retraction by approximately 4-5 cm for optimal
positioning.
Radiology Report
EXAMINATION: Cerebral angiogram to evaluate for vascular lesion patient was
subarachnoid hemorrhage
The following vessels were selectively catheterized and angiography was
performed.
Right common femoral artery
Right common carotid artery
Three-dimensional rotational angiography of the Left internal carotid artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation and review
Right vertebral artery
Left common carotid artery
INDICATION: ___ year old woman with SAH, seizures// Concern for vascular
abnormality with no prior trauma. Diagnostic angiogram
ANESTHESIA: Moderate sedation was provided by administering divided doses of
Versed and fentanyl throughout the total intra service time of 40 minutes
during which the patient's hemodynamic parameters were continuously monitored
by a trained, independent observer. Patient received a total of 100 mcg of
fentanyl and 0.5 mg of Versed and was continuously supervised by the attending
physician.
TECHNIQUE: Cerebral angiogram, complete
COMPARISON: None.
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. She was transferred to the fluoroscopic table supine. Moderate
sedation was administered. Bilateral groins were prepped and draped in
standard sterile fashion. A time-out was performed. The right common femoral
artery was identified using anatomic and radiographic landmarks. The right
common femoral artery was accessed using standard micropuncture technique
after infiltration of local anesthetic. Through the micro dilator,
angiography was performed to the right common femoral artery which
demonstrated that the arteriotomy was proximal to the bifurcation and the
artery was amenable to closure device placement at the conclusion of the
procedure. Next a long 5 ___ sheath was introduced, connected to
continuous heparinized saline flush, and secured. Next a 5 ___ ___ 2
catheter was brought into the field flushed, and connected to continuous
heparinized saline flush. With a 038 glidewire this was brought up through
the aorta under fluoroscopic guidance and selected into the right innominate
artery. The wire was withdrawn and roadmap angiography was performed. Under
roadmap guidance the wire was reintroduced and used to select the right common
carotid artery. The catheter was advanced over the wire the wire was
withdrawn. Vessel patency was confirmed via hand injection. Standard AP and
lateral views were obtained as well as high magnification transorbital and
oblique views and 3D rotational angiography. The catheter was withdrawn
into the innominate roadmap angiography was again performed. Under roadmap
guidance wire was reintroduced and selected into the right vertebral artery.
The catheter was advanced over the wire the wire was withdrawn. Vessel
patency was confirmed via hand injection. Standard AP and lateral views were
obtained catheter was withdrawn while maintaining the ___ hook. The
catheter is in selected into the left common carotid artery. Vessel patency
was confirmed via hand injection. Standard AP and lateral views were obtained
as well as high magnification transorbital and oblique views. Next the
diagnostic catheter was removed. The sheath was removed and the arteriotomy
was closed using a 6 ___ Angio-Seal. The patient was removed from the
fluoroscopy table and remained at his neurologic baseline without any evidence
of thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
Right common carotid artery, intracranial view: Vessel caliber smooth regular.
There is filling of the anterior middle cerebral arteries as well as their
distal territories. The ophthalmic artery is patent as is the posterior
communicating artery fills the posterior cerebral circulation as well as flash
fills into the basilar artery and contralateral posterior cerebral artery. No
aneurysms or AVMs are identified. Normal arterial, capillary, venous phase.
Right vertebral artery: Vessel caliber smooth regular. Is filling the right
posterior inferior cerebral artery with retrograde filling into the left
vertebral artery filling the left posterior inferior cerebellar artery which
has an extradural origin. Bilateral anterior-inferior cerebellar arteries
fill, bilateral superior cerebellar arteries and bilateral posterior cerebral
arteries and their distal territory. There is retrograde filling of the
bilateral posterior communicating arteries with flash filling the anterior
circulation. No aneurysms or AVMs are identified. Normal arterial,
capillary, venous phase.
Left common carotid artery, intracranial view: Vessel caliber smooth regular.
Is filling of the anterior middle cerebral arteries as well as their distal
territories. The ophthalmic artery is patent as is the posterior
communicating artery. No aneurysms or AVMs are identified. Normal arterial,
capillary, venous phase.
IMPRESSION:
Extradural origin left posterior inferior cerebellar artery
Negative cerebral angiogram for intracranial vascular lesion
RECOMMENDATION(S):
1.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman found with AMS and seizures, tSAH// evaluate
for structural lesion
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Head CT from ___. Neck CT from ___
obtained at an outside hospital.
FINDINGS:
There are 1-2 mm punctate areas of slow diffusion, 1 in the left cerebellum
(302:4) and others in the right frontal lobe (302:18, 19, 20). Subtle FLAIR
signal abnormality is appreciated on some of the areas. Chronic infarct in
the right cerebellum is again seen. Trace amount of subarachnoid hemorrhage
in the right sylvian fissure is best seen on the FLAIR sequence) 06:14). The
ventricles and sulci are stable in caliber and configuration. Scattered
periventricular subcortical and deep white matter hyperintensities on T2/FLAIR
weighted images are nonspecific, however likely due to chronic small vessel
ischemic disease in this age group. Hyperostosis frontalis is again seen.
3.0 cm left parotid hypointensity on sagittal T1 weighted imaging is better
seen on the neck CT from ___ (04:21). Partial empty sella is again
seen.
Mucosal thickening of the ethmoid air cells are mild. Aside from postsurgical
changes from bilateral lens replacements, the orbits are unremarkable.
IMPRESSION:
1. Punctate, 1-2 mm areas of slow diffusion in the left cerebellum likely
representing acute embolic strokes.
2. Focus of slow diffusion in the right frontal lobe in the periphery could be
due to subarachnoid blood or acute infarcts.
3. Trace amount of right sylvian fissure subarachnoid hemorrhage. No new or
enlarging hemorrhage.
4. 3.0 cm left parotid lesion, better seen on the neck CT from ___.
Differential includes pleomorphic adenoma and Warthin's tumor.
NOTIFICATION: The findings were discussed with ___. by ___
___, M.D. on the telephone on ___ at 4:17 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old woman with new NGT placement// NCT placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the endotracheal tube projects 3.6 cm from the carina and an
enteric tube projects over the stomach. The tip of a right PICC line projects
over the cavoatrial junction. Surgical clips project over the left axilla.
Low bilateral lung volumes. There is no new consolidation, pleural effusion
or pneumothorax. The size the cardiomediastinal silhouette is unchanged.
IMPRESSION:
The tip of the enteric tube projects over the stomach. Unchanged
cardiopulmonary findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with Seizures, SAH// Remains intubated, please
evaluate lung fields
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Support lines and tubes are unchanged. Cardiomediastinal silhouette is
stable. Lungs are low volume with mild pulmonary vascular congestion.
Surgical clips are seen in the left axilla. No pneumothorax is seen.
Radiology Report
EXAMINATION: Oropharyngeal swallowing videofluoroscopy
INDICATION: ___ year old woman with seizure found to have SAH now failed
swallow exam twice. requested video swallow by slp// swallow assessment
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 3 minutes 28 seconds
COMPARISON: None.
FINDINGS:
There was penetration with thin and nectar thick liquids, which cleared.
There was no evidence of aspiration. Mild vallecular residue was noted with
solids. A nasogastric tube is seen.
IMPRESSION:
1. No evidence of aspiration.
2. Penetration with thin and nectar thick liquids.
3. Mild vallecular residue with solids.
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: CHEST (PORTABLE AP)
INDICATION: ___ with altered mental status, intubated*** WARNING ***
Multiple patients with same last name!// assess for tube placement, assess for
ICH
TECHNIQUE: Portable AP chest
COMPARISON: None available.
FINDINGS:
An ETT is seen within the midthoracic trachea, at the level of the clavicles,
3.4 cm above the carina. Esophageal drainage tube ends in the upper stomach.
Mild perihilar edema surrounds central vascular congestion. No consolidation.
Cardiomediastinal silhouette is within normal limits. Left axillary surgical
clips are noted.
IMPRESSION:
ETT tip is 3.4 cm above the carina. Enteric tube tip is at least within the
stomach. ET tube in standard placement.
Borderline cardiac decompensation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with altered mental status, intubated*** WARNING ***
Multiple patients with same last name!// assess for tube placement, assess for
ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 8.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,706 mGy-cm.
COMPARISON: Head CT ___
FINDINGS:
The exam is motion degraded.
Subarachnoid hemorrhage is seen layering along the posterior right sylvian
fissure. There is no midline shift. The basal cisterns are patent. No
hydrocephalus. There is no evidence of acute infarction,edema, or mass. Mild
parenchymal atrophy. Small chronic right cerebellar infarct, similar.
There is no evidence of fracture. There is hyperostosis frontalis. The
visualized portion of the paranasal sinuses, mastoid air cells, and middle ear
cavitiesare essentially clear. The visualized portion of the orbits show
bilateral lens replacement.
A 2.4 x 1.7 cm left parotid gland mass.
IMPRESSION:
1. Acute subarachnoid hemorrhage right sylvian fissure.
2. Indeterminate 2.4 cm left parotid gland mass, ENT consult recommended.
RECOMMENDATION(S): ENT consult, left parotid mass
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with SAH, ___ of gag reflex// ?in SAH 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 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Same day head CT, same day reference CTA.
FINDINGS:
Study somewhat limited secondary to streak artifact, potentially related to
leads placed on the patient.
Re-demonstrated subarachnoid hemorrhage layering along the posterior right
sylvian fissure, unchanged. There is no midline shift. The basal cisterns
are patent. No hydrocephalus. There is no evidence of acute infarction,
edema, or mass. Mild parenchymal atrophy. Small chronic right cerebellar
infarct, unchanged.
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.
Re-demonstrated partially imaged indeterminate 2.4 x 1.7 cm left parotid gland
mass.
IMPRESSION:
1. Re-demonstrated subarachnoid hemorrhage layering along the posterior right
sylvian fissure, unchanged from prior head CT. No new bleed.
2. Re-demonstrated partially imaged indeterminate 2.4 cm left parotid gland
mass. As reported on prior, ENT evaluation advised.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Seizure, Transfer
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus, Weakness, Nontraumatic subarachnoid hemorrhage, unspecified, Urinary tract infection, site not specified, Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UA
level of acuity: 1.0 | Ms. ___ is a ___ year-old woman with diabetes, HTN, and HLD
who presented from ___ after she was found down with
left sided weakness, aphasia, and forced left gaze followed by
convulsions consistent with GTC.
#Neuro: Subarrachnoid hemorrhage with GTC:
At OSH stroke code called followed by telestroke. While on
telestroke, observed to have GTC. She was given Ativan with
resolution, loaded with fosphenytoin, and given IV labetalol for
SBP >220. She was intubated and transferred to BI. Initial CT
head showed no hemorrhage. Repeat head CT in ICU showed she had
a right frontal subarachnoid hemorrhage in the right sylvian
fissure. CTA negative for any large vessel occlusion.
Conventional angio done with no vascular malformation found. MRI
done with no evidence of metastatic disease given history of
breast cancer. She was hooked up to EEG with no further
epileptiform discharged. She was started on keppra 750mg BID for
further seizure prevention. Etiology likely underlying CAA
causing SAH which then led to seizure. She was transferred out
of the ICU to the floor. Initially issues passing swallow study
therefore requiring NG feeds for a few days. Video swallow was
passed and diet was advanced. She continued to improve with ___
and OT on the floor and was deemed ready for DC to ___
rehab.
#Uncontrolled Diabetes:
While in the ICU she was put on an insulin drip given
uncontrolled blood glucose. She was transitioned to standing
glargine dose with Joseline Diabetes team following closely.
Glargine dose with increased periodically given persistently
elevated blood glucose.
#HTN:
Elevated BPs above 200 and nicardapine drip in ICU. BPs
regulated and home losartan restarted at 50 then increased to
100. Coreg added for additional BP control.
# UTI:
found to have leukocytosis while in ICU. Started on CTX
empirically. Found to have an E. coli UTI. Switched to
nitrofurantoin and completed a 7 day course.
# vaginal discharge:
found to have significant vaginal discharge while in ICU.
Started on 7 day course of
miconazole nitrate vaginal cream. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
LLE Erythema/Hypotension
Major Surgical or Invasive Procedure:
R IJ central line placement
History of Present Illness:
The patient is a ___ with a history of HTN, atrial fib/flutter
s/p pacemaker, and multiple DVTs on lifelong coumadin who
presents with right lower leg erythema, swelling, and pain that
began earlier this evening. He was in his usual state of health
until this subacute pain began, and he later described an
intense cold feeling as well as trembling. This prompted an ED
visit.
.
He immediately triggered on admission to the ED with a BP of
63/38, though he was otherwise afebrile with tachycarida to 100.
His BP was checked several times in the left arm, yielding
___ on each of these assays. He states that he's had
similar swelling and pain before, and that he had to do "shots
in the belly." He maintained normal mentation throughout. Labs
were notable for bandemia to 19%, lactate to 2.9, ___ to cr 1.6,
and an INR of 3.6. Trauma ultrasound revealed no bleed. CTA
chest revealed no massive PE, and no intraabdominal acute
pathology. CVL was placed and he was resuscitated with 4LNS.
Got one gram vancomycin. Placed on low dose norepinephrine with
bolstering of pressure to mid-90s systolic prior to transfer.
.
Upon arrival to the MICU, his initial vitals were T:96.3
BP:99/43 P:78 R:22 O2: 99RA. He is currently in no pain and has
no complaints. He claims to have been asymptomatic during his
hypotension, though his wife found him to be more confused than
usual. With regard to his RLE erythema, he denies previous
episodes of cellulitis. He has baseline edema without erythema
or pain bilaterally. He also mentioned urinary frequency over
the preceding ___ days without dysuria or hematuria.
Past Medical History:
1. Hypertension.
2. Osteoarthritis.
3. Benign prostatic hypertrophy status post transurethral
resection of the prostate.
4. Status post hernia repair.
5. History of depression.
Social History:
___
Family History:
NC
Physical Exam:
Vitals: T:96.3 BP:99/43 P:78 R:22 O2: 99RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD, no JVD appreciated
CV: Regular rate and rhythm, normal S1 + S2, ___ SEM at the
right ___ ICS
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: +foley
Ext: diffuse erythema and warmth encompassing the right leg from
ankle to tibial tuberosity. Tender to touch. Neuro: CNII-XII
intact, ___ strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred,
finger-to-nose intact
Pertinent Results:
Labs on admission and dc:
___ 12:54AM BLOOD WBC-8.2 RBC-4.30* Hgb-13.4* Hct-38.1*
MCV-89 MCH-31.2 MCHC-35.2* RDW-14.1 Plt ___
___ 12:54AM BLOOD Neuts-74* Bands-19 ___ Monos-4 Eos-0
Baso-0 ___ Myelos-0
___ 08:05AM BLOOD WBC-5.9 RBC-3.92* Hgb-11.8* Hct-37.0*
MCV-94 MCH-30.1 MCHC-31.8 RDW-13.9 Plt ___
___:54AM BLOOD ___ PTT-29.7 ___
___ 08:05AM BLOOD ___ PTT-30.9 ___
___ 12:54AM BLOOD Glucose-218* UreaN-32* Creat-1.6* Na-136
K-3.2* Cl-102 HCO3-23 AnGap-14
___ 08:05AM BLOOD Glucose-258* UreaN-28* Creat-1.2 Na-139
K-4.5 Cl-99 HCO3-32 AnGap-13
___ 03:56 Red Clear 1.034
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
___ 03:56 LG NEG TR NEG TR NEG NEG 5.0 TR
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
___ 03:56 >182* 112* FEW NONE 1
Imaging:
TTE ___:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. 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. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: Normal regional and global biventricular systolic
function. No significant valvular abnormality seen. Anterior
echo-lucent space may be due to a loculated pleural effusion or
a pericardial cyst. No evidence of tamponade.
CTA ___:
IMPRESSION:
1. Suboptimal contrast bolus with mixing artifact limits
evaluation for PE.
Within this limitation, there is no evidence of central
pulmonary embolism.
2. No acute aortic injury.
3. Approximate 9.3 cm x 3.2 cm x 7.5 cm anterior mediastinal
cystic lesion
without enhancement and with fluid density and extending to the
base of the
heart. This is most consistent with a pericardial cyst.
4. Right adrenal lesion, previously characterized as myelolipoma
or adenoma,
is unchanged since ___.
5. Uncinate process small cystic lesions as above, unchanged
since prior
examination, likely represents a small focus of side branch
IPMN.
6. Persistent cholelithiasis.
7. Unchanged fat-containing left inguinal hernia.
8. Unchanged enlarged prostate.
9. Small hiatal hernia.
___ ___:
IMPRESSION: No right lower extremity DVT.
Medications on Admission:
BUPROPION HCL - 75 mg Tablet - 1 Tablet(s) by mouth once a day
DIAZEPAM - (Prescribed by Other Provider; takes PRN only) - 10
mg Tablet - 1 Tablet(s) by mouth once a day as needed for only
PRN
DORZOLAMIDE-TIMOLOL [COSOPT] - 0.5 %-2 % Drops - 1 ggts od twice
a day
DOXAZOSIN - 2 mg Tablet - 2 Tablet(s) by mouth at bedtime
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth once
a day dispense tablet only
LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 %
Drops - 1 gtt once a day
LISINOPRIL - 10 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
WARFARIN [___] - 4 mg Tablet - 1 Tablet(s) by mouth once a
day extra ___ tab 3 days per week
Discharge Medications:
1. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic BID (2 times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. doxazosin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
7. diazepam 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. Keflex ___ mg Capsule Sig: One (1) Capsule PO three times a
day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
10. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO ___
___: in addition to 4mg tablet for total of 6mg.
12. Outpatient Lab Work
CBC, INR and Chem 7 on ___ and results to be faxed to
___.
Phone: ___
Fax: ___
13. potassium chloride 20 mEq Packet Sig: One (1) PO once a day
for 7 days.
Disp:*7 packets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Septic shock due to cellulitis and urinary tract
infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with hypertension, history of DVT, evaluate for
PE or other acute process. Please note that attending Dr. ___
requested emergent CT, pending creatinine results.
COMPARISON: None.
TECHNIQUE: MDCT axial images were obtained through the chest with the
administration of IV contrast. Multiplanar reformats were generated and
reviewed. MDCT axial images were also obtained through the abdomen and pelvis
using contrast from CTA runoff.
FINDINGS: The trachea and central airways are patent. Minimal dependent
atelectasis. Small left lower lobe calcified granuloma. No pleural effusion.
No pericardial fluid. Mildy enlarged heart size. Left sided dual lead
pacemaker with leads in the right atrium and right ventricle. Coronary artery
calcifications and aortic arch calfications. Normal three vessel take off.
Mildly ectatic ascending thoracic aorta. Normal caliber descending thoracic
aorta. No aneurysm or dissection.
Minimal foci of air are noted within the right IJ vein and likely bilateral
subclavian vein branches secondary to injection. Suboptimal contrast bolus,
wich limits the evaluation of the segmental and subsegmental pulmonary
arteries. However there is no evidence of central pulmonary embolism. Normal
caliber main pulmonary artery.
An approximate 9.3 cm x 3.2 cm x 7.5 cm anterior mediastinal cystic structure
lesion with no enhancement and with fluid density is seen and extends to the
base of the heart. This is most consistent with a pericardial cyst.
The visualized thyroid is normal. No supraclavicular, axillary, hilar, or
mediastinal lymphadenopathy. A small hital hernia is noted.
Unchanged too small to characterize low attenuation lesions within the liver,
for example, a 13 x 11 mm lesion in the right lobe of the liver (3B, 119). No
intrahepatic or extrahepatic bile duct dilation. The gallbladder is contracted
and again demontrates gallstones. The spleen appears normal in size and
configuration. Unchanged small cystic lesions within the uncinate process of
the pancreas (3B, 135) appears similar to ___ and may connect with
the main pancreatic duct; this may represent a small focus of side branch
IPMN.
2.2 x 2 cm right adrenal nodule is unchanged in size and appearance compared
to ___ and was previously characterized as a myelolipoma versus
adenoma. The left adrenal gland appears normal. Both kidneys enhance and
excrete contrast symmetrically without evidence of hydronephrosis or renal
calculi. Too small to charaxterize low attenuation lesion in the lower pole
of the left kidney is unchanged and likely a cyst. The distal ureters are
within normal limits. The bladder is underdistended. The prostate is again
enlarged, measuring 5.7 x 5.2 cm.
The large and small bowel are within normal limits. There is no free air or
free fluid. No lymphadenopathy. Unchanged small retroperitoneal soft tissue
nodules. The visualized vessels are patent. There is a fat-containing left
inguinal hernia.
No aggressive osseous lesions. Multiple degenerative changes are noted within
the visualized lumbar spine, most prominent at L4-L5 where there is complete
loss of disc height and near fusion, progressed.
IMPRESSION:
1. Suboptimal contrast bolus with mixing artifact limits evaluation for PE.
Within this limitation, there is no evidence of central pulmonary embolism.
2. No acute aortic injury.
3. Approximate 9.3 cm x 3.2 cm x 7.5 cm anterior mediastinal cystic lesion
without enhancement and with fluid density and extending to the base of the
heart. This is most consistent with a pericardial cyst.
4. Right adrenal lesion, previously characterized as myelolipoma or adenoma,
is unchanged since ___.
5. Uncinate process small cystic lesions as above, unchanged since prior
examination, likely represents a small focus of side branch IPMN.
6. Persistent cholelithiasis.
7. Unchanged fat-containing left inguinal hernia.
8. Unchanged enlarged prostate.
9. Small hiatal hernia.
Findings discussed with Dr. ___ at 1:53 am on ___ via telephone.
Radiology Report
AP CHEST, 3:13 A.M., ___
HISTORY: Line placement.
IMPRESSION: AP chest reviewed in the absence of recent prior chest
radiographs:
Right internal jugular line tip projects over the mid SVC. No pneumothorax,
mediastinal widening or pleural effusion. Lungs grossly clear. Heart size
normal. Transvenous right atrial and right ventricular pacer leads in
standard placement.
Radiology Report
INDICATION: Shortness of breath and worsening wheezing, assess for worsening
pulmonary edema.
COMPARISON: Chest radiographs on ___, and CTA chest on ___.
FINDINGS: PA and lateral views of the chest. Transvenous right atrial and
right ventricular pacer leads are in standard placement. The right internal
jugular line tip projects over the mid SVC. Lungs are grossly clear. There
are small bilateral pleural effusions. No pulmonary edema. The cardiac,
mediastinal, and hilar contours are normal.
IMPRESSION:
1. Bilateral pleural effusions.
2. No evidence of pulmonary edema. No focal consolidations.
Radiology Report
INDICATION: Cellulitis and persistent edema, assess for DVT.
TECHNIQUE: Non-invasive right lower extremity venous evaluation.
COMPARISONS: Right lower extremity Doppler ___.
FINDINGS: Grayscale and color Doppler sonography of the right lower extremity
was performed demonstrating normal compressibility and flow in the common
femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins
without evidence of DVT.
IMPRESSION: No right lower extremity DVT.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RLE REDDNESS
Diagnosed with HYPOTENSION NOS, ATRIAL FLUTTER, CELLULITIS OF LEG
temperature: 98.5
heartrate: 100.0
resprate: 18.0
o2sat: 96.0
sbp: 63.0
dbp: 38.0
level of pain: 8
level of acuity: 1.0 | Assessment and Plan: Mr. ___ is a ___ with afib/flutter,
and ?previous DVTs who presents with RLL pain/erythema and who
was found to be profoundly hypotensive with bandemia and ___.
# SEPTIC SHOCK: Felt to be due to cellulitis and possible UTI.
Received ~ 8 liters NS for fluid resuscitation and was on
norepinephrine briefly. Started on vanc/cefepime for cellulitis
and presumed UTI. Urine culture was negative, but tx for seved
days with Ciprofloxacin as culture was obtained after antibiotic
administration. He remained in intensive care unit overnight
only.
# Cellulitis. Initially well responded to vancomycin, however
given negatie nasal swab and no evicence of abcess, was changed
to ___ was negative.
Slow but steady improvement in erytheme and induration was made
and he was transition to PO Keflext on ___. He was diuresed
with lasix for lower extremity edema and was discharged on a
week's course of lasix. ACE bandages are to be applied on daily
basis at time of discharge.
# ACUTE KIDNEY INJURY: due to hypoperfusion. Improved to 1.2
(baseline 1.1 with IVF). Lisinopril was held at discharge until
patient completes course of lasix at which point it can be
reinstituted. HCTZ was likewise held at discharge.
# ATRIAL ARRHYTHMIA: has both atrial flutter and fibrillation
patterns in previous EKGs/telemetry. According to cards notes,
spends about 35% time in atrial arrhythmia. During his ICU
stay, he remained often in atrial fibrillation although
occasionally was atrial paced or venticular paced. As patient
was diuresed his rate normalized and he remained in SR vast
majority of the time. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Gleevec / ciprofloxacin / clindamycin / amiodarone / diltiazem /
Januvia / Dronaderone
Attending: ___.
Chief Complaint:
Failure to thrive, weakness
Major Surgical or Invasive Procedure:
R IJ CVL ___, swapped for PA line ___
L IJ HD line ___
History of Present Illness:
___ year old female with atrial fibrillation on apixaban, CML in
remission, DMII, CVA with left hemianopia, HTN, PVD s/p
bilateral lower extremity interventions, and history of C diff
who presents with generalized malaise, weakness, and poor PO
intake.
Patient reports several episodes of significant diarrhea 4 days
ago for which she took Immodium and had improvement in symptoms,
though continues to have loose stools. Approximately 3 days ago
she began feeling significant fatigue, lethargy, weakness, and
poor PO intake and feels as though she became dehydrated. She
denies fevers, chills, nausea, vomiting, cough, rhinorrhea over
this time.
Evaluation in the ED was notable for initial tachycardia to 110
with BPs 93/70. Patient was afebrile and otherwise
hemodynamically stable. Labs were notable for no leukocytosis,
transaminitis (AST 50, ALT 72), Na 127, bicarb 18 (AGAP 15),
BUN/Cr 41/1.5 (baseline Cr 0.8), and lactate 5.1 --> 4.6 --> 4.0
with IVF. Influenza PCR was negative. UA was inconsistent with
UTI.
CXR showed bilateral pleural effusions without other acute
cardiopulmonary processes. NCHCT showed no acute intracranial
abnormalities. ECG showed atrial fibrilaltion with known LBBB
and without signs of acute ischemia (trops negative x2).
Patient received 1L LR and started on 1L of NS in the ED with
improvement in her lactate. She was then admitted to medicine
for failure to thrive.
Of note she had a recent hospitalization in ___ with atrial
fibrillation with RVR for which she had a PPM placed and was
started on amiodarone.
Upon arrival to the floor, the patient endorses the above. She
reports feeling much better since being admitted.
REVIEW OF SYSTEMS: A 10-point ROS was taken and is negative
except otherwise stated in the HPI.
Past Medical History:
- Atrial fibrillation s/p multiple DCCV and PPM
- CML
- Hypertension
- Hyperlipidemia
- Type II diabetes mellitus
- PVD status post right anterior tibial PCI and popliteal stent
- HFpEF
Social History:
___
Family History:
Father with CAD, died in ___. Mother with CVA in ___. Sister
with lung problems. Grandmother with uterine or ovarian cancer.
No family history of sudden cardiac death.
Physical Exam:
PHYSICAL EXAM:
VITALS: T 97.3 BP 105/77 HR 93 RR 16 SpO2 96% RA
General: Alert, oriented, no acute distress
HEENT: Dry mucous membranes, oropharynx clear, EOMI, PERRL
CV: Irregularly irregular. Normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis. 1+
pitting edema in the shins bilaterally.
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1132)
Temp: 97.7 (Tm 98.0), BP: 101/62 (99-113/62-69), HR: 80
(80-82), RR: 18 (___), O2 sat: 97% (95-97), O2 delivery: RA
I/O: ___: Net - 300cc, ___: Net -1415cc
Telemetry: V-paced
GENERAL: NAD
HEENT: NC/AT, sclera anicteric
NECK: Supple, JVP 10cm on sitting upright
CARDIAC: RRR, no murmurs, rubs, or gallops
LUNGS: CTAB, no crackles
ABDOMEN: Soft, non-tender, non-distended, +BS
EXTREMITIES: warm, trace pitting edema b/l lower extremities
SKIN: ecchymoses but no rashes.
NEURO: AxOx3, follows commands, moves all extremities
anti-gravity
Pertinent Results:
ADMISSION LABS:
===========
___ 06:35PM BLOOD WBC-8.6 RBC-4.39 Hgb-12.4 Hct-39.9 MCV-91
MCH-28.2 MCHC-31.1* RDW-18.6* RDWSD-60.8* Plt ___
___ 06:35PM BLOOD Neuts-85.3* Lymphs-6.4* Monos-6.3 Eos-1.3
Baso-0.2 NRBC-0.3* Im ___ AbsNeut-7.38* AbsLymp-0.55*
AbsMono-0.54 AbsEos-0.11 AbsBaso-0.02
___ 06:35PM BLOOD ___ PTT-32.0 ___
___ 06:35PM BLOOD Glucose-225* UreaN-47* Creat-1.5* Na-127*
K-5.4 Cl-94* HCO3-18* AnGap-15
___ 06:35PM BLOOD ALT-72* AST-50* AlkPhos-125* TotBili-1.1
___ 06:35PM BLOOD cTropnT-<0.01
___ 09:59PM BLOOD cTropnT-<0.01
___ 06:35PM BLOOD Lipase-15
___ 06:35PM BLOOD Albumin-3.6 Calcium-8.6 Phos-4.7* Mg-1.6
___ 06:48PM BLOOD Lactate-5.1*
___ 07:34PM BLOOD Lactate-4.6*
___ 10:33PM BLOOD Lactate-4.0
___ 08:55PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 10:55PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG* pH-7.0 Leuks-NEG
INTERVAL LABS:
==========
___ 06:45PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 06:45PM URINE Blood-TR* Nitrite-POS* Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-LG*
___ 06:45PM URINE RBC-11* WBC-79* Bacteri-FEW* Yeast-NONE
Epi-<1
___ 06:45PM URINE CastHy-42*
___ 06:45PM URINE 3PhosX-FEW
___ 01:26PM URINE Hours-RANDOM UreaN-995 Creat-71 Na-<20
___ 01:26PM URINE Osmolal-596
DISCHARGE LABS:
============
___ 05:57AM BLOOD WBC-6.8 RBC-3.27* Hgb-9.1* Hct-28.7*
MCV-88 MCH-27.8 MCHC-31.7* RDW-19.2* RDWSD-60.4* Plt ___
___ 05:57AM BLOOD ___
___ 05:57AM BLOOD Glucose-123* UreaN-26* Creat-0.9 Na-133*
K-3.7 Cl-93* HCO3-29 AnGap-11
MICROBIOLOGY:
=============
___ Blood Culture: Blood Culture, Routine (Final ___:
NO GROWTH.
___ Urine Culture:
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
___ Urine Culture:
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ Blood Culture:
Blood Culture, Routine (Final ___: NO GROWTH.
___ Blood Culture:
Blood Culture, Routine (Final ___: NO GROWTH.
___ Blood Culture:
Blood Culture, Routine (Final ___: NO GROWTH.
___ Blood Culture:
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
======
CXR ___
Small bilateral pleural effusions. No other acute
cardiopulmonary process
CT HEAD NONCONTRAST ___
1. No acute intracranial abnormalities.
2. Unchanged appearance of right temporo-parieto-occipital
encephalomalacia with ex vacuo dilatation of the right lateral
ventricle.
CT A/P WITHOUT CONTRAST ___
1. Persistent nonspecific mild wall thickening of the ascending
colon. The remainder of the colon is unremarkable.
2. Findings of volume overload, with new bilateral small pleural
effusions, diffuse retroperitoneal edema which has slightly
worsened, and anasarca of the body wall.
3. Reflux of contrast into the IVC and hepatic veins suggests
right-sided
heart failure. Cardiomegaly.
4. Sigmoid diverticulosis without evidence of acute
diverticulitis.
CXR ___:
No evidence of pulmonary edema. Small bilateral pleural
effusions. Enlargement of the cardiac silhouette, unchanged
TTE ___:
VSCAN CONCLUSION: There is visual left ventricular dyssnchrony.
Overall left ventricular systolic function is moderately
depressed. The visually estimated left ventricular ejection
fraction is 30%. Dilated right ventricular cavity. Intrinsic
right ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. There is abnormal
interventricular septal motion c/w combination IVCD and RV
volume overload. The mitral valve leaflets appear structurally
normal. There is moderate [2+] mitral regurgitation. The
tricuspid valve leaflets appear structurally normal. There is an
eccentric, interatrial sepal directed jet of moderate to severe
[3+] tricuspid regurgitation. There is no pericardial
effusion. Compared with the prior TTE (images reviewed) of
___ , biventricular systolic function decreased, more
tricuspid regurgitation, slightly more mitral regurgitation,
septal motion abnormal (RV volume overload and IVCD).
Abdominal Ultrasound ___:
1. Cholelithiasis without evidence of cholecystitis. No biliary
dilation.
2. Patent portal vein.
3. Bilateral small pleural effusions and trace ascites.
TTE ___:
CONCLUSION: The left atrial volume index is mildly increased.
The right atrium is moderately enlarged. The estimated right
atrial pressure is >15mmHg. There is normal left ventricular
wall thickness with a normal cavity size. Overall left
ventricular systolic function is severely depressed secondary to
direct ventricular interaction with a markedly pressure/volume
overloaded right ventricle. The visually estimated left
ventricular ejection fraction is 25%. There is no resting left
ventricular
outflow tract gradient. Normal right ventricular cavity size
with depressed free wall motion. Intrinsic right ventricular
systolic function is likely lower due to the severity of
tricuspid regurgitation. There is
abnormal interventricular septal motion c/w right ventricular
pressure and volume overload. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal with a normal
descending aorta diameter. The main pulmonary artery is dilated.
The aortic valve leaflets (3) are mildly thickened. 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
moderate to severe [3+] mitral regurgitation. The pulmonic valve
leaflets are normal. The tricuspid valve leaflets are mildly
thickened. There is SEVERE [4+] tricuspid regurgitation. Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be UNDERestimated. There is mild pulmonary artery systolic
hypertension. In the setting of at least moderate to severe
tricuspid regurgitation, the pulmonary artery systolic pressure
may be UNDERestimated. There is a trivial pericardial effusion.
A left pleural effusion is present.
Compared with the prior TTE (images reviewed) of ___ ,
tricuspid regurgitation is now frankly severe with marked right
ventricular pressure and volume overload severely compromising
left ventricular function by direct ventricular interaction.
___ RHC:
Elevated left and right heart filling pressures
Cardiogenic shock.
Moderate pulmonary hypertension
___ TEE:
CONCLUSION: There is no spontaneous echo contrast or thrombus in
the body of the left atrium/left atrial appendage. The left
atrial appendage ejection velocity is mildly depressed. No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium/right atrial appendage. There is no evidence for an
atrial septal defect by 2D/color Doppler. Overall left
ventricular systolic function is depressed. The right ventricle
has depressed free wall motion. The aortic valve leaflets (3)
appear structurally normal. No masses or vegetations are seen on
the aortic valve. No abscess is seen. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. No masses or vegetations
are seen on the mitral valve. No abscess is seen. There is a
central jet of mild [1+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. No mass/vegetation
are seen on the tricuspid valve. No abscess is seen. There is an
eccentric jet of moderate [2+] tricuspid regurgitation. Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be
UNDERestimated. There is mild-moderate pulmonary artery systolic
hypetension. A left pleural effusion is present.
IMPRESSION: No intracardiac thrombus seen. Depressed
biventricular systolic function. Mild mitral regurgitation. At
least moderate tricuspid regurgitation. Mild pulmonary
hypertension. Compared with the prior TEE ___ , the
biventricular systolic function is now more depressed.
Other findings are similar.
___ AVJ abl. junctional escape at 40 bpm. Consider BiV
upgrade in future
___ TTE:
The left atrial volume index is SEVERELY increased. There is
mild symmetric left ventricular hypertrophy with a normal cavity
size. There is moderate regional left ventricular systolic
dysfunction with akinesis of the anterior septum and anterior
walls and apex and hypokinesis of the inferior septum and
inferior walls (see schematic) and preserved/normal
contractility of the remaining segments. Quantitative biplane
left ventricular ejection fraction is 35 %. Normal right
ventricular cavity size
with normal free wall motion. There is abnormal septal motion
c/w conduction abnormality/paced rhythm. The aortic valve
leaflets (3) are mildly thickened. The mitral valve leaflets are
mildly thickened.
There is mild [1+] mitral regurgitation. There is mild to
moderate [___] tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is high normal. A left pleural effusion
is present.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and moderate regional dysfunction most c/w
multivessel CAD. Mild mitral regurgitation. Mildmoderate
tricuspid regurgitation. High normal estimated pulmonary artery
systolic pressure.
Compared with the prior TTE (images reviewed) of ___ ,
the severity of mitral regurgitation, tricuspid regurgitation
and estimated PA systolic pressure are now lower and left
ventricular systolic function is slightly improved
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY heart disease
2. Atorvastatin 80 mg PO QPM
3. Cyanocobalamin 250 mcg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Metoprolol Succinate XL 100 mg PO BID
6. MetFORMIN (Glucophage) 850 mg PO BID
7. Amiodarone 200 mg PO DAILY
8. Apixaban 5 mg PO BID
9. amLODIPine 2.5 mg PO DAILY
Discharge Medications:
1. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Miconazole Powder 2% 1 Appl TP TID:PRN rash
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all
dressing changes
7. Senna 17.2 mg PO HS
8. Spironolactone 25 mg PO DAILY
9. Torsemide 40 mg PO DAILY
10. Apixaban 5 mg PO BID
11. Aspirin 81 mg PO DAILY heart disease
12. Cyanocobalamin 250 mcg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Atorvastatin 80 mg PO QPM This medication was held.
Do not restart Atorvastatin until your liver function tests
normalize.
15. HELD- MetFORMIN (Glucophage) 850 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until your
doctor tells you to do so.
16. HELD- Metoprolol Succinate XL 100 mg PO BID This medication
was held. Do not restart Metoprolol Succinate XL until your
doctor tells you to do so.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
HFrEF exacerbation
Secondary Diagnoses:
Acute renal failure
Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with atrial fibrillation (on apixaban), CML,type II diabetes
mellitus, CVA with left hemianopia, HTN, PVDstatus post right anterior tibial
PCI and right popliteal ___, and history of C. difficile
infection.here with lethargy// infection, fluid
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
Lungs appear clear without focal consolidation. There is no pulmonary edema,
or pneumothorax. Small bilateral pleural effusions are noted. A left-sided
pacemaker is seen with transvenous leads in the right atrium and right
ventricle. The cardiomediastinal silhouette and hilar contours are unchanged.
IMPRESSION:
Small bilateral pleural effusions. No other acute cardiopulmonary process
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with lethargy on anticoagulation// bleed, mass
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, 16.1 cm; CTDIvol = 50.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MRI and MRA brain from ___
FINDINGS:
There is encephalomalacia in the right temporo-parieto-occipital region,
unchanged. There is no evidence of acute major vascular territory
infarction,hemorrhage,edema,or mass. There is prominence of the ventricles
and sulci suggestive of involutional changes. There is mild ex vacuole
dilatation of the right lateral ventricle. Atherosclerotic calcifications are
seen in both carotid siphons.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormalities.
2. Unchanged appearance of right temporo-parieto-occipital encephalomalacia
with ex vacuo dilatation of the right lateral ventricle.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with hx proctocolitis who presents with
diarrhea and severe dehydration, ___// any e/o 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 0.5 s, 1.0 cm; CTDIvol = 0.3 mGy (Body) DLP = 0.3
mGy-cm.
2) Stationary Acquisition 5.0 s, 1.0 cm; CTDIvol = 8.3 mGy (Body) DLP = 8.3
mGy-cm.
3) Spiral Acquisition 14.5 s, 44.5 cm; CTDIvol = 7.2 mGy (Body) DLP = 311.4
mGy-cm.
4) Spiral Acquisition 2.4 s, 7.2 cm; CTDIvol = 8.5 mGy (Body) DLP = 50.1
mGy-cm.
Total DLP (Body) = 384 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions, new since prior.
There is cardiomegaly. There is reflux of contrast into the IVC and hepatic
veins. No pericardial effusion. Mild bibasilar atelectasis. Calcified
granuloma is again noted in the right lower lobe.
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. There is vicarious excretion of contrast
into the gallbladder. Gallbladder contains small stones in the fundus without
evidence of gallbladder wall thickening or adjacent fat stranding.
PANCREAS: There is moderate diffuse atrophy of the pancreas. There is no main
ductal dilatation.
SPLEEN: The spleen is normal in size and homogeneous in attenuation.
ADRENALS: Bilateral adrenal glands are normal size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Distension of small bowel
loops with VoLumen is suboptimal, but there is no gross evidence of wall
thickening or inflammation. There is persistent nonspecific mild wall
thickening of the ascending colon, similar to prior. Adjacent pericolonic fat
stranding is likely related to more diffuse retroperitoneal edema in the
setting of volume overload. Apparent mild focal wall thickening of the rectum
is likely due to underdistention (8; 60). Diverticulosis of the sigmoid colon
is noted, without evidence of wall thickening and fat stranding. The appendix
is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of presacral fluid.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is mild diffuse retroperitoneal edema,, right greater than
left, slightly worsened from prior. 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. The celiac artery, SMA, and ___ are patent. Bilateral
renal arteries are patent, with high-grade stenoses at the bilateral ostia
secondary to atherosclerotic plaque.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: An umbilical hernia containing fat is noted. There is diffuse
anasarca of the body wall, increased compared to prior. Re-demonstration of
the 1.8 cm hyperdense lesion in the left perineum adjacent to the vaginal
introitus, similar to prior, likely a Bartholin's cyst.
IMPRESSION:
1. Persistent nonspecific mild wall thickening of the ascending colon. The
remainder of the colon is unremarkable.
2. Findings of volume overload, with new bilateral small pleural effusions,
diffuse retroperitoneal edema which has slightly worsened, and anasarca of the
body wall.
3. Reflux of contrast into the IVC and hepatic veins suggests right-sided
heart failure. Cardiomegaly.
4. Sigmoid diverticulosis without evidence of acute diverticulitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cardiogenic shock// evidence of volume
overload
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
A left chest wall dual lead pacemaker is present. The size of the cardiac
silhouette is enlarged but unchanged. There is no evidence of pulmonary
edema. The left costophrenic angle is not well visualized however small
bilateral pleural effusions are suspected. No pneumothorax or focal
consolidation.
IMPRESSION:
No evidence of pulmonary edema. Small bilateral pleural effusions.
Enlargement of the cardiac silhouette, unchanged
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with LFTs up to the 1000s// evaluation for PVT
or etiology for LFTs to the 1000s
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___.
Abdominal CT from ___.
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 ascites. Bilateral pleural
effusions are small.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm
GALLBLADDER: Stones and sludge without gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 7.6 cm
KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There is no evidence of masses, stones, or hydronephrosis
in the kidneys. The bladder contains a Foley catheter and is decompressed.
There is trace right perinephric fluid.
Right kidney: 10.3 cm
Left kidney: 10.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis. No biliary dilation.
2. Patent portal vein.
3. Bilateral small pleural effusions and trace ascites.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with HF, AF, volume overload, now with R CVL
placed// line placement Contact name: ___: ___
IMPRESSION:
In comparison with the study of ___, there is an placement of right IJ
catheter. The precise position of the tip is difficult to demonstrate, though
it appears to be in the lower SVC. No evidence of post procedure
pneumothorax.
The continued substantial enlargement of the cardiac silhouette with some
elevation of pulmonary venous pressure and left pleural effusion with volume
loss in the left lower lobe. No evidence of acute focal pneumonia.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with HF, PPM and R IJ CVL already in place.//
s/p L IJ CVL placement, CXR for confirmation Contact name: ___,
___: ___
TECHNIQUE: Chest portable AP
COMPARISON: Multiple prior chest radiographs, most recently ___ at
15:23
FINDINGS:
Interval placement of a left internal jugular approach dual lumen dialysis
catheter which terminates near the cavoatrial junction behind the pacer
leads. Stable appropriately positioned right internal jugular central venous
catheter. No pneumothorax. There has been interval improved aeration of the
lungs and decreased pulmonary edema. Small left greater than right pleural
effusions are likely stable. Redemonstrated moderate cardiomegaly.
IMPRESSION:
1. Left internal jugular dialysis catheter terminates in the upper right
atrium near the cavoatrial junction. No pneumothorax.
2. Improved pulmonary edema. Stable small left greater than right pleural
effusions and moderate cardiomegaly.
NOTIFICATION: The findings were discussed with the clinical team, M.D. by
___, M.D. on the telephone on ___ at 12:31 am, 2 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Failure to thrive, Weakness
Diagnosed with Adult failure to thrive
temperature: 97.8
heartrate: 110.0
resprate: 20.0
o2sat: 95.0
sbp: 93.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is an ___ year old female with atrial fibrillation
on apixaban s/p multiple DCCVs and recent PPM placement, CML in
remission, DMII, CVA with left hemianopia, HTN, PVD s/p
bilateral lower extremity interventions, and history of C diff
who presents with diarrhea, generalized malaise, weakness, and
poor PO intake and was found to have heart failure exacerbation
and uncontrolled afib. She was treated in CCU for cardiogenic
shock and renal failure with improvement in cardiac function and
hemodynamics. She will be discharged to rehab for treatment of
deconditioning. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left pleuritic chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ Hx of IVDU and migraines, who had presented ___ w/
serratia bacteremia and aortic valve vegetations causing severe
AR, s/p Aortic Valve replacement (___) and
discitis/osteomyelitis on MRI (___), currently on 8xwk course
of Meropenem/Gent (through ___, re-presenting today w/ L
pleuritic chest pain, found to have PE on chest CTA (w/ negative
___.
Pt presented in ___ to OSH w/ migraines, fevers, and
evidence of endocarditis. Cultures taken at the OSH grew
serratia bacteremia while a TEE demonstrated aortic valve
vegetation and an aortic annular abscess causing aortic sinus
dilation. In addition, the TEE noted severe Aortic Regurg,
additional vegetations on the tricuspid valve, and evidence of
septic emboli to the brain and extremities.
Pt was transferred to ___ where an MRI of brain confirmed
septic emboli. He had a non-focal neuro exam and was mentating
well. Pt complained of significant lower back pain, and an
MR-spine showed disc protrusion at L4-L5 w/ thecal sac and nerve
root compression, yet no spine-infection.
The pt subsequently developed heart failure and pulm edema while
hospitalized. On ___, pt underwent aortic root
replacement at ___ w/ 25 mm ___ Freestyle aortic root
bioprosthesis as well as drainage of aortic root abscess.
Intra-operative cultures confirmed serratia GNR's. Per ID team,
pt was put on Cefepime and Gentamycin for 6 week course via PICC
line. Pt was discharged to Rehab on Abx. Abx regimen was DC'd
on ___ due to rising LFTs discovered on f/u appt w/ ID team.
On ___, pt underwent a f/u TTE which demonstrated a new right
atrial mass and possible vegetation. A TEE was then performed
which showed a 1.6x0.9 cm echo-dense RA mass located near the
___ junction. The cardiology team subsequently started him on
Pradaxa (___). On ___, pt re-presented to ___ w/
fevers, fatigue, confusion, and weakness. Repeat TEE on ___
did not show any atrial mass so anticoagulaton was discontinued.
However, blood cultures once again grew serratia. Pt was
started on Meropenem 500mg IV q6h/Gentamicin 240mg IV q24
(synergistic abx) for 8xweek course (through ___. In
addition, the Pt continued to complain of lower back pain and
repeat MRI and PET Scans (___) demonstrated endplate
irregularity at the L4-L5 level concerning for
discitis/osteomyelitis, w/o evidence of infection.
On ___ (today), the pt presented to the ___ clinic w/ new
pleuritic chest pain in the L chest that worsened when moving
forward/lying back. Pt described pain as increasing in severity
over past ___ days, becoming excruciating the night of ___.
CXRs and LENIs taken at ___ rehab were negative.
In the ED, initial vitals were T98.4 HR85 BP128/87 RR18 100RA.
CTA chest demonstrated probable right medial basal subsegmental
acute pulmonary embolism w/o evidence of dissection. The pt was
started on lovenox 80mg SC given pleuritic chest pain and PE.
UA was notable for RBCs (unchanged from prior UAs).
On the floor, pt is in no acute distress. He describes pain
upon inspiration, that worsens when he transitions from standing
to lying down. Pt describes the pain as both sharp and an
aching quality. He denies SOB, lightheadedness, hematemesis,
palpitations, or R chest pain.
ROS:
(+) Per HPI
(-) Denies fever, chills. Denies headache. Denies cough,
shortness of breath. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
- Serratia bacteremia, Endocarditis s/p bioprosthetic AVR on
___ (s/p cefepime/ gentamicin 6 wks) now on
meropenem/gentamicin
- Hepatitis C genotype 1a: diagnosed during hospitalization for
endocarditis (___)
- Migraines
- IV Heroin abuse
- Tobacco use
Social History:
___
Family History:
Mother with history of diabetes mellitus II
Physical Exam:
ON ADMISSION:
===========================================
VS: T98.5 BP125/85 P78 RR18 100RA
GENERAL: Alert, oriented, no acute distress, Marfanoid
appearance
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Clear, no wheezes, rales, or rhonchi, systolic murmur
auscultated from the back
HEART: RRR, ___ systolic murmur loudest LUSB heard throughout
precordium
ABD: normal BS, nontender, nondistended
EXT: warm, 2+ DP ___ pulses, no lower extremity edema, no calf
tenderness or asymmetry, negative ___ sign
SKIN: well healed mid-sternotomy scar, no ___ lesions or
___ nodes
NEURO: alert and oriented, normal mood and affect
ON DISCHARGE:
===========================================
VS: Tm afeb Tc 98.7 ___ 20 99% RA
GENERAL: Alert, oriented, no acute distress, sitting up in bed
and interactive
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: clear to ascultation bilaterally, no
wheezes/rales/rhonchi
HEART: RRR, ___ systolic murmur loudest LUSB heard throughout
precordium
ABD: normal BS, nontender, nondistended
EXT: no ___ edema
SKIN: well healed mid-sternotomy scar, no ___ lesions or
___ nodes
NEURO: alert and oriented, normal mood and affect
Pertinent Results:
ON ADMISSION:
============================================
___ 11:00AM BLOOD WBC-5.4 RBC-3.91* Hgb-10.9* Hct-33.3*
MCV-85 MCH-28.0 MCHC-32.9 RDW-13.8 Plt ___
___ 11:00AM BLOOD Neuts-59.4 ___ Monos-7.4 Eos-3.1
Baso-0.6
___ 11:00AM BLOOD ___ PTT-39.5* ___
___ 11:00AM BLOOD Plt ___
___ 11:00AM BLOOD Glucose-99 UreaN-25* Creat-0.7 Na-138
K-3.8 Cl-101 HCO3-27 AnGap-14
___ 08:47AM BLOOD ALT-43* AST-25 AlkPhos-94 TotBili-0.3
___ 08:47AM BLOOD Calcium-9.8 Phos-4.0 Mg-1.7
___ 11:16AM BLOOD Lactate-1.1
___ 11:00AM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:00AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 11:00AM URINE RBC-71* WBC-9* Bacteri-FEW Yeast-NONE
Epi-<1
___ 11:00AM URINE CastHy-17*
___ 11:00AM URINE Mucous-FEW
ON DISCHARGE:
=============
___ 06:07AM BLOOD WBC-4.8 RBC-4.24* Hgb-11.6* Hct-35.9*
MCV-85 MCH-27.3 MCHC-32.3 RDW-13.4 Plt ___
___ 06:07AM BLOOD Plt ___
___ 06:07AM BLOOD ___ PTT-46.1* ___
___ 06:07AM BLOOD Glucose-83 UreaN-26* Creat-0.8 Na-139
K-4.1 Cl-101 HCO3-27 AnGap-15
___ 06:07AM BLOOD Calcium-10.3 Phos-3.7 Mg-1.6
___ 06:07AM BLOOD CRP-2.5
MICROBIOLOGY:
============
Blood cultures x3 from ___: NGTD on ___.
IMAGING:
=============================================
CTA CHEST W&W/O C&RECONS, NON-CORONARY (___):
1. Probable acute subsegmental pulmonary embolus within the
right basilar branch, noting motion artifact, but fairly
convincing morphology.
2. Patient is status post aortic root repair with no evidence
of dissection on this non-gated examination.
CHEST (PORTABLE AP) (___): In comparison with the study of ___, there is little change. Left subclavian PICC line extends to
the upper portion of the SVC. No evidence of acute
cardiopulmonary disease.
TTE (___): No mass or thrombus is seen in the right atrium. No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is probably normal. RV with borderline
normal free wall function. There is no mass/thrombus in the
right ventricle. A bioprosthetic aortic valve prosthesis is
present. No masses or vegetations are seen on the aortic valve.
The mitral valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The tricuspid valve leaflets are mildly thickened. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade. Compared with the prior
study (images reviewed) of ___, RV systolic function may
be slightly less vigorous.
TEE (___):
A well seated bioprosthetic aortic valve prosthesis is present.
The prosthetic aortic valve leaflets appear normal No masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. A soft tissue thickening on the posterior wall
of the aortic root in confluence with the anterior Mitral valve
leaflet is unchanged from the post operative view from ___.
No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. No
vegetation/mass is seen on the pulmonic valve.
Impression: No vegatations are seen. The prosthetic aortic valve
appear normal. A soft tissue thickening on the posterior wall of
the aortic root in confluence with the anterior Mitral valve
leaflet is unchanged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fentanyl Patch 25 mcg/h TD Q72H
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
5. Lorazepam 0.5 mg PO HS
6. Gentamicin 240 mg IV Q24H
7. Lidocaine 5% Patch 1 PTCH TD QPM
8. Meropenem 500 mg IV Q6H
9. TraZODone 50 mg PO HS:PRN insomnia
10. Acetaminophen 1000 mg PO Q8H:PRN fever, headache
11. Naproxen 500 mg PO Q8H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN fever, headache
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour apply 1 patch to skin q72 Disp #*15
Patch Refills:*0
5. Gentamicin 240 mg IV Q24H
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Lorazepam 0.5 mg PO HS
RX *lorazepam 0.5 mg 1 tab by mouth at bedtime Disp #*15 Tablet
Refills:*0
8. TraZODone 50 mg PO HS:PRN insomnia
9. Outpatient Lab Work
Weekly OPAT labs: CBC, Chem-7, AST, ALT, AlkPhos, ESR, CRP,
gentamicin trough.
ICD-9: ___
Fax weekly labs to the ___ R.N.s at
___. MD: ___
10. Meropenem 1000 mg IV Q8H Duration: 13 Days
Continue through ___. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
Discontinue when INR between ___ x2 days.
12. Warfarin 3 mg PO DAILY
13. Naproxen 500 mg PO Q8H:PRN pain
14. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Acute subsegmental pulmonary embolism
SECONDARY:
-Spinal discitis / osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male status post aortic root replacement and
endocarditis, presenting with pleuritic chest pain.
COMPARISON: CT chest dated ___.
TECHNIQUE: Axial multidetector CT scan from the upper chest to the diaphragm
was performed following the administration of 100 cc of Omnipaque intravenous
contrast. Multiplanar reformatted images in coronal and sagittal axes were
generated. Oblique maximum intensity projection images were prepared on an
independent workstation.
DLP: 271 mGy-cm.
FINDINGS:
CT OF THE THORAX: Motion artifact somewhat limits examination. The airways
are patent to the subsegmental level. There is no mediastinal, hilar or
axillary lymph node enlargement by CT size criteria. The heart and
pericardium appear within normal limits. Trace pericardial fluid is again
noted.
Patient is status post aortic root repair with post-surgical sutures and
sternotomy wires identified. Persistent retrosternal soft tissue at the
thoracic outlet present on prior examination dated ___ persists,
likely residual thymus tissue. No esophageal abnormality is identified.
Lung windows do not demonstrate any focal opacity. Bibasilar atelectatic
changes are noted. No pleural effusion or pneumothorax is present:
CTA THORAX: The main thoracic vessels are well opacified. The aorta
demonstrates normal caliber throughout the thorax without intramural hematoma
or dissection. The pulmonary arteries are well opacified to the subsegmental
level. Within the right medial basilar segment, there is a filling defect
within the subsegmental branch consistent with a probable acute pulmonary
embolism. No additional filling defect is identified. No arteriovenous
malformation is seen.
OSSEOUS STRUCTURES: No focal osseous lesion concerning for malignancy is
identified.
IMPRESSION:
1. Probable acute subsegmental pulmonary embolus within the right basilar
branch, noting motion artifact, but fairly convincing morphology.
2. Patient is status post aortic root repair with no evidence of dissection
on this non-gated examination.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old male admitted with existing PICC for IV antibiotics
// evaluate PICC position prior to use evaluate PICC position prior to
use
IMPRESSION:
In comparison with the study of ___, there is little change. Left
subclavian PICC line extends to the upper portion of the SVC. No evidence of
acute cardiopulmonary disease.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL
INDICATION: ___ year old man with PICC in place in left arm, now with PE,
concern for source of clot, ?clot on PICC // please eval for ?clot adherent
to PICC
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular and subclavian veins are patent and compressible
with transducer pressure.
A PICC is in place and enters via the left basilic vein. The left axillary,
brachial, basilic, and cephalic veins are patent, compressible with transducer
pressure and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity. PICC in place
via left basilic vein.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with PULM EMBOLISM/INFARCT
temperature: 98.4
heartrate: 85.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 87.0
level of pain: 8
level of acuity: 2.0 | ___ w/ Hx of IVDU who presented in ___ w/ serratia bacteremia
and aortic valve vegetations causing severe AR, s/p Aortic Valve
replacement (___) and discitis/osteomyelitis on MRI (___),
on 8wk course of Meropenem/Gent (through ___, who
re-presented on ___ w/ L pleuritic chest pain, found to have
small right subsegmental PE. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Vicodin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: ERCP
History of Present Illness:
___ M s/p elective lap ccy (___) on ___ presents with
abdominal pain since ___. Vomited X 1 ___ (no
hematemesis). No bowel movements since yesterday but is passing
gas.No fevers.
Per the op report, his cholecystectomy was uneventful aside from
some minor bleeding from the liver bed and a large cystic duct
that was taken with an Endo ___ stapling device. Post
operatively
he did well and was discharged the following day. Pathology
showing chronic cholecystitis and cholelithiasis, mixed type
with
embedded calculus fragments.
Past Medical History:
-Nonalcoholic steatohepatitis, dx via biopsy
-Hx abnormal liver function tests, elevated since ___
-Low-grade oligodendroglioma s/p partial resection, ___
-Hypertension
-Diabetes mellitus type II
-Hx papillary thyroid carcinoma s/p thyroidectomy
-Psoriatic arthritis
-Hx pulmonary embolus, ___ now with IVC filter in place
-Osteopenia of spine
-Hypothyroidism
Social History:
___
Family History:
sister w/ htn
Physical Exam:
GEN: NAD, A7Ox3
___: RRR
CTAB bilaterally
abdomen soft, NT, ND, Well healed incisions without
drainage or hernia.
Ext: WWP
Pertinent Results:
___ 12:29AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:01PM ___ COMMENTS-GREEN TOP
___ 11:01PM LACTATE-2.1*
___ 10:55PM ALT(SGPT)-631* AST(SGOT)-378* ALK PHOS-272*
TOT BILI-3.8* DIR BILI-3.1* INDIR BIL-0.7
___ 10:55PM LIPASE-3504*
___ 10:55PM WBC-14.2*# RBC-4.70 HGB-14.2 HCT-41.8 MCV-89
MCH-30.2 MCHC-34.0 RDW-12.8
___ 10:55PM PLT COUNT-274
___ 10:55PM ___ PTT-27.1 ___
___ 04:49AM BLOOD WBC-7.4 RBC-3.79* Hgb-12.1* Hct-33.5*
MCV-88 MCH-32.0 MCHC-36.2* RDW-12.6 Plt ___
___ 04:49AM BLOOD ALT-503* AST-197* AlkPhos-260*
Amylase-125* TotBili-1.7*
ERCP ___:
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Balloon sweeps were performed in the bile duct with an
extraction balloon and small amounts of stone fragments/sludge
was extracted.
Medications on Admission:
-Labetolol
-Levetiracetam 750mg daily
-Levothyroxine 175mcg daily
-Lisinopril 10mg daily
-Metformin 500mg BID
-Methotrexate sodium 10mg weekly
-Simvastatin 10mg daily
-Calcium-D3 600-400mg BID
Discharge Medications:
1. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis, gallstone pancreatitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Abdominal pain post-cholecystectomy.
COMPARISON: CT available from ___ and ultrasound from ___.
TECHNIQUE: Ultrasonography of the right upper quadrant.
FINDINGS:
The liver is echogenic, as seen on the ultrasound from ___. A
2.5 x 2.9 x 2.8 cm hypoechoic mass appears to lie between the right hepatic
lobe and the upper pole of the right kidney, likely representing an adrenal
mass, which is incompletely visualized on the ___ chest CT
examination. Alternatively, this could be hepatic mass that was not seen on
the prior ultrasound. There is no internal vascular flow. There is no
intrahepatic bile duct dilation. No free fluid is seen. The main portal vein
is patent, demonstrating proper hepatopetal flow. The CBD cannot be
visualized.
IMPRESSION:
1. Post-cholecystectomy. No free fluid detected. The CBD could not be
visualized.
2. Echogenic liver, compatible with steatosis. More advanced disease such as
fibrosis and cirrhosis cannot be excluded.
3. 2.9 cm mass appears to be adrenal, and may reflect an adenoma or
myelolipoma, incompletely imagedon the ___ chest CT examination.
This lesion could also be hepatic. Further assessment of this mass and of the
CBD can be performed with MRCP or CT.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ACUTE PANCREATITIS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 97.4
heartrate: 76.0
resprate: nan
o2sat: 99.0
sbp: 134.0
dbp: 77.0
level of pain: 10
level of acuity: 2.0 | Patient was admitted to the hospital for ERCP after having acute
pancreatitis episode related to choledocholithiasis. He
underwent ERCP and had stone and sludge extracted from the CBD.
After ERCP his labs trended down appropriately and his pain was
much improved. He was started on a diet the day after the ERCP
and was discharged after tolerating this. At time of discharge
he was voiding, had no abdominal pain, and was voiding. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma - fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a ___ year old male s/p fall from ladder down
approx 2 flights of stairs just prior to arrival. He
complains of head strike w/ LOC. He has a headache but
denies any other complaints.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission physical exam
Temp: 98 HR: 100 BP: ___ Resp: 18 O(2)Sat: 99 Normal
Constitutional: Alert, no distress
HEENT: Several abrasions on head but no deformity or
bogginess of scalp, PERRL, EOM intact, nontender facial
structures
OP clear, c-collar in place
Chest: CTAB, nontender chest wall
Cardiovascular: Regular rate, no m/r/g
Abdominal: Soft, Nontender, Nondistended
Extr/Back: Nontender c/t/l spine, pelvis stable, nontender
extremities w/out deformity, well perfused
Skin: Warm and dry, scattered abrasions
Neuro: CN intact, ___ strength throughout, sensation intact
Psych: Normal mentation
Pertinent Results:
___ CXR
IMPRESSION:
No previous images. The cardiac silhouette is within upper
limits of normal
in size and there is no evidence of vascular congestion, pleural
effusion, or
acute focal pneumonia. No evidence of fracture or pneumothorax.
___ CT head
IMPRESSION:
-No acute intracranial hemorrhage or fracture identified.
___ CT c spine
IMPRESSION:
No cervical spinal fracture or traumatic malalignment.
___ CT CAP
IMPRESSION:
Compression fractures of the L3 and L5 vertebral bodies with no
significant
loss of height of the L3 vertebral body and with mild to
moderate loss of
height of the L5 vertebral body. No retropulsion seen.
No evidence of acute visceral or vascular injury in the chest,
abdomen, or
pelvis.
___ L spine
IMPRESSION:
Moderate compression fracture of the L5 vertebral body, burst
component
difficult to entirely exclude radiographically.
___ L spine
IMPRESSION:
Stable short term appearance of the L5 fracture.
___ 12:30PM BLOOD WBC-6.6 RBC-4.91 Hgb-15.0 Hct-41.8 MCV-85
MCH-30.5 MCHC-35.9 RDW-12.5 RDWSD-38.4 Plt ___
___ 12:30PM BLOOD ___ PTT-30.2 ___
___ 12:30PM BLOOD UreaN-16 Creat-1.3*
___ 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:30PM BLOOD Lipase-50
___ 12:35PM BLOOD Glucose-129* Lactate-1.6 Na-139 K-3.7
Cl-105
___ 12:35PM BLOOD freeCa-1.07*
Medications on Admission:
None
Discharge Medications:
1. 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 every four (4) hours
Disp #*40 Tablet Refills:*0
2. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl [The Magic Bullet] 10 mg 1 suppository(s) rectally
at bedtime Disp #*30 Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID
please hold for loose stool
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*63 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Compression fracture of L5 and L3 vertebrae
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: TRAUMA #3 (PORT CHEST ONLY)
INDICATION: TRAUMA
IMPRESSION:
No previous images. The cardiac silhouette is within upper limits of normal
in size and there is no evidence of vascular congestion, pleural effusion, or
acute focal pneumonia. No evidence of fracture or pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with trauma. Evaluate for fracture.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 18.0 cm; CTDIvol = 44.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, acute intracranial hemorrhage hemorrhage,
edema, or mass. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. Mild mucosal thickening of the ethmoidal
air cells. The visualized portion of the remaining paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
-No acute intracranial hemorrhage or fracture identified.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with trauma. Evaluate for fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.8 s, 22.6 cm; CTDIvol = 37.2 mGy (Body) DLP = 840.5
mGy-cm.
Total DLP (Body) = 840 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal stenosis. No significant degenerative
changes are present. There is no prevertebral soft tissue swelling.
Visualized thyroid and lung apices are unremarkable. Mild prominence of the
adenoids. Otherwise, the aerodigestive tract is unremarkable. There is no
cervical lymphadenopathy by size criteria.
IMPRESSION:
No cervical spinal fracture or traumatic malalignment.
Radiology Report
INDICATION: History: ___ with significant fall, now w/ lower back pain // ?
fracture, injury
TECHNIQUE: AP and lateral views of the lumbar spine
COMPARISON: None.
FINDINGS:
There is moderate compression of the L5 vertebral body. No dislocation is
seen. The pubic symphysis and sacroiliac joints appear intact.
IMPRESSION:
Moderate compression fracture of the L5 vertebral body, burst component
difficult to entirely exclude radiographically.
Radiology Report
EXAMINATION: CT CHEST/ABD/PELVIS W/ CONTRAST
INDICATION: ___ year old man with trauma // r/o frx, lung injuries
TECHNIQUE: MDCT acquired axial images of the chest, abdomen, and pelvis were
obtained after administration of intravenous contrast. Enteric contrast was
not given. Coronal and sagittal reformats were prepared and reviewed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 8.8 s, 69.4 cm; CTDIvol = 8.9 mGy (Body) DLP = 616.1
mGy-cm.
Total DLP (Body) = 616 mGy-cm.
Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 8.8 s, 69.4 cm; CTDIvol = 8.9 mGy (Body) DLP = 616.1
mGy-cm.
Total DLP (Body) = 616 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST: Aorta and other great vessels are normal in caliber There is no
mediastinal hematoma. The heart is normal in size. There is no pericardial
effusion. There is no lymphadenopathy. The imaged thyroid is normal.
There is minor bilateral dependent atelectasis. No focal consolidation is
seen. Airways are patent to the subsegmental level. There is no evidence of
contusion or laceration. There is no pneumothorax or pleural effusion.
ABDOMEN: The liver is intact without focal lesion of signs of acute injury.
The spleen is intact and normal in size. The gallbladder, pancreas, and
adrenals are unremarkable. The kidneys enhance symmetrically and excrete
contrast promptly without focal lesion or hydronephrosis. There is no
evidence of renal or collecting system injury. The abdominal aorta is normal
in course and caliber with widely patent major branches. No lymphadenopathy,
free air, or free fluid.
No bowel obstruction or bowel wall thickening is seen.
PELVIS: There is no evidence or bowel or mesenteric injury. The colon is
unremarkable. The bladder is unremarkable and thin-walled. There is no
pelvic free fluid.
BONES: There is a subtle compression fracture of the L3 vertebral body
superiorly without significant loss of vertebral body height. No retropulsion
is seen. There is also compression fracture of the L5 vertebral body with
overall mild loss of height, mild to moderate on the right anteriorly. No
retropulsion is seen. Possible subtle small prevertebral hematoma at the
above levels.
IMPRESSION:
Compression fractures of the L3 and L5 vertebral bodies with no significant
loss of height of the L3 vertebral body and with mild to moderate loss of
height of the L5 vertebral body. No retropulsion seen.
No evidence of acute visceral or vascular injury in the chest, abdomen, or
pelvis.
Radiology Report
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: ___ year old man with L5 burst fraccture // standing films to
check stability standing films to check stability
TECHNIQUE: Two views of the lumbar spine
COMPARISON: Radiograph from ___
FINDINGS:
5 non-rib-bearing lumbar vertebral bodies are present. Again seen is a
compression fracture of the L5 and mild height loss of L5. Compared to the
prior, the anterior superior fracture line is better seen. The disc space
narrowing at L4-5 is unchanged. Alignment is unchanged.
IMPRESSION:
Stable short term appearance of the L5 fracture.
Gender: M
Race: WHITE - BRAZILIAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Unsp intracranial injury w LOC of unsp duration, init, Oth fracture of fifth lumbar vertebra, init for clos fx, Fall on and from ladder, initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Briefly, Mr. ___ was admitted to ___ after falling from the
___ step of a ladder. He was found to have L3 and L5 vertebral
compression fractures on imaging, was evaluated by the
orthopaedic spine team, and had serial lumbar spine films which
showed stable fractures on imaging. He was initially placed on
bedrest, his activity was advanced after his spinal injuries
were cleared by the spine team. He was tolerating a regular
diet, and he had a stable pain control regimen on oral
medication. He was discharged in good condition after being
cleared by both ___ and OT with follow-up scheduled in the
outpatient spine clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
doxycycline / diphtheria,pertussis (acellular),tetanus vaccine
Attending: ___
___ Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with MGUS and prior uterine cancer presenting
with dyspnea.
She was seen at ___ urgent care for evaluation of acute
onset of cough and shortness of breath for 4 days. She was noted
in clinic to be tachypneic with RR 36. She had wheezing which
did not improve with albuterol inhaler. On exam in urgent care,
she was tachypneic with a respiratory rate of 36. O2 sat of 95
and dropped to 93% when walking to the elevator. Peak flow was
270.
She also has had decreased appetite. She had some sore throat,
just after coughing, but has no nasal symptoms, rhinorrhea or
congestion. No earache. She feels weak. No GI or urinary
symptoms. She did not receive flu vaccine. She has no known
history of smoking or asthma.
In the ED, initial vitals were:
100.9 99 146/71 28 94% RA
- Exam notable for diffuse wheezing, decreased air entry
bilaterally.
- Labs notable for:
Cr 1.1
CBC unremarkable
Trop <0.01
FluA positive
Lactate 2.2->1.7
VBG with pH 7.33, pCO2 48, HCO3 26
- Imaging was notable for:
CXR with no evidence of pneumonia.
CTA showed multiple bilateral segmental/subsegmental PEs.
- Patient was given:
___ 18:46 IH Albuterol 0.083% Neb Soln 1 NEB
___ 18:46 IH Ipratropium Bromide Neb 1 NEB
___ 18:46 PO Azithromycin 500 mg
___ 18:46 PO PredniSONE 40 mg
___ 19:45 IH Albuterol 0.083% Neb Soln 1 NEB
___ 19:45 IH Ipratropium Bromide Neb 1 NEB
___ 19:45 IVF NS
___ 19:45 PO/NG OSELTAMivir 75 mg
Vitals prior to transfer:
99.8 79 161/50 22 96% RA
Upon arrival to the floor, patient reports bilateral ankle /
calf pain at baseline, which she attributes to gout (she stopped
her gout medications per her own preference, says she leaves
this untreated). Currently left calf hurts more than right
calf).
Of note she has not had recent plane travel, and has not been
on hormone-containing medications. Never smoker. She does lead a
sedentary lifestyle and spends long periods of time sitting
during the day.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- Hammer toe
- PVD
- Peripheral neuropathy
- Rotator cuff tear ___
- HTN
- MGUS
- Right TKR
- Atrial bigeminy
- Obesity
- Uterine cancer
- Seizure disorder (grand mal seizures as child)
- Thyroid nodule
Social History:
___
Family History:
heart disorder Father
MI ___
___ Brother
___
Hypertension Maternal Grandmother
Physical Exam:
Admission Physical
==================
Vital Signs: 98.8 181/99 84 20 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Soft crackles at bases bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused. Mild edema and tenderness of
bilateral ankles, tenderness over posterior left calf.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge Physical
==================
Vital Signs: 150/82 96 18 90 Ra
General: Alert, oriented, no acute distress
HEENT: EOMI, PERRL. No nasal congestion.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Wheezes and rhonchi throughout. Few crackles at base
bilaterally.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused. Mild tenderness of bilateral ankles.
No calf tenderness.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
Pertinent Results:
Admission Labs
==============
___ 04:00PM BLOOD WBC-4.5 RBC-4.04 Hgb-11.7 Hct-35.7 MCV-88
MCH-29.0 MCHC-32.8 RDW-14.2 RDWSD-45.4 Plt ___
___ 04:00PM BLOOD Neuts-69.5 Lymphs-17.3* Monos-12.6
Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.10 AbsLymp-0.77*
AbsMono-0.56 AbsEos-0.01* AbsBaso-0.01
___ 04:00PM BLOOD Glucose-99 UreaN-15 Creat-1.1 Na-136
K-3.6 Cl-100 HCO3-22 AnGap-18
___ 06:22PM BLOOD ___ pO2-46* pCO2-48* pH-7.33*
calTCO2-26 Base XS--1 Comment-GREEN TOP
Discharge Labs
==============
___ 06:50AM BLOOD WBC-3.9* RBC-4.13 Hgb-11.8 Hct-36.3
MCV-88 MCH-28.6 MCHC-32.5 RDW-14.3 RDWSD-45.7 Plt ___
___ 06:50AM BLOOD Glucose-108* UreaN-12 Creat-1.1 Na-140
K-4.4 Cl-102 HCO3-21* AnGap-21*
___ 06:50AM BLOOD ALT-11 AST-36 LD(LDH)-278* AlkPhos-75
TotBili-<0.2
___ 06:50AM BLOOD TotProt-7.0 Albumin-3.7 Globuln-3.3
Calcium-9.1 Phos-3.7 Mg-2.0
___ 06:50AM BLOOD PEP-AWAITING F FreeKap-73.6*
FreeLam-43.5* Fr K/L-1.69* IgG-1059 IgA-429* IgM-33* IFE-PND
___ 06:47PM BLOOD ___ pO2-33* pCO2-40 pH-7.41
calTCO2-26 Base XS-0
Imaging & Studies
=================
Thyroid u/s ___
Confluent multinodular goiter. All of the nodules have an
appearance similar to each another, and none have overtly
suspicious architecture. This patient has had a known
multinodular goiter for at least 10 or more years having had a
radionuclide thyroid scan in ___. RECOMMENDATION(S): Given the
long history and similar appearance of all of the multiple
thyroid nodules, there are no specific indications for biopsy at
this time. If prior US studies are available we would be happy
to make a comparison. Otherwise follow-up imaging in ___ year is
recommended.
CT chest ___
IMPRESSION:
-Less than 3 mm multiple pulmonary nodules in the setting of
known malignancy.
Follow-up in 3 months is recommended to establish stability.
-Left lower lobe ground-glass opacities, suggestive aspiration.
Attention on
follow-up for interval resolution is recommended.
-No significant interval change in pulmonary embolism, better
seen on the
prior study. No new clot burden.
-Multiple multinodular, enlarged thyroid, previously evaluated
with thyroid
uptake nuclear medicine study in ___.
CT abd/pelvis ___
IMPRESSION:
1. No evidence of local recurrence or metastatic disease. No
evidence of
intra-abdominal or intrapelvic primary malignancy.
2. No acute intra-abdominal or intrapelvic process.
3. Please refer to separate report of CT chest performed on the
same day for
description of the thoracic findings
CTA chest ___
IMPRESSION:
1. Multiple bilateral segmental and subsegmental pulmonary
emboli without
evidence of right heart strain.
2. Enlarged multinodular thyroid gland with substernal
extension. Recommend
thyroid ultrasound for further evaluation if not previously
evaluated.
3. Multiple sub 6 mm pulmonary nodules within the lungs. Per
___
criteria guidelines, if patient is at low risk for lung
malignancy no
follow-up is recommended. If patient is at high risk for lung
malignancy,
optional CT in 12 months can be obtained.
4. Mild diffuse airway wall thickening suggests chronic airways
disease.
RECOMMENDATION(S):
1. Enlarged multinodular thyroid gland with substernal
extension. Recommend
thyroid ultrasound for further evaluation if not previously
evaluated.
2. Multiple sub 6 mm pulmonary nodules within the lungs. Per
___
criteria guidelines, if patient is at low risk for lung
malignancy no
follow-up is recommended. If patient is at high risk for lung
malignancy,
optional CT in 12 months can be obtained
CXR ___
IMPRESSION:
1. Widening of the upper mediastinum likely represents
prominent upper
mediastinal fat/prominence of the great vessels though
thyromegaly is possible
given the patient's documented history of goiter seen on thyroid
scan ___. Possibility of lymphadenopathy or mediastinal mass cannot
definitely be
ruled out.
2. No evidence of pneumonia.
Microbiology
============
FluA PCR - positive
FluB PCR - negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. triamcinolone acetonide 0.5 % topical BID
4. pimecrolimus 1 % topical BID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
Discharge Medications:
1. Apixaban 10 mg PO BID
RX *apixaban [Eliquis] 5 mg ASDIR tablet(s) by mouth twice a day
Disp #*70 Tablet Refills:*0
2. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
3. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*3
Capsule Refills:*0
5. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. pimecrolimus 1 % topical BID
9. triamcinolone acetonide 0.5 % topical BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Asthma exacerbation secondary to influenza A
Pulmonary embolus
Secondary Diagnoses
===================
Monoclonal gammopathy of undetermined significance
Multi-nodular thyroid
Gastroesophageal reflux disease
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with cough, sob// r/p pna
COMPARISON: Thyroid uptake scan ___
FINDINGS:
PA and lateral views of the chest provided.
There is widening of the upper mediastinum. 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:
1. Widening of the upper mediastinum likely represents prominent upper
mediastinal fat/prominence of the great vessels though thyromegaly is possible
given the patient's documented history of goiter seen on thyroid scan ___. Possibility of lymphadenopathy or mediastinal mass cannot definitely be
ruled out.
2. No evidence of pneumonia.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with new onset wheezing and shortness of breath. Evaluate
for pulmonary embolism1.
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and
parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 9.6 mGy (Body) DLP = 4.8
mGy-cm.
2) Spiral Acquisition 3.7 s, 29.1 cm; CTDIvol = 13.0 mGy (Body) DLP = 379.8
mGy-cm.
Total DLP (Body) = 385 mGy-cm.
COMPARISON: Chest radiograph ___
FINDINGS:
HEART AND VASCULATURE: Multiple bilateral pulmonary emboli including segmental
filling defects within the right middle and left lower lobes, as well as
subsegmental filling defects within the right upper lobe, right middle lobe,
and both lower lobes are demonstrated (3:91, 3:110, 3:118, 3:120, 3:128).
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: Multiple subcentimeter mediastinal nodes are
noted. Mildly enlarged 1.1 cm right hilar lymph node is noted (3:110), likely
reactive. No axillary lymphadenopathy is detected.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Multiple pulmonary nodules are noted: 3 mm nodule in the right
middle lobe (3:115), 2 mm nodule in the right lower lobe (3:125), 4 mm nodule
in the right lower lobe (3:92), 2 mm nodule in the left upper lobe (03:56).
No focal consolidation is present. Mild atelectasis is noted in both lower
lobes. Diffuse but mild airway wall thickening is demonstrated. The airways
are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: The thyroid gland is enlarged and heterogeneous, containing
calcifications and extending substernally to the upper mediastinum.
ABDOMEN: Included portion of the upper abdomen demonstrates a small hiatal
hernia.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Multiple bilateral segmental and subsegmental pulmonary emboli without
evidence of right heart strain.
2. Enlarged multinodular thyroid gland with substernal extension. Recommend
thyroid ultrasound for further evaluation if not previously evaluated.
3. Multiple sub 6 mm pulmonary nodules within the lungs. Per ___
criteria guidelines, if patient is at low risk for lung malignancy no
follow-up is recommended. If patient is at high risk for lung malignancy,
optional CT in 12 months can be obtained.
4. Mild diffuse airway wall thickening suggests chronic airways disease.
RECOMMENDATION(S):
1. Enlarged multinodular thyroid gland with substernal extension. Recommend
thyroid ultrasound for further evaluation if not previously evaluated.
2. Multiple sub 6 mm pulmonary nodules within the lungs. Per ___
criteria guidelines, if patient is at low risk for lung malignancy no
follow-up is recommended. If patient is at high risk for lung malignancy,
optional CT in 12 months can be obtained.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:15 pm, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with pulmonary embolism and history of
endometrial cancer stage 1a s/p hysterectomy// Evaluate for intraabdominal
malignancy, lymphadenopathy.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 2,218 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is a small right cortical hypodensity arising from the upper
pole which is too small to characterize but likely represents a cyst.
Otherwise, the kidneys are of normal and symmetric size with normal
nephrogram. There is no evidence of focal renal lesions or hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis. Multiple surgical clips are seen throughout pelvis
from prior hysterectomy.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Multilevel degenerative changes of the visualized thoracolumbar spine are
noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of local recurrence or metastatic disease. No evidence of
intra-abdominal or intrapelvic primary malignancy.
2. No acute intra-abdominal or intrapelvic process.
3. Please refer to separate report of CT chest performed on the same day for
description of the thoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Singing ___ female with history of pulmonary embolism and
endometrial cancer stage IA status post hysterectomy. Evaluate for
malignancy.
TECHNIQUE: MD CT axial images of the chest were obtained after administration
of intravenous contrast. Multiplanar reformats, including coronal, sagittal
and axial maximal intensity projection images were obtained and reviewed on
PACs.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.0 s, 32.2 cm; CTDIvol = 16.2 mGy (Body) DLP = 520.4
mGy-cm.
2) Spiral Acquisition 4.2 s, 66.2 cm; CTDIvol = 17.4 mGy (Body) DLP =
1,149.7 mGy-cm.
3) Spiral Acquisition 2.1 s, 33.2 cm; CTDIvol = 16.3 mGy (Body) DLP = 539.5
mGy-cm.
4) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.8 mGy (Body) DLP =
8.4 mGy-cm.
Total DLP (Body) = 2,218 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Chest CT from ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The thyroid gland is enlarged and
heterogeneous with areas of hypodensity. There is no supraclavicular or
axillary lymphadenopathy by CT size criteria. The bilateral breast parenchyma
are suboptimally imaged on the current modality. Otherwise, the imaged chest
wall is unremarkable
UPPER ABDOMEN: Please refer to the separate report for CT abdomen pelvis from
the same day for details on subdiaphragmatic findings.
MEDIASTINUM: There is no mediastinal lymphadenopathy by CT size criteria.
HILA: There is no hilar lymphadenopathy by CT size criteria.
HEART and PERICARDIUM: The heart size is within normal limits. There is no
significant coronary or valvular calcifications. There is no pericardial
effusion.
PLEURA: There is no pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: Atelectasis is minimal in the bilateral lower lobes. There
are scattered sub 3 mm pulmonary nodules with representative nodules in the
right upper and right lower lobes (302:117, 100, 78, 70). In addition, there
are ground-glass opacities in the left lower lobe, suggestive of aspiration.
2. AIRWAYS: Airways are patent to the subsegmental levels. There is
peribronchial wall in the lower lobes.
3. VESSELS: The ascending and descending aorta are normal in caliber. The
main pulmonary artery is normal in caliber. Aortic arch calcifications are
minimal. As previously, there is filling defect within the subsegmental
pulmonary arteries (302:112, 120, 144), better seen on the dedicated CT PA
study from the prior day. Right lower lobe pulmonary arterial filling defect
is not seen on today's exam. No new filling defects are seen. There is
common origin of the left common carotid artery and the brachiocephalic
artery.
CHEST CAGE: There are no worrisome osseous lesions concerning for malignancy
or infection.
IMPRESSION:
-Less than 3 mm multiple pulmonary nodules in the setting of known malignancy.
Follow-up in 3 months is recommended to establish stability.
-Left lower lobe ground-glass opacities, suggestive aspiration. Attention on
follow-up for interval resolution is recommended.
-No significant interval change in pulmonary embolism, better seen on the
prior study. No new clot burden.
-Multiple multinodular, enlarged thyroid, previously evaluated with thyroid
uptake nuclear medicine study in ___.
RECOMMENDATION(S): Less than 3 mm multiple pulmonary nodules in the setting
of known malignancy. Follow-up in 3 months is recommended to establish
stability.
Radiology Report
EXAMINATION: THYROID U.S.
INDICATION: ___ year old woman with history of multinodular thyroid with CTA
that recommends ultrasound for further evaluation.// Evaluate for evidence of
nodules or lesions concerning for malignancy.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the neck were
obtained.
COMPARISON: CT chest ___
FINDINGS:
Thyroid is enlarged and distorted by multiple nodules.
The right lobe measures: (transverse) 2.1 x (anterior-posterior) 2.7 x
(craniocaudal) 6.7 cm.
The left lobe measures: (transverse) 3.9 x (anterior-posterior) 4.3 x
(craniocaudal) 5.5 cm.
Isthmus is distorted by multiple isoechoic nodules but its anterior-posterior
diameter is 0.5 cm.
There are multiple nodules in the thyroid. There is an isoechoic nodule in
the midpole of the right lobe measuring 2.5 x 1.9 x 2.8 cm. There is an
isoechoic nodule in the lower pole of the right lobe measuring 2.4 x 2.8 x 2.7
cm. In the mid to lower pole of the left lobe, there is the largest isoechoic
nodule measuring 3.7 x 3.9 x 4.7 cm. Adjacent to this is a heterogeneous
echogenic nodule measuring 1.8 x 1.5 x 4.4 cm. There also at least 3
isoechoic nodules in the isthmus.
IMPRESSION:
Confluent multinodular goiter. All of the nodules have an appearance similar
to each another, and none have overtly suspicious architecture. This patient
has had a known multinodular goiter for at least 10 or more years having had a
radionuclide thyroid scan in ___.
RECOMMENDATION(S): Given the long history and similar appearance of all of
the multiple thyroid nodules, there are no specific indications for biopsy at
this time. If prior US studies are available we would be happy to make a
comparison. Otherwise follow-up imaging in ___ year is recommended.
Gender: F
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: Cough, Dyspnea
Diagnosed with Flu due to ident novel influenza A virus w oth resp manifest
temperature: 100.9
heartrate: 99.0
resprate: 28.0
o2sat: 94.0
sbp: 146.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ with MGUS and Stage 1a uterine cancer s/p
hysterectomy who presented to the ED with dypnsea and tachypnea.
She was found to have influenza A and multiple
segmental/subsegmental pulmonary emboli. She was treated for an
asthma/COPD exacerbation with prednisone and azithromycin. She
was treated for influenza A with apixaban 10mg BID. She will be
transitioned to abixipan 5mg BID after the 1 week loading dose.
Given concern for malignancy causing pulmonary embolus with
patient's prior history of malignancy she underwent CT torso
without evidence of malignancy. Also had repeat FLC that showed
slightly increased levels compared with ___ with increased
Fr-K/L ratio. She will have follow up with oncology as an
outpatient, but no active signs of malignancy.
# Asthma exacerbation ___ Influenza A:
Patient with influenza A which has likely triggered asthma
exacerbation with diffuse wheezing. Also found to have pulmonary
embolism on CTA. She was treated with oseltamivir, azithromycin
and prednisone, each for a 5 day course. She was also treated
with duonebs and albuterol. She should continue nebulizer
treatments as an outpatient.
- oseltamivir for 5 days [___]
- azithromycin for 5 days [___]
- prednisone 40mg daily [___]
- duonebs PRN
- albuterol PRN
# Pulmonary emboli:
Noted on CTA to have multiple segmental and subsegmental emboli.
History of MGUS and uterine cancer, but denies prior thrombosis,
family history of blood clots, personal history of spontaneous
abortions, or recent travel. Admits to sedentary lifestyle. CT
torso without evidence of active malignancy. SPEP with elevated
serum FLC compared to prior with elevated Fr K/L ratio. Appears
trending towards smouldering myeloma. A skeletal survey was
deferred given absence of bone pain. She will be continued on
apixaban 10mg BID for 7 day loading dose to end on ___, followed
by apixaban 5mg daily.
# MGUS: Patient with M-spike on SPEP from ___ with free kappa
37.6 and free lambda 29.7, increased from ___. Concern for
progression given bilateral segmental/subsegmental pulmonary
embolism. Will have follow up with oncology as an outpatient.
FreeKap ___ FreeLam ___
Fr-K/L: 1.69
IgG 1059
IgA 429
IgM 33
# Multi-nodular thyroid:
CTA showed enlarged heterogeneous thyroid gland containing
calcification and extending to the upper mediastinum. Had prior
u/s in ___ that was unchanged along with iodine uptake scan in
___ that was not concerning for cancer. Thyroid ultrasound
during this admission without suspicious imaging with
recommendation for f/u in ___ year.
# GERD
Continued on omeprazole
# PVD
Continued on aspirin
Transitional Issues
====================
[] Started on apixiban for treatment of pulmonary embolism. Will
continue on 10mg BID for 7 day load to end on ___ followed by
5mg BID. She should be treated indefinitely given unprovoked PE.
[] C/w azithromycin, prednisone, oseltamivir for 5 day course to
end on ___
[] Patient will follow with her oncologist regarding progression
of MGUS with increasingly elevated Fr-K/L ratio.
[] Repeat thyroid ultrasound in ___ year to assess for stability
[] Follow-up CT chest in 3 months is recommended to establish
stability given less than 3 mm multiple pulmonary nodules in the
setting of known malignancy.
[] Patient had significant hypertension in house and was
discharged on lisinopril 10mg daily
Greater than 30 minutes were spent on this patient's discharge
day management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
___ year old Male with isolated plasmacytoma and spinal stenosis
who presents with increasing back pain over several weeks and an
acute delirium the morning of admission. The patient has had
long-standing lumbar stenosis with chronic back pain for the
past ___ years. He has also had a T12/L5 kyphoplasty
approximately 2.5 months prior to admission. During this
admission operation a lytic bone lesion at L3 was biopsied and
found to be multiple myeloma. He had an x-ray of the lumbar
spine which was reportedly negative for lytic lesions for lytic
lesions in the ___ ED prior to transfer.
Per his daughter, he is receiving XRT for his plasmacytoma and
has completed 7 treatments. The morning of admission his
daughter was called by the nursing home where he lives and was
told he was acting somewhat withdrawn, and appeared groggy and
which was an acute change from his baseline mental status. Per
the daughter little workup was done at ___ in the ED and
she believed that his pain was not being well controlled, so she
requested tranfer to ___.
Per the patient's family he has been significantly more
withdrawn and depressed over the week prior to admission with
decreased PO intake. Of note ___ months prior to admission he
experienced a fall in his bathroom. Prior to that he was social
with friends, living independently, driving and self sufficient.
His vitals at the time of admission were: 98.6, 80, 122/61, 98%
ra, 16. Currently, reports no significant change in his back
pain today, and reports no new numbness or paresthesias in his
legs. He is only oriented to person this evening and cannot
idenitify the year or the place. He rates his current back pain
as ___. He describes the pain to be intermittent, made worse
with walking and improved with sitting down. He is a poor
historian this evening -- he reports that his "mind is so
clogged from so many medications."
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
isolated plasmacytoma at L3
spinal stenosis
s/p kyphoplasty
arthrits
hiatal hernia
vertigo
glacoma
___ years ago - mitral valve repair
hernia repairs
appendectomy
Social History:
___
Family History:
No family history of myeloma.
Physical Exam:
ADMISSION PHYSICAL EXAM
VSS: 97.9, 108/60, 71, 20, 96%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx1, Sleepy, Motor: ___ ___ for flex/ext/finger
spread
DISCHARGE PHYSICAL EXAM
VS - Tc/m99.2 BP ___ 80 18 95%RA
GENERAL - laying in bed, becomes agitated and shouts at examiner
HEENT - NC/AT, mm dry
LUNGS - CTA on right, faint rales on left base anteriorly, (pt
would not sit up for lung exam) no r/rh/wh, good air movement,
resp unlabored, no accessory muscle use
HEART - Normal rate, irregular rhythm. No murmurs.
ABDOMEN - no masses or HSM, no rebound/guarding
EXTREMITIES - no c/c/e
SKIN - no rashes or lesions
NEURO - awake, A&Ox1 -- not oriented to place or time. Moves all
extremities
Pertinent Results:
ADMISSION LABS
___ 07:00AM BLOOD WBC-6.0 RBC-3.43* Hgb-11.5* Hct-35.1*
MCV-103* MCH-33.4* MCHC-32.6 RDW-13.1 Plt ___
___ 03:30PM BLOOD WBC-6.1 RBC-3.21* Hgb-11.0* Hct-33.0*
MCV-103* MCH-34.3* MCHC-33.3 RDW-13.5 Plt ___
___ 03:30PM BLOOD Neuts-66.9 ___ Monos-6.4 Eos-7.5*
Baso-0.5
___ 07:00AM BLOOD ___ PTT-27.7 ___
___ 07:00AM BLOOD Glucose-80 UreaN-22* Creat-1.0 Na-139
K-7.4* Cl-101 HCO3-31 AnGap-14
___ 03:30PM BLOOD Glucose-121* UreaN-22* Creat-1.1 Na-136
K-7.1* Cl-99 HCO3-32 AnGap-12
___ 03:30PM BLOOD ALT-20 AST-80* AlkPhos-49 TotBili-0.6
___ 03:30PM BLOOD Albumin-3.1*
___ 03:15PM URINE Color-Straw Appear-Clear Sp ___
___ 02:30PM URINE Color-Straw Appear-Clear Sp ___
___ 03:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 6:30 am BLOOD CULTURE
DISCHARGE LABS
___ 05:34AM BLOOD WBC-5.4 RBC-2.95* Hgb-9.9* Hct-29.6*
MCV-101* MCH-33.7* MCHC-33.4 RDW-13.8 Plt ___
___ 05:30AM BLOOD Neuts-81.6* Lymphs-11.0* Monos-3.4
Eos-3.6 Baso-0.4
___ 05:34AM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-144
K-3.5 Cl-114* HCO3-20* AnGap-14
___ 09:00PM BLOOD Glucose-107* UreaN-17 Creat-0.8 Na-143
K-4.1 Cl-112* HCO3-24 AnGap-11
___ 06:30AM BLOOD PEP-ABNORMAL B b2micro-3.4* IgG-2665*
IgA-207 IgM-35* IFE-MONOCLONAL
___ 07:50PM BLOOD IgG-2514* IgA-198
IMAGING
CT Head ___:
IMPRESSION:
1. No evidence of hemorrhage or infarction.
2. Small vessel ischemic disease and age-related involution.
Skeletal Survey ___:
IMPRESSION:
1. No definite lytic lesions identified. Lucencies are seen
within humeri,
likely due to bone mineralization. If further evaluation is
needed for a
specific region, recommend further evaluation with MRI which is
more sensitive
to detect myelomatous lesions.
2. Cholelithiasis.
CT Chest ___:
IMPRESSION:
1. Small to moderate loculated left pleural effusion,
chronicity unknown,
most likely chronic given the presence of relatively large left
lower lobe
rounded atelectasis and left upper lobe posterior segment
atelectasis. Small loculated right pleural effusion along the
fissure.
2. Suspected right lower lobe developing / resolving infectious
process,
assessment is limited due to motion artifacts.
3. Extensive coronary artery disease.
4. Status post mitral valvuloplasty.
5. Dilated pulmonary arteries that might reflect pulmonary
hypertension.
Correlation with echocardiography is suggested if clinically
warranted.
IgM-30*
Medications on Admission:
ascorbic acid ___ daily
multivitamin 1 tab
brimonidine 0.2% 1 drop daily
lidocaine 5% patch
cyclobenzaprine 5 mg tab q8h prn
senna
docusate
percocet 1 tab tid
percocet 1 tab q6hour prn
fleet enema
ketoconazole 2% cream
pantoprazole 40 mg daily
rosuvastatin 10 mg po hs
miralax
ondansetrib 8 mg tid
bisacodyl
acetaminophen 650 po q4hours
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q8H
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Furosemide 20 mg PO DAILY
5. Ketoconazole 2% 1 Appl TP BID:PRN itching
6. Omeprazole 20 mg PO DAILY
7. Gabapentin 300 mg PO TID
8. Lidocaine 5% Patch 1 PTCH TD DAILY back pain
9. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
Hold for sedation and RR less than 12
RX *oxycodone 5 mg 1 tablet(s) by mouth every 3 hours Disp #*30
Tablet Refills:*0
10. Bisacodyl 10 mg PR HS:PRN constipation
11. Docusate Sodium 100 mg PO BID
Patient may refuse. Hold if patient has loose stools.
12. Lidocaine 5% Patch 1 PTCH TD DAILY knee pain
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 2 TAB PO HS
Patient may refuse. Hold if patient has loose stools.
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO Q6H:PRN
nausea or anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Pneumonia, Multiple Myeloma
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
REASON FOR EXAMINATION: Failure to thrive, weakness.
No prior studies available for comparison.
PA and lateral upright chest radiographs were reviewed.
The patient is after median sternotomy, reason unclear since no evidence of
CABG is definitely seen. Mediastinum is shifted to the left. Cardiac
silhouette is difficult to assess due to obscuration of the left heart border
by pleural effusion, partially layering and most likely partially loculated,
moderate. There is left lower lobe opacity, most likely reflecting
atelectasis, unclear if secondary to the effusion or due to other reasons.
The right lung is essentially clear except for minimal atelectasis. Left
upper lung is clear as well. No pneumothorax is seen. No evidence of
pulmonary edema is present. Vertebroplasty of the lower thoracic vertebral
body, most likely T11 is noted.
Comparison with prior study is recommended. Otherwise, assessment of the
patient with CT chest preferably with contrast for precise determination of
left lower lobe and pleural effusion appearance might be considered.
Findings submitted to Radiology Dashboard for communication of critical
results by dr ___ on ___ at 1:50 pm
Radiology Report
LUMBAR SPINE MRI WITH AND WITHOUT CONTRAST, ___
INDICATION: ___ man with history of myeloma, spinal stenosis, and
arthritis, now with worsening back pain and altered mental status. Evaluate
for malignancy. The patient has pain in the coccyx, please extend the study
to include the coccyx.
COMPARISON: No previous studies here.
TECHNIQUE: Sagittal T1-weighted, T2-weighted, and fat-suppressed T2-weighted
images of the lumbar spine and sacrum were obtained, with axial T1- and
T2-weighted images. Following intravenous gadolinium administration, sagittal
and axial T1-weighted images were repeated.
FINDINGS: Bone marrow signal is diffusely abnormal, suggesting myelomatous
involvement. Fat-suppressed T2-weighted images demonstrate multiple small
foci of high signal throughout the marrow, suggesting malignancy. Exceptions
to this pattern include low signal within the partially visualized T12
vertebral body, corresponding to vertebroplasty material seen on the chest
radiographs of the same day, and a hemangioma in the L2 vertebral body, which
also has high signal on T1-weighted images. There are small depressions in
the superior endplates of T12, L1, and L2 vertebral bodies. There is a more
pronounced depression in the superior endplate of the L5 vertebral body, with
mild loss of height, but no evidence of associated bone marrow edema. There
is no retropulsion. There is a discrete expansile lesion involving the
spinous process of L3, which extends into the adjacent posterior paravertebral
muscles and the overlying fascia. While the lesion extends to the confluence
of the lamina of L3, it does not encroach upon the spinal canal. There is no
evidence of an epidural mass within the spinal canal.
The distal spinal cord appears unremarkable, with the conus medullaris
terminating at the T12-L1 level. No abnormal intrathecal enhancement or other
intrathecal abnormalities are seen.
Alignment of the lumbar spine is preserved.
At L1-2, there is no spinal canal or neural foraminal narrowing.
At L2-3, there is a minimal disc bulge, thickening of the ligamentum flavum,
and mild bilateral facet arthropathy. There is no spinal canal narrowing.
There is no significant neural foraminal narrowing.
At L3-4, there is a mild disc bulge, thickening of the ligamentum flavum, and
mild facet arthropathy. The subarticular recesses are narrowed, and the
traversing L4 nerve roots are abutted, without clear evidence for compression.
There is no significant neural foraminal narrowing.
At L4-5, there is a disc bulge, a possible small central disc protrusion,
thickening of the ligamentum flavum, and moderate facet arthropathy. These
findings result in moderate-to-severe spinal canal narrowing with compression
of the traversing L5 nerve roots in the subarticular recesses. There is no
significant neural foraminal narrowing.
At L5-S1, there is mild-to-moderate bilateral facet arthropathy. There is no
significant disc bulge. There is no significant spinal canal or neural
foraminal narrowing.
The sacrum and coccyx are fully included on the sagittal images. The axial
images include S1 through S3 levels. There is no evidence of a mass within
the spinal canal or neural foramina of the sacrum. There is no evidence of
focal nerve root compression, either in the spinal canal, neural foramina, or
along the proximal extraforaminal portions of the visualized sacral nerve
roots. Sagittal T2-weighted fat-suppressed images demonstrate abnormal high
signal in the presacral space, extending inferiorly towards the coccyx. An
infiltrative soft tissue abnormality cannot be excluded.
Cystic lesions are partially visualized in the kidneys, incompletely assessed.
IMPRESSION:
1. Diffuse infiltration of the bone marrow of the lumbar spine, sacrum, and
coccyx, likely by the known myeloma. Discrete expansile mass in the L3
spinous process involves the adjacent posterior paravertebral muscles and the
overlying fascia, but does not extend into the spinal canal. No evidence of
epidural or foraminal masses.
2. Superior endplate deformities at T12, L1, L2, and L5, without evidence of
edema to suggest acute fractures. No retropulsion.
3. Abnormal signal in the presacral and pre-coccygeal space. An infiltrative
soft tissue process cannot be excluded. Suggest further evaluation by
contrast-enhanced CT or MRI of the pelvis.
4. Multilevel lumbar degenerative disease. Moderate-to-severe spinal canal
stenosis at L4-5 with compression of the traversing L5 nerve roots. Narrowing
of the subarticular recesses at L3-4, with abutment of the traversing L4 nerve
roots.
5. Partially imaged cystic lesions in the kidneys. Recommend sonography for
further evaluation.
Radiology Report
STUDY: 11 total views from a skeletal survey, ___.
COMPARISON: No bone survey for comparison.
INDICATION: Evaluate for lytic lesions, masses in the setting of multiple
myeloma, history of isolated plasmacytoma, evidence of possible bone marrow
infiltration on lumbar spine MRI.
FINDINGS:
SKULL: No definite lytic lesions within the skull. Incompletely evaluated
degenerative changes of the cervical spine. No definite compression
fractures.
THORACIC SPINE: Median sternotomy. Prior T12 vertebroplasty/kyphoplasty.
Multilevel degenerative changes of the thoracic spine. No definite
compression fractures.
LUMBAR SPINE: Multiple gallstones are noted. Calcifications project over the
left lower quadrant, which may be within bowel or dystrophic calcification
within the mesentery. Prior vertebroplasty of L5. Multilevel degenerative
changes. No definite compression fracture.
PELVIS: Bowel gas obscures the bony detail of the sacrum and SI joints.
Unremarkable pubic symphysis. Degenerative changes of the hips. No definite
lytic lesions.
FEMUR: Mild swelling of the right femur with widened distal portion. Similar
findings are seen on the left. No definite lytic lesions.
HUMERI: Prominent deltoid tuberosities. Very tiny lucencies are seen within
the humeri, however, this may be due to bone mineralization and not lytic
lesions.
IMPRESSION:
1. No definite lytic lesions identified. Lucencies are seen within humeri,
likely due to bone mineralization. If further evaluation is needed for a
specific region, recommend further evaluation with MRI which is more sensitive
to detect myelomatous lesions.
2. Cholelithiasis.
Radiology Report
INDICATION: ___ male with multiple myeloma, presents with mental
status change. Question mass or bleed.
COMPARISON: Reference study dated ___.
TECHNIQUE: Contiguous non-contrast axial images were acquired through the
brain.
FINDINGS: Allowing for significant motion degradation, limiting assessment of
current study, there is no evidence of infarction, hemorrhage, mass effect,
edema, or shift of normally midline structures. The gray-white matter
differentiation appears preserved. There is pronounced periventricular and
subcortical white matter hypoattenuation, compatible with a small vessel
ischemic disease. Ventricles and sulci are prominent, consistent with
age-related involution. Suprasellar and basilar cisterns are patent.
Paranasal sinuses and mastoid air cells are well aerated. Vascular
calcifications are seen in the cavernous carotid arteries and vertebral
arteries. Globes and orbits are preserved. There has been bilateral lens
placement.
IMPRESSION:
1. No evidence of hemorrhage or infarction.
2. Small vessel ischemic disease and age-related involution.
Radiology Report
REASON FOR EXAMINATION: Mental status changes in a patient with history of
multiple myeloma and new loculated pleural effusion on chest radiograph.
COMPARISON: Chest radiograph from ___.
TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to
upper abdomen with subsequent 1.25- and 5-mm collimation. Axial images
reviewed in conjunction with coronal and sagittal reformats.
FINDINGS:
Several mediastinal lymph nodes ranging up to 7 mm in the right lower
paratracheal area, 6 mm in the prevascular area with no pathologically
enlarged mediastinal, hilar or axillary lymph nodes seen. The aorta is normal
in diameter. Main pulmonary artery is normal, 3.2 cm but the right pulmonary
artery and left pulmonary arteries are enlarged up to 3.1 and 3 cm
respectively that might reflect pulmonary hypertension. Extensive coronary
calcifications are present. Heart size is normal. The patient is after
mitral valvuloplasty. Calcifications within the papillary muscles might
reflect prior infarction. There is no pericardial effusion.
The imaged portion of the upper abdomen reveals calcified gallstones and
pancreatic atrophy and otherwise is unremarkable.
Airways are patent to the subsegmental level bilaterally. Partially loculated
left pleural effusion is demonstrated, small to moderate. Consolidation in
the left lower lobe with subsequent volume loss, most likely reflects rounded
atelectasis given the appearance of the vessels and airways. Internal
calcifications are also noted in this loculation.
The assessment of lung parenchyma is somewhat limited due to motion artifact.
Loculated pleural effusion on the right along the major fissure is
demonstrated, 4:89, approximately 5 x 2 cm. At the right lung base, several
ground-glass and solid nodules are noted, might potentially reflect infectious
process such as right lower lobe pneumonia. No definitive evidence of
pneumonia is seen on the left. Within the limitations of this non-contrast
study, no pleural masses are noted.
The patient is after T12 vertebroplasty. Some irregularity within the bones
might be consistent with known history of myeloma.
Left upper lobe posterior segment atelectasis is most likely related to
pleural effusion and unlikely to represent infectious process.
IMPRESSION:
1. Small to moderate loculated left pleural effusion, chronicity unknown,
most likely chronic given the presence of relatively large left lower lobe
rounded atelectasis and left upper lobe posterior segment atelectasis. Small
loculated right pleural effusion along the fissure.
2. Suspected right lower lobe developing / resolving infectious process,
assessment is limited due to motion artifacts.
3. Extensive coronary artery disease.
4. Status post mitral valvuloplasty.
5. Dilated pulmonary arteries that might reflect pulmonary hypertension.
Correlation with echocardiography is suggested if clinically warranted.
Radiology Report
INDICATION: ___ gentleman with new left-sided PICC line, evaluate for
placement.
COMPARISON: ___.
TECHNIQUE: Portable semi-erect chest radiograph.
FINDINGS: There is interval placement of a left-sided PICC line with the tip
terminating in the proximity of the cavoatrial junction. Although, there is a
linear opacity at the tip of the PICC line suggesting a kink, on closer
examination, it appears that the opacity is part of the spine and is seen on
prior studies. The known left-sided pleural effusion persists and is
unchanged. There is a new rounded density at the ___ the right chest.
The size and contour suggest that it is possibly the projection of a foreign
body, however, PA and lateral chest radiographs might be helpful to rule out
any underlying pulmonary processes, if clinically warrented. No pleural
effusions on the right and no pneumothorax.
IMPRESSION:
1. Interval placement of a left-sided PICC line with the tip terminating in
the proximity of the cavoatrial junction.
2. A new rounded opacity is seen projecting over the mid right lung possibly
representing a foreign object.
Radiology Report
CHEST RADIOGRAPH.
INDICATION: Recent PICC line, followup of opacity.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the course of the left PICC
line is unchanged. The opacity seen on yesterday's radiograph projecting over
the right lung is now elucidated by the lateral radiograph. The opacity is
caused by an intrafissural component of pleural effusion. The extent of the
bilateral pleural effusions is unchanged as also documented by the lateral
image. No other relevant changes. Status post vertebroplasty. Sternal wires
in situ. Unchanged appearance of the cardiac silhouette.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BACK PAIN
Diagnosed with OTHER CHRONIC PAIN , LUMBAGO, ALTERED MENTAL STATUS , MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
temperature: 98.6
heartrate: 79.0
resprate: 16.0
o2sat: 99.0
sbp: 122.0
dbp: 61.0
level of pain: 10
level of acuity: 3.0 | ___ w/PMHx multiple myeloma, arthritis, and spinal stenosis
presenting with complaints of poorly controlled back pain, acute
changes in mental status and failure to thrive, now with chest
CT showing consolidation vs. atelectasis on left, with possible
evolving right infectious process on right.
ACTIVE ISSUES
1 Goals of care: After extensive discussion with the patient's
son ___ and daughter (and HCP) ___, the decision was made
to transition to comfort measures only. Antibiotics were
discontinued and medication list was reviewed with unnecessary
medications removed (Simvastatin, vitamin D). The patient was
discharged to skilled nursing with inpatient hospice care. Goals
of care are comfort measures only, DNR/DNI, do not hospitalize
unless symptoms are not controlled with hospice care.
2. Healthcare Associated Pneumonia: Left pleural effusion
discovered on chest x-ray early in admission. After review of
patient's outside CT scans, no effusion was present in CT of ___, only an area of rounded atelectasis on the right. With
these findings, chest CT was performed and possible infectious
process was found on the right, with large areas of
consolidation vs. atelectasis on the left. It was thought that
these areas could likely represent pneumonia in the setting of
this patient who had been persistently delirious and has a
history of stay in a ___ care facility for the last
several months, who is likely to have aspirated, and likely does
not mount a large immune response. He was started on treatment
for presumed HCAP with vancomycin, cefepime, and metronidazole
to be continued for an 8 day course starting ___. After
goals of care discussion, antibiotics were discontinued ___.
PICC line was removed prior to discharge.
3. Altered mental status: Per the patient's family, he had
experienced a decline in mental status after his kyphoplasty
several months ago with a possible history of stroke, however,
his mental status had become acutely worse over the week prior
to admission. CT of the head revealed no acute process, but did
show evidence of chronic ischemic changes. Narcotics were
minimized with the thought that these were contributing to his
delirium. The patient was found to be hypercalcemic to 10.7 and
this was thought to be a possible cause of AMS. Oncology was
consulted and noted that this level of hypercalcemia was not
dramatic enough to cause AMS of the degree seen in this patient.
Other oncologic causes, including hyperviscosity and uremia
were also ruled out. Per oncology, there was no clear
indication that myeloma could be causing this AMS. Medication
effect from over sedation with oxycodone was thought to be a
large part of the etiology for delirium and the patient was
treated conservatively for pain, limiting narcotics.
3. Mutiple myeloma: The patient and family history on this topic
were vague; the outside oncologist Dr. ___ was called to
clarify. Per Dr. ___ patient was discovered to have
an isolated plasmacytoma at L3 in ___, which he was
treating with palliative radiation, with the possibility of
definitive treatment as this was thought to be his only lesion,
and he was thought to be free of systemic disease based on an
unremarkable skeletal survey. The patient had never received
chemotherapy for myeloma, nor had he had bone marrow biopsy.
IgG on ___ was 2500 with elevated kappa spike 27.2. However,
on lumbar MRI performed to evaluate back pain on this admission,
systemic disease was suggested by infiltration of the spine
consistent with extensive myeloma. Oncology was consulted who
noted that there was no urgent indication to treat the patient
for myeloma at this time and that myeloma was not likely to be a
contributing factor to his AMS. Repeat IgG was 2665 and Beta 2
microglobulin was elevated at 3.4. Skeletal survey showed no
definite lytic lesions. At the time of discharge, UPEP, serum
viscosity, and Free kappa and lambda light chains were still
pending and should be followed by the outpatient oncologist
depending on goals of care.
4.Back pain: The patient has a longstanding history of back pain
as well as surgery on the spine with most recently being
kyphoplasty in ___. However, this pain seemed worse.
Lumbar MRI was performed which did not reveal any obvious cause
for his pain but did show an ill-defined region of abnormal
density in the pre-coccygeal/pre-sacral area. The spine service
was consulted who reviewed the MRI with the neuroradiologist and
found no involvement of the spine by the presacral tissue
abnormality. The chronic pain service was also consulted. For
pain, the patient received: tylenol ___ tid, gabapentin 300mg
TID, oxycodone 5mg q6hours PRn, as well as morphine ___ IV prn
q8hrs for breakthrough pain. Narcotics were minimized due to
contribution to delirium. His neuropathic pain with
sciatica-like features improved. However, the patient had
difficulty communicating his overall pain effectively due to
delirium and consistently rated his pain low on a severity
scale.
5. Aspiration: Nursing raised concern for aspiration. Speech and
swallow study was performed with recommendations for
nectar-thick liquids and ground solids.
CHRONIC ISSUES
1. Glaucoma-stable on brimonidine and dorzolamide.
2. ___ esophagus-stable on omeprazole.
TRANSITIONAL ISSUES
UPEP, serum viscosity, and free kappa/lambda light chains are
still pending at discharge and should be followed up by the
outpatient PCP and oncologist
CODE STATUS DNR/DNI, Comfort measures only. Do not hospitalize. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nifedipine / Verapamil / amlodipine
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ with history of hypertension, hyperlipidemia,
atrial fibrillation on apixaban, type 2 diabetes c/b neuropathy
with diabetic foot ulcers, chronic diastolic CHF, and CKD Stage
III who was brought to the ED by her niece for cough and reduced
PO intake.
Notably, she had a recent admission to ___ from ___ for
right anterior shin cellulitis, for which she was treated with
IV
vancomycin while inpatient, then transitioned to doxycycline and
amoxicillin for total 10d course (___).
No additional history was obtained in the ED.
In the ED, initial vitals were: T 99 BP 133/62 HR 66 RR 18 O2
99%
2L NC
Exam was notable for:
- General: Altered, unable to answer questions, moaning
- Respiratory - CTAB
Labs were notable for:
- WBC 8.4, Hgb 10.1
- BUN 46, Cr 1.7
- Flu A positive
- Lactate 2.1
- UA negative
Studies were notable for:
- ___ CXR
No definite radiographic evidence of pneumonia. Stable mild
cardiomegaly.
The patient was given:
- Acetaminophen 650mg, Oseltamivir 30mg, apixaban 2.5mg,
ranitidine 150mg, insulin 24 unit total
- 1L NS
On arrival to the floor, patient reports that she has been
feeling poorly with worsening cough over the past ___ days. Her
cough has been junky but she has been unable to cough up any
secretions. She has been feeling feverish but does not think she
checked a temperature at home. She has also had decreased PO
intake during this time. Her niece, ___, who lives with her,
brought her to the hospital for further evaluation. She denies
abdominal pain, diarrhea, vomiting, or worsening leg pain.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
# HTN/hyperchol
# DM2 w/ neuropathy, nephropathy
# Obesity
# afib on Apixaban
# chronic dCHF
# h/o DVT/PE ___
# CKD III (b/l Cr 1.5-1.9)
# Breast Cancer (L. breast papillary carcinoma, on tamoxifen)
# multinodular goiter
Social History:
___
Family History:
Significant hx of DM2, her sister's daughter had sarcoidosis
Physical Exam:
ADMISSION EXAM
==============
VITALS: Temp: 101.2 PO BP: 146/89 L Lying HR: 71 RR: 18 O2 sat:
95% O2 delivery: 2l on 2L NC
GENERAL: Elderly woman, appears ill, warm to touch, in NAD
HEENT: NC/AT, EOMI, dry MM
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Diffuse wheezes in all lung fields, good air movement
bilaterally, no rhonci/rales
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. R leg wrapped in
ace wrap, mildly erythematous with some surrounding edema, no
purulent drainage
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: Alert, oriented to person/place (hospital), moving
all extremities with purpose, no facial asymmetry
DISCHARGE EXAM
==============
VITALS: 24 HR Data (last updated ___ @ 736)
Temp: 98.6 (Tm 99.1), BP: 124/66 (108-160/57-88), HR: 62
(62-81), RR: 16 (___), O2 sat: 94% (87-99), O2 delivery: 1lnc
(1L-2l)
GENERAL: Elderly woman, lying in bed, very hard of hearing.
HEENT: NC/AT, EOMI, dry MM.
NECK: JVP elevation 2cm above the clavicle with HOP at 90
degrees, prominent carotid pulsation just below the mandible.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: coarse bronchial breath sounds throughout, no distress,
resonant to percussion
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. R leg wrapped in
kerlix, mildly erythematous with trace edema, no
purulent drainage noted. R calf is mildly tender to palpation.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: Alert, oriented to person/place (hospital)/year,
moving all extremities with purpose, no facial asymmetry.
Pertinent Results:
ADMISSION LABS
=============
___ 04:18PM BLOOD WBC-8.4 RBC-4.70 Hgb-10.1* Hct-35.0
MCV-75* MCH-21.5* MCHC-28.9* RDW-16.6* RDWSD-43.3 Plt ___
___ 04:18PM BLOOD Neuts-82.7* Lymphs-8.2* Monos-8.1
Eos-0.6* Baso-0.2 Im ___ AbsNeut-6.98* AbsLymp-0.69*
AbsMono-0.68 AbsEos-0.05 AbsBaso-0.02
___ 04:18PM BLOOD Plt ___
___ 04:18PM BLOOD Glucose-191* UreaN-46* Creat-1.7* Na-145
K-4.8 Cl-103 HCO3-28 AnGap-14
___ 04:18PM BLOOD ALT-14 AST-22 AlkPhos-111* TotBili-0.3
___ 06:50AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.3
___ 08:47PM BLOOD Lactate-2.1*
___ 11:44PM BLOOD ___ pO2-81* pCO2-51* pH-7.37
calTCO2-31* Base XS-2 Comment-GREEN TOP
DISCHAGRE LABS
=============
___ 07:28AM BLOOD WBC-5.2 RBC-4.64 Hgb-10.0* Hct-34.4
MCV-74* MCH-21.6* MCHC-29.1* RDW-16.9* RDWSD-44.3 Plt ___
___ 07:28AM BLOOD Plt ___
___ 07:28AM BLOOD Glucose-86 UreaN-34* Creat-1.3* Na-142
K-4.4 Cl-101 HCO3-31 AnGap-10
___ 07:28AM BLOOD Calcium-9.2 Phos-2.6* Mg-2.1
MICRO
=====
___ 11:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ 4:45 pm BLOOD CULTURE
Blood CultureS, Routine (Pending): No growth to date.
___ 04:54PM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
IMAGING
=======
CXR
FINDINGS:
No focal consolidation. An area of relative opacity in the left
retrocardiac
lung is in stable configuration compared to ___. Lateral view
is suboptimal
secondary to arm positioning. No pneumothorax. No pleural
effusion.
There is mild cardiomegaly which is stable.
IMPRESSION:
No definite radiographic evidence of pneumonia. Stable mild
cardiomegaly.
NCCTH
IMPRESSION:
1. No acute intracranial hemorrhage or large territory
infarction.
2. Air-fluid level in the left sphenoid sinus may be due to
prolonged supine positioning, although acute sinusitis cannot be
excluded.
3. Stable chronic microvascular ischemic disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Apixaban 2.5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. Gabapentin 600 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Tamoxifen Citrate 20 mg PO DAILY
8. Torsemide 140 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
12. Lidocaine 5% Ointment 1 Appl TP DAILY
13. Glargine 16 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Apixaban 2.5 mg PO BID
4. Atorvastatin 20 mg PO QPM
5. Cyanocobalamin 1000 mcg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Gabapentin 600 mg PO DAILY
8. Lidocaine 5% Ointment 1 Appl TP DAILY
9. Lisinopril 10 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. Tamoxifen Citrate 20 mg PO DAILY
12. Torsemide 140 mg PO DAILY
13. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==============
Acute influenza A infection
Hypoxemia
Hypernatremia
Altered mental status
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with fever, AMS pneumonia
TECHNIQUE: Chest AP and lateral
COMPARISON: Prior radiograph ___
FINDINGS:
No focal consolidation. An area of relative opacity in the left retrocardiac
lung is in stable configuration compared to ___. Lateral view is suboptimal
secondary to arm positioning. No pneumothorax. No pleural effusion.
There is mild cardiomegaly which is stable.
IMPRESSION:
No definite radiographic evidence of pneumonia. Stable mild cardiomegaly.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with influenza with altered mental status. On
anticoagulation for Afib.// Rule out intracranial hemorrhage as cause of AMS
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 large territory infarction,hemorrhage,edema, or
mass. There is prominence of the ventricles and sulci suggestive of
involutional changes. Confluent periventricular and subcortical white matter
hypodensities are nonspecific but likely sequela of chronic small vessel
ischemic disease. Again seen is cavum septum pellucidum at vergae.
There is no evidence of acute fracture. A 4 mm calcific density along the
right convexity is unchanged (02:18) and may represent a calcified meningioma.
Other than a small air-fluid level in the left sphenoid sinus, 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 hemorrhage or large territory infarction.
2. Air-fluid level in the left sphenoid sinus may be due to prolonged supine
positioning, although acute sinusitis cannot be excluded.
3. Stable chronic microvascular ischemic disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever, ILI, Transfer
Diagnosed with Flu due to unidentified influenza virus w oth resp manifest
temperature: 99.0
heartrate: 66.0
resprate: 18.0
o2sat: 99.0
sbp: 133.0
dbp: 62.0
level of pain: 3
level of acuity: 3.0 | Patient is a ___ with history of atrial fibrillation on
apixaban, type 2 diabetes c/b neuropathy with diabetic foot
ulcers, chronic diastolic CHF, and CKD Stage III who presented
with fever and hypoxia, found to have acute influenza A
infection, course complicated by altered mental status (most
likely toxic metabolic encephalopathy), hypernatremia, and
recurrent fevers/persistent hypoxia with supplemental oxygen
requirement. Now completed Tamiflu and on room air. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man with esophageal cancer on chemo and s/p XRT with plans
for esophagectomy at some point who presenting with chest pain
and dysphagia found to have radiation esophagitis, s/p J-Tube
placement who was just discharged yesterday ___ where his
prior course was complicated by HA-PNA s/p completed course of
ABx and complicated by intractable nausea and vomiting and
intolerance to tube feeds who was discharged to rehab facility
for ongoing care and ___ and readmitted for recurrent abdominal
pain, nausea, vomiting and an isolated fever.
___ reports that he was feeling fine yesterday when he was
discharged and when he arrived to the rehab immediately "it was
was a horrible place". He reports that the "woman just sat there
on her phone not caring at all" and that when he started having
pain and nausea again "it was 5 or 6 hours before someone came"
and that "they didn't have the medications to give me", he
became frustrated angry and decided "Im getting out of this
place." He reports then his pain became worse, he started having
vomiting and then the pain became so severe that "I was hot all
over", per report he had a fever to 101 so was sent back to
___ ED for evaluation.
In the ED, initial vitals were: 101.2 116 121/62 18 100% RA.
Labs were at baseline, CT A/P without new acute changes, CXR
without PNA, UA and Flu swabs were negative. He was readmitted
to medicine for further work up.
On the floor, ___ reports feeling "better now" that he is
getting his "medications" as he is supposed to and he has no
frank complaints. He reports his abdominal pain is well
controlled at ___ but this is baseline, his nausea is well
controlled and he denies cough, SOB, sputum production, dysuria,
sore throat, sinus congestion or new rash. He feels the same as
he did prior to discharge yesterday.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
diarrhea, constipation. No dysuria. Denies arthralgias or
myalgias. Otherwise ROS is negative.
Past Medical History:
Stage III-IV (T3NxMx) Esophageal cancer on ___ + XRT now
s/p J tube and on tube feeds, plan for esophagectomy in ___
Hypertension
Migraines
PAST SURGICAL HISTORY:
Esophageal biopsy
R thumb surgery
Left finger surgery
Social History:
___
Family History:
Mother with htn
Sister with htn
Brother with throat cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 PO 107 / 70 89 18 93 RA
Pain Scale: ___
General: Patient appears chronically ill, but similar to prior
to DC, seated upright and talking in good humor. Another
"daughter" at the bedside
HEENT: Sclera anicteric, dry mucous membranes
Lungs: Overall clear with faint LLL rales, moving air well and
symmetrically, no wheezes, or rhonchi appreciated. Stable exam
from yesterday
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: Distended but soft, non-tender to palpation, J tube in
placed without surrounding erythema or exudate from insertion
site, no tenderness around insertion site. Normoactive bowel
sounds throughout, no rebound or guarding
Ext: Warm, well perfused, mild bilateral pitting edema to mid
tibia
DISHARGE PHYSICAL EXAM:
Vitals: 97.5 PO 111 / 70 90 18 90
Pain Scale: ___
General: Patient appears chronically ill, but overall improved
from when I have cared for him previously.
Lungs: Overall clear with reduced breath sounds at left base
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: Distended but soft, non-tender to palpation, J tube in
placed without surrounding erythema or exudate from insertion
site, no tenderness around insertion site. Normoactive bowel
sounds throughout, no rebound or guarding
Ext: Warm, well perfused, mild bilateral pitting edema to mid
tibia
Pertinent Results:
Admission Labs:
___ 12:25AM BLOOD WBC-3.6* RBC-3.54* Hgb-10.4* Hct-31.5*
MCV-89 MCH-29.4 MCHC-33.0 RDW-16.0* RDWSD-49.6* Plt ___
___ 12:25AM BLOOD Neuts-64 Bands-3 Lymphs-8* Monos-25*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-2.41 AbsLymp-0.29*
AbsMono-0.90* AbsEos-0.00* AbsBaso-0.00*
___ 12:25AM BLOOD Glucose-113* UreaN-21* Creat-0.9 Na-132*
K-4.4 Cl-94* HCO3-22 AnGap-20
___ 12:25AM BLOOD ALT-16 AST-24 AlkPhos-114 TotBili-0.6
___ 12:25AM BLOOD Lipase-8
___ 12:25AM BLOOD Albumin-3.9 Calcium-9.5 Phos-1.4* Mg-1.8
___ 12:42AM BLOOD Lactate-2.5*
Discharge Labs:
___ 08:10AM BLOOD Glucose-122* UreaN-15 Creat-0.7 Na-132*
K-4.7 Cl-94* HCO3-28 AnGap-15
___ 08:10AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.1
Imaging:
CT A/P: No acute process in the abdomen or pelvis.
CXR PA/LAT: Linear opacity at the left lung base likely
represents atelectasis or sequela of infection seen in ___. No new focal consolidation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Maalox/Diphenhydramine/Lidocaine 5 mL PO TID:PRN reflux
2. Sucralfate 1 gm PO QID prn pain
3. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough/sob
5. Bisacodyl 10 mg PO/PR DAILY:PRN c
6. Calcium Carbonate 500 mg PO QID:PRN heartburn
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
8. Fentanyl Patch 25 mcg/h TD Q72H
9. Hyoscyamine .25 mg PO QID:PRN esophageal secretions
10. Lidocaine 5% Patch 1 PTCH TD QPM
11. LORazepam 1 mg PO Q8H:PRN anxiety
12. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO Q3HR:PRN
Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Prochlorperazine 10 mg PO Q8H:PRN Nausea
15. Ramelteon 8 mg PO QHS
16. Senna 8.6 mg PO BID
17. TraZODone 50 mg PO QHS:PRN insomnia
18. Sumatriptan Succinate 25 mg PO BID:PRN headache
19. Ondansetron ODT 8 mg PO Q8H:PRN Nausea
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 15 ML by
mouth Every 6 hours Refills:*0
2. lansoprazole 30 mg oral DAILY
RX *lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
3. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg/5 mL 6.5 ml by mouth Every 6 hours
Refills:*1
4. Bisacodyl 10 mg PO/PR DAILY:PRN c
RX *bisacodyl 10 mg 1 suppository(s) rectally Daily Disp #*12
Suppository Refills:*0
5. Calcium Carbonate 500 mg PO QID:PRN heartburn
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth four times a day Disp #*100 Tablet Refills:*0
6. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour Apply 1 patch Every 72 hours Disp #*5
Patch Refills:*0
7. Hyoscyamine .25 mg PO QID:PRN esophageal secretions
RX *hyoscyamine sulfate 125 mcg/5 mL 10 ml by mouth Four times a
day Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % Apply 1 patch Every evening for 12 hours Disp
#*15 Patch Refills:*0
9. LORazepam 1 mg PO Q8H:PRN anxiety
RX *lorazepam 1 mg 1 mg by mouth Every 8 hours Disp #*21 Tablet
Refills:*0
10. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO Q3HR:PRN
Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *morphine 10 mg/5 mL 10 mg by mouth Every 3 hours Disp #*500
Milliliter Milliliter Refills:*0
11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth Every 8 hours Disp
#*90 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth
Daily Refills:*0
13. Prochlorperazine 10 mg PO Q8H:PRN Nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth Every 8
hours Disp #*30 Tablet Refills:*0
14. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth Nightly Disp
#*30 Tablet Refills:*0
15. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 Tab by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Sucralfate 1 gm PO QID prn pain
RX *sucralfate 1 gram/10 mL 10 ml by mouth four times a day
Refills:*0
17. Sumatriptan Succinate 25 mg PO BID:PRN headache
RX *sumatriptan succinate 25 mg 1 tablet(s) by mouth twice a day
Disp #*5 Tablet Refills:*0
18. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Active:
- Radiation esophagitis
- Esophageal cancer s/p XRT
- Nausea with Vomiting
- GERD
- Moderate Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ just d/c-ed after admission w/hcap, now back with
fever and increased sputum pdt// any e/o new pna?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph on ___, CT abdomen pelvis on ___
FINDINGS:
Linear opacity at the left lung base likely represents atelectasis or residua
of infection seen in ___. No pleural effusion or pneumothorax is
seen. The cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION:
Linear opacity at the left lung base likely represents atelectasis or sequela
of infection seen in ___. No new focal consolidation.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: NO_PO contrast; History: ___ with recent J tube placement with
abdominal pain and feverNO_PO contrast// intraabdominal abscess or perforation
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 596 mGy-cm.
COMPARISON: CT abdomen and pelvis on ___
FINDINGS:
LOWER CHEST: Opacity at the left lung base may represent atelectasis or
residua of infectious process seen in ___. There is mild right
basilar atelectasis. There is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Few
scattered subcentimeter hepatic hypodensities are too small too characterize,
however likely represent hepatic cysts or biliary hamartomas. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Subcentimeter cortical hypodensities bilaterally are too small too
characterize, however likely represent cysts. There is no hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. A J-tube is present, entering
through the left anterior abdominal wall (2:46). Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
colon and rectum are within normal limits. The appendix is normal (601b:24).
There is no free intraperitoneal air.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
No acute process in the abdomen or pelvis.
Radiology Report
INDICATION: ___ year old man with esophageal cancer s/p G-J tube with blocked
J tube.// Please evaluate and mend J tube.
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 10 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: Lidocaine
CONTRAST: 10 ml of Optiray contrast.
PROCEDURE: 1. Replacement jejunal tube
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. The initial jejunal tube was
completely clogged no contrast could be passed through. A Glidewire was
slowly introducing navigated through the obstructed segment of the tube in
plasty into the jejunum. The existing tube was removed. A Kumpe catheter was
placed. A small contrast injection confirmed jejunal placement. Then an
Amplatz wire was placed. Over the Amplatz wire a 12 ___ Wills-Oglesbytube
was placed. This was sutured to the skin with 0 silk sutures. The patient
tolerated the procedure well.
FINDINGS:
1. Clotted J-tube
2. New ___ ___ tube in place
IMPRESSION:
Successful exchange of clotted J tube with 12 ___ ___ tube. The
tube is ready for use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Fever, unspecified
temperature: 101.2
heartrate: 116.0
resprate: 18.0
o2sat: 100.0
sbp: 121.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | ___ yo man with esophageal cancer on chemo and s/p XRT with plans
for esophagectomy at some point who was just discharged from my
service yesterday ___ after a 5 week hospitalization where he
was managed for radiation esophagitis, s/p J-Tube
placement, HA-PNA s/p completed course of ABx and intractable
nausea and vomiting with intolerance to tube feeds who was
readmitted from nursing facility <12 hours from discharge with
recurrent symptoms and isolated fever.
# Fever
# Abdominal pain
One isolated fever to 101 without new or focal symptoms. Seems
that the fever was an adrenergic response to severe abdominal
pain and nausea while at ___. During his course he had no focal
findings on exam and no localizing symptoms other than chronic
issues and with stable labs without leukocytosis. CT A/P, CXR,
UA, Flu swab and Cdiff PCR all negative. BCx and stool Cx NGTD.
He remained hemodynamically stable without signs of sepsis
throughout his course without need for antibiotics.
# Radiation Esophagitis
# Stage III-IV esophageal cancer on chemo s/p XRT
# Moderate Malnutrition: No PO intake, albumin 3.0 during prior
admission, peripheral muscle wasting on exam.
# Nausea with vomiting
Overall he appeared stable, pain and nausea controlled and at
baseline from prior to last discharge. As per prior work up and
documentation from last admission, radiation esophagitis was
confirmed on biopsy EGD ___. His last admission pain was very
difficult to control following J tube placement and he required
high dose IV Morphine which was changed to PO solution AND SC
morphine. Prior to discharge he was only requiring oral morphine
solution. Recurrent severe pain at ___ was likely related to
missing several doses of morphine and being underdosed from what
he was receiving at ___. Furthermore, nausea and vomiting were
best controlled at ___ when zofran and compazine were
staggered Q4 Hr. While at ___ seems he did not receive any
antiemetics, this likely accounted for worsening symptoms rather
than new acute pathology. During his admission he had no
evidence of worsening diarrhea, fevers, chills or leukocytosis
to support infectious etiology. No abdominal tenderness on exam
and normoactive bowel sounds, CT A/P negative and passing
flatus, SBO highly unlikely. Cdiff and stool cultures all
negative. Continued continuous tube feeds at 70ml/hr as per
prior hospitalization, restarted Ondansetron Q8H and Compazine
Q8H standing and stagger within 4 hours of each other. EKG
monitored and QT remained around 425. Continued Fentanyl 25
mcg/patch for basal pain control, Omeprazole, liquid
acetaminophen, sucralfate slurry, lidocaine patch as during
prior admission. Continued also
Maalox/diphenhydramine/lidocaine/levsin. Continued 10 mg oral
morphine solution q2hrs initially as recommended by palliative
care which was tapered to Q3HRS:PRN in conjunction with
palliative care recs. On discharge the plan was to continue
weaning to Q4HRs:PRN, this was communicated to outpatient
providers by palliative care.
# Hyponatremia
Mild and consistent with prior values during last admit. Likely
hypovolemic from vomiting, resolved with IVFs.
# Anemia:
# Leukpenia
Stable on admission from prior to discharge, downtrended in
setting of IVFs but remained stable therafter. Likely related to
chemotherapy, radiation and chronic disease, not neutropenic and
without signs of blood loss.
# Opiate use disorder:
History of and no longer active. For now priority is achieving
pain control for his severe esophagitis as before then discuss
weaning opiates in conjunction with palliative care. Morphine
tapering should continue as discussed in notes and in discussion
with palliative care, high risk for addiction. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worsening hydropneumothorax
Major Surgical or Invasive Procedure:
Placement of TPA in Chest Tube
History of Present Illness:
___ year old male h/o SCLC s/p XRT and radiation, HTN, afib,
gout recently admitted with R sided empyema s/p chest tube
placement, ___ currently on CTX who presented to ___ clinic
with worsening hydropneumothroax and loculation.
Pt not feeling more dyspneic than usual. Denies fevers, chills,
N/V, chest pain, pleuritic pain. Endorses mild productive cough
and congestion. Reports only having 25cc drained daily from
chest tube.
Patient had a recent admission to the MICU for right sided
pleural effusion and dyspnea. He had chest tube placed at that
time
In the ED, initial VS were 98.3 ___ 24 98/RA.
Exam notable for:
Decreased breath sounds over R lung field. Mild diffuse
wheezing
Tachycardic. RRR. S1, S2.
Chest tube dressed anteriorly. No tenderness
Labs showed:
11.8 > 9.3/30.5 < 482
133 | 95 | 11
--------------< 88
4.9 | 27 | 0.5
phos 5.4
INR 1.5
Imaging showed
CXR: persistent large, loculated right pleural effusion with
associated air fluid level and locules of pleural gas
CT chest:
-Increase in fluid volume of large probably multiloculated
right hydro pneumothorax, most of which is remote from the plane
of the lateral and anterior position of the tunneled right
pleural drainage catheter.
-New epicardial edema. Even though the volume of right
pericardial effusion is small, it should be monitored with
echocardiography to detect any evidence of developing purulent
pericarditis.
-The bronchus intermedius is stented. Narrowing of the right
main and upper lobe bronchi has improved. Right hilar mass still
occludes right middle and lower lobe bronchi and those lobes are
collapsed.
Interventional Pulmonology was consulted and put tPA through
the chest tube.
Received intrapleural alteplase and dornase Alfa through the
chest tube. Patient also received metoprolol for tachycardia.
Also received 75 cc/hr IVF.
Transfer VS were 98.5 114 108/68 20 96% RA.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient denies any complaints. No
chest pain and no SOB. He says he has been getting around at
home just fine with physical therapy.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
Hyperlipidemia
Gout
COPD
s/p hernia repair
Deviated septum
SCLC, ___ years ago, s/p chemoradiation + prophylactic cranial
radiation
Social History:
___
Family History:
Mother: thyroid disease
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS - 97.7 ___ 18 97% RA
GENERAL: NAD, AAOX3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: tachycardic, regular rhythm, S1/S2, no murmurs,
gallops, or rubs
LUNG: slightly decreased breath sounds at right base. Otherwise
CTAB. Chest tube in place
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE
Vitals: afebrile, 93/69, 105, 18, 94% RA
GENERAL: NAD, AAOX3
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
CARDIAC: tachycardic, regular rhythm, no murmurs
LUNG: decreased breath sounds at right base extending ___ up R
lung field, dullness to percussion on R. Otherwise CTAB. Chest
tube in place, on suction.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION
___ 12:56PM BLOOD WBC-11.8* RBC-3.50* Hgb-9.3* Hct-30.5*
MCV-87# MCH-26.6 MCHC-30.5* RDW-15.7* RDWSD-49.8* Plt ___
___ 12:56PM BLOOD Neuts-87* Bands-0 Lymphs-6* Monos-5 Eos-2
Baso-0 ___ Myelos-0 AbsNeut-10.27* AbsLymp-0.71*
AbsMono-0.59 AbsEos-0.24 AbsBaso-0.00*
___ 12:56PM BLOOD ___ PTT-40.1* ___
MICRO:
___ URINE CULTURE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL; FUNGAL
CULTURE-PRELIMINARY ___.
___ 11:04 am PERITONEAL FLUID
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
IMAGING/OTHER STUDIES:
___HEST W/O CONTRAST
IMPRESSION:
Slight decrease in overall volume and in the fluid component of
multiloculated right hydro pneumothorax. No change in position
of course of the right pigtail drainage catheter.
Bronchus intermedius stent unchanged in position. Improved
patency to right middle lobe bronchus and right lower lobe
segmental bronchi.
___ Cardiovascular ECHO
Overall left ventricular systolic function is normal (LVEF>55%).
There is mild right ventricular global free wall hypokinesis.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Tiny pericardial effusion, not significantly
changed since the prior study of ___
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Compared to chest radiographs ___ through ___.
Left PIC line ends in the upper SVC. Restrictive right pleural
thickening
persists but there has been a decrease in the volume of
dependent pleural
effusion. I cannot tell whether this has been replaced by
pleural air or
re-expanded lung. Basal pleural drainage tube is still in
place. Heart size top-normal. Left lung clear.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
In comparison to ___ radiograph, a pleural catheter
is in place in the right hemi thorax, with a persistent large,
loculated right pleural
effusion with associated air fluid level and locules of pleural
gas, more
fully evaluated by recent chest CT performed less than 1 hr
earlier.
Postoperative and post radiation changes in the right hemi
thorax are more
fully evaluated by CT.
___HEST W/O CONTRAST
IMPRESSION:
Increase in fluid volume of large probably multiloculated right
hydro
pneumothorax, most of which is remote from the plane of the
lateral and
anterior position of the tunneled right pleural drainage
catheter.
New epicardial edema. Even though the volume of right
pericardial effusion is
small, it should be monitored with echocardiography to detect
any evidence of
developing purulent pericarditis.
The bronchus intermedius is stented. Narrowing of the right
main and upper lobe bronchi has improved. Right hilar mass
still occludes right middle and lower lobe bronchi and those
lobes are collapsed.
Labs on Discharge:
___ 06:16AM BLOOD WBC-12.8* RBC-3.48* Hgb-9.1* Hct-29.9*
MCV-86 MCH-26.1 MCHC-30.4* RDW-16.0* RDWSD-50.3* Plt ___
___ 06:16AM BLOOD ___ PTT-37.6* ___
___ 06:16AM BLOOD Glucose-91 UreaN-21* Creat-1.4* Na-131*
K-5.1 Cl-92* HCO3-24 AnGap-20
___ 06:16AM BLOOD Calcium-9.6 Phos-7.1* Mg-1.8
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with hx of empyema, lung cancer and trapped lung,
now has TPC // evaluate trapped lung and pleural fluids
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.1 s, 38.7 cm; CTDIvol = 11.6 mGy (Body) DLP =
438.5 mGy-cm.
Total DLP (Body) = 449 mGy-cm.
COMPARISON: CHEST CT OF ___, AND ___, read in conjunction with
conventional chest radiographs since ___ showing the recent
re-accumulation of moderate right pleural effusion following exchange of
pleural drainage devices.
FINDINGS:
Supraclavicular and left axillary and numerous sub cm right axillary lymph
nodes are not pathologically enlarged or growing.
There is no soft tissue abnormality in the chest wall suspicious for
malignancy or infection, including the course of the tunneled pleural drainage
catheter that enters the right lower chest anterolaterally and ascends to the
anterior pleural space.
A moderate to large right nonhemorrhagic pleural effusion has grown larger
since ___, replacing the some of the previous large pockets of pleural
air, containing smaller pockets of air. It lies primarily posterior and
inferior to the right lung, which is encased in thickened visceral pleura.
Parietal pleura is particularly thickened with induration of the extra
pleural, intrathoracic soft tissue, but no extravasation of fluid or
infiltration involving the chest wall. Largest discrete air and fluid
collection is in the upper right posterior hemi thorax, probably in the
pleura, although given the severity of bullous emphysema, a superinfected
bulla is not excluded.
Small pericardial effusion is stable but there is an increase in edema of
epicardial fat, suggesting inflammation. There is no evidence of tamponade
physiology. The left pleural space is normal.
Thyroid is unremarkable. Atherosclerotic calcification is moderately heavy in
head and neck vessels but not evident in coronary arteries. Aorta is normal
size. Main pulmonary artery is mildly dilated, 34 mm today, 33 mm on ___.
A large infiltrative right hilar mass contiguous with extensive subcarinal
mediastinal adenopathy obstructs the right bronchial tree below a short stent
in the bronchus intermedius, occluding both the middle and lower lobe bronchi
and major segments. The right main bronchus and upper lobe bronchus are
surrounded by tumor, but are less narrowed today than on ___.
Nevertheless large portion of the right upper lobe is collapsed against the
mediastinum, perhaps due to prior radiation therapy,Although this history is
not provided to me. Right middle and lower lobes are entirely collapsed.
There is lesser adenopathy in the prevascular mediastinum and left hilus,
unchanged. In addition to previously described large scale subcarinal
adenopathy, also stable is mild adenopathy in the prevascular mediastinum and
left hilus. Dystrophic calcifications lie in lymph nodes medial to the
bronchus intermedius. Left bronchial tree is patent.
. .
Emphysema is severe in the aerated right upper lobe, less pronounced
throughout the left lung. There is no pneumonia or nodulation in the left
lung.
Loss of height in several thoracic vertebrae is due to depression of there
superior endplates, unchanged in severity since ___, and not necessarily
due to tumor infiltration. A sclerotic expansion of the posterior aspect of a
right lower rib is a healed fracture, possibly pathologic. There are no other
osseous lesions in the chest cage concerning for metastasis or infection.
IMPRESSION:
Increase in fluid volume of large probably multiloculated right hydro
pneumothorax, most of which is remote from the plane of the lateral and
anterior position of the tunneled right pleural drainage catheter.
New epicardial edema. Even though the volume of right pericardial effusion is
small, it should be monitored with echocardiography to detect any evidence of
developing purulent pericarditis.
The bronchus intermedius is stented. Narrowing of the right main and upper
lobe bronchi has improved. Right hilar mass still occludes right middle and
lower lobe bronchi and those lobes are collapsed.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with hx of pleural effusion s/p TPC placed //
?effusion / resolution
IMPRESSION:
In comparison to ___ radiograph, a pleural catheter is in place in
the right hemi thorax, with a persistent large, loculated right pleural
effusion with associated air fluid level and locules of pleural gas, more
fully evaluated by recent chest CT performed less than 1 hr earlier.
Postoperative and post radiation changes in the right hemi thorax are more
fully evaluated by CT.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema // interval change interval
change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Left PIC line ends in the upper SVC. Restrictive right pleural thickening
persists but there has been a decrease in the volume of dependent pleural
effusion. I cannot tell whether this has been replaced by pleural air or
re-expanded lung. Basal pleural drainage tube is still in place. Heart size
top-normal. Left lung clear.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ years old man with trapped lung, empyema and chest tube
insertion // chest tube and residual pleural effusion
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.4 s, 39.9 cm; CTDIvol = 12.0 mGy (Body) DLP =
459.1 mGy-cm.
Total DLP (Body) = 470 mGy-cm.
COMPARISON: Chest CT scans since ___, most recently ___.
FINDINGS:
Overall volume of the extensive right hydro pneumothorax has decreased
slightly since ___, but there is still a moderately large volume of
fluid with multiple small gas loculations and severe restrictive pleural
thickening partially responsible for contraction of the right hemi thorax and
rightward shift of the mediastinum. The largest pleural fluid collection, in
the apex is smaller, largely replaced by air. The right pleural drain
entering anterolaterally and ascending anterior to the right upper lobe is
unchanged in position and there is no the fluid or other abnormality
associated with its tunneled course in the right chest wall.
Small to moderate pericardial effusion is unchanged. There is no
calcification the and no increase in the mild edema of epicardial fat or any
evidence of tamponade.
Short bronchial stent in the bronchus intermedius is unchanged. The
infiltrative peribronchial tissue in the right hilus with a masslike
appearance is inseparable from atelectasis. Bronchial patency has definitely
improved in the right middle lobe and superior and basal segments of the lower
lobe although the lower lobe remains a largely collapsed. Left lung is clear
of focal abnormality. Other findings are unchanged since ___.
IMPRESSION:
Slight decrease in overall volume and in the fluid component of multiloculated
right hydro pneumothorax. No change in position of course of the right
pigtail drainage catheter.
Bronchus intermedius stent unchanged in position. Improved patency to right
middle lobe bronchus and right lower lobe segmental bronchi.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Other pneumothorax
temperature: 98.3
heartrate: 111.0
resprate: 24.0
o2sat: 98.0
sbp: 104.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old male h/o SCLC s/p XRT ___ years ago,
HTN, afib on apixiban, gout recently admitted with complicated
R-sided empyema and presented from ___ clinic for management of
worsening hydropneumothorax and new loculations of this known
empyema. He was recently treated with 6 week course of
ceftriaxone and placement of a chest tube for drainage of the
empyema. Previous pleural fluid culture grew S. pneumo. CT scan
obtained in ___ clinic on the day of admission showed loculations
of the empyema, and he was sent to ___ ED. ___ was held
and TPA placed in the chest tube X 3 with good effect. He was
restarted on a 6 week course of CTX. He was mildly tachycardic
on admission but this resolved with home metoprolol. Plan for
patient to follow-up in clinic regarding continued care of this
complex loculated hydropneumothorax.
Active Medical Issues
======================
#Empyema: Patient presented from ___ clinic for management of
worsening hydropneumothorax and new loculations of this known
empyema. He was recently treated with 6 week course of
ceftriaxone and placement of a chest tube for drainage of the
empyema. Previous pleural fluid culture grew S. pneumo. CT scan
obtained in ___ clinic on the day of admission showed loculations
of the empyema, and he was sent to ___ ED. The patient was
evaluated by Infectious disease who recommended repeat 6 week
course of CTX (anticipated end date ___. Apixiban was held
and TPA placed in the chest tube X 3 with good effect. Of note,
chest CT showed a new mass highly suspicious for recurrence of
small cell lung cancer, which may explain the etiology of the
patient's persistent empyema. Plan for patient to follow-up in
clinic regarding continued care of this complex located empyema
and further workup of lung mass.
#Sinus tachycardia: Patient with history of sinus tachycardia
and Afib. Had afib and pauses on telemetry ___ seconds) on his
last admission at ___. On this admission, found to be in sinus
tach, resolved with resumption of home metoprolol. HD stable.
Home ASA and apixaban were initially held iso tPA infusion,
restarted upon discharge. Home diltiazem was stopped given
patient had intermittent low BPs during hospital course.
#Pericardial effusion: Pt w/ persistent small pericardial
effusion since at least ___, per previous notes.
Patient with tachycardia, however pressures normal and stable w/
negative pulsus paradoxus. TTE on ___ and ___ also
showed very small pericardial effusion, without
echocardiographic signs of tamponade. Patient did show evidence
of new epicardial edema on CT scan ___ concerning for
pericarditis, but patient asymptomatic and EKG w/ no e/o
pericarditis.
Chronic Medical Issues:
=======================
#Gout: Patient notes several acute gout exacerbations per year,
most recently involving L knee. Continued home allopurinol.
#COPD: continued home inhalers, albuterol prn
#HLD: continued home simvastatin, home fenofibrate
#HTN: continued home quinapril, continued home spironolactone. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / simvastatin
Attending: ___.
Chief Complaint:
Chief Complaint: Dyspnea
Reason for MICU transfer: Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male, with past history of CAD s/p
CABG, aspirations, presenting with increased dyspnea, shortness
of breath and respiraotry distress. Patient was initially
hypoxic to the ___ by EMS, and placed on NRB with improvement to
93%. Patient is admitted to the FICU for hypoxemic respiratory
distress.
In report, patient was seen earlier in the evening, after
vomiting choking/gaged with dinner. Patient had chicken pot pie
and pudding. Per son, patient was eating dinner, and felt full,
and thn vomiting. Patient then had a syncopal episode, where he
was unresponsive to questions for about 5 minutes. During this
time, family notes that he did not appear cyanotic, was still
breathing, however was unable to respond to verbal stimuli, and
then recovered. EMS was initially called, and reportedly vitals
were fine, and patient was able to walk with his walker, and
therefore EMS left. Overnight, son noted that that the patient
was having difficulty sleeping ___ to coughing and dyspnea, and
therefore called EMS. Upon arrival, EMS found patient to be
hypoxic, and tachypneic to the ___. Patient was then placed on
NRB, continued to tachhypneaic and hypoxic on RA. Reportedly
course breath sounds bibasilar, and then started on BiPAP. Only
awakening to stimuli and appropriate.
Patient is a DNR, however if needed intubation is ok for short
term. Per son, patient was on a thin liquid diet from the rehab
after piror discharge, however resolved. Patient on full diet at
home.
In the ED, initial vitals: - Initial Vitals/Trigger: 0 99.5 125
183/90 36 93% In the ED, patient was placed on NIV PSV 8/PEEP
8, FIO2 40%. Initial labs with leukocytosis to 18.1, with PMN
predominance. Patient also signficant for elevated BUN 34/Cr
1.8. Patient had proBNP 465, neg Trop <0.01. Lactate elevated to
5.6. Patent underwent chest and abdominal plain films.
On arrival to the FICU, patient was placed on NIPPV, and
reponding to verbal stimuli. Patient was able to nod yes/no to
questions, however unable to speak to questions, and continued
to fall asleep during interview. Therefore discussed with son.
Patient denied any pain, denied any shortness of breath,
abdominal pains, chest pains, palpitations.
Past Medical History:
1. CAD: status post CABG in ___ (LIMA to LAD and SVG to the
PDA, and SVG to the OM) and cardiac catheterization in ___
with Hepacoat stent of SVG-OM (SVG-PDA was noted to be occlued
at
this time). Most recent persatine-mibi ___ demonstrated a
mild inferior fixed defect, with EF 61%.
# PCI ___ w/Hepacoat stent of the SVG-OM and the SVG to
the PDA was noted to be occluded at this time, most recent
p-MIBI ___ w/mild inferior fixed defect
# Congestive heart failure (LVEF 45% on ___, chronic DOE
# HTN
# HL
# Peripheral neuropathy
# H/o paroxysmal afib in the setting of infection
# BPH s/p TURP in ___
# Cataracts
# Cholestasis c/b cholangitis s/p ERCP
# Degenerative joint disease C-spine
# Hearing impairment
# B12 deficiency
# Carpal tunnel syndrome
# H/o colonic polyps (___)
# Prior admissions for urosepsis.
Social History:
___
Family History:
Denies history of cancer or liver disease
Physical Exam:
>> Admission Physical Exam:
Vitals- 101.3 axillary, BP 93/47 O2 98 on BIPAP 40% FIO2, 8PEEP.
HR 101
General: Mask, responding with nodding. Patient appears stated
age. Lower lip is purple, with skin abrasion on left cheek
superficailly. PERRL. EOMI.
Neck: Supple, no LAD apprecaited.
Lungs: Difficult to auscultate breath sounds bialterally on
anterior. Unable to auscultated posterior.
CV: Distant, S1, S2. No rub, extra sounds heard.
Abdomen: DIstended, Hyperactive BS+. No rebound, guarding, no
grimacing to palpation.
Extremities: Lower extremities cool to touch L > R. Hands warm
to touch. Pulses 2+ .
.
>> Discharge Physical Exam:
VSS
GEN: NAD frail-appearing
CV: RRR, Nl S1/S2, ___ SEM
PULM: CTA B
GI: +BS, mild TTP in RUQ
EXT: WWP, no CCE bilat pedal edema R>L
SKIN: no rashes
NEURO: aao x3, CNs ___ intact, strength ___ throughout
PSYCH: appropriate, normal affect, not depressed
Pertinent Results:
>> Admission Labs :
___ 11:20PM BLOOD WBC-18.1*# RBC-4.57* Hgb-14.1 Hct-43.7
MCV-96 MCH-30.9 MCHC-32.3 RDW-14.3 Plt ___
___ 06:27AM BLOOD WBC-16.3* RBC-3.63* Hgb-11.4* Hct-34.0*
MCV-94 MCH-31.5 MCHC-33.6 RDW-13.7 Plt ___
___ 11:20PM BLOOD Neuts-83.0* Lymphs-12.5* Monos-3.5
Eos-0.7 Baso-0.3
___ 06:27AM BLOOD Neuts-85* Bands-7* Lymphs-2* Monos-5
Eos-0 Baso-0 ___ Myelos-1*
___ 11:20PM BLOOD Glucose-159* UreaN-34* Creat-1.8* Na-145
K-4.5 Cl-98 HCO3-28 AnGap-24*
___ 06:27AM BLOOD Glucose-135* UreaN-38* Creat-1.7* Na-140
K-4.3 Cl-104 HCO3-26 AnGap-14
___ 06:27AM BLOOD Albumin-3.4* Calcium-8.3* Phos-2.2*
Mg-1.9
___ 04:18AM BLOOD Type-ART Temp-39.7 pO2-93 pCO2-52*
pH-7.32* calTCO2-28 Base XS-0 Intubat-NOT INTUBA
___ 11:37PM BLOOD Lactate-5.6*
___ 11:37PM BLOOD Lactate-5.6*
___ 04:18AM BLOOD Lactate-2.7*
.
>> Pertinent Reports:
___: Blood Culture x 1: pending.
Images:
___ CXR
Minimal interval improvement in bibasilar
left-greater-than-right opacities.
___ CXR
Substantial iimprovement in bibasilar opacities since 1 day ago.
___: CXR: Low lung volumes with bibasilar opacities which
may represent atelectasis or infection in the appropriate
clinical setting.
___: Abdominal X-ray: Non specific bowel gas pattern with
minimally dilated bowel of small bowel seen in the mid abdomen
however gas and stool are seen throughout the colon and rectum.
Possible small bowel obstruction can't be completely excluded.
___ Cardiovascular ECHO: Suboptimal image quality. No
intracardiac source of syncope identified. Globally preserved
biventricular systolic function in the setting of regional wall
motion abnormalities, as described above. Mild aortic stenosis.
Mild mitral regurgitation. Borderline pulmonary artery systolic
hypertension. Left Ventricle - Ejection Fraction: >= 60%
Hypokinesis of the basal and mid inferior and inferoseptal
segments is seen
EKG: ED EKG: SInus, 130, ST depressions, in V4-V6.
.
>> Discharge Labs:
___ 07:50AM BLOOD WBC-8.9 RBC-3.67* Hgb-11.1* Hct-33.8*
MCV-92 MCH-30.3 MCHC-32.9 RDW-13.7 Plt ___
___ 07:50AM BLOOD Glucose-95 UreaN-22* Creat-1.4* Na-138
K-4.3 Cl-103 HCO3-27 AnGap-12
___ 07:50AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Citalopram 10 mg PO QHS
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Gabapentin 200 mg PO Q12H
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Tolterodine 4 mg PO QHS
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Citalopram 10 mg PO QHS
4. Clopidogrel 75 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Gabapentin 100 mg PO BID
7. Tolterodine 4 mg PO QHS
8. Vitamin D 1000 UNIT PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Metoprolol Succinate XL 25 mg PO DAILY
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth once Disp
#*1 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aspiration ___
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with resp failure, asp event // infiltrate
COMPARISON: Chest radiograph from ___.
FINDINGS:
AP view of the chest provided.
Since prior study from 1 day ago, bibasilar opacities have decreased.
Cardiomediastinal and hilar structures are otherwise stable. There are no
pleural effusions.
IMPRESSION:
Substantial iimprovement in bibasilar opacities since 1 day ago.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with tachpnea, aspiration PNA, wheezing // pulm
edema, worsened PNA, pneumonitis
COMPARISON: None.
FINDINGS:
Compared with ___ at 05:05, there may have been minimal improvement
in the bibasilar left-greater-than-right opacities, but the overall appearance
is similar. No new opacity and no gross effusion is identified. Upper zone
redistribution, without other evidence of CHF, not significantly changed.
Cardiomediastinal silhouette, with sternotomy wires, unchanged.
IMPRESSION:
Minimal interval improvement in bibasilar left-greater-than-right opacities.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC, VOMITING
temperature: 99.5
heartrate: 125.0
resprate: 36.0
o2sat: 93.0
sbp: 183.0
dbp: 90.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ year old male, with prior history of
aspirations by history, CAD s/p CABG, who presented to ___
acute respiratory distress and hypotension after vomiting.
ACUTE ISSUES
# Sepsis ___ Aspiration Pneumonia: Patient briefly febrile with
leukocytosis on admission. Lactate elevated and there was a new
infiltrate noted in b/l bases concening for aspiration pneumonia
vs pneumonitis. Hypoxic on arrival, briefly requiring NIPPV, but
rapidly down-titrated to NRB and then NC. Initially treated with
vancomycin/zosyn. Zosyn later changed to cefepime/metronidazole
given a penicillin allergy and vancomycin discontinued. After
24 hours, patient no longer had on oxygen requirement, was
afebrile, had appropriate urine output and lactic acidosis had
resolved. Patient's blood pressures remained lower than reported
baseline however improved and home bblocker was restarted. He
was called out of the ICU where he was transitioned to
levo/flagyl with continued improvemnt. ___ompleted while in the hospital.
# Aspirations: Patient with aspiration pneumonia in the setting
of recurrent aspiration and dysphagia. Originally evaluated by
speech and swallow who recommended he remain NPO, but on
re-evaluation he was deemed safe to place on a modified diet.
On further discussion with the patients family, they do not want
to pursue further w/u for this. Per family request, patient was
seen by palliative care in the hospital for discussions about
end of life and DNH, however ultimately pt was discharged to
rehab with ongoing discussions about goals of care.
# Delerium: pt with AMS while in the hospital, likely due to
infection. Pt was aaox 3 throughout and was improved at the
time of discharge although is intermittently somnolent.
# Heart Failure with preserved EF: Patient appeared euvolemic on
examination. BNP 465 on admission, not concerning for
exacerbation of diastolic CHF.
# ___ on CKD: Patient with baseline creatinine of 1.3, presented
with 1.8. Improved with IVF hydration to 1.4.
# Paroxysmal Atrial fibrillation: Occured in the setting of
infection, no recurrent tachycardia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Mirapex / aloe ___ / Vitamin D3
Attending: ___
Chief Complaint:
Global Aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old left handed male with a history of ?
epilepsy and a-fib c/b strokes now presenting with recurrent
aphasia.
The patient's neurologic history is long and nebulous. When he
and his wife married ___ years ago, he had several episodes of
brief LOC that were thought to reflect seizure. His wife is not
sure what was done for w/u. He was maintained on PHT for many
years without LOC (had a spell when was off PHT briefly). He
also has a history of atrial fibrillation and is anticoagulated.
He has a number of strokes that have been seen on prior imaging,
possibly a mix of small vessel and embolic.
His recent neurologic history began in ___. Please
refer to discharge summary for full details. In brief, on
___ pt had ~90 minutes of slurred speech and diminished
output (said "no" to most questions). Stroke w/u showed chronic
R basal ganglia nd L lacunar strokes without any acute lesions.
He was started on a statin (LDL 115). Immediately after
discharge, he had new aphasia, inability to read, R face droop,
RUE weakness. He was transferred back to ___ and admitted
from ___. cvEEG showed slowing over the right
hemisphere but no seizures or epileptiform discharges. LEV was
increased from 500mg to 750mg BID.
In the interim, speech has been normal per wife and he has not
had any episodes of LOC. Recently he has had a chest cold,
coughing but without fevers/chills; this has been improving. He
was last seen normal at approximately 10:30 this morning by his
wife. She called him for lunch at 12:30 and when he came to eat
his sandwich (which he did without choking or coughing), he was
trying to tell his wife something but his speech was non-fluent
and unintelligible. She calls EMS and he was brought to ___
___. There, ___ reportedly 7 (speech only with a normal
motor exam; telestroke with a Dr. ___ ___.
Creatinine 0.9 at OSH. CXR was clear. ___ was without acute
process and he was sent here for further evaluation.
On arrival here 0 98.5 66 126/70 12 96%. The examination was
essentially unchanged, revealing a global aphasia but no other
abnormalities. CTA head/neck & C- were unchanged compared to
priors (loss of right V4, numerous bilateral hypodensities).
Repeat INR was 3. Basic labs were WNL.
Past Medical History:
1. Paroxysmal atrial fibrillation, on Coumadin.
2. History of left lacunar stroke.
3. History of diminished dorsalis pedis pulses.
4. Hyperlipidemia.
5. OSA, on CPAP.
6. History of prior stroke.
7. Seizure disorder.
8. Neuropathy.
9. Restless legs.
10. Depression.
11. Gait instability.
12. Urinary incontinence.
13. Varicose veins.
14. Chronic ___ otitis media.
15. History of skin cancer.
16. Sensorineural hearing loss.
Social History:
___
Family History:
Mother died of "bone cancer". Father died from an aneurysm. Only
child. No biologic children.
Physical Exam:
Admission Physical Examination:
98.5 66 126/70 12 96%
Gen: NAD NT ND
HEENT: NC/AT no ptosis
Neck: restricted ROM bidirectionally
Card: Irregularly irregular, faint sounds
Pulmonary: Wheezes throughout, moving air well
Abdomen: Soft NT ND
Extrem: Venous stasis, hairless shins - bilaterally
Neurologic
- MS: Awake, alert. Says own name, but cannot say date or
location. Speech is non-fluent and on initial exam, cannot name
objects on the stroke card (makes noises). Produces both
syllables and occasional inappropriate words (e.g. at end of
exam
when I re-examined his speech, called all of the stroke card
objects a "blanket"). He can write his name, but no more (when
asked where he lives writes 12 tophert A ___. Cannot repeat.
Simple midline commands are sometimes understood but no others.
Cannot read. No apparent neglect.
- CN: PERRL, difficult to assess visual fields but appears to
respond to stimulus on both sides. Full horizontal eye
movements.
Face seems symmetric to pin based on grimace. Activates face
equally. Hearing grossly intact. Tongue and palate midline.
Shrug
full.
- Motor: No drift. Full strength save for ? 4 range IOs (vs not
being able to understand what I want him to do). Toes start
slightly up, ? withdrawal vs Babinski R, left seems mute. No
___.
- Sensory: I can pantomime enough of the exam to discern that
he
does not extinguish to double (with eyes closed, points to
left/right/both when I touched his legs) and is sensitive to
pain
on both sides. More sophisticated exam difficult given speech;
could not tell if there was any difference to pin on both sides
and we could not do hallux proprioception. Romberg deferred
given
patient size and chronic gait imbalance ___ years.
- Reflexes: Attenuated throughout save brisk patellars and
absent L ankle jerk.
- Cerebellar: Smooth heel/shin and no obvious tremor or ataxia
grabbing for my hand. No truncal ataxia at edge of bed with arms
crossed, eyes closed, feet off of ground.
- Gait: Somewhat wide base, unsteady on his own - sat him back
down quickly (confirmed chronicity of gait imbalance with wife).
========================
Discharge Physical Exam:
Gen: NAD
HEENT: NC/AT, no ptosis, moist mucus membranes
Neck: Restricted ROM bidirectionally
Card: Irregularly irregular, faint sounds
Pulmonary: Comfortable on room air
Abdomen: Soft, nondistended, nontender
Extrem: Venous stasis with skin discoloration bilaterally
Neurologic
MS: Awake, alert and oriented to person, place and date. Speech
is fluent but still a little slow. Naming intact. Able to
read. No neglect. Repetition intact. Able to follow both
appendicular and axial commands. Some difficulty with multistep
commands.
CN: PERRL, blinks to threat bilaterally. Full horizontal eye
movements.
Face is symmetric at rest and with activation. Hearing grossly
intact. Tongue and palate midline. Shrug full.
Motor: No drift. Full strength throughout.
Sensory: Intact to light touch bilaterally
Reflexes: Attenuated throughout save brisk patellars and
absent L ankle jerk.
Cerebellar: No dysmetria. No truncal ataxia.
Pertinent Results:
___ 05:25AM BLOOD WBC-5.1 RBC-4.31* Hgb-13.7* Hct-38.4*
MCV-89 MCH-31.8 MCHC-35.7* RDW-13.1 Plt ___
___ 05:25AM BLOOD Neuts-61.4 ___ Monos-9.0 Eos-3.0
Baso-0.3
___ 05:10AM BLOOD ___ PTT-42.2* ___
___ 05:10AM BLOOD UreaN-24* Creat-0.9
___ 11:30AM BLOOD Glucose-83 UreaN-16 Creat-0.9 Na-140
K-4.0 Cl-105 HCO3-28 AnGap-11
___ 11:30AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
___ 04:09PM BLOOD Glucose-111* Na-139 K-4.2 Cl-102
calHCO3-28
MRI:
1. Small 6 mm acute to subacute infarct of the left temporal
lobe. No
associated mass effect.
2. Numerous chronic infarcts of the cerebral white matter,
bilateral basal
ganglia, and thalami. Severe chronic microangiopathy.
3. Moderate generalized parenchymal volume loss.
4. Asymmetric enlargement of the right temporal horn, although
this appears to
be due to adjacent temporal lobe volume loss rather than
specifically volume
loss of the right hippocampus.
5. Occlusion of the V4 segment of the right vertebral artery,
unchanged from
CTA on ___.
EEG:
This telemetry captured no pushbutton activations. It showed a
slow background throughout, indicative of a widespread
encephalopathy.
Medications, metabolic discharges, and infection are among the
most common causes. In addition, there was prominent delta
slowing broadly over the left hemisphere, suggestive of an
additional subcortical dysfunction there. Minimal slowing was
evident on the right. There were no epileptiform features or
electrographic seizures.
This telemetry captured one pushbutton activation for an episode
of confusion. There was no electrographic correlate. Otherwise,
it showed
prominent delta slowing over the left hemisphere suggestive of
focal cerebral dysfunction. In addition, the background was slow
and disorganized throughout suggestive of a widespread
encephalopathy which is non-specific with regard to etiology.
There were no epileptiform features or electrographic seizures.
CT Head and Neck:
1. No evidence for acute intracranial abnormalities on
noncontrast head CT.
Nondiagnostic CT perfusion study due to technical factors.
2. Multiple chronic infarcts are again seen in the right
thalamus, left
caudate, and left lentiform nucleus/corona radiata/external
capsule.
3. No flow-limiting arterial stenosis in the neck.
4. Unchanged atherosclerotic occlusion of the distal V4 segment
of the non
dominant right vertebral artery.
5. Bronchiectasis in the visualized upper lungs with apparent
new bronchial
wall thickening compared to ___, which may represent
superimposed
infectious/inflammatory process versus technical differences.
Clinical
correlation is recommended.
6. Severe cervical spinal stenosis, previously assessed by MRI
in ___.
Medications on Admission:
1. Warfarin 2 mg PO DAILY16
2. LeVETiracetam 750 mg PO BID
3. Citalopram 20 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Metoprolol succinate 25 mg PO QAM
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Atorvastatin 40 mg PO QPM
3. Citalopram 20 mg PO DAILY
4. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Warfarin 2 mg PO DAILY16
7. Outpatient Physical Therapy
Please evaluate and treat.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subacute to Acute Stroke
History of prior strokes
Seizures
Atrial Fibrillation
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND NECK WITH PERFUSION
INDICATION: ___ with aphasia, negative noncontrast CT at ___. Evaluate
for acute thrombosis.
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion of Omnipaque intravenous
contrast material. CT perfusion studies also performed. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated. This report is based on interpretation of all of these images.
DOSE: DLP: 3754.96 mGy-cm; CTDI: 367.04 mGy
COMPARISON: CTA head and neck of ___.
FINDINGS:
HEAD CT:
Multiple chronic infarcts are again seen, including the right thalamus,
caudate, and left carina radiata/lentiform nucleus/external capsule, the
latter with associated ex vacuo enlargement of the anterior body of the left
lateral ventricle. There also confluent areas of low density in the
subcortical, deep, and periventricular white matter of the cerebral
hemispheres, nonspecific but the sequela of chronic microangiopathy. There is
no acute intracranial hemorrhage and no evidence for an acute major vascular
territorial infarct. There is stable global cerebral volume loss with
associated prominence of the ventricles and sulci.
No suspicious blastic or lytic osseous lesions. Moderate mucosal thickening
of the maxillary sinuses as well as partial opacification of the ethmoid air
cells and milder mucosal thickening of the frontal and sphenoid sinuses are
identified. The mastoid air cells middle ear cavities are well pneumatized
and clear.
CT PERFUSION:
Nondiagnostic secondary to technical factors.
NECK CTA:
There is common origin of the right brachiocephalic and left common carotid
arteries. The carotid and vertebral arteries and their major branches are
patent with no evidence of stenoses. There is mild atherosclerotic
calcification of the bilateral carotid bifurcations without cervical internal
carotid stenosis by NASCET criteria. There is a retropharyngeal course of the
left common and cervical internal carotid arteries.
HEAD CTA:
Atherosclerotic calcification of the bilateral cavernous and supra clinoid
ICAs is noted without evidence for flow-limiting stenosis. Anterior and
middle cerebral arteries are patent. The right vertebral artery is diminutive
distal to the ___ with a calcification at the mid V4 segment and
apparent chronic occlusion of the distal V4 segment. The left vertebral
artery is dominant. There is no flow-limiting stenosis elsewhere in the
posterior circulation. There is fetal origin of the right PCA. There is no
evidence for an aneurysm.
OTHER:
There is bronchiectasis and bronchial wall thickening in the visualized upper
lungs bilaterally, with a bronchial thickening apparently new compared to
___, which may be infectious or an fine. The upper lobe
demonstrates a calcified granuloma and there are multiple calcified
mediastinal lymph nodes, compatible with prior granulomatous disease.
Palatine and left lingual tonsilliths are identified. There is mass effect on
the posterior aspect of the left pharynx secondary to retropharyngeal course
of the left common and internal carotid arteries. There is no evidence for an
exophytic mucosal mass.
Severe multilevel cervical spondylosis resulting in spinal canal narrowing and
neural foraminal narrowing is identified, previously assessed by MRI on ___.
IMPRESSION:
1. No evidence for acute intracranial abnormalities on noncontrast head CT.
Nondiagnostic CT perfusion study due to technical factors.
2. Multiple chronic infarcts are again seen in the right thalamus, left
caudate, and left lentiform nucleus/corona radiata/external capsule.
3. No flow-limiting arterial stenosis in the neck.
4. Unchanged atherosclerotic occlusion of the distal V4 segment of the non
dominant right vertebral artery.
5. Bronchiectasis in the visualized upper lungs with apparent new bronchial
wall thickening compared to ___, which may represent superimposed
infectious/inflammatory process versus technical differences. Clinical
correlation is recommended.
6. Severe cervical spinal stenosis, previously assessed by MRI in ___.
RECOMMENDATION(S): MRI would be more sensitive for an acute infarction, if
clinically warranted.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with episodic global aphasia. Seizure protocol
please. // Seizure protocol please!
TECHNIQUE: Axial susceptibility and diffusion axial images of the brain
acquired. Sagittal 3D FLAIR images were obtained. Coronal fast inversion
recovery images were acquired. Coronal post there is generalized parenchymal
volume loss with commensurate enlargement of the ventricles, sulci, and
cisterns. Gadolinium MPRAGE images were obtained with axial and sagittal
reformats.
COMPARISON: CTA head ___
FINDINGS:
There is a 6 mm focus of slowed diffusion with corresponding FLAIR signal
abnormality in the left temporal lobe along the sylvian fissure, consistent
with an acute infarct (series 402, image 20 and series 300b, image 47). No
additional acute infarcts are identified. There are numerous chronic infarcts
of the coronal radiata, bilateral basal ganglia, and bilateral thalami. There
are numerous patchy and confluent foci of FLAIR hyperintensity in the
subcortical, deep, and periventricular white matter, consistent with severe
chronic microangiopathy. There may be hemosiderin associated with some of
these old infarcts. There is focal ex vacuo dilatation of the left lateral
ventricle adjacent to old infarcts. There is moderate generalized chronic
volume loss with commensurate prominence of the ventricles, sulci, and
cisterns. There is a cavum septum pellucidum et vergae, a developmental
variant.
The V4 segment of the right vertebral artery is occluded, as seen CTA from ___. The major intracranial vessels otherwise demonstrate normal
patency.
Coronal high-resolution images asymmetric enlargement of the right temporal
horn relative to the left, although the hippocampi by appear normal in
morphology and signal. There is no evidence of migration abnormality
identified.
IMPRESSION:
1. Small 6 mm acute to subacute infarct of the left temporal lobe. No
associated mass effect.
2. Numerous chronic infarcts of the cerebral white matter, bilateral basal
ganglia, and thalami. Severe chronic microangiopathy.
3. Moderate generalized parenchymal volume loss.
4. Asymmetric enlargement of the right temporal horn, although this appears to
be due to adjacent temporal lobe volume loss rather than specifically volume
loss of the right hippocampus.
5. Occlusion of the V4 segment of the right vertebral artery, unchanged from
CTA on ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with OTHER SPEECH DISTURBANCE, LONG TERM USE ANTIGOAGULANT
temperature: 98.5
heartrate: 66.0
resprate: 12.0
o2sat: 96.0
sbp: 126.0
dbp: 70.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is an ___ year old left handed man who presented with
isolated global aphasia similar to a prior MRI-negative episode
in ___ thought to be seizure vs stroke.
Initially, given the exam and the identical nature of his
current aphasia to an MRI-negative spell in ___, seizure
was higher consideration than stroke. However, EEG showed no
epileptiform activity. It showed left greater than right
slowing. Previous EEG showed right greater than left slowing.
However, due to the clinical suspicion for seizure, whether of
unknown etiology or secondary to stroke, we have increased his
Keppra 1000mg BID. Although the initial CT was negative, an MRI
showed a small posterior insular cortex. His stroke risk
factors have been assessed. He is currnetly on Atorvastatin
40mg qday. His last LDL was 66. He has afib and is currently
on Coumadin 2mg with theurapeutic INRs. His INR on discharge
was 3.1. His INR will continue to be trended by his primary
care doctor. We were going to obtain an Echo since his last
Echo was ___, however, the result will not change management.
He will follow up with his outpatient Neurologist.
In regards to pulmonary, Mr. ___ had some wheezing on inital
exam that improved throughout the hospital course. He had a CTA
that showed bronchiectasis visualized in the upper lungs with
apparent new bronchial wall thickening compared to ___, which may represent superimposed infectious/inflammatory
process. Mr. ___ did endorse a recent viral illness.
Additionally, Mr. ___ was found to have pancytopenia of unknown
etiology. The pancytopenia improved over the course of the
hospitalization. He will follow up with his outpatient primary
care doctor. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
necrotizing fasciitis to left arm
Major Surgical or Invasive Procedure:
- Debridement of left arm necrotizing fasciitis
- Irrigation and placement of VAC dressing
- Split-thickness skin graft reconstruction of left upper
extremity wound
- Bilayer skin substitute matrix reconstruction
- Wound vacuum takedown
History of Present Illness:
___ on warfarin for AF, stroke, HTN presenting with falls and
injury to left arm. Patient's son states she was recently
hospitalized for high INR and was discharged two weeks with
decreased mental status. He states that for the last week or so
she has had several falls with one wound on her left elbow which
he noticed ___. He states that the arm and hand were swollen
with some redness. He states that he has been putting ice packs
on the arm for the past couple of days. He states that this
morning the arm and hand were much more swollen with redness and
blister extending through the whole forearm.
Past Medical History:
right MCA stroke as above
HTN
Afib on coumadin
DVT
dementia
humerus fracture
hypothyroidism
Social History:
___
Family History:
None
Physical Exam:
Admission physical:
Gen: Somnolent, but arousable
Cardiac: tachycardic
Extremities: LUE edematous and erythematous up to just proximal
to elbow with weeping, hemorrhagic bullae, fingers are fairly
pale but dopplers reveal good radial pulse, compartments are
tense, but no evidence of compartment syndrome.
Discharge physical:
Vitals: 97-98.4 ___ 18 100% RA I/O ___
(-900)
General: Elderly woman, comfortably lying ___ bed. A&Ox1.
HEENT: Sclera anicteric, right eye closed, MMM.
CV: irregularly irregular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally anteriorly only, no
wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: PICC line ___ place at inner right arm, no erythema. Left
arm ___ hard shell cast with clean gauze wrap. ___ warm, well
perfused, no cyanosis, clubbing, or edema.
GU: Foley present, draining clear urine
Neuro: Left facial droop due to CN VII paralysis though CN VII
Pertinent Results:
ADMISSION LABS:
===============
___ 11:35PM TYPE-ART PO2-210* PCO2-34* PH-7.41 TOTAL
CO2-22 BASE XS--1
___ 11:35PM GLUCOSE-136* LACTATE-1.6 K+-3.6
___ 11:35PM O2 SAT-99
___ 11:35PM freeCa-1.04*
___ 11:11PM GLUCOSE-139* UREA N-55* CREAT-1.6* SODIUM-145
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-20* ANION GAP-17
___ 11:11PM CALCIUM-7.9* PHOSPHATE-4.3 MAGNESIUM-1.8
___ 11:11PM WBC-18.6* RBC-2.90*# HGB-8.0*# HCT-25.3*#
MCV-87 MCH-27.6 MCHC-31.6* RDW-15.9* RDWSD-50.2*
___ 11:11PM PLT COUNT-236
___ 11:11PM ___ PTT-29.2 ___
___ 11:11PM ___
___ 10:30PM TYPE-ART PO2-273* PCO2-33* PH-7.39 TOTAL
CO2-21 BASE XS--3 VENT-CONTROLLED
___ 10:30PM GLUCOSE-131* LACTATE-2.0 NA+-143 K+-3.8
CL--116*
___ 10:30PM HGB-8.6* calcHCT-26
___ 10:30PM freeCa-1.00*
___ 09:17PM TYPE-ART PO2-229* PCO2-36 PH-7.35 TOTAL
CO2-21 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED
___ 09:17PM GLUCOSE-131* LACTATE-2.1* NA+-143 K+-3.8
CL--114*
___ 09:17PM HGB-9.9* calcHCT-30 O2 SAT-99 CARBOXYHB-0 MET
HGB-0
___ 09:17PM freeCa-1.06*
___ 07:26PM LACTATE-4.7*
___ 07:20PM ___ PTT-34.0 ___
___ 05:00PM URINE HOURS-RANDOM
___ 05:00PM URINE HOURS-RANDOM
___ 05:00PM URINE UHOLD-HOLD
___ 05:00PM URINE GR HOLD-HOLD
___ 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
___ 05:00PM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
___ 05:00PM URINE HYALINE-20*
___ 05:00PM URINE MUCOUS-RARE
___ 03:47PM LACTATE-5.4*
___ 03:35PM GLUCOSE-111* UREA N-61* CREAT-2.0*
SODIUM-147* POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-17* ANION
GAP-25*
___ 03:35PM estGFR-Using this
___ 03:35PM CRP->300
___ 03:35PM WBC-23.0*# RBC-4.32 HGB-11.8 HCT-38.7 MCV-90
MCH-27.3 MCHC-30.5* RDW-16.0* RDWSD-52.5*
___ 03:35PM NEUTS-90* BANDS-5 LYMPHS-1* MONOS-4* EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-21.85* AbsLymp-0.23*
AbsMono-0.92* AbsEos-0.00* AbsBaso-0.00*
___ 03:35PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-3+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-2+ BURR-2+
PENCIL-OCCASIONAL BITE-OCCASIONAL ACANTHOCY-1+ FRAGMENT-1+
ELLIPTOCY-OCCASIONAL
___ 03:35PM PLT SMR-NORMAL PLT COUNT-310
___ 03:35PM ___ PTT-36.8* ___
PERTINENT LABS
==============
___ 10:43AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 10:43AM URINE RBC-12* WBC-135* Bacteri-FEW Yeast-FEW
Epi-0
___ 10:43AM URINE Color-Yellow Appear-Hazy Sp ___
DISCHARGE LABS:
===============
___ 05:10AM BLOOD WBC-7.2 RBC-2.75* Hgb-7.7* Hct-24.1*
MCV-88 MCH-28.0 MCHC-32.0 RDW-17.4* RDWSD-54.9* Plt ___
___ 05:10AM BLOOD ___ PTT-29.6 ___
___ 05:10AM BLOOD Glucose-83 UreaN-11 Creat-0.8 Na-138
K-4.2 Cl-104 HCO3-28 AnGap-10
___ 05:10AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.9
IMAGING:
========
___ Imaging DX CHEST PORTABLE PICC
IMPRESSION:
New right PICC line. The tip of the line is slightly coiled ___
the mid to low SVC. If fully deployed, the tip would be located
at the cavoatrial junction. No complications, no pneumothorax.
The previous right internal jugular vein catheter was removed.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Since ___ the patient is been extubated and although lung
volumes are lower, there is no discernible atelectasis, however
there may be new mild edema at least at the right lung base.
Severe cardiomegaly is long-standing. Small pleural effusions
are new or newly apparent. No pneumothorax. Right jugular line
ends ___ the low SVC.
___ TTE
The left atrium is normal ___ size. The right atrium is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF= ___ %). The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis
seen. Moderate (2+) aortic regurgitation is seen. Mild to
moderate (___) mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion
seen.
IMPRESSION: Overall depressed Left Ventricular Systolic Function
with approximate EF ___. Housestaff Officer Dr. ___ was
notified ___ person of the results on ___ at 15:30.
Radiology Report HAND (PA,LAT & OBLIQUE) LEFT Study Date of
___ 4:15 ___
IMPRESSION:
Diffuse osteopenia. Degenerative changes, as above. No acute
fracture seen. Subtle linear tract of relative lucencies along
the lateral aspect of the partially imaged forearm could be due
to subcutaneous edema but soft tissue gas is not excluded.
Consider CT for more sensitive evaluation.
.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
5:49 ___
IMPRESSION:
1. An area of hypodensity ___ the left occipital lobe is new from
___, and may represent a subacute to chronic infarct. MRI is
more sensitive ___ detecting acute ischemia.
2. No acute intracranial hemorrhage.
.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of
___ 5:50 ___
IMPRESSION:
Please note that this study is degraded by patient motion
artifact.
Allowing for this limitation, there is no definite acute
fracture or traumatic malalignment.
.
Radiology Report CT UP EXT W/O C Study Date of ___ 5:58
___
IMPRESSION:
Extensive soft tissue stranding and fluid within the
subcutaneous and deep
tissues of the left forearm. No foci of soft tissue gas
identified.
.
MICRIOBIOLOGY:
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ 10:43 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
___ URINE URINE CULTURE-FINAL NEGATIVE
___ MRSA SCREEN MRSA SCREEN-FINAL NEGATIVE
___ 9:00 pm SWAB LEFT FOREARM.
GRAM STAIN (Final ___:
Reported to and read back by ___. ___ @ 1030PM ON
___.
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
WOUND CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 3 mg PO DAILY16
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Ditropan XL (oxybutynin chloride) 5 mg oral DAILY
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Amlodipine 2.5 mg PO DAILY
5. Apixaban 2.5 mg PO BID
6. CeftriaXONE 2 gm IV Q24H
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO DAILY:PRN constipation
11. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
12. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
13. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
Please continue through ___. Ascorbic Acid ___ mg PO DAILY Duration: 10 Days
Please continue through ___. Heparin Flush (10 units/ml) 1 mL IV DAILY and PRN, line
flush
16. Metoprolol Tartrate 12.5 mg PO BID
Please hold for HR <60 or SBP <90
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Acute issues:
#L elbow necrotizing fasciitis
#A-fib with RVR
#Sinus bradycardia
#Supratherapeutic INR
#new diagnosis systolic CHF
#Leukocytosis
#Normocytic anemia
Chronic issues:
#HTN
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with falls, injury to left arm, with progressing
erythema and swelling // concern for nec fasc, trauma?
TECHNIQUE: AP and lateral views of the left forearm
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen. There is relative diffuse
osteopenia.
Olecranon spur is noted. There appears to be some soft tissue edema.
IMPRESSION:
Osteopenia. No acute fracture.
Radiology Report
INDICATION: History: ___ with falls, injury to left arm, with progressing
erythema and swelling // concern for nec fasc, trauma?
TECHNIQUE: Left hand, three views
COMPARISON: None.
FINDINGS:
The bones are diffusely osteopenic. There are moderate to severe
osteoarthritic change at the first carpometacarpal joint, with joint space
narrowing, marginal sclerosis, and subchondral cystic formation. There also
may be slight lateral subluxation of the first carpometacarpal joint. No
definite acute fracture is identified. There is soft tissue swelling. Subtle
linear tract of relative lucency along the lateral aspect of the partially
imaged forearm could be due to subcutaneous edema however, given concern for
subcutaneous emphysema, soft tissue gas is not excluded and in this clinical
setting.
IMPRESSION:
Diffuse osteopenia. Degenerative changes, as above. No acute fracture seen.
Subtle linear tract of relative lucencies along the lateral aspect of the
partially imaged forearm could be due to subcutaneous edema but soft tissue
gas is not excluded. Consider CT for more sensitive evaluation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with several unwitnessed falls in past week, on
warfarin. // traumatic injury? intracranial process?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 49.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT of the head dated ___.
FINDINGS:
An area of hypodensity in the left occipital lobe is new from ___.
There is no evidence of acutehemorrhage, edema, or mass. There is prominence
of the ventricles and sulci suggestive of involutional changes. Areas of
hypodensity in the bilateral frontal lobes appears unchanged from prior, and
is most consistent with encephalomalacia related to prior infarct.
Periventricular white matter hypodensities are consistent with sequela of
chronic small vessel ischemic disease. Encephalomalacia is also seen within
the medial left temporal lobe, unchanged from prior.
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. An area of hypodensity in the left occipital lobe is new from ___, and may represent a subacute to chronic infarct. MRI is more sensitive
in detecting acute ischemia.
2. No acute intracranial hemorrhage.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with several unwitnessed falls in past week, on
warfarin. // traumatic injury? intracranial process? traumatic injury?
intracranial process?
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 4.8 s, 18.6 cm; CTDIvol = 36.7 mGy (Body) DLP = 682.2
mGy-cm.
4) Spiral Acquisition 2.4 s, 9.3 cm; CTDIvol = 33.9 mGy (Body) DLP = 316.8
mGy-cm.
Total DLP (Body) = 999 mGy-cm.
COMPARISON: None.
FINDINGS:
Please note that this study is degraded by patient motion artifact.
Allowing for this limitation there is no definite acute fracture or traumatic
malalignment. The bones appear diffusely demineralized. Multilevel,
multifactorial degenerative changes are seen throughout the cervical spine,
including disc height loss and anterior osteophytosis at C4-7. The
prevertebral soft tissues are unremarkable. Incidental note is made of a
medial course of the common carotid arteries. The thyroid gland is grossly
unremarkable. Assessment of the lung apices is limited due to patient motion.
IMPRESSION:
Please note that this study is degraded by patient motion artifact.
Allowing for this limitation, there is no definite acute fracture or traumatic
malalignment.
Radiology Report
INDICATION: ___ year old woman with L arm pain swelling // eval necrotizing
soft tissue infection
TECHNIQUE: Multi detector CT imaging was performed of the left upper forearm
without the administration of intravenous contrast. Multiplanar reformatted
images in coronal and sagittal planes are provided.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 3.5 s, 17.1 cm; CTDIvol = 24.0 mGy (Body) DLP = 410.7
mGy-cm.
Total DLP (Body) = 411 mGy-cm.
COMPARISON: Radiograph of the left forearm dated ___, and CT
abdomen and pelvis dated ___.
FINDINGS:
Exam is somewhat limited due to difficulties with patient positioning. Note
is made of significant soft tissue stranding and fluid within the subcutaneous
and deep tissues of the left forearm. No foci of gas are identified within
the soft tissues of the left forearm. No fracture or dislocation.
Limited views of the chest reveal cardiomegaly and lingular atelectasis. No
pleural or pericardial effusion. A 1.6 cm cyst is seen left lobe of the
liver. The previously described left adrenal adenoma is partially seen.
IMPRESSION:
Extensive soft tissue stranding and fluid within the subcutaneous and deep
tissues of the left forearm. No foci of soft tissue gas identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ETT s/p surgery // ? ETT placement ?
ETT placement
IMPRESSION:
In comparison with the study of ___, there is now an endotracheal tube
in place with its tip approximately 4.4 cm above the carina. Opacification at
the left base obscures the hemidiaphragm, most likely relating to small
pleural effusion and volume loss in the left lower lobe.
No evidence of pulmonary vascular congestion and the right lung is essentially
clear.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new CVL, OGT // ? CVL placement, OGT
placement Contact name: ___: ___
TECHNIQUE: Single view of the chest
COMPARISON: Prior radiographs on ___
FINDINGS:
Compared with prior radiographs on ___, there has been interval
placement of the a right IJ catheter, which terminates in the lower SVC. An
OG tube passes below the diaphragm and into the stomach, however the side port
lies above the diaphragm in the esophagus. An ET tube terminate 5.5 cm above
the carina. There is increased aeration at the left lung base. The right
lung is unchanged in appearance. There is no new focal consolidation or
pneumothorax. Cardiomediastinal silhouette is unchanged.
IMPRESSION:
OG tube side port lies above the diaphragm in the esophagus, and should be
advanced into the stomach. A right IJ catheter terminates in the low SVC.
RECOMMENDATION(S): OG tube should be advanced so that side port lies within
the stomach.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephoneon ___ at 12:18 ___, 45 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with increasing WBC count, ? source. // rule
out PNA. rule out PNA.
COMPARISON: Chest radiographs since ___, most recently ___
and ___.
IMPRESSION:
Since ___ the patient is been extubated and although lung volumes are
lower, there is no discernible atelectasis, however there may be new mild
edema at least at the right lung base. Severe cardiomegaly is long-standing.
Small pleural effusions are new or newly apparent. No pneumothorax.
Right jugular line ends in the low SVC.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with picc for abx ? TPN // s/p r 37cm DLPicc
non heparin power picc Contact name: ___: ___ s/p r 37cm
DLPicc non heparin power picc
IMPRESSION:
New right PICC line. The tip of the line is slightly coiled in the mid to low
SVC. If fully deployed, the tip would be located at the cavoatrial junction.
No complications, no pneumothorax. The previous right internal jugular vein
catheter was removed.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with Picc line repositioned // Line pulled
back 2cm please recheck tip Contact name: ___ , ___: ___ Line
pulled back 2cm please recheck tip
IMPRESSION:
In comparison with the earlier study of this date, the subclavian PICC line is
been pulled back so that the tip lies at or just above the cavoatrial
junction. Otherwise little change.
Gender: F
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by WALK IN
Chief complaint: L Hand injury, L Arm injury
Diagnosed with Cellulitis of right upper limb
temperature: 95.8
heartrate: 78.0
resprate: 20.0
o2sat: nan
sbp: 111.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | BRIEF SUMMARY
=============
Ms. ___ is a ___ with a PMH of A-fib on warfarin, R MCA
stroke, HTN, and dementia who presented to ___ with falls and
injuries to her left arm. She was found to have evidence of
necrotizing fasciitis of the left arm likely secondary to a
wound sustained after a recent fall. She was admitted to the
plastic surgery service and underwent significant debridement of
the left arm from above the elbow to the dorsum of the hand,
with a washout several days later and skin grafting a few days
later. Her initial operation was complicated by Afib w/ RVR, and
she required an ICU stay for BP support. After achieving stable
vitals, she was transferred to the floor. For the
supratherapeutic INR, she was given FFP and vitamin K. She was
continued on her metoprolol for her Afib, but subsequently
developed bradycardia, which held stable until discharge. She
was started on Apixaban for anticoagulation and was discharged
to rehab after her wound vac was taken down.
ACUTE ISSUES
============
#L elbow necrotizing fasciitis: The patient was recently
hospitalized at ___ for a supratherapeutic INR ___ the setting
of poor PO intake. After discharge, she suffered several falls
resulting ___ a wound on her left elbow, which became
progressively more reddened and swollen. The day prior to
presentation, she noted blisters on her forearm and was taken to
the ED. ___ the ED, she was noted to have e/o necrotizing soft
tissue infection on exam. She was started on vancomycin,
clindamcyin, and meropenem and taken to the OR, where the L arm
was extensively debrided. Her OR course was complicated by A-fib
w/ RVR requiring multiple doses of esmolol. She was briefly
admitted to the TSICU w/ intubation, pressor support, and close
monitoring, then transferred to the plastic surgery service. Her
wound cultures revealed group A strep, and her antibiotics were
switched to clindamycin and ceftriaxone per ID. The patient was
subsequently transferred to the medicine floor, and was taken
back to the OR for a washout, again for a skin graft placement,
and then again for wound vac takedown (done at bedside). Her
clindamycin was discontinued with plans to continue her
Ceftriaxone for 2 weeks post-debridement. She remained afebrile
with negative cultures and was discharged to rehab.
SURGICAL/ICU COURSE: Data upon admission: WBC 23, Cr 2, Na 147,
lactate 5.5, fascial plane air on plain films, and necrotic
bullae formation. INR was 7 and she was given 2 units FFP and
IV vitamin K x 1. She was taken to the OR once INR down to 2.4
a few hours later. Patient was tachycardic and somnolent ___ the
ED, but maintaining her pressure. ___ OR, she developed A-fib w/
RVR requiring multiple bouts of esmolol before starting the
case. She was maintained on neo throughout case. The patient
was taken to the OR and circumferentially debrided soft tissue
of entire left forearm, dorsal and including some digital soft
tissue, down to the elbow proximally. Much of the dorsal
tendons paratenon had to be removed, adaptic placed on this
before the VAC. Circumferential VAC applied on 75 mmHg,
intermittent suction. The patient was transferred to the ICU
post-surgery for blood pressure support with pressor therapy.
Pressor therapy was discontinued on hospital day #2. Patient
given digoxin load for a-fib with RVR. Patient restarted her
amlodipine on hospital day #4 and she was also started on PO
Lopressor with good control. The patient was maintained
intubated and on ventilator until she was able to be weaned from
vent on hospital day #2. Post-operatively, the patient was given
IV fluids. An NG tube was inserted and coffee ground gastric
contents were drained, guaiac positive. Patient was started on
IV pantoprazole and monitored closely. On hospital day#4,
patient pulled out her NG tube. Her diet was advanced when
appropriate, which was tolerated well. She was also started on a
bowel regimen to encourage bowel movement. Wound cultures
revealed beta streptococcus group A and patient's antibiotic
therapy to changed to ceftriaxone and clindamycin per Infectious
Disease.
#A-fib with RVR: At home, the patient is controlled with
metoprolol 25 mg BID and anticoagulated with warfarin 5 mg. The
patient was noted on admission to have a supratherapeutic INR,
requiring vitamin K and FFP. As noted above, the patient
developed A-fib with RVR during her initial OR course, requiring
several doses of esmolol, with subsequent hypotension and
pressor requirement ___ the ICU. On the medicine floor, she was
noted to be ___ A-fib with controlled rate on metoprolol 25 mg
BID, however she subsequently converted to sinus rhythm with
bradycardia. Her metoprolol dose was decreased to 12.5 mg BID
for this. Regarding her anticoagulation, because of her need to
go to the OR several times, the patient was maintained on a
heparin drip. After a discussion with her son (HCP), he felt
that the risks of anticoagulation ___ the setting of her falls
were outweighed by the risks of stroke, so felt that she should
be anticoagulated at discharge. Given her INR lability, she was
started on Apixiban on the day of discharge. She was discharged
on 12.5 bid metoprolol with holding parameters (to be
administered if HR ?60).
#Supratherapeutic INR: The patient was hospitalized ___ ___
for a supratherapeutic INR ___ the setting of poor PO intake, and
was again found to have a supratherapeutic INR during this
admission. See above two problems for further detail.
#Sinus bradycardia: Patient ___ A-fib at admission which
converted to sinus rhythm during her floor course. Bradycardia
likely due to metoprolol effect. She was also noted to have
occasional atrial and ventricular ectopy on telemetry. She
remained asymptomatic during her course. Metoprolol adjusted per
above.
#Anemia: Likely secondary to post-op blood loss combined with
dilutional effect. H/H slowly trended down and required a
transfusion of 1 u pRBCs on the day of discharge.
#Malnutrition: The patient was noted to have poor PO intake with
no dysphagia. Nutrition was consulted, and recommended
supplements and possible feeding tube placement. Given her
functional ability to eat and difficulty with rehab placement ___
the setting of feeding tube placement, we opted to continue her
on a PO diet with supplements and assistance with eating. She
will eat well with one-to-one assistance with feeding and this
should be encouraged.
#new diagnosis of systolic CHF: The patient had a TTE during
this admission showing an EF of ___ with moderate (2+) aortic
regurgitation, mild to moderate (___) mitral regurgitation, and
moderate to severe [3+] tricuspid regurgitation. After talking
with the PCP, this is a new diagnosis, and according to the PCP
the patient has never experienced CHF symptoms. ___ consider
starting ACE/statin ___ the future after further discussion
regarding patient goals.
#Chest pain: The patient reported chest pain on two occasions,
once while working with ___. Pain was described as dull and
intermittent, ___ the ___ her chest. No SOB. EKG showed no
evidence of ischemia.
CHRONIC ISSUES
==============
HTN: Patient is on metoprolol and amlodipine at home, these
medications were continued and her BPs remained stable.
TRANSITIONAL ISSUES
===================
-Ms. ___ need a CBC checked on ___ to ensure that her
Hgb/Hct is stable (she required 1U PRBC's on ___.
-Patient was discharged on ceftriaxone only with her course
ending on ___.
-Patient's metoprolol should be administered only if HR is >60
to avoid bradycardia; it is important to continue this
medication when possible, however, to prevent A-fib with RVR.
-Patient needs assistance with feeding and should be encouraged
to take po's.
-The patient was started on Apixaban due to INR lability on
warfarin. Will need to continue discussions as an outpatient
with the patient's son regarding risks and benefits.
- She was noted to have an EF of ___, however we have no
previous ECHOs on record and her PCP was unaware of any previous
reports.
- ___ consider starting ACE-I given reduced EF
- ___ Consider statin therapy, although risks and benefits will
need to be assessed given patient's goals.
-Patient will f/u with plastic surgery |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hallucinations
Major Surgical or Invasive Procedure:
___: Embolization of vasculature to known ___ mass, Dr.
___
___: tumor resection, Dr. ___
___ of Present Illness:
___ year old woman with PMHX significant for HTN, DM, HLD, visual
hallucinations, blindness and recently diagnosed intracranial
mass p/w hallucinations.
She reports seeing women holding snakes and other snakes
regularly for the last 3 weeks. Over the last three days she has
been unable to sleep because of the hallucinations. While in the
ED she is actively complaining of snakes in the room. She is
blind but orientates to voice. ROS is negative.
Her PMHx is notable for recent diagnosis of intracranial ___
mass. She was evaluated by neurologist through CHA in ___. Symptoms started ___ years ago with blurred vision,
which progressed to complete visual loss in her left eye ___ years
ago and her right eye over the past year. She recently moved to
___ from ___ ___ year ago. She was evaluated by
ophthalmology Dr. ___, found to have b/l optic atrophy at
which point a ___ MRI was ordered which demonstrated large
___ enhancing mass 6.3x5.9x5.1cm with surrounding edema
in b/l frontal region. ROS at the time of neurology evaluation
in ___ was negative for headaches, dizziness/vertigo. Positive
for visual hallucinations for 6 months: she saw a little girl
coming out of a closet and a boy with a baseball bat, sometimes
violent hallucinations with the boy changing in size. Denies
auditory hallucinations. She was referred to Dr. ___ at ___
___ for evaluation. She defered surgical intervention
at the time in early ___ given lack of social support in the
area, her husband was out of the country.
In the ED, initial vitals were: 98.3, 109, 156/99, 16, 99% RA
Labs notable for: K 4.3, Cr 0.6, WBC 7.8, H/H 12.7/40.1
Imaging notable for:
- CT Head w/o contrast: No significant change in size of a 6.1
x 5.6 cm midline mass since ___, with resulting mass
effect on the frontal lobes and frontal horn of both lateral
ventricles. It is largely homogeneous in attenuation with the
exception of an ___ hyperdense focus anteriorly, which
is unlikely due to hemorrhage or calcification, and may
represent intrinsic intralesional
hyperdensity.
Patient was given: Keppra 500mg
Neurosurgery was consulted and recommended:
No emergent intervention indicated. Pt deferred OR earlier this
month because Family was out of the country, no social support.
Pt can be scheduled for OR within the next few weeks with Dr.
___. Can start Keppra 500mg BID. Please obtain CTA head to
evaluate vasculature. Discussed with Dr. ___,
___ ___
Vitals prior to transfer: 98.4, 96, 148/92, 18, 100% RA
On the floor, patient is resting but arousable. Denies
headache, dizziness, nausea, vomiting, fevers, chills. She
denies current hallucinations and is unable to state what
brought her into the hospital other than she is "sick in the
head."
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
HTN
HLD
DM
Depression
Bifrontal ___ mass
Visual hallucinations
Bilateral Optic atrophy, blindness
Social History:
___
Family History:
Father: DM, HTN, MI deceased at age ___
Mother: DM, HTN,
No family history of ___ tumors
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs:97.8 PO 154 / 93R Lying ___ RA
General: NAD, AO to place, name and month. Incorrectly states
year as ___. Sleeping but arousable
HEENT: Sclera anicteric, MMM, oropharynx clear, no light
perception, PER minimally reactive to light, neck supple, no LAD
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, obese, ___, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Unable to accurately assess CN as patient sleeping, upper
and lower extremity strength grossly ___, sensation in tact
grossly, gait deferred.
DISCHARGE PHYSICAL EXAM:
========================
A&Ox3, Pupils 5NR, bilateral blindness. ___ drift. ___
strength throughout. Slight subgaleal fluid collection on left
frontal region. Sutures OTA, c/d/i.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:55PM BLOOD ___
___ Plt ___
___ 07:55PM BLOOD ___
___ Im ___
___
___ 07:55PM BLOOD ___
___
___ 06:35AM BLOOD ___
DISCHARGE LABS:
===============
#################
IMPORTANT STUDIES/IMAGING:
==========================
MRI ___ with and without contrast ___, from OSH): 6.3 cm
___ midline mass causes significant mass effect on the
underlying rbain parenchyma. Differential considerations include
esthesioneuroblastoma, malignant or aggressive meningioma,
metastatic disease. There may be involvement of the orbits and
cribriform plate. Empty sella of uncertain etiology.
CT Head w/o contrast (___): No significant change in size
of a 6.1 x 5.6 cm midline mass since ___, with
resulting mass effect on the frontal lobes and frontal horn of
both lateral ventricles. It is largely homogeneous in
attenuation with the exception of an ___ hyperdense
focus anteriorly, which is unlikely due to hemorrhage or
calcification, and may represent intrinsic intralesional
hyperdensity.
CTA Head (___): NECT: The large anterior ___, midline
mass exerting mass effect on the bilateral frontal lobes and
causing significant mass effect of the anterior horns of the
lateral ventricles with surrounding edema is unchanged from head
CT ___, and is better characterized on this study and
MRI from ___. There remains a hyperdense focus in the
right anterior portion of the mass (series 3, image 14),
representing heterogeneity in the mass, versus hemorrhage or
calcification. There is no evidence of new
hemorrhage or large territorial infarct. The visualized
paranasal sinuses, middle ears and mastoid air cells appear
clear. The visualized orbits are unremarkable.
CTA: There is superior and posterior displacement of the
bilateral A1
segments, and superior and left lateral displacement of
bilateral A2 and A3 segments. Otherwise, the vessels of the
circle of ___ and their major branches appear normal without
evidence of stenosis, occlusion or aneurysm formation greater
than 3 mm.
CXR ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There are
no focal
consolidations, pleural effusion, or pulmonary edema. There are
no
pneumothoraces.
___ CEREBRAL ANGIOGRAM/EMBOLIZATION
IMPRESSION:
Bilateral common carotid artery angiograms demonstrated no
significant
arterial supply from the anterior circulation that could be
successfully
embolized.
MICROBIOLOGY
=============
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
___ - MRI WAND
1. No interval change appearance of a 6.0 cm likely olfactory
groove/planum
sphenoidale meningioma.
2. The inferior aspect of the lesion appears to contact the
optic chiasm
(series 600, image 79).
___ - CT Head without Contrast:
Post surgical changes following meningioma resection including 6
mm leftward shift of midline structures, small amount of
subdural blood along the falx, small hemorrhage along the
resection bed and pneumocephalus.
___ - MR ___ +/- Contrast:
Expected postsurgical changes are seen without evidence of an
obvious area of residual nodular enhancement.
___ - CTA Chest:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. 2.4 cm hypodense left thyroid nodule. Heterogeneous
appearance of the
right lobe of the thyroid without distinct nodule. Recommend
further
evaluation with nonurgent thyroid ultrasound, if this has not
already been
performed.
3. Incompletely evaluated left upper pole renal lesion measures
less than 1 cm. Recommend further evaluation with nonurgent
renal MRI.
RECOMMENDATION(S):
1. 2.4 cm hypodense left thyroid nodule. Heterogeneous
appearance of the
right lobe of the thyroid without distinct nodule. Recommend
further
evaluation with nonurgent thyroid ultrasound, if this has not
already been
performed.
2. Incompletely evaluated left upper pole renal lesion measures
less than 1 cm. Recommend further evaluation with nonurgent
renal MRI.
___ - LENIs:
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
is
demonstrated in the tibial and peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ - ECHO
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
No valvular pathology or pathologic flow identified.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: ___ female with a bifrontal extra-axial mass. Evaluate
vascular anatomy for surgical planning.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
848.0 mGy-cm.
2) Stationary Acquisition 4.8 s, 0.5 cm; CTDIvol = 73.0 mGy (Head) DLP =
36.5 mGy-cm.
3) Spiral Acquisition 6.0 s, 19.2 cm; CTDIvol = 30.7 mGy (Head) DLP = 590.4
mGy-cm.
Total DLP (Head) = 1,475 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
The large anterior extra-axial, midline mass exerting mass effect on the
bilateral frontal lobes and causing significant mass effect of the anterior
horns of the lateral ventricles with surrounding edema is unchanged from head
CT ___, and is better characterized on this study and MRI from ___. There remains a hyperdense focus in the right anterior portion of
the mass (series 3, image 14), representing heterogeneity in the mass, versus
hemorrhage or calcification. The lesion demonstrates are they contrast
enhancement on CTA images. There is 5 mm of leftward shift of midline
structures, similar prior. There is no evidence of new hemorrhage or large
territorial infarct.
The visualized paranasal sinuses, middle ears and mastoid air cells appear
clear. The visualized orbits are unremarkable.
CTA HEAD: Visualized portions of the bilateral ICAs appear patent without
evidence of dissection, stenosis or occlusion.
There is superior and posterior displacement of the bilateral A1 segments, and
superior and left lateral displacement of bilateral A2 and A3 segments. There
is no evidence of an anterior communicating artery. There is a left fetal
type PCA. Otherwise, the vessels of the circle of ___ and their major
branches appear normal without evidence of stenosis, occlusion or aneurysm
formation greater than 3 mm.
IMPRESSION:
1. Large anterior midline extra-axial mass with surrounding edema exerting
mass effect the bilateral frontal lobes and causing effacement of the anterior
horns of the lateral ventricles and 5 mm of leftward midline shift, unchanged
from prior CT, likely representing an olfactory groove or planum sphenoidale
meningioma.
2. Superior and posterior displacement of the bilateral A1 segments, and
superior and left lateral displacement of the bilateral A2 and A3 segments
without evidence of stenosis or occlusion. An A-comm is not visualized.
3. No evidence of intracranial arterial stenosis or occlusion.
Radiology Report
INDICATION: ___ year old woman with tachycardia and fever // r/o pneumonia
COMPARISON: None.
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There are no focal
consolidations, pleural effusion, or pulmonary edema. There are no
pneumothoraces.
Radiology Report
EXAMINATION: Right common carotid artery angiogram.
Left common carotid artery angiogram.
Right common femoral artery angiogram.
INDICATION: ___ year old woman with known olfactory groove meningioma. //
Embolization of olfactory groove meningioma.
TECHNIQUE: ANESTHESIA: General anesthesia was administered by the
anesthesiology department. Please refer to anesthesiology notes for details.
Patient was brought into the angio suite, ID was confirmed via wrist band.The
patient was placed supine on fluoroscopy table and bilateral groins were
prepped and draped in the usual sterile manner. Time-out procedure was
performed per institutional guidelines. The location of the right mid femoral
head was located using anatomic and radiographic landmarks. 10 cc of
subcutaneous lidocaine was infused into the tissue. Micropuncture kit was
used to gain access to the right femoral artery, serial dilation was
undertaken until a long 5 ___ groin sheath connected to a continuous
heparinized saline flush could be inserted. ___ catheter was
connected to the power injector and also to a continuous heparinized saline
flush. This was advanced over the 0.038 glidewire brought up the aorta used to
select the right common carotid artery. AP and lateral views of the anterior
cerebral circulation were obtained .
Catheter was then pulled back in the aorta and used to select the left common
carotid artery. AP, and lateral views of the anterior cerebral circulation
were obtained.
The catheter was then pulled back in the aorta fully removed from the body. A
common femoral arteriogram was performed prior to use of a closure device,
subsequently Angio-Seal was put in. At the conclusion of the procedure, there
is no evidence of thromboembolic complication and the patient was at his
neurologic baseline.
COMPARISON: None
FINDINGS:
Right common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis.
Right internal carotid artery: The distal right ICA, proximal and distal MCA
and ACA branches are well-visualized. Vessel caliber smooth and tapering.
Significant displacement of the ACA complex more obvious on the A2 segment
bilaterally by the lesion, otherwise normal arterial and capillary phase . On
the venous phase we noticed that there is no filling of the anterior third of
the superior sagittal sinus. No tumor blush could be seen, neither from the
internal carotid no large from the external carotid artery.
Left common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis.
Left internal carotid artery: Distal left ICA, proximal and distal MCA and
ACA branches are well-visualized. Vessel caliber smooth and tapering. Again
noticed significant displacement of the ACA complex more obvious on the A2
segment bilaterally by the lesion, otherwise normal arterial and capillary
phase . On the venous phase we noticed that there is no filling of the
anterior third of the superior sagittal sinus. No tumor blush could be seen,
neither from the internal carotid no large from the external carotid artery.
Large PCOM likely compatible with fetal PCA.
Right common femoral artery: Well-visualized with a good caliber size for
closure device.
I, ___, participated in the procedure. I, ___, was
present for the entirety of the procedure and supervised all critical steps.
I, ___, have reviewed the report and agree with the fellow's
findings.
IMPRESSION:
Bilateral common carotid artery angiograms demonstrated no significant
arterial supply from the anterior circulation that could be successfully
embolized.
RECOMMENDATION(S): We will communicate this information with Dr. ___.
Radiology Report
EXAMINATION: PRE-SURGICAL PLANNING WAND STUDY ___ MR HEAD
INDICATION: ___ year old woman with bifrontal brain mass // surgical planning
TECHNIQUE: After administration of 11 mL of Gadavist intravenous contrast,
axial imaging was performed with MPRAGE and T1 technique. Sagittal and coronal
orientation reformatted images of the MPRAGE acquisition was then produced.
COMPARISON: CTA head with without contrast ___, cerebral angiogram
of ___, outside hospital MRI head of ___.
FINDINGS:
The examination is mildly motion degraded.
Unchanged appearance of a 6.0 x 5.8 x 4.4 cm (AP, TRV, SI) mass in the
anterior interhemispheric fissure, compatible with an olfactory groove or
planum sphenoidale meningioma exerting mass effect with surrounding edema
pattern on the medial frontal lobes. No additional lesions are identified.
External stereotactic markers are identified. The dural venous sinuses are
patent on postcontrast MP-RAGE. Although the anterior cerebral arteries are
poorly visualized secondary to motion artifact, re- identified is left lateral
displacement of the A2 and A3 segments. There is a partial empty sella. The
mass appears to contact the superior aspect of the anterior optic chiasm
(series 600, image 79).
There is no ventriculomegaly.
IMPRESSION:
1. No interval change appearance of a 6.0 cm likely olfactory groove/planum
sphenoidale meningioma.
2. The inferior aspect of the lesion appears to contact the optic chiasm
(series 600, image 79).
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ woman status post olfactory groove meningioma
resection. Please perform at 01:00 for postoperative evaluation.
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: Title Lock head from ___ and CT from ___. .
FINDINGS:
The patient is status post right frontal craniotomy for a meningioma
resection, and there is bifrontal soft tissue swelling and subcutaneous
emphysema. There is expected pneumocephalus along the right frontal
convexity. There is a small amount of hemorrhage along the resection bed, and
there is a small amount of subdural blood along the cerebral falx. There
continues to be edema in the bilateral frontal lobes. There is associated
mass effect and approximately 5 mm of leftward shift of midline structures.
The basilar cisterns are patent.
There is mild mucosal thickening in the bilateral ethmoid air cells. The
mastoid air cells and middle ear cavities are clear. The visualized portions
of the orbits are unremarkable.
IMPRESSION:
Post surgical changes following meningioma resection including 6 mm leftward
shift of midline structures, small amount of subdural blood along the falx,
small hemorrhage along the resection bed and pneumocephalus.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with olfactory groove meningioma resection //
post operative resection evaluation
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
COMPARISON: ___.
FINDINGS:
The patient has undergone resection of large olfactory groove meningioma since
the previous study of ___. Arch surgical cavity is identified with
blood products and mild surrounding restricted diffusion from postoperative
change. Minimal surrounding enhancement appears postoperative in nature. No
residual nodular enhancement is identified. Expected postsurgical changes
including pneumocephalus and extra-axial fluid are seen. Previously seen
edema in the frontal lobe is unchanged. A small focus of chronic
microhemorrhage in the right temporal region is also unchanged.
IMPRESSION:
Expected postsurgical changes are seen without evidence of an obvious area of
residual nodular enhancement.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with chest tightness earlier this morning. CXR
to rule out pathology. // CXR to rule out chest pathology given complaints of
chest tightness earlier this morning. CXR to rule out chest pathology given
complaints of chest tightness earlier this morning.
IMPRESSION:
Comparison to ___. Mild cardiomegaly. No pneumonia, no pulmonary
edema, no pleural effusions. Lung volumes are normal.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old woman with intermittent chest pain. Concern for PE.
CTA chest to rule out PE. // CTA chest to rule out PE.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 472 mGy-cm.
COMPARISON: None.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
A 2.4 x 2.4 cm hypodense nodule is seen in the left lobe of the thyroid gland.
The right lobe of thyroid gland appears heterogeneous, without distinct
nodularity.
There is no evidence of pericardial effusion. There is no pleural effusion.
There is no evidence of pulmonary parenchymal abnormality. The airways are
patent to the subsegmental level.
Limited images of the upper abdomen are notable for a a 0.8 x 0.9 cm
hyperdense lesion in the upper pole of the left kidney.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. 2.4 cm hypodense left thyroid nodule. Heterogeneous appearance of the
right lobe of the thyroid without distinct nodule. Recommend further
evaluation with nonurgent thyroid ultrasound, if this has not already been
performed.
3. Incompletely evaluated left upper pole renal lesion measures less than 1
cm. Recommend further evaluation with nonurgent renal MRI.
RECOMMENDATION(S):
1. 2.4 cm hypodense left thyroid nodule. Heterogeneous appearance of the right
lobe of the thyroid without distinct nodule. Recommend further evaluation with
nonurgent thyroid ultrasound, if this has not already been performed.
2. Incompletely evaluated left upper pole renal lesion measures less than 1
cm. Recommend further evaluation with nonurgent renal MRI.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman s/p intracranial surgery. Has been on bedrest
for prolonged time. LENIs of bilateral LEs to rule out DVTs. // Bilateral
lower extremity non-invasive Doppler studies to rule out DVTs.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hallucinations
Diagnosed with Altered mental status, unspecified
temperature: 98.3
heartrate: 109.0
resprate: 16.0
o2sat: 99.0
sbp: 156.0
dbp: 99.0
level of pain: 0
level of acuity: 2.0 | ___ year old woman with PMH significant for HTN, DM, HLD, visual
hallucinations, and blindness who was recently diagnosed with
intracranial mass. Now she presents with acute on chronic
worsening of visual hallucinations. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Dilaudid (PF)
Attending: ___.
Chief Complaint:
Headache, Blurry Vision, and Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with PMH significant for
DM type II on insulin, hypercholesterolemia, hypertension,
NAFLD, and hx. of pulmonary embolism at ___ y/o on OCPs who
presents with acute onset headache, blurred vision, and chest
pain.
Pt. was in her usual state of health prior to the onset of her
symptoms early in the morning of the day of presentation. She
has an abnormal sleep cycle at baseline. At approx 1:30AM, pt.
developed acute onset left frontal stabbing supraorbital pain.
She has never experienced pain like this before. At this time,
she checked her BS and it was 171. Associated with the onset of
her pain, the pt. noted double vision that resolved when she
covered either eye but persisted when usually both eyes to
visualize. She denies any focal weakness, numbness, confusion,
or difficulty with speech during this time period. These
symptoms lasted approximately 5 minutes and resolved
spontaneously.
On resolution of her symptoms, the patient notes the gradual
onset of substernal heavry chest pain with some radiation to the
base of the left neck. She describes the pain as a "heavy lump
inside" her chest. At this time, the patient checked her blood
pressure which was 222/119 (typical blood pressure is 130s/70s).
She also noted shortness of breath at this time. She reports a
history of this type of chest pain, albeit less intense, at
baseline approx ___ week. She notes her BPs to be in the
165s/80s when this occurs and also has the association of SOB.
She called for an ambulance and following taking 325mg aspirin
and sublingual nitro, her cp significantly imiproved.
On arrival to the ED, her chest pain soon thereafter resolved
lasting 1 hour in duration. In the ED, initial vs were: 98.3,
114, 147/90, 18, 94 on RA. Pt. was placed on oxygen, given
insulin, and dosed 12.5mg of her HCTZ. She was stable and
transfered to the floor. Vitals on Transfer: 98.1 98 138/74 22
96% RA
Past Medical History:
Recent Pneumonia - ___ Tx with levofloxacin 500 mg qd x 7
days
Chest Pain Admission - ___ Wk-up Negative with stress echo,
EKG, CTA
DM type II on insulin- 34 Units lantus in AM with sliding scale
HTN
Hyperlipidemia
Gallstones s/p cholecystectomy, ERCP with sphincterotomy for
retained stone
NAFLD
H/o toxin-induced hepatitis from overdose of OTC medication
GERD
Chronic cough - ___ lisinopril; pt. did not tolerate losartan,
back on lisinopril
Anxiety, panic attacks
Anemia
Hemorrhoids
Pulmonary Embolus - at age ___ while on OCPs
"Congenital heart problem in which blood was flowing the wrong
way"
Last Colonoscopy - ___ Normal colon to ileocecal valve,
however incomplete due to pt. intolerance, recommended repeat ___
year under MAC anesthesia.
Social History:
___
Family History:
Pt. did not know her biological father. Her mother has a
history of DM type 2, peptic ulcer disease. Brother with
hypertension and heart disease of some type. She has a maternal
grandmother with hx. of angina. Maternal ___ cousins with hx.
brain hemorrhage and hypertension. Denies family history of
early MI, arrhythmia, cardiomyopathies, sudden cardiac death,
migraine, lung cancer, or colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4, 97, 157/96, 22, 97 on RA
General: NAD
HEENT: NCAT, MMM, oropharynx clear
Neck: Supple, JVD <7cm
CV: RRR, S1/S2, grade ___ early systolic decrescendo murmur
heard best at the RUSB, increases on expiration
Lungs: Inspiratory crackles at the right base otherwise CTAB
Abdomen: Soft, protuberant, non-tender non-distended, +BS, no
rebound or guarding
Ext: WWP, no ___ edema, 2+ pulses bilaterally throughout
Neuro: CN ___ intact, visual fields intact, strength ___ and
sensation intact to light touch bilaterally in the UE and ___
Skin: No rashes, petechiae, or ecchymosis
Vitals: 158/90 (134-158/90), 81, 20, 98%RA BG: 189, 250
General: Well appearing female, NAD
HEENT: MMM, NCAT
Lungs: CTAB
CV: RRR no m/r/g
Abdomen: Mildly TTP in RUQ
Ext: no edema
Pertinent Results:
ADMISSION LABS
___ 04:15AM BLOOD WBC-7.3 RBC-5.10 Hgb-12.7 Hct-38.0
MCV-74* MCH-25.0* MCHC-33.6 RDW-14.7 Plt ___
___ 04:15AM BLOOD Neuts-73.7* ___ Monos-5.0 Eos-2.2
Baso-0.5
___ 04:15AM BLOOD ___ PTT-30.6 ___
___ 04:15AM BLOOD Glucose-288* UreaN-16 Creat-0.9 Na-136
K-4.5 Cl-102 HCO3-22 AnGap-17
___ 04:15AM BLOOD cTropnT-<0.01
NOTABLE LABS
___ 04:15AM BLOOD cTropnT-<0.01
___ 10:13AM BLOOD cTropnT-0.02*
___ 01:10PM BLOOD cTropnT-0.02*
___ 09:10PM BLOOD cTropnT-<0.01
___ 08:10AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
___ 08:10AM BLOOD WBC-6.0 RBC-5.25 Hgb-13.1 Hct-39.4
MCV-75* MCH-25.0* MCHC-33.3 RDW-14.4 Plt ___
___ 08:10AM BLOOD Glucose-222* UreaN-16 Creat-0.9 Na-138
K-4.3 Cl-101 HCO3-28 AnGap-13
___ 08:10AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.9
___ 08:10AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Exercise Stress Test (___):
IMPRESSION: Possible anginal type symptoms in the setting of
Persantine
infusion. Uninterpretable ST segment changes for ischemia in the
setting of LBBB. Nuclear report sent separately.
Cardiac Perfusion Study (___):
Left ventricular cavity size is normal.
Stress perfusion images reveal uniform tracer uptake throughout
the left
ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 47%
Compared with prior perfusion study dated ___, there has
been no
significant change in perfusion, although the patient's EF has
decreased from
70% to 47%.
IMPRESSION: 1. Normal myocardial perfusion.
2. Decreased in EF, 70% previously, now 47%.
Carotid Ultrasound (___):
Grayscale and doppler examination of both common carotid,
internal carotid,
external carotid and vertebral artery was performed. The right
carotid
vasculature has mild heterogeneous plaque. The left carotid
vasculature has
no plaque. There is normal flow in the vertebral arteries
bilaterally.
The right common carotid artery had peak systolic/diastolic
velocities of
58/18 cm/sec in its proximal, 71/21 cm/sec in its mid and 70/21
cm/sec in its
distal portion. The peak systolic velocity was 69 cm/sec in the
common
carotid, 80 cm/sec in the external carotid and 30 cm/sec in the
vertebral
artery. The right ICA/CCA ratio is 1.0.
The left common carotid artery had peak systolic/diastolic
velocities of 63/18
cm/sec in its proximal, 71/28 cm/sec in its mid and 56/19 cm/sec
in its distal
portion. The peak systolic velocity was 82 cm/sec in the common
carotid, 86
cm/sec in the external carotid and 43 cm/sec in the vertebral
artery. The
left ICA/CCA ratio is 0.86.
IMPRESSION:
Less than 40% stenosis on the right and no atherosclerotic
plaque noted on the
left.
CT Head w/o Contrast (___): No evidence of acute
intracranial process
CXR (___): No evidence of acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 34 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Omeprazole 20 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Glargine 34 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Lisinopril 40 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Hypertensive Emergency
2. Reduced Ejection Fraction
Secondary
1. Diabetes Mellitus - Type 2, Insulin Dependent
2. Chronic Cough - Secondary to lisinopril
3. Hypertension
4. Hyperlipidemia
5. Gastroesophageal Reflux Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain.
COMPARISON: CT from ___.
FINDINGS:
PA and lateral views of the chest demonstrate chronic appearing opacities in
the right lower lobe as well as elevation of the right hemidiaphragm. These
findings are consistent with atelectasis/volume loss. The left lung is
essentially clear. The cardiac silhouette is normal in size. There is
tortuosity of the aorta. In addition, a convex bulge of the left upper
mediastinum is once again present, but this is due to vascular structures and
aberrant subclavian artery as was seen on the recent CT.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Radiology Report
HISTORY: Headache.
TECHNIQUE: CT of the head without IV contrast.
CTDIvol: 60 mGy
DLP: 1026 mGy-cm
COMPARISON: None
FINDINGS:
There is no evidence of hemorrhage, mass effect, shift of the normally midline
structures or infarction. Gray-white matter differentiation is preserved
throughout. Ventricles and sulci are normal in size.
A subtle hyperdensity located in near the right cerebellar tonsil is thought
to be artifactual (2, 4)
No osseous or soft tissue abnormalities. Mastoid air cells are well aerated.
Paranasal sinuses are well aerated.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
HISTORY: Diabetes mellitus, hypertension, hyperlipidemia presents with
findings of blurry vision. Is there any carotid disease.
COMPARISON: No relevant comparisons available.
FINDINGS:
Grayscale and doppler examination of both common carotid, internal carotid,
external carotid and vertebral artery was performed. The right carotid
vasculature has mild heterogeneous plaque. The left carotid vasculature has
no plaque. There is normal flow in the vertebral arteries bilaterally.
The right common carotid artery had peak systolic/diastolic velocities of
58/18 cm/sec in its proximal, 71/21 cm/sec in its mid and 70/21 cm/sec in its
distal portion. The peak systolic velocity was 69 cm/sec in the common
carotid, 80 cm/sec in the external carotid and 30 cm/sec in the vertebral
artery. The right ICA/CCA ratio is 1.0.
The left common carotid artery had peak systolic/diastolic velocities of 63/18
cm/sec in its proximal, 71/28 cm/sec in its mid and 56/19 cm/sec in its distal
portion. The peak systolic velocity was 82 cm/sec in the common carotid, 86
cm/sec in the external carotid and 43 cm/sec in the vertebral artery. The
left ICA/CCA ratio is 0.86.
IMPRESSION:
Less than 40% stenosis on the right and no atherosclerotic plaque noted on the
left.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with HEADACHE, DIPLOPIA, CHEST PAIN NOS, OTHER NONSPECIFIC FX ON EXAM, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.3
heartrate: 114.0
resprate: 18.0
o2sat: 94.0
sbp: 147.0
dbp: 90.0
level of pain: 4
level of acuity: 2.0 | BRIEF SUMMARY STATEMENT:
Ms. ___ is a ___ year old female with PMH significant for
DM type II on insulin, hypercholesterolemia, hypertension,
NAFLD, and hx. of pulmonary embolism at ___ y/o on OCPs who
presents with acute onset headache, blurred vision, and chest
pain. The patient's symptoms occured in the setting of elevated
blood pressures likely consistent with an episode of
hypertensive emergency.
# Chest Pain: The pt. has history of similar type of chest
pain, not necessarily related to activity and more related to
anxiety type events. On this admission, her chest pain occurred
in the setting of elevated blood pressures in the 220s/120s.
Her chest pain slowly improved as her blood pressures improved.
She was found to have a mildly elevated troponin at 0.02. Her
troponin peaked at this level and slowly returned to normal. It
was thought that the mechanism of her chest pain is related to
transient ischemic injury from increased cardiac demand in the
setting of high afterload with significantly elevated blood
pressures. This type of mechanism supports an episode of
hypertensive emergency as there is evidence of end organ damage.
The patient's EKG was without significant change (Sinus rhythm
with LBBB) other than a slight change in QRS morphology in the
lateral leads likely attributable to lead placement. Stress
test showed possible anginal type symptoms in the setting of
Persantine infusion, with uninterpretable ST segment changes for
ischemia in the setting of LBBB. Nuclear perfusion test showed
decreased cardiac output of 47%, down from 70% previously. The
patient was asymptomatic during her stay. She will follow up
with cardiology as an outpatient.
# Headache and Blurry Vision: The patient presented with acute
onset left-sided supraorbital sharp pain associated with blurry
vision that lasted approximately 5 minutes. The quick onset and
remission of these symptoms in the setting of significantly
elevated blood pressures is consistent with hypertensive
emergency causing end organ damage manifested in this case by
blurry vision and headache. Other diagnoses we considered were
transient ischemic attach from sometype of embolic event. The
patient was noted to be in sinus rhythm without evidence of
atrial fibrillation. A carotid ultrasound was performed which
showed Less than 40% stenosis on the right and no
atherosclerotic plaque noted on the
lef. This made an embolic event less likely. Her neurologic
exam remained non-focal and she remained hemodynamically stable
throughout admission.
# Hypertension: The patient's blood pressure at home before
admission was in the 220s. However, during admission the
patient's blood pressure was well controlled. The patient was
continued on lisinopril 40mg PO daily and HCTZ 12.5mg PO daily.
CHRONIC ISSUES
# Diabetes Mellitus: Stable. The patient was continued lantus
34 units in the AM and on a humalog insulin sliding scale.
# Constipation with Right upper quadrant pain: The patient
reported a chronic history of stable abdominal pain since
antibiotic treatment several months ago for her pneumonia. She
denied a history of diarrhea, however she does endorse
significant constipation associated with RUQ abdominal pain.
This was managed with constipation regimen.
# Chronic Cough: Likely related to the lisinopril. The
patient was tried on losartan in the past and was not able to
tolerate secondary to GI upset. As such, will continue
lisinopril.
# Hyperlipidemia: Pt. with known history however is no longer
taking statin ___ myalgias. She is also not taking primary
prophylaxis with aspirin ___ gastric intolerance
# GERD: Stable. Continued on omeprazole
TRANSITIONAL ISSUES
#Hypertension Management: We discharged the patient on her home
regimen; however it is unclear why the patient's blood pressure
was in the 220s at home before admission. She may need increased
blood pressure control and should be monitored. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Dilaudid / Lipitor
Attending: ___.
Chief Complaint:
fevers, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with ESRD on HD, T2DM,
CHF, HTN, HLD, Afib (not anticoagulated ___ history of GI Bleed)
presenting with fever, cough x1 day, and shortness of breath. He
reports that yesterday morning he felt very hot, also had
chills, fever to 103, and had strong, non productive cough
starting that morning.
Sent in from rehab for temp 103 and hypoxia. Pt reports cough
since yesterday, worse when supine. Last dialysis ___ (HD
___.
In the ED initial vitals were: 20:31 100.4 109 118/53 20 91% ra.
Tmax was 103.1, at that time HR was 112, BP 110/67, RR 30. 95 on
3L.
- Labs were significant for BNP of 21,569 (last BNP 30,950
___, creatinine of 6.0 (baseline ___, on HD),
leukocytosis to 11.1, microcytic anemia of 35.5 (baseline ~30)
- Patient was given Ceftriaxone and Vancomycin 1g.
At rehab (___) also had low sat 85 on 3L.
Digoxin recently discontinued in ___ clinic ___ ESRD on ___.
Recent admission ___ - ___ for hip pain of unclear
etiology, discharged to rehab. On that admission, enteroscopy
was
pursued in ___ given hx of GI bleed requiring transfusions,
and the study indicated single non-bleeding pseudopolyp in the
proximal jejunum. Otherwise normal EGD to mid jejunum.
On the floor, he reports he was very sick this morning but is
feeling better. Denies chest pain, continues to have cough. He's
sad bc he missed his grandson's birthday. Reports chronic foot
pain and pain from buttock ulcer.
Review of Systems: please see HPI, does not make urine
Past Medical History:
1. ESRD on HD ___ at ___ Dialysis, ___ ___,
___
2. Type 2 diabetes mellitus c/b peripheral neuropathy
3. CAD: On review of records, he had demand ischemia in ___
with no flow-limiting stenoses on cardiac cath. MIBI in ___
showed reversible defects inferior/lateral. Baseline troponin
0.2-0.4. Cath in ___ - normal coronaries.
4.Chronic systolic CHF with EF 30% ___ TTE)
5. Atrial fibrillation/AFlutter s/p ablation ___ h/o atrial
tachycardia s/p EPS ___ and ablation x 2. not on coumadin due
to history of GIBs.
6.Hypertension
7. Dyslipidemia: ___ TC 101, LDL 54, HDL 29, ___ 112
8. History of GI bleeds: Duodenal, jejunal, and gastric AVMs s/p
thermal therapy; diverticulosis throughout colon
9. Chronic pancreatitis
10. Possible Hepatitis C infection, HCV Ab + ___, but neg
___
- GERD
- Gout
- s/p arthroscopy with medial meniscectomy ___
- Depression with multiple hospitalizations due to SI
- Polysubstance abuse: crack cocaine, EtOH, tobacco
- frequent bouts of chest pain following crack/cocaine use
- Erectile dysfunction s/p inflatable penile prosthesis ___
- H/o C diff in ___
Social History:
___
Family History:
Mother had ESRD on HD, died from MI at the age of ___. 4 brothers
and 2 sisters, nearly all with DM2.
Physical Exam:
ADMISSION
Vitals: 99.6 - 100/___ - 100 on 3L, ___ pain (feel),
weight ___
GENERAL: no respiratory distress, elderly ___
gentleman appearing older than stated age, chronically ill,
attentive, pleasant, conversational, wearing a black beanie
HEENT: AT/NC, EOMI, anicteric sclera, MM dry, nontender supple
neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: crackles bilateral bases/dependent areas, good effort
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, fistula w/ palpable thrill, audible bruit
NEURO: face symmetric, moves all extremities against gravity,
speech fluent, oriented x3
SKIN: 0.5cm clean based ulcer at midline gluteal fold,
hyperpigmentation
DISCHARGE
Vitals: 97.8 afeb 109/56 90 20 100% 2L -> currently on RA
GENERAL: awake, alert, NAD
HEENT: EOMI, OMM no lesions
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: crackles in bases anteriorly otherwise good air entry
ABDOMEN: nondistended, +BS, nontender, no r/g/r
EXTREMITIES: no cyanosis, clubbing or edema, fistula w/ palpable
thrill
NEURO: face symmetric, moves all extremities against gravity,
speech fluent, oriented x3
SKIN: shallow approx 0.5cm round ulcer over coccyx, no drainage,
purulence, or erythema
Pertinent Results:
ADMISSION LABS
___ 09:20PM BLOOD WBC-11.1*# RBC-4.52* Hgb-10.9* Hct-35.5*
MCV-79* MCH-24.1* MCHC-30.7* RDW-18.1* Plt ___
___ 09:20PM BLOOD Neuts-86.4* Lymphs-7.0* Monos-5.7 Eos-0.5
Baso-0.4
___ 03:44PM BLOOD ___
___ 09:20PM BLOOD Glucose-175* UreaN-34* Creat-6.0* Na-137
K-4.7 Cl-97 HCO3-24 AnGap-21*
___ 09:20PM BLOOD ALT-23 AST-20 AlkPhos-258* TotBili-0.6
___ 09:20PM BLOOD CK-MB-3 cTropnT-0.33* ___
___ 07:30AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.4
DISCHARGE LABS
___ 06:45AM BLOOD WBC-5.2 RBC-4.45* Hgb-10.8* Hct-35.0*
MCV-79* MCH-24.2* MCHC-30.8* RDW-17.5* Plt ___
___ 06:45AM BLOOD Glucose-292* UreaN-58* Creat-7.7*# Na-134
K-4.6 Cl-93* HCO3-24 AnGap-22*
___ 06:45AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.6
MICRO
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
___ Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
IMAGING
___ Imaging CHEST (PA & LAT)
IMPRESSION: Mild pulmonary edema and persistent right effusion,
similar to prior.
___ Imaging CHEST (PA & LAT)
FINDINGS: Cardiomegaly is accompanied by pulmonary vascular
congestion and improving pulmonary edema. More confluent
opacities at the bases have worsened, and are concerning for
possible infectious or aspiration pneumonia given history of
fever. Small pleural effusions are present, but there is no
visible pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain, fever
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Aquaphor Ointment 1 Appl TP TID:PRN itchy skin
4. Mupirocin Ointment 2% 1 Appl TP TID
5. Cinacalcet 90 mg PO DAILY
6. Citalopram 20 mg PO DAILY
7. Diltiazem Extended-Release 360 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q6H:PRN cough
10. ___ Tar (coal tar) 2 % topical HS
11. Gabapentin 200 mg PO DAILY
12. Gabapentin 300 mg PO BID
13. HydrOXYzine 25 mg PO Q6H:PRN itcxhing
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. Nephrocaps 1 CAP PO DAILY
16. Nitroglycerin SL 0.4 mg SL PRN chest pain
17. Omeprazole 40 mg PO BID
18. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
19. Sarna Lotion 1 Appl TP QID:PRN itchy ksin
20. Senna 8.6 mg PO BID:PRN constipation
21. sevelamer CARBONATE 2400 mg PO TID W/MEALS
22. TraZODone 50 mg PO HS:PRN insomnia
23. Ondansetron 4 mg PO BID:PRN nausea/vomiting
24. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using lispro Insulin
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain, fever
2. Aquaphor Ointment 1 Appl TP TID:PRN itchy skin
3. Citalopram 20 mg PO DAILY
4. Diltiazem Extended-Release 360 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 200 mg PO DAILY
7. Gabapentin 300 mg PO BID
8. HydrOXYzine 25 mg PO Q6H:PRN itcxhing
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Mupirocin Ointment 2% 1 Appl TP TID
11. Nephrocaps 1 CAP PO DAILY
12. Omeprazole 40 mg PO BID
13. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
14. Sarna Lotion 1 Appl TP QID:PRN itchy ksin
15. Senna 8.6 mg PO BID:PRN constipation
16. sevelamer CARBONATE 2400 mg PO TID W/MEALS
17. TraZODone 50 mg PO HS:PRN insomnia
18. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
19. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q6H:PRN cough
20. ___ Tar (coal tar) 2 % topical HS
21. Nitroglycerin SL 0.4 mg SL PRN chest pain
22. Ondansetron 4 mg PO BID:PRN nausea/vomiting
23. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using lispro Insulin
24. CefTAZidime 2 g IV POST HD
last dose to be given after dialysis on ___
25. Guaifenesin ___ mL PO Q4H:PRN cough
26. Vancomycin 1000 mg IV HD PROTOCOL
last dose to be given after dialysis on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: healthcare associated pneumonia
Secondary: ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ male with shortness of breath and fever. History of
CHF.
COMPARISON: ___.
FINDINGS: Slightly low lung volumes are again noted although mild pulmonary
edema is seen. There is no confluent consolidation. Small right pleural
effusion is unchanged from prior. The cardiac silhouette is moderately
enlarged. No acute osseous abnormality is identified.
IMPRESSION: Mild pulmonary edema and persistent right effusion, similar to
prior.
Radiology Report
PA AND LATERAL CHEST, ___
COMPARISON: Radiograph ___.
FINDINGS: Cardiomegaly is accompanied by pulmonary vascular congestion and
improving pulmonary edema. More confluent opacities at the bases have
worsened, and are concerning for possible infectious or aspiration pneumonia
given history of fever. Small pleural effusions are present, but there is no
visible pneumothorax.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ILI, Hypoxia, Fever
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 100.4
heartrate: 109.0
resprate: 20.0
o2sat: 91.0
sbp: 118.0
dbp: 53.0
level of pain: nan
level of acuity: 2.0 | Mr. ___ is a ___ year old gentleman with ESRD on HD, T2DM,
CHF, HTN, HLD, Afib (not anticoagulated ___ history of GI Bleed)
presenting with fever, cough x1 day, and shortness of breath.
# Fever, leukocytosis, cough, hypoxia - Concerning for pneumonia
vs ILI. Given his recent hospitalizations, rehab residence, and
dialysis, patient was started on HCAP coverage with vancomycin
and cefepime. Sputum cultures did not grow a specific pathogen
and viral DFA and culture was negative. Patient's symptoms
improved with empiric HCAP coverage. Vanc/cefepime was changed
to vanc/ceftazadime at discharge for ease of dialysis dosing.
Patient will complete a 7d course of antibiotics, last dose of
vanc and ceftazadime to be given after dialysis session on
___.
# Diastolic CHF: BNP is lower than recent admissions, though pt
does have bilateral lower crackles, concerning for contribution
of mild fluid overload. Echo in ___ with EF 55-60%. Patient was
maintained on a low-sodium diet with a 2L fluid restriction.
Patient was dialyzed as per outpatient schedule, supplemental 02
was weaned and patient remained comfortable on room are for
>___.
CHRONIC ISSUES
# History of GI bleed. Per GI Dr. ___ was
pursued in ___ given hx of GI bleed requiring transfusions,
and the study indicated single non-bleeding pseudopolyp in the
proximal jejunum. Otherwise normal EGD to mid jejunum.
Patient has f/u with GI. Hematocrits were stable throughout his
course without signs of active bleed.
# ESRD on HD: outpatient schedule ___. Nephrology was
consulted, continued sevelamer, nephrocaps. Nephro recommended
holding cinacalcet at discharge as patient's calcium was low.
Recommend following calcium and PTH at outpatient dialysis and
restarted cinacalcet as per outpatient nephrologist.
# T2DM: Last HbA1c 10.7 on ___. Repeat during this
admission was 7.4. Multiple complications including peripheral
neuropathy, retinopathy, nephropathy. He was continued on his
home insulin regimen.
# Atrial fibrillation/AFlutter (s/p ablation ___ s/p ablation
x 2 in ___, EPS for atach in ___ (thought to be trigger vs.
reentrant) not on warfarin due to history of GIBs. Continued
diltiazem.
# Hypertension. Stable. Continued home diltiazem and imdur.
TRANSITIONAL ISSUES
# Code: Full, confirmed
# Emergency Contact: ___ (girlfriend/HCP) ___
Cell ___. Alternate HCP is son ___
___/ home ___.
# cinacelcet held on discharge due to low calcium, recommend
following calcium and PTH at outpatient dialysis and restarting
as per outpatient nephrologist
# needs to complete course of antibiotics for HCAP (vanc and
ceftazadime, last dose after dialysis session ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ Yo M with PMH of GERD, CVA, HIV, DMII, Celiac disease,
Pressure ulcer on coccyx, depression and poor hearing who
presented to the ED with GI bleeding. History is obtained from
the chart. He had a labs performed by his ___ (___
___) today which was remarkable for WBC 13.8, Hgb 5.9,
Glucose 319 and BUN 38. He was then transported to ___. At
___, he was tachycardic to 108 and BP was 95/52. Physical
exam revealed dark red, almost maroon blood per rectum, guaiac
positive. Hgb was 6.1, BUN 33, WBC 13.9 and INR 1.15. According
to note, most recent available Hct was 25 from ___. On
evaluation there, he had no complaints and no history of GI
bleeding. No blood thinner on medication list. According to
notes, he has a DNR/DNI order but wanted a transfusion and "care
for GI bleed". He received emergency release blood products: 2u
pRBC and 1u FFP. He also received protonix 80mg IV x1. The case
was discussed with GI on call at ___ who recommended
transfer to ___ in case his GI bleed worsened overnight and
necessitated more immediate attention as this is not available
overnight at ___. He was then transferred to ___.
Ancillary history: ___, ___ at ___: Bloody ___, dark stool,
prompted labs which showed hgb drop, tachycardia to 107, not
uncomfortable, no chest pain, SOB, abd pain, no change in mental
status. Baseline mental status; usually confused (unclear
recognition / orientation), very hard of hearing, does not use
HA, responsible party ___ HCP (not dead
per their records). Baseline BP: 100-110s/60s. Chart says HIV,
no meds, "tested positive for it at one point," records not
available. Needs assistance for transfer, bedbound, does not
walk, no ___ currently, lived there since ___
In ED initial VS: T99.0, HR 88, BP 97/44, RR 16, SpO2 98% RA
Exam: noted to have tunneling wound on coccyx
Access: two 18 gauge PIVs
Labs significant for: Hgb 7.6 from 6.1 at ___. Coags and
fibrinogen normal. BUN 28, Cr 0.7. Lactate 2.3. Repeat CBC
pending at time of transfer.
Patient was given: no additional medications
Imaging notable for: none obtained
Consults: GI was notified who requested that he be NPO and
given PPI
VS prior to transfer: T98.1, HR74, BP91/40, RR17, SpO295% RA.
On arrival to the MICU, patient is very hard of hearing but
responds to questions. Confused but denies fever, chest pain,
SOB, abd pain, hematemesis.
Past Medical History:
DMII
CVA
Celiac disease
Pressure ulcer on coccyx
Sensorineural hearing loss
Insomnia
Major depressive disorder
HIV by chart but no labs / meds
Social History:
___
Family History:
unable to obtain due to confusion
Physical Exam:
=======================
Admission Physical Exam
=======================
VITALS: 98.1 74 94/60 27 99% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, pale conjunctiva, 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: cool, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
SKIN: cool, dry, 2cm moist stage IV pressure ulcer on coccyx
without erythematous border, drainage, malodor
NEURO: alert, interactive, face symmetric, MAE
========================
Discharge Physical Exam
========================
VS: T98.2 BP 122/80 HR 94 RR 18 SpO2 92 Ra
GENERAL: Pleasant elderly man in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, adentulous
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNGS: 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
SKIN: 2cm moist stage IV pressure ulcer on coccyx without
erythematous border, drainage, malodor.
PULSES: 2+ DP pulses bilaterally
NEURO: Alert and oriented x3 (not able to state exact date) CN
III-XII grossly intact. Extremely hard of hearing
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 02:22AM BLOOD WBC-9.2 RBC-2.62* Hgb-7.6* Hct-22.7*
MCV-87 MCH-29.0 MCHC-33.5 RDW-14.6 RDWSD-45.6 Plt ___
___ 02:22AM BLOOD ___ PTT-26.9 ___
___ 02:22AM BLOOD Glucose-358* UreaN-28* Creat-0.7 Na-138
K-3.7 Cl-100 HCO3-23 AnGap-15
___ 02:22AM BLOOD ALT-9 AST-12 AlkPhos-71 TotBili-0.4
___ 02:22AM BLOOD Albumin-3.3*
___ 02:22AM BLOOD CRP-9.9*
___ 02:37AM BLOOD Lactate-2.3*
EGD ___
Impression: Small hiatal hernia
Otherwise normal EGD to third part of the duodenum
Recommendations: - no findings on upper endoscopy to suggest
upper GI source
- clears today, start prep for colonoscopy tomorrow with plan
for ___ on ___
___ ___
Findings:
Protruding Lesions A single sessile 35 mm polyp of benign
appearance was found in the ascending. Cold forceps biopsies
were performed for histology.
Excavated Lesions A single 25 mm ulcer was found in the rectum.
This had the appearance of a stercoral ulcer. Cold forceps
biopsies were performed for histology at the rectal ulcer.
Impression: Polyp in the ascending (biopsy)
Ulcer in the rectum (biopsy)
Otherwise normal colonoscopy to cecum and TI
Recommendations: Follow up pathology
Prevent constipation
Depending on overall health, EMR for ascending polyp could be
considered after ulcer has had time to heal
Follow up with inpatient GI team
===================
Discharge Labs
===================
___ 07:25AM BLOOD WBC-8.3 RBC-3.04* Hgb-8.7* Hct-27.7*
MCV-91 MCH-28.6 MCHC-31.4* RDW-15.6* RDWSD-49.0* Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-80 UreaN-8 Creat-0.7 Na-142 K-4.1
Cl-106 HCO3-24 AnGap-12
___ 07:25AM BLOOD Calcium-8.3* Phos-4.4 Mg-1.9 Iron-18*
___ 07:25AM BLOOD calTIBC-247* Ferritn-29* TRF-190*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 14 Units Bedtime
2. Mirtazapine 15 mg PO QHS
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Senna 8.6 mg PO DAILY
5. Sertraline 12.5 mg PO DAILY
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. Sodium Bicarbonate 650 mg PO BID heartburn
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
9. Bisacodyl ___AILY:PRN constipation
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Fleet Enema (sodium phosphates) ___ gram/118 mL rectal
DAILY:PRN
13. GuaiFENesin 10 mL PO Q6H:PRN cough
14. Sorbitol 30 mL PO DAILY:PRN constipation
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
16. Aspirin 81 mg PO DAILY
17. Atorvastatin 20 mg PO QPM
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
RX *ascorbic acid (vitamin C) 250 mg 1 tablet(s) by mouth twice
a day Disp #*60 Tablet Refills:*0
2. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2
tablet(s) by mouth once daily Disp #*60 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
once daily Disp #*30 Packet Refills:*0
4. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
5. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth once
daily Disp #*14 Capsule Refills:*0
6. Glargine 14 Units Bedtime
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 20 mg PO QPM
11. Bisacodyl ___AILY:PRN constipation
12. Fleet Enema (sodium phosphates) ___ gram/118 mL rectal
DAILY:PRN
13. Fluticasone Propionate 110mcg 1 PUFF IH BID
14. GuaiFENesin 10 mL PO Q6H:PRN cough
15. Milk of Magnesia 30 mL PO DAILY:PRN constipation
16. Mirtazapine 15 mg PO QHS
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Senna 8.6 mg PO DAILY
19. Sertraline 12.5 mg PO DAILY
20. Sodium Bicarbonate 650 mg PO BID heartburn
21. Sorbitol 30 mL PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
==================
Primary Diagnosis
==================
Lower GI bleed secondary to stercoral ulcer
===================
Secondary Diagnosis
===================
Anemia secondary to acute blood loss
Ascending colon polyp
Hypernatremia
Constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with GI bleed, hypotension// eval for infiltrate
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits and there is
no evidence of vascular congestion.
There is suggestion of asymmetric opacification in the left suprahilar region
and possibly the left base, which given the clinical history could be a
manifestation of consolidation.
NOTIFICATION: Dr. ___, immediately by telephone on identification of
this appearance at 10:12 on ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI bleed, Transfer
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 99.0
heartrate: 88.0
resprate: 16.0
o2sat: 98.0
sbp: 97.0
dbp: 44.0
level of pain: 0
level of acuity: 2.0 | =========
Summary
=========
___ year old man with PMH of GERD, CVA, DMII, celiac disease,
pressure ulcer on coccyx, depression and poor hearing who
presented with GI bleeding. Colonoscopy revealed stercoral
ulcer. Hgb stabilized, no further bleeding.
=============================
Acute Medical/Surgical Issues
=============================
# GI Bleed:
# Acute blood loss anemia
Patient presented with hgb drop in the setting of dark stools
without hematemesis with a history of GERD on daily aspirin. No
history of liver disease, malignancy, trauma. Required 3 units
pRBC and 1 unit FFP and H/H stabilized with no further
melena/hematochezia. BPs recovered with blood and fluid. EGD
unrevealing. Colonoscopy on ___ revealed a stercoral ulcer in
the rectum with no signs of bleeding. Biopsies were take which
are pending at discharge. His home aspirin 81 was held but
restarted at discharge.
# Hypotension: initially hypotensive to ___ (baseline is
100s systolic), felt to be related to hypovolemia/blood loss. He
was pancultured without revealing infectious source to
contribute to a sepsis etiology of hypotension. BP improved to
95-105 systolics which appears to be his baseline.
#DMII: Hyperglycemic on admission, unclear etiology but could be
due to stress of infection or bleed. Given that he is NPO, dosed
reduced home insulin regimen of glargine 14U qHS with ISS while
on clear liquid/NPO diet here. Once diet resumed, restarted on
home dose.
CHRONIC
# Coccyx wound: in the setting of bedbound status and potential
malnutrition. Wound does not currently look infected on
admission. CRP low making osteo less likely. Wound care was
consulted and recommended pressure relief per pressure ulcer
guidelines with turn and reposition every ___ hours and prn off
affected area. Nutrition consulted and given celiacs disease,
started on supplementation with vitamin C, zinc sulfate for 14
days, vitamin D, and calcium carbonate.
# Potential HIV
Chart diagnosis without labs or medications by history. Patient
confused and does not know if he has diagnosis. CD4 and HIV
viral load negative making HIV unlikely. Would remove from past
medical history
#CAD primary prevention: continued Atorvastatin 20 mg PO QPM and
restarted ASA at discharge.
#Constipation: Stercoral ulcer likely developed in setting of
chronic constipation. Would put patient on standing bowel
regimen with Senna 8.6mg PO daily and Miralax. Would continue
PRN regimen of Bisacodyl ___AILY:PRN constipation; Milk
of Magnesia 30 mL PO DAILY:PRN constipation; and Fleet Enema
(sodium phosphates) ___ gram/118 mL rectal DAILY:PRN if patient
without stool for 2 days.
#Rhinitis: continued home Fluticasone Propionate 110mcg 1 PUFF
IH BID; GuaiFENesin 10 mL PO Q6H:PRN cough; Albuterol Inhaler 2
PUFF IH Q6H:PRN dyspnea
#Depression/insomnia: continued home Sertraline 12.5 mg PO
DAILY, Mirtazapine 15 mg PO QHS
#Nutrition: continued Multivitamins W/minerals 1 TAB PO DAILY
and started on supplementation with vitamin C, zinc sulfate for
14 days, vitamin D, and calcium carbonate given history of
celiacs disease.
#Dyspepsia: Restarted Sodium Bicarbonate 650 mg PO BID heartburn
at discharge.
==================
Medication Changes
==================
- Started vitamin C 250mg BID
- Zinc sulfate 220mg daily for 14 days (D1: ___
- Vitamin D 800U daily
- Calcium Carbonate 1000mg daily
=====================
Transitional Issues
=====================
[] Constipation: important in preventing further stercoral
ulcers. Place patient on standing bowel regimen with senna 8.6mg
PO daily and miralax daily. Would try PRN medications in this
order if no stool in 2 days: Bisacodyl ___AILY:PRN
constipation; Milk of Magnesia 30 mL PO DAILY:PRN constipation;
and Fleet Enema (sodium phosphates) ___ gram/118 mL rectal
DAILY:PRN
[] Ascending colon polyp: Will schedule follow-up appointment
with GI to consider EMR for ascending polyp at a later date and
follow-up stercoral ulcer pathology
[] History of Celiac's Disease: Please have patient on
gluten-free diet. Nutrition recommendations are supplementation
with vitamin C, zinc sulfate for 14 days, vitamin D, and calcium
carbonate as patient likely malnourished.
[] Coccyx wound: Wound care was consulted and recommended
pressure relief per pressure ulcer guidelines with turn and
reposition every ___ hours and prn off affected area. Please
have on gluten free diet and continue supplementation as above
as malnutrition will impair wound healing.
[] Continue aspirin 81mg here at discharge. Given patient's age
and functional status, would continue to evaluate risk of
bleeding vs cardiovascular benefit and consider stopping if
indicated.
# Communication: HCP: ___, sister - ___
# Code: DNR/DNI, confirmed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Nausea, vomiting x2 days
Major Surgical or Invasive Procedure:
EGD and colonoscopy
History of Present Illness:
Ms. ___ is a ___ woman with a PMH of HTN and treated Hepatitis
C (previously followed by GI at ___ who initially presented
to ___ with a 2-day history of vomiting and
diarrhea. The vomiting was reportedly non-bloodly-non-bilious
and there was no blood in her stool. She also described new
heartburn, described as burning sensation after drinking ginger
ale, nonradiating, felt in her "throat." Felt like prior
episodes heartburn. Lasted about 1 hour, the self-resolved. Her
grandson is ___ years old, who does not live with her but who she
sees twice weekly, had an illness with GI symptoms approx 2
weeks prior to her presentation. Has had intermittent
periumbilical pain, relieved with emesis and defecation, max
___, nonradiating, now resolved. Last time she was able to take
POs was ___, had oatmeal. At ___, she
was unable to tolerate po's. CT abdomen showed enteritis and an
EKG showed NSR at ___epressions (v4-6), TW III, and
no STE. Last prior EKG in ___epressions. Her
cTnI was 0.07. She denied any chest pain, SOB, diaphoresis. She
was given a full dose ASA, morphine for pain, and transferred to
___ for further work-up.
In the ED, initial vitals were: 98.6 110 134/80 18 96%. Her
nausea, vomiting, and diarrhea had improved by the time she
arrived in the ED. Labs were significant for: BUN 1.6/Cr 1.6,
HCO3 19, and lipase ___. Her CBC, LFT's, and UA were WNL. Her
lipase was then repeated several hours later (on ___ and had
increased to 3208. Troponins x 2 were <0.01. Liver US showed
hepatic ductal dilatation, gallbladder sludge but no stones,
pancreas not visualized. She received 2L IVF and a dose of 1g
CTX. She was then transferred to medicine for further work-up of
her likely pancreatitis/question choledocholithiasis/enteritis,
___, and possible unstable angina.
On the floor, pt reports that her symptoms are improving. She
does continue to have diarrhea, but no further episodes of
emesis. She denies CP, ___ edema, orthopnea, diaphoresis, weight
gain or loss, night sweats, rash, hematuria, hematochezia,
melena, dysuria.
ROS: (+) Per HPI, all other ROS negative.
Past Medical History:
HTN
Hepatitis C (Type 1 diagnosed ___, followed by GI, successfully
treated)
Hypothyroidism
(Herpes? on bid valacyclovir?)
Social History:
___
Family History:
Mother had heart disease, died at age ___. Father with diabetes,
leukemia, died at age ___.
Physical Exam:
Vitals: 98.4, 130/78, 82, 20, 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP 8 cm H2O, no supraclavicular or cervical LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Negative ___ sign.
Nontender to palpation over epigastrium.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: grossly intact.
Discharge exam:
Vitals: T 97.9 150s/80s P 58 RR 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Negative ___ sign. Soft, non tender
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: grossly intact.
Pertinent Results:
Admission Labs:
___ 06:15AM cTropnT-<0.01
___ 05:30AM URINE HOURS-RANDOM
___ 05:30AM URINE HOURS-RANDOM
___ 05:30AM URINE UHOLD-HOLD
___ 05:30AM URINE GR HOLD-HOLD
___ 05:30AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:30AM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
___ 05:30AM URINE HYALINE-17*
___ 05:30AM URINE MUCOUS-RARE
___ 03:46AM LIPASE-3208*
___ 01:49AM ___ COMMENTS-GREEN TOP
___ 01:49AM LACTATE-1.3
___ 01:40AM GLUCOSE-112* UREA N-44* CREAT-1.6* SODIUM-136
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-19* ANION GAP-19
___ 01:40AM estGFR-Using this
___ 01:40AM ALT(SGPT)-20 AST(SGOT)-32 ALK PHOS-64 TOT
BILI-0.5
___ 01:40AM ___ 01:40AM cTropnT-<0.01
___ 01:40AM ALBUMIN-4.4 CALCIUM-9.3 PHOSPHATE-4.2
MAGNESIUM-1.8
___ 01:40AM WBC-7.8 RBC-4.52 HGB-13.7 HCT-40.2 MCV-89
MCH-30.3 MCHC-34.0 RDW-13.9
___ 01:40AM NEUTS-75.5* ___ MONOS-5.2 EOS-0.5
BASOS-0.3
___ 01:40AM PLT COUNT-195
___ 01:40AM ___ PTT-30.5 ___
Relevant labs:
___ 06:15AM BLOOD ALT-43* AST-51* AlkPhos-55 TotBili-1.0
___ 01:40AM BLOOD ___ 03:46AM BLOOD Lipase-3208*
___ 01:40AM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD cTropnT-<0.01
___ 05:30PM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD cTropnT-<0.01
Discharge Labs:
___ 05:46AM BLOOD WBC-4.7 RBC-3.70* Hgb-11.1* Hct-32.4*
MCV-88 MCH-30.0 MCHC-34.3 RDW-13.3 Plt ___
___ 05:46AM BLOOD Glucose-84 UreaN-8 Creat-0.9 Na-144 K-3.6
Cl-113* HCO3-24 AnGap-11
___ 05:46AM BLOOD ALT-99* AST-99* AlkPhos-58 TotBili-0.7
___ ECG:
Sinus rhythm. Non-specific T wave flattening in the limb leads
and T wave
inversion in the precordial leads with slight sagging ST
segments in
leads V4-V6. Compared to tracing #1 sinus tachycardia is absent.
T wave
inversion is now present in leads V3-V6.
___ Liver US:
Mild intrahepatic ductal dilatation within the left hepatic
lobe. The common bile duct and pancreatic duct are within
normal. Visualized portions of the pancreas are unremarkable.
MRCP is advised for further evaluation of the dilated left
intrahepatic duct.
Cholelithiasis and sludge without evidence of cholecystitis
___ CT abd at ___:
1. Uncomplicated diverticulosis.
2. Nonspecific small bowel pattern, with fluid density material
proximal colon, a few mildly thickened small bowel loops,
possibly
mild enteritis, clinical correlation required.
3. Tiny fat-containing umbilical hernia. Suspected small hiatal
hernia. Other incidental findings as noted above.
___ ___:
Findings:
Excavated Lesions Multiple diverticula with mixed openings were
seen in the sigmoid colon and descending colon. Diverticulosis
appeared to be of moderate severity.
Impression: Diverticulosis of the sigmoid colon and descending
colon
Otherwise normal colonoscopy to cecum
Recommendations: Diverticulosis is the likely source of bleeding
___ EGD:
Impression: Angioectasia in the duodenal bulb
Normal mucosa in the second part of the duodenum (biopsy)
Normal mucosa in the whole esophagus (biopsy)
Otherwise normal EGD to third part of the duodenum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Aspirin-Caffeine-Butalbital Dose is Unknown PO DAILY
3. Atenolol 25 mg PO DAILY
4. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN heartburn
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroenteritis
Mild demand ischemia
Lower GI bleed
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 nausea vomiting and elevated lipase.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen 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 mild intrahepatic biliary dilation noted within the left
hepatic lobe. No ductal dilatation within the right hepatic lobe is
identified. The CBD measures 2 mm.
GALLBLADDER: Echogenic debris and an echogenic focus within the gallbladder
lumen reflects sludge and a stone respectively. There is no gallbladder wall
thickening or edema to suggest 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.
KIDNEYS: Limited views of the right kidney demonstrate no hydronephrosis.
IMPRESSION:
Mild intrahepatic ductal dilatation within the left hepatic lobe. The common
bile duct and pancreatic duct are within normal. Visualized portions of the
pancreas are unremarkable. MRCP is advised for further evaluation of the
dilated left intrahepatic duct.
Cholelithiasis and sludge without evidence of cholecystitis.
NOTIFICATION: Recommendations for MRCP communicated to Dr. ___
readout via telephone by A. Trotter at 8:41 am on ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: n/v/d, Transfer
Diagnosed with ACUTE PANCREATITIS
temperature: 98.6
heartrate: 110.0
resprate: 18.0
o2sat: 96.0
sbp: 134.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | ___ yo woman with a PMH of HTN and treated Hepatitis C w/SVR
(previously followed by Liver clinic at ___ presenting with
2-day history of vomiting and diarrhea, admitted for inability
to tolerate POs, went initially to ___ had CT demonstrating
likely gastroenteritis as well as elevated lipase level without
clinical evidence of pancreatitis and very mild troponin
elevation with non specific ECG changes in setting of ___.
Transferred to ___ and over course of hospitalization
developed maroon stools from likely diverticular bleed.
# Vomiting/diarrhea: Resolved, likely from gastroenteritis
# Elevated lipase: Unclear etiology. Clinically does not have
pancreatitis and never had pain. ___ have had transient
obstruction in panc duct, but presentation is odd. ? related to
gastroenteritis. Will need follow up lipase level
# GI bleed: Maroon stools. No evidence of hemodynamic
instability or HCT drop. Likely from diverticulosis seen on
___. No active bleeding found. EGD also performed with
insignifcant AVM in duodenum. The bleeding only took place over
the course of one morning then resolved.
# Potential demand ischemia: Trop I at OSH 0.07 (nl <0.03).
EKGs with Nonspecific ST-T changes, pt denies CP, SOB, ___ edema,
orthopenia, diaphoresis to suggest active ischemia or failure.
Pt with serial cardiac enzymes here which were negative.
Possible demand in setting of dehydration, illness and ___. Pt
may benefit from ETT as OSH. Discussed with PCP. Pt continued
on beta blockade and started on baby aspirin after resolution of
GI bleed.
# Rising LFTs: Pts LFTs initially normal. Over the last two
days of admission had rise in LFTs to 100 Asymptomatic. Should
f/u as outpt. Potentially from stone although no symptoms, no
pain. ? recurrence of hep C. ? autoimmune hepatitis. ?
associated with viral infection. Pt should have follow up LFTs
at outpt appt next week. If rising or still elevated should have
follow up HCV viral load level and should be referred to liver.
Also needs outpt MRCP
# Mild intrahepatic ductal dilatation within the left hepatic
lobe: Needs MRCP
# Hypertension: Currently well controlled
# Hypothyroidism:
- Continue home levothyroxine - med dosing confirmed with pt's
pharmacy |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
immune globulin,gamma (IgG) human
Attending: ___.
Chief Complaint:
Dyspnea, fevers
Major Surgical or Invasive Procedure:
intubation ___ and extubation ___
temporary central venous line placement and removal
History of Present Illness:
___ year old female with history of breast cancer stage ___ s/p R
partial mastectomy and sentinel LN biopsy previously on adjuvant
letrozole now discontinued, hypertension, HLD and
hypothyroidism, recently diagnosed Stage 4 metastatic lung
adenocarcinoma on palliative chemo (last session ___
presenting with fevers, acute on chronic dyspnea on exertion,
cough.
Patient called the office of Dr. ___ she had
recurrent chills for the past few days with fevers up to 101.5.
She was told to go to the ED for further care.
In regards to her recent oncologic history, patient initially
presented at OSH in ___ with worsening of her chronic
dyspnea where CT showed innumerable lung nodules and LUL mass as
well as infiltrative hypodense mass in segment 8 of the liver
concerning for malignancy. She was transferred to ___ where
she underwent ultrasound-guided biopsy of this liver lesion on
___ and underwent bronchoscopy with biopsy/brush,
bronchoalveolar lavage and EBUS-TBNA on ___, which demonstrated
adenocarcinoma. A subsequent PET scan/liver biopsy confirmed
revealed multiple FDG avid nodules in the lung and solitary
hepatic metastasis. She was also found to have an indeterminate
brain lesion which has been stable on subsequent MRIs and for
which she has neuro onc f/u arranged. She was started on
palliative carboplatin, Pemetrexed, Pembrolizumab IV q3weeks on
___.
Past Medical History:
PAST ONCOLOGIC HISTORY:
In ___, an asymmetry was noted in the anterior third of the
superior right breast on screening mammography. Her tissue
density was B. The following day, she had compression views and
the area did not persist. Annual followup was recommended.
This year, on ___, she underwent a bilateral examination
showing another area of focal asymmetry in the upper outer
quadrant of the right breast. She underwent a diagnostic
mammogram of this and the area showed a small persistent mass
during spot compression. This was separate and distinct from the
area evaluated a year earlier. An ultrasound of this showed a
6-mm hypoechoic mass that was 8 cm from the nipple at 10
o'clock.
A biopsy was performed and a clip was placed on ___.
Pathology showed invasive ductal carcinoma with some lobular
features. This was interpreted as grade I to II. There was
intermediate nuclear grade DCIS as well. The estrogen receptor
was highly positive with progesterone receptor that was low
positive. HER-2 was negative.
She subsequently had an excision performed by Dr. ___. This
showed no residual cancer. Hence, her lesion was entirely
removed
during the core procedure. A sentinel node was also negative.
Thus, her final stage based on microscopic measurement of the
invasive component was a T1a 4 mm tumor that we interpreted as a
grade I. The estrogen receptor was positive at 95% and
progesterone receptor positive at 1%-10%.
PAST MEDICAL HISTORY:
- Hyperlipidemia
- Hypertension
- Hypothyroidism
- GERD
- Arthritis
- s/p tubal ligation
- s/p left knee arthroscopy
- s/p tonsillectomy
Social History:
___
Family History:
Maternal grandfather with cancer of the larynx.
Maternal great-grandmother with breast cancer. Multiple family
members with heart disease.
Physical Exam:
ON ADMISSION
VITALS: Reviewed in metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple
LUNGS: decreased BS at LUL, diffuse crackles/poor air flow
bilaterally
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, no edema
ON DISCHARGE:
HEENT: NC/AT, EOMI, no oral lesions
CARDIAC: RRR, no murmurs appreciated
LUNG: mild inspiratory crackles bilaterally, no increased work
of
breathing.
ABD: Soft, nontender, nondistended, BS+
EXT: Warm, well perfused, no lower extremity edema
NEURO: A&Ox3, CN2-12 intact
SKIN: No significant rashes, bandage over prior R. IJ site c/d/i
ACCESS: Left chest wall port.
Pertinent Results:
======================
Admission labs:
======================
___ 07:33PM URINE RBC-4* WBC-10* BACTERIA-NONE YEAST-NONE
EPI-<1
___ 03:45PM PO2-51* PCO2-32* PH-7.51* TOTAL CO2-26 BASE
XS-2 COMMENTS-PORT
___ 03:45PM LACTATE-1.2
___ 03:37PM cTropnT-<0.01
___ 03:31PM GLUCOSE-139* UREA N-11 CREAT-0.6 SODIUM-126*
POTASSIUM-4.5 CHLORIDE-87* TOTAL CO2-22 ANION GAP-17
___ 03:31PM WBC-17.1* RBC-3.37* HGB-10.3* HCT-30.6*
MCV-91 MCH-30.6 MCHC-33.7 RDW-14.8 RDWSD-48.5*
___ 03:31PM NEUTS-79.8* LYMPHS-6.3* MONOS-12.4 EOS-0.2*
BASOS-0.5 IM ___ AbsNeut-13.67* AbsLymp-1.08*
AbsMono-2.12* AbsEos-0.03* AbsBaso-0.09*
___ 03:31PM PLT SMR-HIGH* PLT COUNT-520*
___ 03:31PM ___ PTT-26.8 ___
======================
Dicharge labs:
======================
___ 06:14AM BLOOD WBC-8.5 RBC-2.37* Hgb-7.5* Hct-23.2*
MCV-98 MCH-31.6 MCHC-32.3 RDW-19.1* RDWSD-67.7* Plt ___
___ 06:14AM BLOOD Plt ___
___ 06:14AM BLOOD Glucose-78 UreaN-15 Creat-0.7 Na-136
K-4.1 Cl-95* HCO3-30 AnGap-11
___ 06:14AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.1
Other relevant labs:
___ 05:33AM BLOOD calTIBC-272 Ferritn-730* TRF-209
___ 05:33AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1 Iron-67
=====================
IMAGING:
=====================
CTA chest ___: 1. No evidence of pulmonary embolism.
2. Confluent regions of consolidation in the lungs bilaterally,
more extensive
on the left than on the right as above worrisome for multifocal
pneumonia.
3. Small left pleural effusion.
4. Innumerable bilateral cavitary lung lesions as seen
previously worrisome
for cavitary lung metastases without definite new lesion noting
that
significant portion of the lung is obscured by consolidation.
CHEST PORT LINE PLACEMENT ___
Status post endotracheal intubation, orogastric tube placement,
and placement of right internal central jugular venous catheter.
Unchanged multifocal opacities suggesting widespread pneumonia.
CXR ___
Consolidation in the left lung appears to have progressed since
two days
prior.
CXR ___
ET tube remains in place. Enteric tube passes below the
diaphragm with tip in the stomach. Overall, there is been no
interval change from exam performed earlier the same day.
CXR ___
No significant interval change.
CXR ___
IMPRESSION:
ET tube tip is 6 cm above the carina. NG tube tip is in the
stomach. Right internal jugular line tip is at the level of
lower SVC. Port-A-Cath catheter tip is at the level of the
proximal right atrium. There is minimal interval additional
progression and left middle lower lung consolidations and right
widespread parenchymal opacities compared to previous
examination. No interval increase in pleural effusion. No
pneumothorax.
TTE ___: IMPRESSION: Mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function. Normal right ventricular cavity size and systolic
function. Borderline mild aortic valve stenosis. At least
moderate aortic regurgitation. Mild tricuspid regurgitation.
Mild pulmonary artery systolic hypertension. Liver cysts
visible, clinical correlation suggested.
CT CHEST w/ contrast ___
IMPRESSION:
Improving multifocal bilateral consolidative opacities
consistent with
resolving pneumonia. Stable small left pleural effusion.
Numerous bilateral pulmonary metastasis with evidence of
cavitation.
CXR ___
IMPRESSION:
Comparison to ___. The lung volumes have minimally
increased,
potentially reflecting improved ventilation. These increase is
more obvious on the right and on the left. However, the very
extensive bilateral parenchymal opacities, left more than right,
are not substantially changed in extent and severity. Stable
position of the monitoring and support devices.
CXR ___
IMPRESSION:
Compared to chest radiographs ___ through ___.
Predominantly interstitial abnormality right lung mildly
worsened since ___. More severe infiltrative process in the
left lung improved since ___, unchanged since ___,
includes a component of volume loss explaining leftward
mediastinal shift. Small left pleural effusion is
underestimated on the conventional radiograph. No pneumothorax.
Indwelling cardiopulmonary support devices in standard
placements.
CHEST PORT LINE PLACEMENT ___
IMPRESSION:
Compared to chest radiographs ___ through ___.
Component of acute pulmonary edema has almost resolved from the
right lung. Severe infiltration on the left has not changed.
Pleural effusions small on the left if any. No pneumothorax.
Heart is not enlarged but the borders are obscured by severe
parenchymal abnormality in the left lung.
ET tube in standard placement. Right jugular line and left
supraclavicular
central venous infusion catheter both end in the low SVC.
Nasogastric
drainage tube passes below the diaphragm and out of view.
CT Chest ___
Continued improvement in previously severe predominantly
left-sided pneumonia, initially dense consolidation on ___,
improved to generally ground-glass involvement on ___.
Progressive, severe interstitial abnormality, also left greater
than right is probably an organizing phase of the previous
insult, and is more typical of drug-induced reaction than
infection. Lymphangitic carcinomatosis is less likely.
Multiple cavitary pulmonary metastases right lung. Residual and
residual left suprahilar mass unchanged since ___. Small to
moderate left pleural effusion is smaller, probably layering.
CXR ___
IMPRESSION:
No significant interval change since the chest radiograph dated
___.
=========================
MICRO:
=========================
___ 3:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:31 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:33 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 11:50 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 8:14 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:06 pm BLOOD CULTURE Source: Line-port.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:18 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 5:29 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
___ 1:20 pm BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE #1 LINGULA.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 1:22 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE
#2.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
Immunofluorescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 1:22 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE
#2.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
___ 1:22 pm Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE #2.
**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 ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions..
Recommend new sample be submitted for confirmation..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Reported to and read back by ___ ___ AT 11:04A.
___ 1:22 pm Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE #2.
**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 ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions..
Recommend new sample be submitted for confirmation..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Reported to and read back by ___ ___ AT 11:04A.
___ 1:05 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 4:50 pm BLOOD CULTURE Source: Line-RIJ.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:00 pm BLOOD CULTURE Source: Line-port 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
====================
REPORTS:
====================
BRONCHIAL LAVAGE ___
ATYPICAL.
- Rare degenerated atypical epithelial cells in a background of
pulmonary macrophages, bronchial epithelial cells, and mucin.
BRONCHIAL LAVAGE ___
NEGATIVE FOR MALIGNANT CELLS.
- Pulmonary macrophages, bronchial epithelial cells, and mucin.
Medications on Admission:
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Dexamethasone 4 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Lidocaine-Prilocaine 1 Appl TP PRN prior to port access
6. Simvastatin 10 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 70 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 70 mg SC every twelve (12) hours
Disp #*60 Syringe Refills:*0
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN dyspnea
RX *hydromorphone 2 mg 1 tablet(s) by mouth q4h prn Disp #*12
Tablet Refills:*0
4. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Pantoprazole 40 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. PredniSONE 80 mg PO DAILY
10. Senna 8.6 mg PO DAILY
11. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Aspirin 81 mg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Levothyroxine Sodium 100 mcg PO DAILY
16. Ondansetron 8 mg PO Q8H:PRN nausea
17. Prochlorperazine 10 mg PO Q6H:PRN nausea
18. Simvastatin 10 mg PO QPM
19. Vitamin D ___ UNIT PO DAILY
20. HELD- Dexamethasone 4 mg PO DAILY This medication was held.
Do not restart Dexamethasone until you follow-up with your
Oncologist.
21. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until you f/u with your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Drug induced pneumonitis
Acute Hypoxic Respiratory Failure
Secondary:
Anxiety
Pulmonary Embolism
Metastatic Lung Adenocarcinoma
Steroid-Induced Hyperglycemia
Hyponatremia
Leukocytosis
Anemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypoxia// pneumonia, pulm edema
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Left-sided Port-A-Cath tip terminates in the low SVC. Cardiac silhouette size
is not engorged. Dense atherosclerotic calcifications are seen at the
thoracic aortic arch. Ill-defined left perihilar opacity likely correlates
with the known dominant mass. Increased consolidative opacification is seen
in the left lung base. Diffuse cavitary nodular opacities throughout the
lungs are also re-demonstrated, better assessed on prior CT. A probable small
left pleural effusion is likely present. No pneumothorax. Increased
interstitial opacities in the left lung may reflect lymphangitic spread of
tumor. No acute osseous abnormalities present.
IMPRESSION:
1. Increased consolidative opacity within the left lung base concerning for
pneumonia.
2. Diffuse metastatic nodules, many which are cavitary, and dominant left
perihilar mass are re-demonstrated and better assessed on prior CT.
3. Probable small left pleural effusion.
Radiology Report
EXAMINATION: Chest CTA.
INDICATION: ___ with hypoxia, dyspnea. Evaluate for PE or 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 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
3) Spiral Acquisition 7.7 s, 29.5 cm; CTDIvol = 7.3 mGy (Body) DLP = 203.9
mGy-cm.
Total DLP (Body) = 217 mGy-cm.
COMPARISON: Chest CT from ___.
FINDINGS:
HEART AND VASCULATURE: The pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
Scattered atherosclerotic calcifications are seen in the aorta. Otherwise,
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. The tip of the left
Port-A-Cath terminates in the right atrium.
AXILLA, HILA, AND MEDIASTINUM: Prominent paratracheal lymph nodes are present,
not meeting CT criteria for lymphadenopathy. There is left hilar mass
measuring 3.3 x 2.8 cm, similar in size and appearance to the previous study.
PLEURAL SPACES: Small bilateral pleural effusions, greater on the left.
LUNGS/AIRWAYS: Bilateral scattered patchy consolidations involving all lobes
in both lungs are demonstrated, most confluent in the left lower lobe and in
the left upper lobe but also seen in the right upper/middle lobes as well. In
addition, multiple small cavitary lung nodules are seen throughout both lung
fields. There is no convincing evidence for new pulmonary nodule/cavitation,
previously characterized as cavitary metastatic disease noting that underlying
progression could be obscured by new areas of consolidation. 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: A 3.9 x 3.6 cm hypodensity is seen in the left lobe of the liver,
largely unchanged. Otherwise, the included portion of the upper abdomen is
unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Postoperative changes at the lateral aspect of the right breast are similar
compared to prior.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Confluent regions of consolidation in the lungs bilaterally, more extensive
on the left than on the right as above worrisome for multifocal pneumonia.
3. Small left pleural effusion.
4. Innumerable bilateral cavitary lung lesions as seen previously worrisome
for cavitary lung metastases without definite new lesion noting that
significant portion of the lung is obscured by consolidation.
Radiology Report
INDICATION: ___ year old woman with pneumonia/pneumonitis, worsening O2
requirement in MICU// ___ year old woman with pneumonia/pneumonitis, worsening
O2 requirement in MICU
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray and chest CT from ___.
FINDINGS:
Bilateral regions of consolidation which are more confluent on the left are
again noted with interval progression at the left upper lung. Less confluent
consolidation persists on the right as well not significantly changed.
Cardiac silhouette cannot be assessed.
IMPRESSION:
Consolidation in the left lung appears to have progressed since two days
prior.
Radiology Report
INDICATION: ___ year old woman now intubated with OG tube, confirm position//
___ year old woman now intubated with OG tube, confirm position
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from earlier on ___ at 04:27.
FINDINGS:
ET tube remains in place. Enteric tube passes below the diaphragm with tip in
the stomach. Overall, there is been no interval change from exam performed
earlier the same day.
Radiology Report
EXAMINATION: Chest radiograph, portable AP semi-upright view.
INDICATION: ___ year old woman with new R IJ CVL placed// R IJ placement
Contact name: ___ Resident, ___: ___
COMPARISON: Earlier on the same day.
FINDINGS:
Patient has been intubated. Endotracheal tube terminates about 5 cm above the
carina. Orogastric tube heads into the stomach, its inferior extent not
imaged. A new right internal jugular central venous catheter terminates at
the cavoatrial junction. Pre-existing Port-A-Cath terminating shortly below
the right cavoatrial junction appears unchanged. Cardiac, mediastinal and
hilar contours are partly obscured but show no definite change. Dense
heterogeneous opacities involving the left mid to lower lung show no
short-term change. More scattered but widespread opacities in the right lung
and at the left lung apex are also unchanged. There is thickening of the
upper pleural surface which is suspected to represent part of a small pleural
effusion. There is no pneumothorax.
IMPRESSION:
Status post endotracheal intubation, orogastric tube placement, and placement
of right internal central jugular venous catheter. Unchanged multifocal
opacities suggesting widespread pneumonia.
Radiology Report
INDICATION: ___ year old woman with respiratory failure// Improvement compared
to prior?
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-rays over the past few days most recently from ___.
FINDINGS:
When compared to previous exam, there has been no significant interval change.
Bilateral parenchymal opacities which are more confluent on the left are
essentially unchanged. Support lines and tubes remain in place.
IMPRESSION:
No significant interval change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old female with history of breast cancer stage 1,
hypertension, HLD and hypothyroidism, recently diagnosed Stage 4 metastatic
lung adenocarcinoma on palliative chemo presenting with fevers, acute on
chronic dyspnea on exertion, cough, found to be in hypoxic respiratory failure
___ multifocal pneumonia.// please evaluate ET tube placement please
evaluate ET tube placement
IMPRESSION:
ET tube tip is 6 cm above the carina. NG tube tip is in the stomach. Right
internal jugular line tip is at the level of lower SVC. Port-A-Cath catheter
tip is at the level of the proximal right atrium. There is minimal interval
additional progression and left middle lower lung consolidations and right
widespread parenchymal opacities compared to previous examination. No
interval increase in pleural effusion. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old female with history of breast cancer stage 1,
hypertension, HLD and hypothyroidism, recently diagnosed Stage 4 metastatic
lung adenocarcinoma on palliative chemo presenting with fevers, acute on
chronic dyspnea on exertion, cough, found to be in hypoxic respiratory failure
___ pembolizumab associated pneumonitis// New findings contributing to
hypoxia? New findings contributing to hypoxia?
IMPRESSION:
Comparison to ___. The lung volumes have minimally increased,
potentially reflecting improved ventilation. These increase is more obvious
on the right and on the left. However, the very extensive bilateral
parenchymal opacities, left more than right, are not substantially changed in
extent and severity. Stable position of the monitoring and support devices.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman history of metastatic lung Ca intubated with
worsening hypoxia concerning for chemo induced pneumonitis vs pulmonary edema
vs PNA.// Comparison to prior film. Is there worsening of consolidation?
Comparison to prior film. Is there worsening of consolidation?
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions. Axial sagittal and coronal images were acquired.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.6 s, 34.9 cm; CTDIvol = 6.9 mGy (Body) DLP = 243.4
mGy-cm.
Total DLP (Body) = 243 mGy-cm.
COMPARISON: To a prior study done on ___
FINDINGS:
THORACIC INLET: Thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes. Left-sided central line projects to the right
atrium. The ET and NG tube are in acceptable position.
BREAST AND AXILLA : There are no enlarged axillary lymph nodes.
MEDIASTINUM: Small mediastinal and bilateral hilar lymph nodes are unchanged.
Aorta and pulmonary artery normal in caliber. There is mild cardiomegaly.
There is no pericardial effusion.
PLEURA: The left pleural effusion is small but unchanged. Trace right pleural
effusion is also stable.
LUNG: Previously visualized dense consolidative opacities bilaterally have
decreased in density but remain similar in extent. Multiple bilateral
cavitary lesions consistent with known metastasis are again seen. There is a
small left apical pneumothorax now seen. No new consolidations. There is
bibasilar atelectasis.
BONES AND CHEST WALL : Review of bones is unremarkable.
UPPER ABDOMEN: Limited sections through the upper abdomen shows a large
hypodense lesion in the left lobe of liver which could represent cyst. There
are gallstones. No adrenal masses are seen
IMPRESSION:
Improving multifocal bilateral consolidative opacities consistent with
resolving pneumonia.
Stable small left pleural effusion.
Numerous bilateral pulmonary metastasis with evidence of cavitation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pembrolizulmab pneumonitis// please
evaluate daily ET tube placement and lung fields please evaluate daily ET
tube placement and lung fields
IMPRESSION:
Compared to chest radiographs ___ through ___.
Predominantly interstitial abnormality right lung mildly worsened since ___. More severe infiltrative process in the left lung improved since ___,
unchanged since ___, includes a component of volume loss explaining
leftward mediastinal shift. Small left pleural effusion is underestimated on
the conventional radiograph. No pneumothorax.
Indwelling cardiopulmonary support devices in standard placements.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ y/o F with breast cancer stage 1, hypertension, HLD and
hypothyroidism, recently diagnosed Stage 4 metastatic lung adenocarcinoma on
palliative chemo and pneumonitis// ET tube position ET tube position
IMPRESSION:
Compared to chest radiographs ___ through ___.
Component of acute pulmonary edema has almost resolved from the right lung.
Severe infiltration on the left has not changed.
Pleural effusions small on the left if any. No pneumothorax. Heart is not
enlarged but the borders are obscured by severe parenchymal abnormality in the
left lung.
ET tube in standard placement. Right jugular line and left supraclavicular
central venous infusion catheter both end in the low SVC. Nasogastric
drainage tube passes below the diaphragm and out of view.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old female with history of breast cancer stage 1,
hypertension, HLD and hypothyroidism, recently diagnosed Stage 4 metastatic
lung adenocarcinoma on palliative chemo presenting with fevers, acute on
chronic dyspnea on exertion, cough, found to be in hypoxic respiratory failure
___ pembolizumab associated pneumonitis// Any changes s/p IVIG x5 days? Any
consolidation? (uptrending leuk)
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 32.4 cm; CTDIvol = 8.0 mGy (Body) DLP = 252.8
mGy-cm.
2) Spiral Acquisition 1.2 s, 7.9 cm; CTDIvol = 8.0 mGy (Body) DLP = 57.8
mGy-cm.
Total DLP (Body) = 311 mGy-cm.
COMPARISON: Chest CT ___. Read in conjunction with
conventional chest radiographs, ___.
FINDINGS:
CHEST PERIMETER: No thyroid lesions warrant further imaging. Supraclavicular
and axillary lymph nodes are not enlarged. Evaluation of the breasts is
reserved for mammography. There is no soft tissue abnormality in the imaged
chest wall concerning for malignancy. This study is not appropriate for
subdiaphragmatic diagnosis, but shows no adrenal mass. Large calcified
gallstone is noted but not fully evaluated.
CARDIO-MEDIASTINUM:Esophagus is unremarkable. Atherosclerotic calcification
is mild to moderate in the head and neck vessels and scattered in coronary
arteries. Central venous infusion catheter ends in the right atrium. Aorta
and pulmonary arteries are normal size. Aortic valvular calcification is
moderately severe and could be hemodynamically significant. Pericardium is
physiologic.
THORACIC LYMPH NODES: Thoracic lymph nodes, are not enlarged in the
mediastinum. Right hilar nodes cannot be assessed. Left hilum is normal
size.
LUNGS, AIRWAYS, PLEURAE: Multifocal ground-glass opacification in both lungs
has improved in both severity and extent. It is still more pronounced in the
left lung than the right, but has improved in both.
Suprahilar residual left suprahilar mass is unchanged. Severe interstitial
reticulation in the left lung could be due to tumor infiltration, but I think
it is probably rapidly developing interstitial phase of the previously severe
consolidative and then and ground-glass pneumonia in the left lung.
Multiple cavitary pulmonary metastases are seen throughout the right lung.
Small nonhemorrhagic left pleural effusion is smaller, still dependent. No
pleural effusion no right pleural effusion.
CHEST CAGE: No pathological compression fractures or large destructive bone
lesions. Although there are no bone lesions in the imaged chest cage
suspicious for malignancy or infection, it should be noted that radionuclide
bone and FDG PET scanning are more sensitive in detecting early osseous
pathology than chest CT scanning.
IMPRESSION:
Continued improvement in previously severe predominantly left-sided pneumonia,
initially dense consolidation on ___, improved to generally ground-glass
involvement on ___. Progressive, severe interstitial abnormality, also
left greater than right is probably an organizing phase of the previous
insult, and is more typical of drug-induced reaction than infection.
Lymphangitic carcinomatosis is less likely.
Multiple cavitary pulmonary metastases right lung. Residual and residual left
suprahilar mass unchanged since ___. Small to moderate left pleural
effusion is smaller, probably layering.
Radiology Report
INDICATION: ___ year old woman with pembrolizumab pneumonitis// monitor
pneumonitis
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT chest dated ___ chest radiograph dated ___
FINDINGS:
The tip of a left chest wall Port-A-Cath projects over the right atrium.
There is no significant interval change in the appearance of the lungs
including reticular prominence and consolidative opacities in the left lung.
The appearance of the right lung is also unchanged. Multiple cavitary
metastases were better evaluated on the recent CT chest. There is no
pneumothorax or pleural effusion. The size and appearance of the
cardiomediastinal silhouette is unchanged including left hilar prominence.
IMPRESSION:
No significant interval change since the chest radiograph dated ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chills, Dyspnea, Fever
Diagnosed with Pneumonia, unspecified organism
temperature: 102.2
heartrate: 109.0
resprate: 18.0
o2sat: 83.0
sbp: 131.0
dbp: 47.0
level of pain: 0
level of acuity: 2.0 | SUMMARY:
___ female with history of breast cancer, hypertension, HLD,
hypothyroidism, now recently diagnosed with metastatic lung
adenocarcinoma, on palliative chemotherapy, presented with
fevers and acute on chronic dyspnea on exertion. Imaging on
admission notable for extensive consolidation consistent with
multifocal pneumonia superimposed on underlying malignancy. She
was started on broad antibiotics. She was admitted to ICU for
hypoxic respiratory failure and intubated ___. Infectious workup
was unrevealing. CT showed pulmonary embolisms for which she was
started on heparin and ultimately lovenox. Her respiratory
failure was attributed to penbrolizumab induced pneumonitis. She
was treated with high dose steroids and IVIG with improvement,
and was extubated on ___ and weaned to nasal cannula. She had
persistent dyspnea on exertion and desaturations but her
respiratory status was improving by time of discharge. She was
discharged on prednisone 80mg with plan for long steroid taper. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ who experienced a mechanical fall while showering this
morning. She fell backwards and struck her head, but was able
to crawl over to the "help cord" in her assisted living
residence. Denies LOC. Only complains of right elbow pain.
Past Medical History:
HTN, osteoporosis, GERD, hard of hearing
PSH: Left hip replacement, ?liver cyst removal
Social History:
___
Family History:
NC
Physical Exam:
Admission exam:
98.2 88 136/74 16 96% on 2L
Gen: no distress, A&O x 3, GCS 15
HEENT: PERLA, EOMI, anicteric, no lesions on head, b/l tympanic
membranes clear, oropharynx clear
CHEST: RRR, lungs clear, no abrasions
Abd: soft, nontender, nondistended, well healed midline and
right
paramedian incisions
Ext: MAEW, palpable pulses, abrasion to left lateral lower leg,
no edema, chronic venous stasis changes
Pertinent Results:
___ 10:30AM BLOOD WBC-9.2 RBC-4.54 Hgb-13.4 Hct-39.7 MCV-87
MCH-29.4 MCHC-33.7 RDW-13.6 Plt ___
___ 10:30AM BLOOD Glucose-98 UreaN-23* Creat-0.7 Na-135
K-3.8 Cl-98 HCO3-25 AnGap-16
___: Elbow x-ray: IMPRESSION: Acute fracture through the
olecranon process with associated elbow joint effusion.
Pelvis X-ray: IMPRESSION: No acute fractures.
Outside hospital: HCT with R subdural hemorrhage
Medications on Admission:
diovan 320', prilosec 20', norvasc 10', fosamax 70 qweekly,
fluticasone nasal spray
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*15
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R SDH
R olecranon fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity status: ambulatory- independent
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___.
HISTORY: ___ female, fall on right elbow with low back pain.
Question pneumonia.
FINDINGS: Single supine AP view of the chest. No prior. There are increased
interstitial markings throughout the lungs, which could reflect chronic
underlying interstitial process. There is more dense consolidation with
irregularity identified at the right lung base medially overlying the cardiac
silhouette. Elsewhere, the lungs are clear of confluent consolidation.
Cardiac silhouette is enlarged, potentially accentuated by positioning and
technique. Degenerative changes are noted at the shoulders bilaterally. No
other definite displaced fracture is identified. Degenerative changes noted
in the upper lumbar spine.
IMPRESSION: Increased interstitial markings at the lungs, potentially in part
due to technique with possible chronic underlying parenchymal disease. Region
of increased opacity at the right lung base medially for which dedicated
two-view chest x-ray suggested to further characterize.
Radiology Report
RIGHT ELBOW, THREE VIEWS: ___.
HISTORY: ___ female with fall on right elbow.
FINDINGS: AP, lateral, and oblique views of the right elbow. No prior.
There is an acute fracture identified through the olecranon process of the
ulna. There is no significant displacement or angulation. There is a large
associated elbow joint effusion. Elsewhere, osseous structures are intact
without evidence of other fracture.
IMPRESSION: Acute fracture through the olecranon process with associated
elbow joint effusion.
Radiology Report
HISTORY: ___ female with fall on the right elbow and low back pain.
Evaluate for fracture.
COMPARISON: None.
TECHNIQUE: Single AP view of the pelvis along with one single view of the
left hip.
FINDINGS: A left-sided total hip replacement is in place with no evidence of
hardware complications or ___ lucencies. Vascular calcifications
are noted throughout the leg. Degenerative changes are seen in the lower
lumbar spine as well as the right hip with joint space narrowing and increased
sclerosis. An apparent increased sclerosis of the right hemipelvis could be
due to overlying soft tissues. No acute fractures or dislocations are
identified.
IMPRESSION: No acute fractures.
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: Followup right basilar opacity on portable exam.
FINDINGS: AP and lateral views of the chest are compared to portable film
from earlier the same day. Right basilar opacity on this two-view exam is
less conspicuous. There is, however, mildly increased density in this region
likely due to costochondral calcifications superimposed on probable bibasilar
bronchiectasis/scarring. Lungs are clear of large confluent consolidation.
There is no definite pulmonary vascular congestion. Cardiac silhouette is
slightly enlarged. Lower thoracic/upper lumbar compression deformity is
suspected due to acute kyphosis in this region. However, cortical margins are
difficult to delineate given osteopenia and overlying diaphragmatic contours.
IMPRESSION: No definite acute cardiopulmonary process. Right basilar opacity
on portable x-ray likely due to confluence of shadows from costochondral
calcifications and suspected bibasilar scarring and bronchiectasis. Suspected
___ thoracic/lumbar compression deformity, age indeterminate without prior.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with TRAUMATIC SUBDURAL HEM, FX OLECRAN PROC ULNA-CL, UNSPECIFIED FALL, CAD UNSPEC VESSEL, NATIVE OR GRAFT, HYPERTENSION NOS
temperature: 98.2
heartrate: 88.0
resprate: 16.0
o2sat: 96.0
sbp: 136.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ was admitted to the ___ service for her injuries.
Orthopedic surgery was consulted and placed her R elbow in a
splint. She is to follow-up with them in 2 weeks in clinic.
Neurosurgery was consulted for her SDH. Her neurological exam
remained stable and no further imaging was performed. She
remained hemodynamically stable. She was given a regular diet,
which she tolerated. She worked with physical therapy and
occupational therapy. She voided without difficulty. She was
ready for discharge to her assisted living facility with
services on HD3. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o dementia, aortic stenosis on plavix, and hypertension
who sustained a fall at her nursing home. The patient was taking
a shower with the help of an aide when she fell face forward
while attempting to pick up a bar of soap. She struck her face
and per the aide who witnessed her fall did not have any loss of
conciousness or change in mental status after the fall. She did
have signs of facial trauma and was taken to ___ for
evaluation. There, her workup showed a left sided sub-dural
hematoma, left posterior intra-parenchimal hemorrhage, and
interpeduncular subarachnoid hemorrhage. She was neurologically
at her baseline of dementia oriented to self only and was having
a laceration on her lip sutured when she began vomiting what
appeared to be old blood. She then had a decline in her
respiratory status and was intubated for airway protection. She
was then transferred to ___ for further management. Upon
arrival she was intubated, sedated, and had visible diffuse
facial ecchymosis and a lip laceration.
Past Medical History:
HTN, aortic stenosis, dementia, hypothyroid
PSH: hemmorhoidectomy
Social History:
___
Family History:
___
Physical Exam:
Upon admission,
HR: 72 Resp: 18 O(2)Sat: 100 Normal
Constitutional: Sedated
HEENT: Large contusion to brow line, periorbital ecchymosis,
pupils are 3mm b/l are reactive to light 7.5 ETT, 20 @ lip.
c-collar in place. Lip laceration
sutured.
Chest: Equal b/l breath sounds.
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds
Abdominal: Nondistended, Soft
Extr/Back: Multiple areas of ecchymosis over LUE.
Skin: Warm and dry
Neuro: intubated
On discharge,
VS: 98.8 79 157/93 18 98% (2L NC)
Constitutional: well-appearing, in no acute distress
HEENT: Diffuse bruises on face and scalp
Cardiopulmonary: RRR, normal S1 and S2, systolic aortic murmur,
bilateral base crackles. In no respiratory distress
Abdomen: Soft, non-tender, non-distended
Neurologic: AAOx1, grossly intact
Pertinent Results:
___ 01:30PM WBC-9.2 RBC-3.45* HGB-11.0* HCT-35.0*
MCV-101* MCH-31.9 MCHC-31.5 RDW-12.8
___ 01:30PM NEUTS-81.4* LYMPHS-7.9* MONOS-10.1 EOS-0.3
BASOS-0.3
___ 01:30PM PLT COUNT-156
___ 01:30PM CALCIUM-6.9* PHOSPHATE-2.1* MAGNESIUM-1.8
___ 01:30PM GLUCOSE-121* UREA N-20 CREAT-0.6 SODIUM-142
POTASSIUM-4.0 CHLORIDE-112* TOTAL CO2-19* ANION GAP-15
___ 04:06PM O2 SAT-97
___ 07:40PM PLT COUNT-160
___ 07:40PM WBC-13.0* RBC-3.34* HGB-10.9* HCT-32.6*
MCV-98 MCH-32.7* MCHC-33.4 RDW-12.8
___ 07:40PM GLUCOSE-126* UREA N-20 CREAT-0.5 SODIUM-141
POTASSIUM-3.0* CHLORIDE-109* TOTAL CO2-22 ANION GAP-13
___ 07:45PM TYPE-ART PO2-154* PCO2-38 PH-7.40 TOTAL
CO2-24 BASE XS-0
Medications on Admission:
1. Simvastatin 10 mg PO DAILY
2. Furosemide 10 mg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. Aripiprazole 2 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Ciprofloxacin HCl 250 mg PO Q12H
7. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Simvastatin 10 mg PO DAILY
2. Furosemide 10 mg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. Aripiprazole 2 mg PO DAILY
5. Acetaminophen 1000 mg PO Q8H
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Ciprofloxacin HCl 250 mg PO Q12H
9. Losartan Potassium 50 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: extubation, rib fractures, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the monitoring and support
devices are unchanged. No change in appearance of the cardiac silhouette and
of the lung parenchyma, with exception of a minimal blunting of the left
costophrenic sinus. This, however, could be positional. The known right rib
fractures are less well seen than on the previous examination. No current
evidence for the presence of a pneumothorax.
Radiology Report
HISTORY: Fall and rib fractures.
COMPARISON: ___ through ___.
FINDINGS:
A single semi-upright portable chest radiograph was obtained. There is marked
enlargement of the mediastinal contours since the prior exam yesterday at
6:00. In particular of the ascending aorta is enlarged. There is also
enlargement of the aortic arch to a lesser extent. There are new bilateral
pleural effusions and right lower lobe consolidation. There is no
pneumothorax.
Impression
IMPRESSION:
Marked enlargement of the aortic contour, particularly the ascending aorta
over the last 24 hours. A CTA of the chest should be considered to exclude
acute aortic process.
Discussed with Dr ___ phone at approximately 0830 on ___.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Widening mediastinum on chest x-ray. Evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient is now less
rotated. Previously enlarged mediastinal and hilar structures on the right
appear again within normal range. Moderate middle and lower lobe collapse on
the right. Moderate cardiomegaly without evidence of overt pulmonary edema.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Right lower lobe collapse, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient is rotated.
There is, however, no relevant change. Moderate cardiomegaly with tortuosity
of the thoracic aorta. The tortuosity is exaggerated by the rightward
rotation of the patient. No pleural effusions. Mild fluid overload but no
overt pulmonary edema. No pneumonia. Mild right and left lower lobe
atelectasis are constant in appearance.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Line placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
right-sided PICC line. The course of the line is unremarkable, the tip of the
line projects over the mid SVC. There is no evidence of a complication,
notably no pneumothorax.
Lung volumes have increased, causing a further decrease in size and extent of
the pre-described right basilar opacity. Borderline size of the cardiac
silhouette. Tortuosity of the thoracic aorta.
Radiology Report
HISTORY: ___ female status post fall. Evaluate for pneumonia.
COMPARISON: Multiple prior examinations dated through ___.
FINDINGS:
Portable semi-erect radiograph demonstrates improved bilateral aeration.
There is continued vascular congestion that may be improved although this can
be secondarily related to improved aeration. There is bilateral basilar
atelectasis with a possible small left pleural effusion. No new focal
consolidation. No pneumothorax. The right-sided PICC is seen at the level of
the mid SVC.
IMPRESSION:
No pneumonia. Continued but improved vascular congestion possibly related to
better aeration.
Radiology Report
HISTORY: Intubated.
TECHNIQUE: Portable AP view of the chest.
COMPARISON: None. The patient is listed as EU critical at the time of study
interpretation.
FINDINGS:
Endotracheal tube tip terminates approximately 5.2 cm from the carina.
Enteric tube is noted with tip located within the stomach. The heart size is
top normal. The aorta is tortuous and diffusely calcified. Mediastinal and
hilar contours are otherwise unremarkable. There is no pulmonary vascular
congestion. No focal consolidation, pleural effusion or pneumothorax is
demonstrated. Acute fractures of the right ___ and ___ lateral ribs are
noted. Remote fracture of the left ___ lateral rib and ___ right posterior
rib are also demonstrated. Partially imaged is hardware within the right
humeral head.
IMPRESSION:
1. Standard positioning of the endotracheal and enteric tubes.
2. Right ___ and ___ acute lateral rib fractures.
Radiology Report
HISTORY: Fall from standing, subdural hematoma, and subarachnoid hemorrhage,
evaluate for extension of bleed.
TECHNIQUE: Contiguous axial MDCT images were obtained from the brain without
the administration of IV contrast material. Reformatted coronal and sagittal
and thin section bone algorithm reconstructed images were obtained.
COMPARISON: Non-enhanced CT of the head from ___ at 9:03 a.m. at
___ (patient's name is ___, but patient is currently
listed as EU Critical).
FINDINGS: There is interval increase in subarachnoid hemorrhage within the
prepontine and perimesencephalic cistern, now involving not only the
interpeduncular cistern (2:12), but also extending inferiorly into the
premedullary cistern and involving the crural cisterns bilaterally,
approaching the ambient cisterns (602b:36). There is small amount of
intraventricular hemorrhage seen within the bilateral occipital horns of the
lateral ventricles and fourth ventricle (2:8,15). There is no evidence of
hydrocephalus or interval change in ventricular size. A small subdural
layering hematoma along the left cerebellar tentorium is stable from prior
scan (601b:29). A 6-mm left occipital subarachnoid hemorrhage is also stable
in appearance (601b:83,2:16). Prominent ventricles and sulci are likely
secondary to age-related atrophy. There is no evidence of acute vascular
territorial infarction. There is preservation of normal gray-white matter
differentiation, and the basilar cisterns appear patent. No shift of midline
structures is seen. Please refer to the facial bone CT from earlier today for
detailed evaluation of facial fractures. The globes are intact.
IMPRESSION:
1. Interval enlargement of the subarachnoid hemorrhage involving the
perimesencephalic cistern, as well as the pre-pontine and pre-medullary
cisterns.
2. Small intraventricular hemorrhage within the bilateral occipital horns of
the lateral ventricles and fourth ventricle without evidence of hydrocephalus.
3. Stable 6 mm left occipital subarachnoid hemorrhage.
4. Stable small subdural hemorrhage layering along the left cerebellar
tentorium.
Radiology Report
HISTORY: Subdural hematoma and subarachnoid hemorrhage, evaluate for interval
change.
COMPARISON: Non-contrast head CT ___.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone algorithm images.
DLP: 1003.42 mGy-cm.
CTDIvol: 51.12 mGy.
FINDINGS:
CT HEAD WITHOUT CONTRAST: There is re-demonstration of subarachnoid
hemorrhage layering within the pre-pontine and perimesencephalic cistern,
unchanged from ___. Small amount of blood in the occipital horns of
the lateral ventricles and fourth ventricle is unchanged. Trace subdural
hematoma layering along the superior margin of the left tentorium cerebelli is
unchanged. A rounded focus of subarachnoid blood in a left medial occipital
sulcus is also unchanged. No new focus of hemorrhage is identified. There is
no edema, mass effect or evidence of a new large vascular territorial infarct.
Moderate cerebral atrophy with prominent ventricles and sulci is again seen.
Previously noted left maxillary alveolar ridge fracture is not fully included
in the field of view. There is mild right and moderate left ethmoid air cell
mucosal thickening, mild mucosal thickening or fluid in the inferior frontal
sinuses, and fluid within the sphenoid air cells, which may be related to
endotracheal and orogastric intubation. The mastoid air cells and middle ear
cavities are well aerated.
IMPRESSION: No change in intracranial hemorrhage compared to ___. No evidence of new intracranial abnormalities.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: S/P FALL HEADBLEED
Diagnosed with TRAUM SUBARACHNOID HEM, TRAUMATIC BRAIN HEM NEC, UNSPECIFIED FALL, TOOTH (BROKEN) (FRACTURED) (DUE TO TRAUMA), WITHOUT MENTION OF COMPLICATION, OPEN WOUND OF LIP, TETANUS TOXOID INOCULAT, FRACTURE ONE RIB-CLOSED
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mrs. ___ was admitted to our institution after being
transferred from an outside hospital where she was brought in by
ambulance after sustaining mechanical fall face forward while
showering. Reportedly, patient was intubated at OSH for airway
protection after an episode of bloody emesis. Upon arrival she
was sedated and had visible diffuse facial ecchymosis and a lip
laceration. Repeat imaging studies showed interval increase in
prepontine and interpeduncular subarachnoid hemorrhage tracking
inferiorly, and confirmed the presence of a small
intraventricular and a left subdural hemorrhage. Given findings,
the neurosurgery team was consulted and recommended conservative
management and monitoring for further interval changes. Patient
was thus admitted to the ___ for further care.
Regarding her facial injuries, the ___ team was consulted to
assess the lip laceration and dental injuries. Evaluation and
repair was initially difficult given the presence of an
endotracheal tube. A repeat head CT scan showed no interval
changes 24 hours later. Upon stabilization of her respiratory
status, patient was extubated on hospitalization day #1. A
tertiary survey revealed no further injuries. At this point,
___ was able to repair the lip laceration. There was avulsion
of tooth #9, as well as mild mobility in teeth #8 and 10. At
this point, decision was made not to place a dental splint given
time elapsed from injury and questioned benefit from it. She was
advised to stay on a full-liquid diet and follow-up with outside
dentist once medically stable for definitive care.
On hospitalization day #2 patient was started on ciprofloxacin
for a urinary tract infection (confirmed by urinalysis and
cultures positive for Klebsiella). Home medications were
restarted upon diet tolerance, except for Plavix, to be held for
one week post-injuries per neurosurgery recommendations. Given
favorable response, she was transferred to the floor on
hospitalization day #4. Foley catheter was then removed and
patient had several episodes of incontinence. Anticipating
discharge, physical therapy was consulted and determined need
for extensive ___ rehab. Case management was
involved in the rehab selection process.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. She was tolerating a full-liquids diet,
and pain was well controlled. The patient's family members and
aide received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Ace Inhibitors
Attending: ___
Chief Complaint:
TIA/stroke eval
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___
year-old right-handed obese ___ man with atrial fibrillation
(longstanding A/C, but subtherapeutic INR this past week & just
finished Lovenox bridge, now INR back up to 2.3), HTN, DM, HL,
?OSA, CKD-III (but no known Neurologic history). He was
transferred from a scheduled office visit to our ED today due to
his PCP's concern that he had a stroke or TIA yesterday. We
(Neurology) were consulted to evaluate after the ED got a story
of LUE weakness (since resolved) and found a facial droop on
exam.
Mr. ___ was in his USOH (with a couple exceptions, see
below) until yesterday around 2:30 pm. At that time, he was
awakened from a nap in his chair by the phone ringing. He
reached
out to grab it with is Left hand and realized he could not grasp
the receiver. This problem continued for the next half hour or
so, but within a few hours his hand was back to full strength.
He
does not recall numbness in his hand or face(the ED resident got
a history of F/A numbness, obtained from the same patient less
than an hour earlier). No symptoms in the Left leg at any time.
He doesn't think his speech was any different yesterday or today
than recently, but recently ___ months), he has noticed
intermittent difficulty finding his words. This has an episodic
character to it, and some friends have pointed it out to him.
Indeed, several times during our interview, the pt stopped
answering my questions for several seconds and looked down. He
denies any history of seizures. He has, however, noticed
intermittent twitching movements of his hands on and off over
the
past year or two (I think this is asterixis, see Exam).
He has been having difficulty walking recently due to a gout
flare in his Right knee, but the leg is not weak. He uses a cane
to walk during these flares, for help with pain, not for
imbalance or difficulty controlling his legs.
Review of Systems: negative except as above
No vision or hearing change. No diplopia. No vertigo. +_abit
lightheaded on standing. Denies difficulties comprehending
speech. Denies any current weakness, numbness, parasthesiae
(except yesterday). +pain in R knee (gout). No bowel or bladder
incontinence or retention. No recent fever or chills or recent
weight loss or gain (wants to lose weight, can't). Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Past Medical History:
1. IDDM (Lantus just incr to 20U at night, also on glipizide).
Does not know last A1c; PCP note says last was 7.8% in ___ and
then 10.8% last week at ___ on Januvia until stopping it
himself this year
2. HTN on ___
3. "Weakness of left side of body" ?today per PCP/Atrius
4. Neck pain on left side
5. Atrial fibrillation on warfarin (see above re. INR)
6. Hypercholesterolemia on high-dose Lipitor
7. Obstructive sleep apnea no CPAP, has daily somnolence and
dozed off on today's PCP visit and with me. Had to nap in ___'s
office before driving himself here.
8. CKD-III (baseline Cr 1.4-1.6), ___
9. obesity (BMI 43)
10. recent hosp at ___ (___) with BG in 500s, Cr 2.2,
cough, chills denies heart disease or prev neurologic dis incl
stroke, sz
Social History:
___
Family History:
per Atrius records noncontributory
Physical Exam:
ADMISSION PE:
Vitals: afebrile, VSS
General: Obese AAF. Lethargic, cooperative, NAD.
HEENT: Atraumatic. No scleral icterus. Mucous membranes are
moist. No lesions noted in oropharynx.
Neck: Supple, with full range of motion. No bruits.
Pulmonary: Lungs CTA bilateral bases. Non-labored.
Cardiac: RRR, S2 more prominent (distant HS), no loud M/R/G.
Abdomen: Obese; Soft, non-tender, and non-distended.
Extremities: Well-perfused, Bilateral mild pitting edema to
mid-shin bilaterally. Right knee is warm and mildly tender with
several ___ of CC effusion. (MTPs not warm/swollen/tender).
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Oriented to ___ (initially said ___, hospital,
thought
it was BWH. Despite lethargy and pauses in speech, he is
formally
attentive, and able to name ___ backward without difficulty.
Speech is mildly dysarthric, but comprehensible. Language is
fluent with intact repetition and comprehension, though he
paused
occasionally and looked down (always re-oriented and anwered my
questions when I asked a second time). Prosody is diminshed
(flat
affect). There were no paraphasic errors. Naming is intact to
both high and low frequency objects including knuckles, thumb,
ring, stethoscope, watch (not face or clasp). Calculation
impaired -- 8 quarters in 1.75, but correctly answers $0.68 to
1.00-0.32). There was no evidence of apraxia or neglect or
ideomotor apraxia; the patient was able to reproduce and
recognize hammering a nail and brushing teeth with both hands.
There was no evidence of left-right confusion.
-Cranial Nerves:
II: PERRL. Visual fields are FTC.
III, IV, VI: EOMs full and conjugate; no nystagmus.
V: Facial sensation intact and subjectively symmetric to pin
V1-V2-V3.
VII: Left nasolabial fold flattened at rest (pt's daughter says
this is new since she last saw him). Full, symmetric facial
elevation with smile, no lag on left that I can appreciate. Brow
elevation is symmetric. Eye closure is strong and symmetric. No
ptosis.
VIII: Hearing intact and subjectively equal.
IX, X: Palate elevates symmetrically with phonation.
XI: ___ equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline.
-Motor:
Moderate asterixis, bilateral hands; pt says this is the
"twitching" in his hands from the past couple years. No overt
drift, but possibly subtle on left (thought pt unable to fully
supinate bilaterally either hand). Normal muscle bulk and tone.
Delt Bic Tri WE FF FE IOs | IP Q Ham TA ___
L ___ ___ 5 5 5* 5 5 5 5
R ___ ___ 5 5 5 5 5 5 5
* pain-limited, but seems briefly strong
-Sensory:
No deficits to pinprick in any extremity. Joint position sense
is
normal in both lower extremities (great toes). Eyes-closed
Finger-to-nose testing revealed no proprioceptive deficit (did
not miss nose).
Cortical sensory testing: No agraphesthesia. No extinction to
DSS.
-Reflexes (left; right):
Biceps (++;++)
Triceps (+;+)
Brachioradialis (+;+)
Quadriceps / patellar (++;++)
___ / achilles (+;+)
Plantar response was flexor bilaterally.
-Coordination:
Finger-nose-finger testing and heel-knee-shin testing with no
dysmetria or intention tremor. No dysdiadochokinesia noted on
rapid-alternating movements (maybe slight on the left; but not
clearly different from right). No orbiting.
-Gait:
Stands without difficulty. Uses cane and has antalgic gait he
blames on Right knee pain. Good initiation. Narrow-based, normal
stride. Turns quickly. Romberg absent; pt c/o lightheadedness.
DISCHARGE PE:
Vitals: afebrile, VSS
General: Obese AAF. Alert, conversant, cooperative, NAD.
HEENT: Atraumatic. No scleral icterus, but with scleral pigment.
Mucous membranes are moist. No lesions noted in oropharynx.
Neck: Supple, with full range of motion. No bruits.
Pulmonary: Lungs CTA bilateral bases. Non-labored while upright
but has mild SOB with lying down (likely ___ central obesity)
Cardiac: RRR, (distant HS), no loud M/R/G apprecitaed
Abdomen: Obese; Soft, non-tender, and normal bowel sounds.
Extremities: Well-perfused, Bilateral mild pitting edema to
mid-shin bilaterally. Right knee is warm and mildly tender.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status: Alert and orienter to person place and time (but
intiall said it was ___, then corrected self). Attentive,
says ___ backwards well. Speech is easily comprehensible and
does not appear dysarthric but difficult to assess subtle
dysarthria given ___-Creole accent. Language is fluient with
intact repetition, nameing, and comprehension, without pauses or
stutter. Mildly flat affect persists. No paraphasic erros.
Has difficulty with calculations (5 quarters is $1.50, there are
7 quarters in $2, etc). No evidence of apracia or neglect, no
left-right confusion.
-Cranial Nerves:
II: PERRL. Visual fields are FTC. Cannot assess fundi ___ small
pupils and light sensitivity.
III, IV, VI: EOMs full and conjugate; no nystagmus.
V: Facial sensation intact and subjectively symmetric.
VII: Left nasolabial fold flattened at rest. Full, symmetric
facial elevation with smile, no lag on left compared to right.
Brow elevation is symmetric. Eye closure is strong and
symmetric. No ptosis.
VIII: Hearing intact and subjectively equal.
IX, X: Palate elevates symmetrically.
XI: ___ equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline.
-Motor:
Moderate asterixis, bilateral hands, may be mild intention
tremor with activation. No pronator drift. Normal muscle bulk
and tone.
Delt Bic Tri WE FF FE IOs IP Q Ham TA ___
L ___ ___ ___ 5 5 5 5
R ___ ___ ___ 5 5 5 5
* giveway weakness ___ pain, but seems initially strong
-Sensory:
No deficits to pinprick in any extremity. Joint position sense
is normal in both lower extremities. Eyes-closed Finger-to-nose
testing revealed no proprioceptive deficit.
-Reflexes: 2+ bilat biceps and patellar, 1+ bilateral triceps,
BR, and ankles, toes down-going bilaterally.
-Coordination:
Finger-nose-finger testing and heel-knee-shin testing with no
dysmetria or intention tremor. No dysdiadochokinesia noted on
rapid-alternating movements (but both movements are
slower/clumsier than one mgiht expect, but there is no assymetry
to this).
-Gait:
Stands without difficulty. Uses cane secondary to gout pain.
Good initiation. Narrow-based, normal stride. Turns quickly.
Romberg absent.
Pertinent Results:
___ 07:15AM BLOOD WBC-5.2 RBC-5.01 Hgb-15.4 Hct-47.1 MCV-94
MCH-30.7 MCHC-32.7 RDW-14.5 Plt ___
___ 05:58PM BLOOD WBC-5.9 RBC-5.21 Hgb-15.9 Hct-49.0 MCV-94
MCH-30.4 MCHC-32.3 RDW-14.2 Plt ___
___ 05:58PM BLOOD Neuts-49.1* ___ Monos-7.7 Eos-1.9
Baso-0.2
___ 07:15AM BLOOD ___ PTT-43.1* ___
___ 05:58PM BLOOD ___ PTT-49.1* ___
___ 07:15AM BLOOD Glucose-199* UreaN-29* Creat-2.0* Na-138
K-4.5 Cl-102 HCO3-26 AnGap-15
___ 05:58PM BLOOD Glucose-231* UreaN-29* Creat-2.1* Na-138
K-4.8 Cl-101 HCO3-26 AnGap-16
___ 07:15AM BLOOD ALT-32 AST-25 AlkPhos-140* TotBili-0.4
___ 05:58PM BLOOD ALT-33 AST-18 AlkPhos-141* TotBili-0.4
___ 07:15AM BLOOD Albumin-3.7 Calcium-8.6 Phos-4.1 Mg-1.7
Cholest-PND
___ 08:30AM BLOOD %HbA1c-11.0* eAG-269*
___ 07:15AM BLOOD Triglyc-PND HDL-PND
___ 07:15AM BLOOD TSH-PND
___ 05:58PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:01PM BLOOD ___ pO2-39* pCO2-52* pH-7.33*
calTCO2-29 Base XS-0
___ 06:01PM BLOOD Lactate-0.9
PENDING AT THE TIME OF DISCHARGE: Fasting lipid panel, TSH.
Medications on Admission:
1. Ambien 5 mg Tab Oral ___ Tablet(s) , at bedtime, as needed
2. colchicine 0.6 mg Tab Oral ___ Tablet(s) Once Daily
3. Lipitor 80 mg Tab Oral 1 Tablet(s) Once Daily
4. tamsulosin ER 0.4 mg 24 hr Cap Oral 1 Capsule, Ext Release 24
hr(s) Once Daily
5. glipizide 10 mg Tab Oral 1 Tablet(s) Twice Daily
6. warfarin 2.5 mg Tab Oral ___ Tablet(s) Once Daily
7. metoprolol tartrate 25 mg Tab Oral 2 Tablet(s) Once Daily in
morn, and 1 in the afternoon
8. Lasix 20 mg Tab Oral 1 Tablet(s) Once Daily
9. cholecalciferol (vitamin D3) 1,000 unit Tab Oral 2 Tablet(s)
Once Daily
10. valsartan-hydrochlorothiazide 320 mg-25 mg Tab Oral 1
Tablet(s) Once Daily
11. Lantus Solostar 100 unit/mL (3 mL) Sub-Q Insulin Pen
Subcutaneous 20 units Insulin Pen(s) Once Daily, at bedtime
12. amlodipine 10 mg tablet Oral 1 tablet(s) Once Daily
13. Tylenol-Codeine #3 300 mg-30 mg tablet Oral ___ tablet(s)
Every ___ hrs, as needed
14. Carbatrol 100 mg capsule, extended release Oral 2 capsule,
ER
multiphase 12 hr(s) Twice Daily
15. allopurinol ___ mg tablet Oral 2 tablet(s) Once Daily
16. lidocaine HCl 5 % Ointment Topical 1 Ointment(s) Three times
daily, as needed
17. gabapentin 300 mg capsule Oral 1 capsule(s) Twice Daily
18. gabapentin 300 mg capsule Oral 4 capsule(s) Once Daily, at
bedtime
19. baclofen 10 mg tablet Oral 1 tablet(s) Three times daily, as
needed
20. ferrous sulfate -- Unknown Strength 1 capsule, extended
release(s) Once Daily
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Baclofen 10 mg PO TID as needed for pain
4. Carbamazepine (Extended-Release) 200 mg PO BID
5. Colchicine 0.6 mg PO EVERY OTHER DAY
6. Furosemide 20 mg PO DAILY
7. Gabapentin 300 mg PO MORNING, NOON
8. Gabapentin 1200 mg PO HS
9. Glargine 20 Units Bedtime
10. Metoprolol Tartrate 25 mg PO Q 8H
11. Tamsulosin 0.4 mg PO HS
12. Warfarin 7.5 mg PO DAILY16 afib, home med
please adjust your coumadin dose according to your INR checks at
___ via Dr ___
13. Zolpidem Tartrate 5 mg PO HS insomnia
**** INSTRUCTED TO CONTINUE ALL HOME MEDS UNLESS INSTRUCTED
OTHERWISE BY PCP***
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Ischemic Attack
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: ___ male with left-sided weakness onset at ___ yesterday,
now partially resolved.
TECHNIQUE: Contiguous axial images were obtained from skullbase to vertex
without intravenous contrast. Coronal and sagittal reformats were reviewed.
COMPARISON: None listed.
FINDINGS:
There is no acute intra-axial or extra-axial hemorrhage, mass, midline shift
or territorial infarct. The ventricles and sulci are symmetric and
unremarkable. Basal cisterns are patent. The gray-white matter
differentiation is preserved.
Orbits are symmetric and unremarkable. The mastoids and included paranasal
sinuses are clear. Skull and extracranial soft tissues are unremarkable.
IMPRESSION:
Normal head CT.
Radiology Report
INDICATION: Right-sided stroke, patient has unexplained lethargy and
asterixis on exam. Evaluate for etiology of infection.
COMPARISON: None.
TECHNIQUE: PA and lateral upright radiographs of the chest.
FINDINGS: There are no focal opacities to suggest pneumonia. Mild bibasilar
atelectasis, left greater than right is noted. Mild cardiomegaly is present.
The mediastinal silhouette and hilar contours are normal. There is no pleural
effusion or pneumothorax.
IMPRESSION:
1. Mild cardiomegaly.
2. Bibasilar atelectasis, left greater than right.
3. No evidence of pneumonia.
Radiology Report
CLINICAL INFORMATION: ___ man with transient left upper extremity
weakness yesterday, now with mild dysarthria and left facial droop. Evaluate
for stroke.
COMPARISON: Head CT from ___.
TECHNIQUE: MRI of the head was performed without intravenous contrast
including sagittal T1, axial FLAIR, T2, susceptibility, and diffusion images.
MRA of the head was performed utilizing 3D time-of-flight technique with
multiple maximum-intensity projection reformats of the circle of ___. MRA
of the neck was performed utilizing 2D time-of-flight technique with multiple
MIP reformatted images.
FINDINGS:
MRI HEAD: There is mild prominence of the ventricles and sulci compatible
with age-related volume loss. Areas of increased T2 and FLAIR signal in the
subcortical, periventricular, and deep white matter bilaterally are
nonspecific, but likely reflect the sequela of chronic small vessel disease.
There is no evidence of hemorrhage, and no diffusion abnormality to indicate
acute or subacute ischemia. There is no abnormal intra- or extra-axial fluid
collection, mass lesion, mass effect, or shift of normally midline structures.
Intracranial flow voids are maintained. The paranasal sinuses, orbits, and
mastoids are unremarkable. The superior ophthalmic veins are prominent
bilaterally.
MRA BRAIN FINDINGS: The vertebral arteries and the basilar arteries are
normal in appearance without evidence of stenosis, occlusion, dissection, or
an aneurysm. The intracranial portions of the internal carotid arteries are
unremarkable without evidence of stenosis, occlusion, or dissection. The
anterior, middle, and posterior cerebral arteries are patent without evidence
of stenosis, occlusion, or dissection. There is no aneurysm or vascular
malformation.
MRA NECK FINDINGS: The aortic arch and the origins of the great vessels as
well as the vertebral artery origins are unremarkable. The bilateral
vertebral arteries are normal in course and caliber without stenosis,
dissection, or occlusion. The vertebral arteries are codominant. The
bilateral common, internal, and external carotid arteries are normal in
appearance without evidence of hemodynamically significant stenosis,
occlusion, or dissection. The distal left internal carotid artery measures 5
mm and the distal right internal carotid artery measures 5 mm.
IMPRESSION:
1. No evidence of infarct. No vascular occlusion in the head or neck.
2. Mild generalized brain volume loss. White matter signal changes, which are
nonspecific, but likely reflect the sequela of chronic small vessel disease.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: ? CVA
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, FACIAL WEAKNESS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS
temperature: 98.2
heartrate: 80.0
resprate: 18.0
o2sat: 97.0
sbp: 183.0
dbp: 96.0
level of pain: 0
level of acuity: 2.0 | 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 = pending at time of discharge)
- () 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: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
___ right-handed obese ___ man with past medical history
significant for afib (with subtherapeutic INR this past week
just finished Lovenox bridge,) also HTN, DM, HL, OSA, CKD-III,
who presented with transient left-hand weakness which has since
resolved.
# Neurologic: likely had a TIA
- head CT normal
- MRI/MRA head and neck showed No evidence of infarct. No
vascular occlusion in the head or neck. Mild generalized brain
volume loss. White matter signal changes, which are nonspecific,
but likely reflect the sequela of chronic small vessel disease.
- TTE showed no cardiac source of embolus identified other than
atrial fibrillation. However, views were suboptimal secondary to
obesity.
- telemetry stable throughout admission
- EEG was considered on admission due to intermittent speech
arrest episodes, but by the following day this was no longer
evident and so EEG was not pursued
- BP was 100/Doppler on AM on ___, held valsartan and
amlodipine and BPs normalized shortly thereafter
- AM fasting lipids were drawn and are pending, (as he was
already on Lipitor 80; we would recommend Crestor if LDL is
still high)
- tox screens WNL, TSH pending at time of discharge
- continue carbamazepine (200mg BID) and gabapentin
(300/300/1200mg)
- held baclofen overnight for somnolence, this was improved by
the next day so restarted on ___
- We left a message with his PCP ___: recs for follow up with
___ Neurology
# Pulmonology: severe OSA, obesity hypovent/restrictive etiology
- stable overnight without CPAP but would likely benefit from
this in the future
# Infectious Disease: no active issues (non-toxic, afeb, no
leukocytosis)
- CXR showed no evidence of pneumonia
# Cardiovascular:
- Troponin normal
# Hematology/Oncology: no active issues
- CBC stable on admission
# Endocrine: IDDM
- Gave half dose of insulin glargine (Lantus) first night of
admission to prevent hypoglycemic worsening of TIA, but as his
symptoms did not return he was sent home on full dosing
- DM diet
- HbA1C quite elevated 11
# Nephrology/Urologic:
- Stage 3 CKD, Cr at baseline 2.0 during admission
# GI/Liver: no active issues
- Took in enteric feeds (DM diet), passed dysphagia screen
# Prophylaxis:
- DVT: boots; already A/C (continued warfarin INR goal ___, INR
on d/c was 2.1)
- ___ Eval --> safe for home |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Femoral dialysis line placement
Dialysis
History of Present Illness:
This is an ___ male with PMHx HTN who is presenting with
altered mental status. The night of admission, his grandson
visited the patient and saw that he was not ambulating and
appeared to be very weak, which differs greatly from his
baseline independent functional status. His grandson last saw
him 1 week ago and spoke with the patient's wife ___ days ago
and she stated he was fine at that time. Per patient's wife, the
patient has not been eating or drinking for the last two days,
nor did he take his medications. The patient himself is a poor
historian.
Per chart review, the patient had a PSA of 30 in ___ and
refused prostate biopsies/further work up in general. His Cr
started rising from a baseline of 1.1 t 1.2 in ___ and to 1.5
in ___.
In the ED, initial vitals: 98.8 73 166/92 18
- Labs significant for:
- Na 140 K 9.8 (repeat 8.2) Cl 90 HCO3 9 BUN 184 Cr 41.7
- Ca: 10.4 Mg: 4.0 P: 14.7
- WBC 6.2 Hgb 11.5 Hct 34.2 Plt 275
- Trop-T: 0.08 -> Trop-T: 0.08
- Lactate: 1.4
- EKG: Sinus rhythm, normal rate, peaked T waves in V3-V5,
normal QRS interval
- Imaging: Bedside US - Distended bladder w/ possible
hydronephrosis
- Received: 1L IVF, 10 units Insulin and Dextrose 50% 25 gm, IV
Calcium Gluconate 2 g x 2
- Urology and Renal consulted
On transfer, vitals were: 83 ___ 93% RA
On arrival to the MICU, patient is frail-appearing, following
basic commands in ___ with some jerking movements.
Review of systems:
unable to assess
Past Medical History:
Hypertension
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION:
Vitals: T: 98.8 BP: 235/90 P: 79 R: 18 O2: 99% RA
GENERAL: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: asterixis present
DISCHARGE:
Vitals: 98.5 74 109/47 99RA
GENERAL: AOx3, no acute distress
HEENT: Sclera anicteric, oropharynx clear
LUNGS: Anterior exam CTAB
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, nondistended
GU: Foley in place no longer draining clots
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, site of femoral line clean, dry and intact
Pertinent Results:
ADMISSION LABS:
==================
___ 07:01PM BLOOD WBC-6.2 RBC-3.81* Hgb-11.5* Hct-34.3*
MCV-90 MCH-30.2 MCHC-33.5 RDW-13.9 RDWSD-45.6 Plt ___
___ 07:01PM BLOOD Neuts-83.9* Lymphs-9.6* Monos-5.7
Eos-0.2* Baso-0.3 Im ___ AbsNeut-5.16 AbsLymp-0.59*
AbsMono-0.35 AbsEos-0.01* AbsBaso-0.02
___ 07:01PM BLOOD Glucose-86 UreaN-184* Creat-41.7*# Na-140
K-9.8* Cl-90* HCO3-9* AnGap-51*
___ 07:01PM BLOOD cTropnT-0.08*
___ 08:36PM BLOOD cTropnT-0.08*
___ 07:01PM BLOOD Calcium-10.4* Phos-14.7* Mg-4.0*
___ 07:08PM BLOOD Lactate-1.4 K-8.2*
DISCHARGE LABS:
=================
___ 06:14AM BLOOD WBC-6.1 RBC-2.44* Hgb-7.4* Hct-22.9*
MCV-94 MCH-30.3 MCHC-32.3 RDW-13.2 RDWSD-45.1 Plt ___
___ 07:00AM BLOOD ___ PTT-27.5 ___
___ 06:14AM BLOOD Glucose-148* UreaN-19 Creat-1.2 Na-132*
K-3.7 Cl-98 HCO3-26 AnGap-12
___ 06:14AM BLOOD Calcium-8.6 Phos-2.0* Mg-1.6
IMAGING:
============
RUQ ___
IMPRESSION:
1. Mild right hydronephrosis and mild fullness of the left renal
pelvis.
2. Nonobstructing left kidney stones, measuring up to 2 mm.
3. Significant bladder wall thickening with debris in the
urinary bladder
likely hemorrhagic material in the setting of hematuria.
___ CT abd/peliv w/o contrast
1. No retroperitoneal hematoma.
2. Dense calcification at the splenic hilum is likely the
sequela of prior granulomatous infection.
3. Bilateral renal cysts.
MICRO:
==========
1. MRSA NOT ISOLATED
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 10 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
3. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- obstructive uropathy
SECONDARY DIAGNOSES
- hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen/pelvis without contrast
INDICATION: ___ year old man with drop in hemoglobin over two days and removal
of emergent dialysis line yesterday // ?RP bleed
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 12.5 s, 43.0 cm; CTDIvol =
6.9 mGy (Body) DLP = 285.5 mGy-cm. Total DLP (Body) = 298 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is a small left pleural effusion with adjacent linear
atelectasis or scarring. Visualized lung fields are otherwise within normal
limits. There is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation.
The gallbladder is within normal limits.
PANCREAS: The pancreas is not well evaluated, but grossly unremarkable. .
There is no pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: There is an approximately 6 x 7 mm dense calcification at the splenic
hilum, likely the sequela of prior granulomatous infection. The spleen shows
normal size and attenuation throughout, without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is an
approximately 9 x 9 mm hypoattenuating lesion in the posterior aspect of the
left kidney and an approximately 11 x 13 mm hypoattenuating lesion in the
lateral aspect of the right kidney compatible with simple cysts. There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is normal.
PELVIS: There is diffuse thickening of the bladder wall with a small amount of
intraluminal gas and a Foley catheter.
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. Overall hypoattenuation the blood pool likely reflects anemia.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Incidental note is made a bone island in the left iliac bone.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No retroperitoneal hematoma.
2. Dense calcification at the splenic hilum is likely the sequela of prior
granulomatous infection.
3. Bilateral renal cysts.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with ___, likely urinary obstruction // eval for
hydonephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 9.9 cm. A simple right renal cyst measures up to
1.2 cm. The left kidney measures 8.9 cm. A 9 mm simple cyst is noted in the
left kidney. Multiple nonobstructing stones measuring up to 2 mm are noted on
the left. Mild right hydronephrosis and mild fullness of the left renal
pelvis noted. Cause of urinary tract obstruction is not determined and the
possibility of stone is considered, though in the setting of hematuria,
difficult to exclude passing clots. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
The bladder is collapsed with a Foley catheter. Marked thickening of the
urinary bladder wall with luminal debris which likely represents blood clot in
the setting of hematuria.
The prostate volume is 44.7 cc.
IMPRESSION:
1. Mild right hydronephrosis and mild fullness of the left renal pelvis.
2. Nonobstructing left kidney stones, measuring up to 2 mm.
3. Significant bladder wall thickening with debris in the urinary bladder
likely hemorrhagic material in the setting of hematuria.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Dizziness, Failure to thrive
Diagnosed with Acute kidney failure, unspecified, Hyperkalemia
temperature: 98.8
heartrate: 73.0
resprate: 18.0
o2sat: nan
sbp: 166.0
dbp: 92.0
level of pain: 0
level of acuity: 3.0 | ___ male with PMHx HTN who is presenting with altered
mental status, found to have acute renal injury and was
emergently dialyzed for uremia and hyperkalemia.
# Acute renal injury: Patient presenting with acute kidney
injury (BUN 184, Cr 41). Patient's Cr has been trending up over
the past ___ years (1.1 in ___, 1.5 in ___. In the ED he was
underwent a bedside ultrasound, which showed bilateral
hydronephrosis, an enlarged prostate, with 3+ liters in his
bladder. Given that he had a PSA of 30 in ___, most likely
cause thought to be obstructive uropathy secondary to enlarged
prostate or prostate malignancy. Patient had foley placed by
urology which initially revealed clear urine which quickly
become bloody, consistent with hemorrhagic decompression.
Patient emergently dialyzed overnight for uremia and
hyperkalemia with improvement in electrolyte abnormalities. He
was started on tamsulosin. Following emergent dialysis, renal
function ultimately improved with discharge Cr of 1.2 and normal
electrolytes. Though patient previously declined work up for
prostate cancer, he will follow up with urology as an
outpatient.
# Altered Mental Status: Patient's altered mental status
initially alert and oriented only to person likely secondary to
toxic metabolic encephalopathy in the setting of uremia and
gross electrolyte abnormalities. Following treatment of
obstructive uropathy with dialysis and foley placement, his
mental status significantly improved. Patient was alert and
oriented x3 at time of discharge.
# Hypertensive Urgency: Patient severely hypertensive on
admission, BP 234/101. Patient had not taken meds in a couple of
days prior to admission and it is unknown how long patient has
been hypertensive. Patient was given 10 mg IV Hydralazine
overnight and was started on Amlodipine in the ICU. Patient's
BPs stabilized with amlodipine 5mg daily. His lisinopril was
held in the setting of ___, and his home hydralazine was stopped
with the initiation of tamsulosin.
# Social Issues: At baseline, patient was living at home
independently and taking care of sick wife. During admission,
family raised concerns for safety to care for himself at home
alone. Reportedly, family went to the home and saw blood and
garbage and disarray that was concerning. Social work was
consulted and their team began filing documentation to Elder
Protective Services.
======================
TRANSITIONAL ISSUES
======================
- Patient will have followup with urology for workup of enlarged
prostate and possible cystoscopy.
- Patient's foley should remain in place until urology followup.
- Patient was found to have anemia in the setting of hematuria.
He should have a repeat h/h on ___.
- The patient's electrolytes have largely normalized, but he
continues to have low phosphorus levels. Lytes, including phos,
should be checked on ___ to assess levels.
- Due to concern for inadequate housing situation, Elder
Services was notified, and will follow up on any need for
increased services.
- The patient's lisinopril was held in the setting of ___, and
hydralazine was held after he was started on tamsulosin. He was
started on amlodipine and tamsulosin in the hospital. He may
need additional blood pressure medication titration in the
outpatient setting.
# CONTACT: wife ___ ___
# CODE STATUS: Full (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Celexa / Penicillins / Amoxicillin / ciprofloxacin
Attending: ___
Chief Complaint:
Dyspnea and chest pain
Major Surgical or Invasive Procedure:
1. Coronary artery bypass graft x3, left internal mammary
artery to left anterior descending artery, and saphenous
vein grafts to diagonal and obtuse marginal arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
___ year old with history of Brugada,
VT arrest (thought to be secondary to Brugada syndrome), s/p
AICD
placement ___, and recent admissions ___ and ___ for CHF exacerbation who initially presented to ___
with dyspnea and left sided chest pain radiating to his back. Of
note, he has been planning to have a cardiac cath done as an
outpatient, but due to the risk of kidney injury he has been
delaying.
He states that roughly one week ago he developed worsening
dyspnea on exertion, orthopnea, and ___ edema. He states that he
continued to take his home Lasix 20mg daily and was largely
adherent to a low sodium diet. Starting three days ago he
developed sharp left sided chest pain that started at rest and
was not related to exertion. He states the pain radiated to his
left arm, left side of his neck, and to his back under the
shoulder blade. He states that pain was nearly constant, and
after three days he decided to present to ___ for
evaluation ___.
At ___, EKG was performed and did not demonstrate
evidence of active ischemia. CXR demonstrated pulmonary vascular
congestion. Labs were notable for ___ ___, troponin T 0.02,
and Cr 2.04. Pt received Zofran, morphine, and Lasix 40mg IV x
1.
He was transferred to ___ for management of CHF and cardiac
catheterization. Catheterization was obtained and revealed three
vessel disease. He is now being referred to cardiac surgery to
evaluate for surgical revascularization.
Past Medical History:
DM2 - uncontrolled
HLD ___
OSA
___ ___ tendinitis, s/p surgery
Adjustment disorder w/depressed mood
Anxiety
Social History:
___
Family History:
Father died of MI @ ___ (first MI @ ___, CABG @ ___)
Mother died of ___ @ ___
Paternal grandparents with DM, heart disease, died in ___
Paternal grandmother with cancer
One sister with heart disease, in mid ___ now.
One sister with MI @ ___ s/p CABG
One brother with DM
Children are healthy
Physical Exam:
Pulse:73 Resp:16 O2 sat:96/RA
B/P Right:114/70 Left13___/___
Height: 5'7" Weight:81.2 kg
Discharge wgt: 82kg
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:p Left:p
DP Right:p Left:p
___ Right:p Left:p
Radial Right:p Left:p
Carotid Bruit Right:- Left:-
Pertinent Results:
___ 07:30AM BLOOD WBC-11.8* RBC-3.15* Hgb-8.8* Hct-27.9*
MCV-89 MCH-27.9 MCHC-31.5* RDW-16.0* RDWSD-50.8* Plt ___
___ 06:30AM BLOOD WBC-10.7* RBC-3.06* Hgb-8.7* Hct-27.0*
MCV-88 MCH-28.4 MCHC-32.2 RDW-16.0* RDWSD-50.8* Plt ___
___ 03:13AM BLOOD ___ PTT-43.8* ___
___ 07:30AM BLOOD Glucose-111* UreaN-64* Creat-2.6* Na-143
K-4.2 Cl-107 HCO3-22 AnGap-18
___ 07:30AM BLOOD ALT-298* AST-110* LD(LDH)-370*
AlkPhos-379* TotBili-0.8
___ 07:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ PA&lat
Bilateral pleural effusions are small, left greater than right.
Mild left
basilar atelectasis. No change in the left-sided pacer with
leads projecting
to the right atrium and right ventricle. Interval removal of
the right IJ
sheath. Moderate cardiomegaly is unchanged. No evidence of
pneumothorax.
Intact median sternotomy wires and mediastinal surgical clips
are also
unchanged position.
IMPRESSION:
Small bilateral effusions, left greater than right.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. HydrALAzine 10 mg PO TID
4. Isosorbide Mononitrate 30 mg PO DAILY
5. Sertraline 150 mg PO DAILY
6. Carvedilol 12.5 mg PO BID
7. Furosemide 20 mg PO DAILY
8. Humalog ___ 30 Units Breakfast
Humalog ___ 14 Units Dinner
Discharge Medications:
1. DME
Straight cane
dx: CAD, s/p CABG
prognosis: good
length of need: 13 months
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
5. Furosemide 40 mg PO DAILY
RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
6. HydrALAZINE 10 mg PO Q8H
RX *hydralazine 10 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*60 Tablet Refills:*1
7. Humalog ___ 30 Units Breakfast
Humalog ___ 14 Units Dinner
8. Sertraline 150 mg PO DAILY
9. Docusate Sodium 100 mg PO BID Duration: 2 Weeks
10. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q 3
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage. Edema trace
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with burgada syndrome s/p AICD placement and chf
now with SOB, chest pain // eval for pul edema
IMPRESSION:
In comparison to previous radiograph of 2 days earlier, pulmonary vascular
congestion persists, but mild edemahas resolved in the interval. There are no
areas of consolidation to suggest the presence of pneumonia, and no pleural
effusion or pneumothorax is detected.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with CKD stage III-IV, Insulin dependent diabetes
mellitus, Brugada, VT arrest (thought to be secondary to Brugada syndrome),
s/p AICD placement ___, and recent admissions ___ and ___
for CHF exacerbation (EF 35% thought to be secondary to ischemic
cardiomyopathy) presenting initially to ___ with dyspnea and left sided
chest pain radiating to his back, found to have troponin elevation and to be
in acute decompensated heart failure, s/p Cath 3 vessel disease. Preop
radiograph prior to CABG.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph of ___ and ___.
FINDINGS:
Compared to the prior radiograph, previous mild edema has improved. Unchanged
positioning of the pacer leads, projecting to the right atrium and right
ventricle.
No focal consolidation, effusion, or pneumothorax. Mild cardiomegaly is
unchanged.
IMPRESSION:
Previous mild edema has improved. No focal consolidation.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with CAD s/p CABG. Please ___ at
___ with abnormalities. // FAST TRACK EXTUBATION CARDIAC SURGERY, ?line
placement, r/o PTX/Effusion Contact name: ___: ___ FAST TRACK
EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effusion
IMPRESSION:
Compared to prior chest radiographs ___ through ___,
12:13.
Normal postoperative cardiomediastinal silhouette, including small
pneumopericardium. Lungs clear. No pleural abnormality. No pneumothorax.
Lines and tubes in standard placements.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CABG // eval for hemothorax eval for
hemothorax
IMPRESSION:
Comparison to ___. The nasogastric tube, the endotracheal tube, and
the Swan-Ganz catheter were removed. Moderate cardiomegaly. No overt
pulmonary edema. No larger pleural effusions. Stable alignment of the
sternal wires.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p cabg // s/p ct removal ? ptx s/p
ct removal ? ptx
IMPRESSION:
Comparison to ___. Removal of the mediastinal drains. No evidence
of pneumothorax. Unchanged moderate cardiomegaly. Pacemaker leads in stable
position. The right venous introduction sheet is also stable. No larger
pleural effusions.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with s/p cabg. Eval for effusion.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs of ___ and ___.
FINDINGS:
Bilateral pleural effusions are small, left greater than right. Mild left
basilar atelectasis. No change in the left-sided pacer with leads projecting
to the right atrium and right ventricle. Interval removal of the right IJ
sheath. Moderate cardiomegaly is unchanged. No evidence of pneumothorax.
Intact median sternotomy wires and mediastinal surgical clips are also
unchanged position.
IMPRESSION:
Small bilateral effusions, left greater than right.
Radiology Report
INDICATION: ___ year old man with s/p cabg // nausea and distention r/o
obstruction
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT torso from ___ and radiograph from ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable. Cardiomegaly, left-sided pacer and median
sternotomy wires are better seen on date chest radiograph from the same day.
Left lower lobe opacity is better evaluated on the chest radiograph.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Normal bowel gas pattern.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: NSTEMI, Transfer
Diagnosed with Cardiomyopathy, unspecified, Heart failure, unspecified
temperature: 100.1
heartrate: 89.0
resprate: 18.0
o2sat: 95.0
sbp: 132.0
dbp: 69.0
level of pain: 2
level of acuity: 2.0 | The patient was admitted to the hospital and brought to the
operating room on ___ where the patient underwent CABGx3.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable requiring Neosynepherine for hypotension, that was weaned
off by POD#1. He developed acute on chronic renal failure, with
significant acidosis/hyperkalemia, required bicarbonate gtt. His
PPM was interrogated in the post-op period and it was determined
that his A wire was not working. His device was changed to VVI.
He has been in SR/SB with occasional pacing and prolonged QTC.
He will need to have his PPM lead revised as determined by
cardiology as an outpatient. He is tolerating Beta blocker. He
was followed by the renal service for his acute on chronic renal
failure and was gently diuresed. His creat peaked at 3.6 and is
currently downtrending. He is being discharged on daily Lasix
and will f/u with Dr. ___ in 2 weeks. The patient was
transferred to the telemetry floor POD#3 for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 6 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to home in good condition with
appropriate follow up instructions |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Malnutrition
Dehydration
Major Surgical or Invasive Procedure:
PEG placement ___
History of Present Illness:
This is a ___ year-old female with the history below who
presented to the ___ Emergency room complaining of poor po
intake, weakness, malaise, and pain in the mouth related to
known cancerous lesion, over the past week. She has been
undergoing chemo/radiation for SCC of the floor of the mouth,
and has been having sig difficulty eating foods over the past
___ weeks. Her appetite is present, but foods taste unusual and
she cannot eat them as a result, she also has pain in her mouth
limiting the intake. She reports being able to take liquids,
but was dehydrated on presentation and has clinically improved
after mult litres of ivf in the ED
She was advised to present to the ED for IV hydration, and for
evaluation, including for possible enteral tube placement
(suspect PEG given mouth cancer and xrt to area..)
Past Medical History:
Squamous cell carcinoma of soft palate, uvula, tonsils:
currently on chemo and radiation therapy
Anxiety
Social History:
___
Family History:
No other family members with ___ of mouth
Physical Exam:
Admission Exam:
===============
VS: Afebrile and vital signs stable (reviewed by me today - see
according flowsheet); specific comments regarding VS:
FSBG (if recorded - reviewed by me today - see according
flowsheet); specific comments regarding FSBG:
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERRL, EOMI, no conjuctival injection, anicteric
Dry mouth
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops.
No JVD. No carotid bruits
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema. WWP
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ strength throughout all
extremities and symmetric. No sensory deficits to light touch
appreciated. No pass-pointing on finger to nose.
2+DTR's-patellar and biceps. No asterixis, no pronator drift,
fluent speech.
Psychiatric: pleasant, appropriate affect
GU: no urinary catheter in place
Discharge Exam:
===============
VS:98.7 PO 119 / 52 95 18 94 RA
General: NAD, but tearful and anxious
HEENT: sclera anicteric, MMM, unable to fully visualize
oropharynx, but there are some erosions visible on the L
posterior soft palate.
Neck: moderate erythema of the skin of the inferior neck
Lungs: CTAB, nl WOB
CV: RR, no m/r/g
Abdomen: soft, non-tender, nondistended, normoactive bowel
sounds throughout, no rebound or guarding, +PEG in place with
dressing clean and dry, no induration
MSK: grossly normal strength in arms & legs
Neuro: AAOx4, clear speech, conversant
Psych: intermittently tearful
Pertinent Results:
Admission Labs:
===============
___ 05:30PM BLOOD WBC-3.1* RBC-3.44* Hgb-11.2 Hct-32.4*
MCV-94 MCH-32.6* MCHC-34.6 RDW-12.9 RDWSD-43.4 Plt ___
___ 05:30PM BLOOD Neuts-68.4 ___ Monos-9.9 Eos-1.3
Baso-0.3 AbsNeut-2.15 AbsLymp-0.63* AbsMono-0.31 AbsEos-0.04
AbsBaso-0.01
___ 05:30PM BLOOD Glucose-87 UreaN-16 Creat-0.7 Na-135
K-4.2 Cl-93* HCO3-25 AnGap-17
___ 05:37PM BLOOD Lactate-1.9
Imaging:
========
AXR:
IMPRESSION:
Nonobstructive bowel gas pattern. Colonic stool burden is mild.
Discharge labs:
===============
___ 07:08AM BLOOD WBC-2.1* RBC-2.45* Hgb-8.2* Hct-22.6*
MCV-92 MCH-33.5* MCHC-36.3 RDW-13.2 RDWSD-42.4 Plt Ct-82*
___ 07:08AM BLOOD Neuts-54.8 ___ Monos-19.0*
Eos-0.5* Baso-0.0 Im ___ AbsNeut-1.15* AbsLymp-0.53*
AbsMono-0.40 AbsEos-0.01* AbsBaso-0.00*
___ 07:08AM BLOOD Glucose-112* UreaN-18 Creat-0.7 Na-130*
K-4.9 Cl-92* HCO3-31 AnGap-7*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
3. Ranitidine 75 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN c
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Jevity 1.5 Cal (lactose-reduced food with fibr) 240 ml can
oral ASDIR
1 can (240 mL) five times daily
RX *lactose-reduced food with fibr [___ 1.5 Cal] 0.06
gram-1.5 kcal/mL 1 can G tube ASDIR Disp ___ Milliliter
Milliliter Refills:*0
3. LORazepam 0.5 mg PO TID:PRN nausea
try reglan (metoclopramide) first
RX *lorazepam 0.5 mg 1 tablet by mouth three times a day Disp
#*10 Tablet Refills:*0
4. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth four times a day
Disp #*90 Tablet Refills:*3
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*3
6. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day
Refills:*3
7. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice daily Disp #*30 Packet Refills:*3
8. Senna 8.6 mg PO QHS
RX *sennosides [senna] 8.6 mg 1 tab by mouth every night Disp
#*30 Tablet Refills:*3
9. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth every 12
hours Disp #*30 Tablet Refills:*0
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
11. Ranitidine 75 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Squamous cell carcinoma of the soft palate, uvula and
tonsils, moderate malnutrition, Dehydration, anxiety
SECONDARY: Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN (SUPINE AND ERECT)
INDICATION: ___ year old woman with no BM in several days (though passing gas)
and difficulty tolerating TFs// please eval for dilated bowel loops or stool
impaction
TECHNIQUE: AP upright and supine views of the abdomen
COMPARISON: None
FINDINGS:
There is gas within the colon and rectum. There is a small amount of formed
stool in the rectal vault however there is no significant stool burden in the
colon. There is paucity of small bowel gas. There is an air-fluid level in
the stomach. There is no evidence of pneumatosis or free air. Changes
related to vertebroplasty and posterior fusion hardware are noted in the
thoracolumbar spine. There are severe degenerative changes in the lower
lumbar spine. A gastrostomy tube projects over the left upper quadrant.
IMPRESSION:
Nonobstructive bowel gas pattern. Colonic stool burden is mild.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Difficulty swallowing
Diagnosed with Dehydration, Nausea
temperature: 98.3
heartrate: 100.0
resprate: 16.0
o2sat: 97.0
sbp: 165.0
dbp: 81.0
level of pain: 3
level of acuity: 3.0 | ___ is a ___ female with a history of head and neck cancer,
squamous cell carcinoma of the soft palate, uvula and tonsils
who presents with malnutrition and dehydration.
# Malnutrition, moderate
# Dehydration
# Squamous cell carcinoma of soft palate, uvula, tonsils
At this point in time it appears that she is failing oral
nutrition and hydration and needs enteral feeding via PEG tube.
After multidisciplinary discussion with oncology, radiation
oncology, patient's daughter/healthcare proxy and patient
herself, decision was made to pursue PEG placement. PEG was
placed uneventfully, and she was started on cycled tube feeds
that were gradually transitioned to bolus feeding. The patient
was discharged on self-administered bolus TFs (Jevity 1.5, one
can (240mL), 5 times daily), which she was tolerating well prior
to discharge.
# Pancytopenia:
Chemo related, monitoring CBC/Diff to evaluate for ANC, which
nadired at 1020 during this hospitalization. In discussion with
her outpatient oncologist, decision was made to hold off on her
last scheduled chemotherapy cycle and re-evaluate in the
outpatient setting. |
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 pin
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
HPI: ___ y.o with history of hypopharyngeal SCC s/p trach,
subsequently removed, G-tube dependent, with recent ___ guided
exchange presenting with epigastric pain, elevated lipase, and
imaging significant for choledocholithiasis. He first went to an
OSH where he was found to have evidence of choledocholithiasis.
He was given zosyn and flagyl and transferred to ___ for ERCP
evaluation.
Upon arrival to ___, the patient reported minimal abdominal
pain in the epigastric and right upper quadrant. He otherwise
has
no pain.
In the ED, initial VS were 98.6, HR 80, BP 113/68, RR 19, 95% on
RA
OSH CT scan significant for choledocholithiasis with
extrahepatic
biliary dilatation, but no significant intrahepatic biliary
diltiation.
LFTS elevated to 601/562, with elevated alkaline phos of 33,
lipase of 2895. T. bili elevated to 2.52.
He received LR in the ED.
Upon arrival to the floor, the patient appears well. He reports
that he had acute onset of epigastric pain yesterday morning. It
is sharp, nonradiating pain. He had associated nausea and
vomiting. He reports he spit up approximately one tablespoon of
blood. He otherwise denies fevers, chills, chest pain, dysuria,
backpain. He reports he has intermittent shortness of breath
which is baseline for him, not clearly exertional, and has not
changed in nature. He reports he has minimal epigastric pain at
this time.
Of note, he does not take any food or drink by mouth. He
occasionally drinks by mouth but then spits it out and does not
swallow.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Hypopharyngeal squamous cell carcinoma s/p chemotherapy,
radiation and tracheostomy, now w/ tracheostomy removed
- Gtube pending
- Alcohol abuse
- Hypertension
- Hyperlipidemia
- Nicotine addiction
- Depression
- Insomnia
- BPH
Social History:
___
Family History:
FAMILY HISTORY: He is adopted.
Physical Exam:
ADMISSION EXAM
VITALS: 97.4 PO 162 / 83 74 18 96 Ra
GENERAL: Alert, audible wheeze with raspy voice, but in no
apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, mucous mebranes moist
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally, no wheezes at rest
GI: Abdomen soft, minimal tenderness in the epigastrium
MSK: Neck supple, moves all extremities, gait WNL
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION
___ 11:32PM BLOOD WBC-9.1 RBC-4.97 Hgb-15.2 Hct-47.3 MCV-95
MCH-30.6 MCHC-32.1 RDW-14.1 RDWSD-49.0* Plt ___
___ 11:32PM BLOOD Glucose-134* UreaN-19 Creat-1.0 Na-142
K-5.8* Cl-104 HCO3-25 AnGap-13
___ 11:32PM BLOOD ALT-634* AST-538* AlkPhos-350*
TotBili-3.5*
___ 11:32PM BLOOD Lipase-3650*
___ LIVER OR GALLBLADDER US
1. Collapsed gallbladder with cholelithiasis. No acute
cholecystitis.
2. The common bile duct is not definitively visualized on this
exam, but was better seen on the same-day CT exam demonstrating
choledocholithiasis.
___ ERCP
A benign intrinsic 9 mm stricture that appeared at 20 cm from
the incisors was seen in the upper third of the esophagus. The
EGD scope could not traverse the stricture. A pediatric scope
was
used to traverse the stricture.
___ dilation was performed from ___ to ___ FR successfully.
The duodenoscope traversed the stricture after dilation with no
resistance.
The gastrotomy tube balloon was seen in the stomach.
The scout film was normal. The major papilla was normal.
The PD was partially cannulated using a Rx sphincterotome
preloaded with 0.035in guidewire. No contrast was injected.
The CBD was then successfully cannulated using a Rx
sphincterotome preloaded with 0.035in guidewire.
Contrast injection revealed a filling defect in the CBD
consistent with a stone.
A biliary sphincterotomy was successfully performed at the 12
o'clock position. There was no post-sphincterotomy bleeding.
The bile duct was swept multiple times using a biliary balloon
catheter.
One stone and small amount amount of sludge material were
successfully removed.
Occlusion cholangiogram revealed no more filling defects.
There was excellent contrast and bile drainage at the end of
the
procedure.
___ 07:20AM BLOOD WBC-6.9 RBC-3.47* Hgb-10.9* Hct-33.1*
MCV-95 MCH-31.4 MCHC-32.9 RDW-13.9 RDWSD-48.2* Plt ___
___ 08:38AM BLOOD WBC-8.1 RBC-3.77* Hgb-12.0* Hct-35.7*
MCV-95 MCH-31.8 MCHC-33.6 RDW-13.7 RDWSD-47.4* Plt ___
___ 07:20AM BLOOD Glucose-144* UreaN-14 Creat-0.7 Na-145
K-3.7 Cl-104 HCO3-30 AnGap-11
___ 08:38AM BLOOD ALT-198* AST-71* AlkPhos-224* TotBili-1.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Scopolamine Patch 1 PTCH TD Q72H
3. BuPROPion 150 mg PO BID
4. Atorvastatin 20 mg PO QPM
5. FoLIC Acid 1 mg PO DAILY
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
7. TraZODone 25 mg PO QHS
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
9. Thiamine 100 mg PO DAILY
10. TraZODone 25 mg PO Q6H:PRN anxiety / agitation
11. Tamsulosin 0.4 mg PO QHS
12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
last day last ___ in the am
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Senna 17.2 mg PO QHS:PRN constipation
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
5. BuPROPion 150 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Scopolamine Patch 1 PTCH TD Q72H
10. Tamsulosin 0.4 mg PO QHS
11. Thiamine 100 mg PO DAILY
12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
13. TraZODone 25 mg PO QHS
14. TraZODone 25 mg PO Q6H:PRN anxiety / agitation
15. HELD- Atorvastatin 20 mg PO QPM This medication was held.
Do not restart Atorvastatin until you have your liver enzymes
rechecked in about 1 week
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
gallstone pancreatitis
choledocholithiasis
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 epigastric pain and CT showing gallstones//
?choledocholithiasis ?CBD dilation
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis with contrast from ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD is not
definitively visualized on this exam, and was better seen on the same-day CT
abdomen and pelvis exam.
GALLBLADDER: There is a large stone seen in the gallbladder, which causes
shadowing and obscures further evaluation of the remaining gallbladder.
However, it does not appear hydropic and there is no evidence of surrounding
inflammatory changes.
PANCREAS: The head and body of the pancreas are within normal limits, however
better evaluated on concomitant CT which demonstrates pancreatitis. The tail
of the pancreas is not visualized due to the presence of gas.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
IMPRESSION:
1. Collapsed gallbladder with cholelithiasis. No acute cholecystitis.
2. The common bile duct is not definitively visualized on this exam, but was
better seen on the same-day CT exam demonstrating choledocholithiasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Acute pancreatitis without necrosis or infection, unsp
temperature: 98.6
heartrate: 80.0
resprate: 19.0
o2sat: 95.0
sbp: 113.0
dbp: 68.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old male with past medical history of
head/neck squamous cell cancer s/p chemo and XRT, previously
trach dependent, s/p G-tube, admitted ___ with
choledocholithiasis and gallstone pancreatitis, status post ERCP
w sphincterotomy and stone extraction.
# Gallstone pancreatitis / Choledocholithiasis Patient
presented with abdominal pain with lipase of 3k, and abnormal
LFTs. Imaging was concerning for choledocholithiasis. Patient
was made NPO, started on IV fluids, and given concern for
cholangitis on OSH CT scan, started on antibiotics. Patient
underwent ERCP with sphincterotomy and stone extraction without
signs of purulence or cholangitis. He was recommended to take
cipro for 5 days post procedure. Last day ___ AM. He was
evaluated by the surgical team during admission and they did not
recommend any surgery during admission but recommended short
interval outpt f/u (arranged).
# Esophageal Stricture
ERCP incidentally found a "A benign intrinsic 9 mm stricture" at
20cm, which was subsequently dilated. Per advanced endoscopy;
no follow-up is necessary unless patient were to develop
dysphagia in the future--if so, the would recommend repeat
endoscopy.
# Hyperlipidemia
Held home atorvastatin pending normalization of LFTs. Would
repeat LFTs in outpt setting and resume when able.
# Anxiety
Continued Bupropion, trazodone
# Hypothyroidism
Continued Levothyroxine
# Oropharyngeal squamous cell cancer s/p prior radiation therapy
Continued scopolamine patch for help with secretions. Outpt f/u.
Resumed tube feeds. Would consider need for repeat speech and
swallow study as outpt.
# BPH
Continued tamsulosin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left chest and back pain
Major Surgical or Invasive Procedure:
___
___ aspiration of mediastinal mass
___
Left video-assisted thoracoscopic surgery (VATS) and debridement
of mediastinal abscess
___
Right PICC line
History of Present Illness:
Mr. ___ is a ___ male who
was brought to the ___ ED by ambulance from ___,
he presents with a complaint of 2 weeks of intrascapular back
pain with accompanying left arm and chest "discomfort". He
describes the pain ___ his back as dull and "like a screwdriver"
boring into his muscle. The pain started between his scapulae
approximately 2 weeks ago, on ___, was initially
non-radiating and then progressed to include the dorsum of his
left upper extremity and axilla and a discrete area ___ the
midclavicular line, spanning from the 2nd rib to the ___
intercostal space on the left side, where there is an area of
soft tissue swelling. He took 4 x ___ mg advil ~q8h for the
first
5 days of this pain, which relieved his symptoms. The pain
continued and he began to feel nauseated on ___ of the ___
week. On that day he saw a nurse practitioner at ___
who performed an EKG, which was normal, and gave him a
prescription for cyclobenzaprine for muscle pain/spasm. He also
noticed that lying down was uncomfortable from that time
forward.
Mr. ___ states that he used cyclobenzaprine through the weekend
and also began taking advil 4 x ___ mg tabs combined with
tylenol
2 x ___ mg tabs q 2h, every day from ___ for most
of the day.
On ___, Mr. ___ was too nauseated to stay at work; he went
home and found that he had to sleep ___ a recliner for comfort or
sit upright because being ___ a supine position increased his
discomfort. The patient met with his PCP, ___ told him
to discontinue the advil/tylenol regimen and ordered labs, which
the patient did not bring to ___. That evening, Mr. ___
became
febrile and had more chest and back "discomfort" for which he
saw
called his PCP the next morning. The PCP ordered ___ CXR for the
following day, ___. On ___, he met with his PCP to
discuss the CXR and was told that there was a concerning finding
on CXR and abnormalities ___ his laboratory tests, but that his
WBCs were normal. Dr. ___ Levaquin and Vicodin,
which
the patient took on the weekend from ___. During this
time, he continued to feel nauseated and had new fever, chills
and rigors, with dizziness when he walked up and down stairs. On
___ he had persistent fever and chills with decreased
pain. Dr. ___ a CT scan, read by outside an radiologist
to suggest a retrosternal abscess. Mr. ___ was sent to the
___ ED and subsequently transferred to ___.
Past Medical History:
1. Hypertension
Social History:
___
Family History:
Mother-heavy life-long smoker, died of lung CA, age ___
Father-heavy life-long smoker, died of lung CA, age ___
Siblings-Sister died of brain CA, age ___
Offspring--3 children, healthy
Other
Physical Exam:
Temp: 99.2 HR: 114 BP: 142/84 RR: 17 O2 Sat: 97% RA
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[x] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[x] Abnormal findings: Soft tissue swelling, to the left of the
midclavicular line, spanning between the 2nd rib and the ___
intercostal space, approximately 2.5 inches medially to
laterally.
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 11:15PM WBC-14.1* RBC-3.95* HGB-12.0* HCT-35.1*
MCV-89 MCH-30.4 MCHC-34.2 RDW-12.2
___ 11:15PM PLT COUNT-409
___ 11:15PM ___ PTT-32.3 ___
___ 11:15PM GLUCOSE-111* UREA N-15 CREAT-0.8 SODIUM-136
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15
___ 09:00PM ALT(SGPT)-60* AST(SGOT)-35 LD(LDH)-185 ALK
PHOS-180* TOT BILI-1.3
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
___ 05:33 4.6 3.16* 9.2* 27.8* 88 29.0 32.9 12.4
384
Source: Line-picc
___ 07:10 6.1 3.62* 10.2* 32.0* 89 28.2 31.8 12.2
448*
___ 07:25 6.9 3.34* 9.3* 29.3* 88 27.9 31.9 12.0
436
___ 11:15 13.9* 3.72* 10.9* 33.1* 89 29.2 32.8 12.3
672*
___ 18:40 14.1* 3.57* 10.5* 31.1* 87 29.2 33.6 12.3
480*1
___ 06:40 15.7* 3.52* 10.2* 31.7* 90 29.0 32.2 12.3
505*
___ 06:50 17.1* 3.82* 10.9* 33.8* 89 28.7 32.4 12.1
494*
___ 20:10 11.8* 3.84* 11.2* 33.6* 88 29.1 33.3 11.9
444*
___ 21:00 11.4* 4.06* 11.8* 36.0* 89 29.0 32.7 12.2
418
___ 23:15 14.1* 3.95* 12.0* 35.1* 89 30.4 34.2 12.2
409
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:33 106*1 16 1.6* 139 4.1 102 30 11
Source: Line-picc
___ 07:10 106*1 16 1.7* 139 4.0 99 31 13
___ 07:25 108*1 1.9* 136 3.8 99 29 12
___ 11:15 121*1 23* 2.3* 135 4.1 97 25 17
___ 18:40 113*1 26* 2.4* 132* 4.0 96 26 14
___ 06:40 961 24* 2.5* 134 4.6 96 28 15
___ 06:50 104*1 19 1.7* 132* 4.3 95* 25 16
___ 20:10 127*1 11 0.8 13 4.0 100 27 12
___ 21:00 115*1 11 0.8 135 4.0 96 28 15
___ 23:15 111*1 15 0.8 136 3.9 99 26 1
___ 4:40 pm ABSCESS ANTERIOR MEDIASTINAL ABSCESS.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
___ 1:29 pm TISSUE MEDIASTINAL TISSUE.
GRAM STAIN (Final ___:
Reported to and read back by ___. ___ @ 530PM
___.
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ FROM
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ 1:17 pm FLUID,OTHER MEDIASTINAL FLUID LEFT.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
Reported to and read back by DROWN ___ @ 06:41PM ON
___.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___-___ FROM
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
___ 1:15 pm PLEURAL FLUID LEFT PLEURAL FLUID.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ CXR :
Somewhat widened appearance of the mediastinum, with a vague
opacification overlying the anterior mediastinum. No evidence
of pneumothorax.
___ Cardiac echo :
Suboptimal image quality. Dilated thoracic aorta. No valvular
pathology or pathologic flow identified. Normal biventricular
cavity sizes with preserved global biventricular systolic
function
___ Abd US :
1. Normal-appearing liver not grossly enlarged and without
focal lesion.
2. Poor visualization of the spleen and left kidney secondary
to overlying bandages. On comparison CT of the chest limited
view of the left spleen maximally measured 15 cm.
___ Chest CT :
1. Interval decrease of left anterior mediastinum collection
with
questionable involvement of the first anterior costochondral
cartilage.
2. New left lower lobe disease is likely a combination of
atelectasis and aspiration/pneumonia. Right lower lobe
abnormality is likely atelectasis.
3. Increased density of the left lung is due to mild pulmonary
edema,
4. Small left anterior pneumothorax is postprocedural.
5. Small left base pleural effusion
___ CXR :
___ comparison with the study of ___, the left chest tube has
been
removed, and there is no definite pneumothorax. Continued low
lung volumes. Extensive opacification ___ the left hemithorax
persists, though appears to be improving. The hemidiaphragms
again are not well seen, consistent with atelectatic changes and
effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
4. nafcillin 2 gram injection Q 4 hrs
thru ___
RX *nafcillin 2 gram 2 Gm IV every four (4) hours Disp #*38 Vial
Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
6. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MSSA anterior mediastinal abscess
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Anterior mediastinal mass. Query infection vs necrotic neoplasm
COMPARISON: CT chest ___.
OPERATORS: Dr. ___ abdominal imaging fellow, Dr. ___
radiology resident, and Dr. ___ staff ___.
PROCEDURE:
The procedure, including risks, benefits and alternatives were explained to
the patient, and after detailed discussion, informed written consent was
obtained from the patient. A time-out was performed using 3 unique patient
identifiers prior to commencing the procedure utilizing the ___ protocol.
A limited non contrast CT was performed through the area of interest with the
patient in the supine position, and the skin was marked. The patient was
prepped and draped in the usual sterile fashion.
Approximately 7 cc of 1% lidocaine was utilized for local anesthesia. Using
CT guidance, with the patient in the supine position, a 17 gauge guide coaxial
needle was advanced into the left anterior mediastinum. Blunt needle
dissection was utilized after the chest wall musculature had been traversed.
3cc of yellowish pus was aspirated. A 0.35 ___ wire was then advanced
into the collection, and a further ___ of bloody pus was aspirated.
Post aspiration residual phlegmon was demonstrated however there was no
residual drainable cavity . The aspirated collection was too small for
placement of a catheter. There was residual phlegmon demonstrated, however
given the presence of pus/necrotic material, biopsy was not performed.
3cc sample of purulent material was sent for culture and sensitivity.
There were no immediate postprocedural complications. The patient tolerated
the procedure well.
The patient received 75mcg of fentanyl and 1.5mg of Versed. The patient's
vitals were continuously monitored by dedicated Radiology nursing. Total
intra service time was 15 min.
The attending radiologist Dr. ___ was present for the entire procedure.
FINDINGS:
Phlegmonous anterior mediastinal collection measuring approximately 6.0 x 3.2
cm.
IMPRESSION:
Successful CT guided aspiration of anterior mediastinal inflammatory
collection. Sample has been sent for microbiology.
Radiology Report
HISTORY: Status post CT guided sampling of an anterior mediastinal phlegmon.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
COMPARISON: Comparison is made to CT chest dated ___.
FINDINGS:
The mediastinum is somewhat widened, and there is a vague opacity noted to be
overlying the anterior mediastinum, consistent with the inflammatory phlegmon
which was sampled on ___. There is a small left sided pleural
effusion with minimal adjacent atelectasis noted. No pneumothorax, or
pulmonary edema is identified. The heart size is normal. No bony
abnormalities are detected.
IMPRESSION:
Somewhat widened appearance of the mediastinum, with a vague opacification
overlying the anterior mediastinum. No evidence of pneumothorax.
Radiology Report
AP CHEST, 4:35 P.M. ___
HISTORY: ___ man with mediastinal infection after mediastinal
washout.
IMPRESSION: AP chest compared to preoperative chest radiograph, ___:
Left hemithorax is relatively stable, no pneumothorax or pleural effusion,
three pleural tubes in place. New atelectasis and small effusion at the base
of the right chest. Heart size normal.
Radiology Report
AP CHEST, 8:26 AM, ___
HISTORY: Mediastinal abscess after washout.
IMPRESSION: AP chest compared to ___:
New edema or hemorrhage has developed in the left lung. Small left pleural
effusion is larger. No pneumothorax. Right lung is low in volume but grossly
clear. Stomach is severely distended with gas. Two left apical pleural
drains, unchanged. Heart size and mediastinal contours are partially
obscured, but there may be widening in the region of the aortic arch.
Dr. ___ was paged to discuss these findings.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___.
FINDINGS: Two chest tubes remain in place in the left hemithorax, with no
visible pneumothorax. Stable widening of cardiomediastinal contours. Diffuse
interstitial thickening, combined with alveolar opacities in the left mid and
lower lung region have slightly worsened in the interval, and may reflect
either asymmetrical edema or pulmonary hemorrhage. Right lung is clear except
for localized atelectasis at the right base. Moderate left and small right
pleural effusions are unchanged.
Radiology Report
INDICATION: Unknown source mediastinal abscess. ? hepatomegaly,
splenomegaly.
COMPARISON: Outside CT of the chest ___.
TECHNIQUE: Grayscale and color Doppler ultrasound images of the abdomen.
FINDINGS: The liver is normal in echogenicity and echotexture without
lesions, intra- or extra-hepatic biliary duct dilation. The gallbladder is
normal without stones, wall thickening or pericholecystic fluid. The portal
vein is patent with hepatopetal flow.
The midline structures including the aorta and pancreas are obscured by
overlying bowel gas. However, small portions of the mid and distal aorta are
normal in caliber. The right kidney measures 14.5 cm and is without
hydronephrosis, mass or stone.
Evaluation of the left upper quadrant is limited by overlying bandage and poor
acoustic windows. The left kidney measures approximately 13.4 cm without
evidence of gross hydronephrosis. The spleen is incompletely imaged. On the
CT of ___ the spleen maximally measured 15 cm. Visualized
portions of the IVC are unremarkable.
IMPRESSION:
1. Normal-appearing liver not grossly enlarged and without focal lesion.
2. Poor visualization of the spleen and left kidney secondary to overlying
bandages. On comparison CT of the chest limited view of the left spleen
maximally measured 15 cm.
Radiology Report
PA AND LATERAL CHEST ___
COMPARISON: Study of earlier the same date.
FINDINGS: One of three left chest tubes had been removed with a tiny left
apical pneumothorax. Combined alveolar and interstitial opacities in the left
lung have slightly improved, particularly in the mid lung region. There
remains dense consolidation with air bronchograms at the left base. Right
hemidiaphragm remains elevated with adjacent area of atelectasis. Small left
partially loculated pleural effusion appears unchanged. Within the imaged
portion of the upper abdomen, air-fluid levels are present within mildly
distended loops of bowel, possibly due to postoperative ileus, but
incompletely evaluated on this radiograph.
Radiology Report
HISTORY: ___ man with mediastinal abscess MSSA, status post drainage
and washed out, still with fevers, leukocytosis. Please assess abscess.
TECHNIQUE: Multidetector helical scanning of the chest was obtained from
thoracic inlet to upper abdomen in supine position without administration of
IV contrast. Axial images were reviewed in conjunction with multiplanar
reconstruction.
COMPARISON: Exam is compared to CT ___.
FINDINGS: After drainage of the left anterior mediastinum fluid collection
has markedly reduced, now with maximal diameters of 3.4 x 3.2 cm (S2:I20). It
was of 5 x 4.3 cm in ___. Mediastinal lymphadenopathy is
unchanged since ___ with the largest lymph node in the prevascular
space 2:20 measuring 1.4 x 1.2 cm. There is no peripheral lymphadenopathy.
Thyroid gland is unremarkable.
Heart size is normal with minimal pericardial effusion along the right
anterior cardiac border 2:35. Low blood density is due to anemia 2:39.
Small left pleural effusion is mainly intrafissural ___. Left posterior
pleural drain has tip ending in the left apex medially 2:9. There is no right
pleural effusion.
ABDOMEN: Even though this exam is not tailored for abdominal imaging.
Mild-to-moderate splenomegaly with maximal diameter of 16 cm 2:53 is unchanged
since ___. Liver, adrenals glands, kidneys and pancreas are
unremarkable.
BONES: The appearance of the sternoclavicular joint and the first anterior
costochondral cartilage is minimally changed since prior examination, bone
involvment is questionable 2:19. There are no other bone lesions suspicious
for infection.
LUNGS AND AIRWAYS: Airways are patent to subsegmental level bilaterally.
Small left anterior pneumothorax is likely postprocedural. Lung volume
asymmetry is due to partial collapse of the left lung for previously described
pneumothorax. Left lung parenchyma has increased attenuation with interlobular
septal thickening suggestive of mild pulmonary edema 2:27. New band-like
consolidation in the left lower lobe is likely due to atelectasis, however
there are ground-glass nodular opacities and rounded opacity suggesting
aspiration or pneumonia in the appropriate clinical setting. Increased
atelectasis also of the right lower lobe is present. Right lung is otherwise
clear.
IMPRESSION:
1. Interval decrease of left anterior mediastinum collection with
questionable involvement of the first anterior costochondral cartilage.
2. New left lower lobe disease is likely a combination of atelectasis and
aspiration/pneumonia. Right lower lobe abnormality is likely atelectasis.
3. Increased density of the left lung is due to mild pulmonary edema,
4. Small left anterior pneumothorax is postprocedural.
5. Small left base pleural effusion
Findings were reported to Dr. ___ at 8:30 p.m. by Dr. ___.
Radiology Report
HISTORY: Mediastinal abscess with chest tube withdrawn.
FINDINGS: In comparison with the study of ___, the left chest tube has been
removed, and there is no definite pneumothorax. Continued low lung volumes.
Extensive opacification in the left hemithorax persists, though appears to be
improving. The hemidiaphragms again are not well seen, consistent with
atelectatic changes and effusion.
Radiology Report
REASON FOR EXAMINATION: PICC line placement.
AP radiograph of the chest was reviewed in comparison to prior study obtained
at 5:55 p.m. on ___.
The right central venous line tip is at the level of low SVC/cavoatrial
junction. Bibasilar atelectasis is present, unchanged. No definitive
pneumothorax is seen.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: RETROSTERNAL ABSCESS
Diagnosed with CHEST SWELLING/MASS/LUMP
temperature: 99.2
heartrate: 120.0
resprate: 16.0
o2sat: 96.0
sbp: 147.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to the hospital and taken to
Interventional Radiology for CT guided drainage of his anterior
mediastinal abscess. Yellow pus was aspirated and he was placed
on broad spectrum antibiotics. MSSA grew from that sample and he
was scheduled for surgical washout. His WBC was 14K and he
continued Vancomycin and Zosyn therapy. His admission blood and
urine cultures were negative. On ___ he underwent a left
video-assisted thoracoscopic surgery (VATS) and debridement of
mediastinal abscess. He tolerated the procedure well and
returned to the PACU ___ stable condition with 3 chest tubes ___
place for drainage.
Following transfer to the Surgical floor he had adequate pain
relief and his chest tubes remained ___ place. His WBC gradually
trended down but he developed acute renal failure to a maximum
creatinine of 2.7. His urine output was adequate and the renal
service was consulted. They felt it may be due to a combination
of multiple contrast studies as well as the use of high dose
Ibuprofen during his episodes of severe pain. With adequate
hydration his creatinie gradually decreased and he will remain
off of NSAIDS and not receive contrast until his kidney function
is back to normal.
The Infectious Disease service followed him closely during his
admission and ___ addition to pan culturing also recommended a
cardiac echo which showed no vegetations. His antibiotics were
tapered to Cefazolin with plans to change to Nafcillin once his
renal function returned to normal.
His chest tubes were gradually removed and he felt much better.
He was afebrile and his WBC was normal. He had a palm sized area
above his waist along the left posterolateral area which was
minimally erythematous. It was well below the incisions or
chest tube sites but was watched closely and remained stable.
He underwent a chest CT on ___ which showed a decreased
fluid collection. The plan will be to treat him with 6 weeks of
IV antibiotics via a right PICC line which was placed on
___.
His creatinine gradually decreased and on ___ was 1.6. At
that time he was switched to Nafcillin for better coverage. he
will receive this at home at 2 Gm every 4 hours which will
continue through ___. The ___ will draw labs twice a week
including CBC w/diff, chem 7, LFT's, ESR, CRP. If there is any
trouble with his renal function the Infectious Disease service
will adjust the medication. He will have an MRI of the chest on
___ to evaluate the collection and R/O any evidence of
osteomylitis and will then follow up with Infectious Disease and
Thoracic Surgery. After a long hospital course he was
discharged to home on ___ aqnd will have ___ services to
help with home IV antibiotic therapy and wound assessment. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Motrin / Morphine / Penicillins
Attending: ___.
Chief Complaint:
chest pain abd pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ y/o M with PMH of HTN who presents with 3 days
of L sided pleuritic CP.
Patient was in his USOH until 3 days prior to admission. Noted
the sudden osnet of L sided CP that was worse with activity or
lying flat. No known trauma to the area. Never had this pain
before. Denies dyspnea or palpitations.
The patient also c/o N/V which coincided with the onset of CP.
Vomit is described as green but non-bloody. Endorses diffuse
abdominal pain and has been unable to take POs. While in the ED,
the patient had watery diarrhea x1. He endorses ongoing alcohol
use with ___ of gin on weeekend days and 4 beers a night during
the week. Last drink 3 days ago. No h/o DTs or seizures. No
known sick contacts or recent travel.
In the ED, initial VS were 8 98.2 78 152/105 16 96% RA. EKG
significant for ST depressions and TWI in anterolateral leads.
Labs, including troponin x1, were largely unremarkable. Patient
was given 0.4mg SL nitroglycerin and 5mg IV morphine with relief
in symptoms. Plavix load given in the ED as patient reports
itchiness with ASA. Given valium for agitation and clonidine for
elevated BP. Decision made to admit to medicine for r/o MI and
detox.
ROS: (+) as per HPI. A 12-point ROS was otherwise negative.
Past Medical History:
PAST MEDICAL HISTORY:
- HTN
- Chronic alcoholism x ___ years
- Avascular necrosis of b/l hips s/p hip replacements last in
___
- h/o polysubstance abuse
Social History:
___
Family History:
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
VS: 98.1 75 141/88 12 100%RA
General: Appears well, lying in bed in NAD
HEENT: PERRLA, EOMI, anicteric, MMM
Neck: Supple, no JVD
CV: RRR, s1 and s2, no m/r/g. Exquisitely TTP over left
mid-clavicular chest wall between ___ rib.
Lungs: CTAB, no w/r/r
Abdomen: Soft, non-distended, TTP diffusely but worst on the
left. Pain described as shooting up to the left chest wall.
Ext: No edema
Skin: No rashes noted
PULSES: 2+ throughout
LABS: Reviewed. See OMR.
STUDIES:
EKG: SR@ 75. STD and TWI in anterolateral leads new since ___.
on d/c vitals wnl, exam unchanged, still has slightly tender
abdomen
Pertinent Results:
___ 05:25PM BLOOD WBC-6.4 RBC-4.22* Hgb-11.9* Hct-36.8*
MCV-87 MCH-28.2 MCHC-32.3 RDW-15.4 Plt ___
___ 05:25PM BLOOD Neuts-40.6* Lymphs-52.4* Monos-4.1
Eos-1.8 Baso-1.1
___ 05:25PM BLOOD ___ PTT-28.8 ___
___ 05:25PM BLOOD Glucose-83 UreaN-8 Creat-1.2 Na-137 K-4.3
Cl-97 HCO3-28 AnGap-16
___ 05:25PM BLOOD ALT-39 AST-40 AlkPhos-98 TotBili-0.3
___ 05:25PM BLOOD Albumin-4.4
ct abd
IMPRESSION: No acute findings to explain the patient's
abdominal pain.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
Hold for SBP < 100 or HR < 55
2. Hydrochlorothiazide 25 mg PO DAILY
3. CloniDINE 0.2 mg PO BID
Hold for SBP < 110
Discharge Medications:
1. Atenolol 100 mg PO DAILY
2. CloniDINE 0.2 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Ranitidine 75 mg PO DAILY
RX *ranitidine HCl [Acid Control] 75 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 17 g by
mouth daily Disp #*30 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary: constipation, abdominal pain, possible alcohol
gastritis
secondary: alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: None.
FINDINGS:
There are low lung volumes. This accentuates the size of the cardiac
silhouette which is mild to moderately enlarged. The aorta is tortuous. The
hilar contours are normal, and the pulmonary vascularity is not engorged.
There is minimal bibasilar atelectasis. No focal consolidation, pleural
effusion or pneumothorax is identified. There are no acute osseous
abnormalities.
IMPRESSION:
Low lung volumes with mild bibasilar atelectasis.
Radiology Report
INDICATION: History of hypertension and alcohol abuse, now with diffuse
abdominal pain and voluntary guarding with rebound tenderness on physical
exam, here to evaluate for acute intra-abdominal pathology.
COMPARISON: No prior studies available.
TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases to
the pubic symphysis following the uneventful administration of intravenous and
enteric contrast. Coronal and sagittal reformatted images were generated and
reviewed.
FINDINGS: The imaged lung bases show mild posterior dependent positional
changes. Limited imaging of the heart demonstrates enlarged size without
pericardial effusion. The distal esophagus and descending thoracic aorta are
within normal limits.
The liver enhances homogeneously without perfusion defects. Tiny sub-5-mm
hypodensities (5:19, 13), are too small to fully characterize, but most likely
represent benign biliary hamartomas. No suspicious focal hepatic lesion is
identified. No intrahepatic or extrahepatic biliary ductal dilation is seen.
The gallbladder is collapsed and otherwise unremarkable. The pancreas
enhances homogeneously without focal mass. There is no peripancreatic
stranding or fluid collection to suggest pancreatitis. The spleen is not
enlarged. The bilateral adrenal glands are within normal limits. Both
kidneys enhance symmetrically and excrete contrast normally without evidence
of hydronephrosis or solid renal mass.
The stomach is moderately distended with heterogeneous ingested contents mixed
with enteric contrast. The duodenum and intra-abdominal loops of small and
large bowel are unremarkable without evidence of wall thickening or
obstruction. A normal appendix is visualized in its entirety in the right
lower quadrant (5:31).
No free air or ascites is present. No retroperitoneal or mesenteric
lymphadenopathy is detected. The abdominal aorta is normal in caliber
throughout with mild calcified atherosclerosis involving the bilateral common
iliac arteries.
A small uncomplicated fat-containing ventral hernia is noted.
Evaluation of the pelvis is limited by metallic streak artifact from bilateral
hip prostheses. Within this limitation, the urinary bladder, rectum, sigmoid
colon, and prostate are within normal limits. The seminal vesicles are not
well seen. There is no free pelvic fluid or inguinal/pelvic lymphadenopathy
detected.
OSSEOUS STRUCTURES: The patient is status post bilateral total hip
arthroplasty. Healed fractures at the posterior left tenth and ninth ribs are
noted. No osseous destructive lesion concerning for malignancy is detected.
IMPRESSION: No acute findings to explain the patient's abdominal pain.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by OTHER
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS, ABDOMINAL PAIN UNSPEC SITE, NAUSEA WITH VOMITING, ALCOH DEP NEC/NOS-UNSPEC
temperature: 98.2
heartrate: 78.0
resprate: 16.0
o2sat: 96.0
sbp: 152.0
dbp: 105.0
level of pain: 8
level of acuity: 2.0 | ___ y/o M with h/o alcohol abuse p/w positional CP and abdominal
pain that he feels is related to alcohol. Pt was intiially on
the ___ service and they cardiologist felt this was unlikely
cardiac related and more likely abdominal pain related and pt
was transferred to medicine service for further workup.
.
#abdominal pain - Etiology likely from constipation (CT imaging
showing lots of stool in colon) vs alcohol gastritis vs PUD. ACS
was ruled out by serial EKGs while on the cardiology service.
Lipase/LFTs WNL. CT abdomen showing no acute findings except for
stool on colon. On exam he was diffusely tender and abdoinal
exam did not change while here but he was able to tolerate PO.
No fever/leukocytosis to suggest major infectious process. He
was started on ranitidine, was given bowel regimen with miralax,
senna, docusate, bisacodyly. H pylori serologies sent were neg.
He had BM day of d.c and was tolerating PO. He still had
abdominal pain when he was discharged and knows to follow up
with PCP for further workup if this persisits.
.
#. EtOH abuse - No reported h/o withdrawal seizures. Last drink
3 days prior to admission. Has did not score on CIWA. was given
Thiamine, folate, MVI. Social work saw him and pt showed no
interest in stopping alcohol
.
#. HTN
- Continued home medication regimen |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Flagyl / Keflex / lactated
ringers / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Headache, Left arm weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old right-handed man with
a history of myoclonic and abdominal seizures, undifferentiated
mitochondrial disorder, migraines, and radiculoneuropathy,
recent
prolonged hospitalization in ___ for perforated
diverticulitis s/p ___ repair and stomal retraction, now
s/p
reversal of colostomy who presents for evaluation of an 11 day
history of progressively severe headache and left arm weakness.
History provided by the patient.
Patient reports he was in his usual state of health until 11
days
prior to presentation. At that time, he began developing
gradual
onset of a headache. The headache was different than his
baseline headaches, which are discussed below. This pain was
different and that it was described as pain "deep inside"his
head, located over the occipital region with radiation towards
the left neck. He notes that it was somewhat similar to the
headache he experienced after having a post epidural headache
during his recent hospitalization in ___. However, it is
different from even that headache in that it is not as severe
and
is associated with left arm weakness. When the headache started
11 days ago, he did not make much of the headache as it was
quite
mild in severity. He was able to go about his usual activities.
___ days after the headache started, he tried taking his home
Zomig nasal spray, which typically aborts his migraines, and it
did not help. He also tried taking over-the-counter Tylenol,
Aleve, and Advil without relief. Over the last 11 days, the
pain
gradually became more severe and more debilitating. The pain
began to spread throughout his head, not just occipital but
spread into the right temporal area, and then the left temporal
area. The headache eventually became so severe, that it did
wake
him up from sleep multiple times (he is explicit about this).
Headache is not worsened with Valsalva. It is not positional.
It is associated with mild phonophobia and nausea. He denies
associated visual symptoms, denies any associated
numbness/tingling, denies vomiting, denies
lightheadedness/dizziness. It is not the worst headache of his
life.
Also, at some point throughout this time, his left arm began to
feel weak. He cannot pinpoint when exactly this started. He
noticed that the left arm did not have quite the same strength
and was slower to move than the right. Nonetheless, he was able
to do all the things with this arm that he wanted to do,
including opening and closing hands, and opening and closing
doors. He had never had associated weakness with his headaches
before.
Regarding his baseline headaches, he has what he describes as
migraines. These are characterized by throbbing pain located
between his eyes, associate with intense photophobia. These are
relieved by lying in a dark room and taking his sumatriptan
nasal
spray. He has no preceding aura. He has mild nausea without
vomiting associated with it. He has never had associated
weakness or sensory symptoms with a headache. Headaches
typically last for 6 hours and occur once a month.
Given his ongoing, refractory headache, he was planned to see
his
outpatient neurologist Dr. ___ 2 days ago, however the
appointment was canceled due to the ___ parade. As a
result,
due to ongoing symptoms that have led to his inability to
function and sleep properly, he came to the emergency room today
for further evaluation.
Of note, prior to onset of the symptoms above, patient denies
any
recent changes in his routine. He denies any recent new or
missed medications. His blood pressure have been running high
recently, and his nephrologist have plan to start losartan,
however patient was reluctant to do so due to difficulty
tolerating losartan in the past. No recent illness. No
fevers/chills, no recent upper respiratory symptoms. No recent
trauma. No recent neck manipulations. He has gone to the
barber
shop where his hair was washed on the open end sink 5 weeks ago.
Patient recently had a prolonged hospitalization in ___,
after presenting with perforated diverticulitis, status post
repair and stoma retraction, subsequently status post reversal
of
colostomy on ___. He required epidural placement for the
operation at T11/T12. Neurology was consulted postoperatively
due to intermittent severe headache status post procedure. This
headache was notably postural, worse with sitting or elevation
and improved with lying flat. He was felt to be likely due to
post epidural headache, less likely due to migraine. He
improved
with aggressive hydration and symptomatic treatment. For
workup,
he underwent MRI of the cervical spine which showed moderate to
severe degenerative disease without cord enhancement. He did
not
require placement of an epidural blood patch. There also was a
significant component of cervicalgia.
Regarding the remainder of his neurologic history:
- Per Dr. ___ consult note in ___: "Mr.
___ has a history of abdominal seizures, first diagnosed
in
___. While abroad for work in ___, he described eating tainted
fish that made him feel nauseous. On his trip back
to ___, he had fits of vomiting followed by severe fatigue.
His vomiting continued whenever he ate, and he lost 55 lb in 3
months. Around this time, he experienced myoclonic seizures with
full-body jerks as well, with occasional waves of pain that felt
like lanceting electrical shocks down the anterior aspects of
his
thighs. He began seeing Dr. ___ at ___ for his seizures in
___, and reports that his seizures have been well-controlled on
Lamictal 400mg/500mg and Onfi 20mg qhs with recent lamictal
level
in ___ being therapeutic. He reports that he has not had a
seizure in several years. Dr. ___ notes that Mr.
___ previously has had temporal seizures where he feels a
sense of familiarity/ unfamiliarity. These episodes usually last
a minute and are followed by fatigue."
- He has an undifferentiated Mitochondrial encephalomyopathy,
for
which he also follows w/ Dr. ___. Per OMR, in ___, Mr. ___ developed myoclonic jerks and lost 55 pounds in 3.5
months. He had additional symptoms including elevated lactic
acid, global fatigue, exercise-induced myalgias, small fiber
polyneuropathy, pain, and intermittent hypoxia with REM
hypoventilation. He was on a feeding tube for ___ years and was
diagnosed with abdominal epilepsy.
-At baseline, on neurologic exam he has "significant decreased
rapid coordinated function, specifically,rapid finger movements,
forearm alterations, hand tapping and also some cerebellar signs
with dysdiadochokinesis where he has difficulty doing
finger-nose-finger testing" per Dr. ___.
Past Medical History:
- recent hospitalization for diverticulitis as above
- Mitochondrial encephalomyopathy
- Migraines
-Benign prostatic hypertrophy
-OSA: Mild; Failed CPAP ___ inability to tolerate mask.
-Radicular leg pain: s/p epidural injections
-Positive PPD
-Ulceration in the terminal ileum ___
- Diverticulosis of the sigmoid colon & descending colon
___
- Anal fistula repair
-Right knee partial medial menisectomy
-Transurethral prostate resection ___ adenocarcinoma ___
Social History:
___
Family History:
- Mother had dementia and died at ___ ___ stroke.
- Father had DM and died at ___ ___ "old age".
- Oldest brother has colon and prostate cancer.
- Another brother has ankylosing spondylitis.
Physical Exam:
==============
ADMISSION EXAM
==============
Physical Exam:
Vitals: T 98.5F, HR 94, BP 153/90, RR 18, O2 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: no palpable muscle tension in neck. Supple, No nuchal
rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name 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 apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Fundoscopic
exam performed, revealed no papilledema, exudates, or
hemorrhages.
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 bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
+ Orbiting around L hand
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 4+* 5 4+* 5 4+* 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
4+/5 in bilateral ADM
*there is a give way weakness component, but even when asked to
give 2 seconds of best effort it is easily breakable.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS. Romberg with sway but not
positive.
-DTRs:
Bi Tri ___ Pat Ach
L ___ 1 0
R ___ 1 0
Plantar response was flexor on right, extensor on left.
-Coordination: No intention tremor. reduced speed and amplitude
of rapid alternating movements of hands, though not overtly
ataxic. No clear overshoot on cerebellar mirroring. No dysmetria
on HKS bilaterally.
-Gait: Good initiation. Gait is hesistant and somewhat wide
base, sways back and forth but not to either direction. No
truncal ataxia. Falls back in bed when asked to do tandem walk.
Can take a few steps without assistance, but is unsteady. Unable
to do Unteberger due to unsteadiness.
==============
DISCHARGE EXAM
==============
Unchanged except as noted below:
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
* Give-way weakness on every muscle tested on left side. All
were full strength on momentary best effort.
-Sensory: Proprioception intact to fine movements of bilateral
index fingers and great toes. No deficits to light touch
throughout.
-Coordination: FNF intact bilaterally.
-Gait: Ambulating independently with normal gait, stride, base.
Pertinent Results:
====
LABS
====
___ 04:30AM BLOOD WBC-11.1* RBC-4.75 Hgb-15.5 Hct-46.2
MCV-97 MCH-32.6* MCHC-33.5 RDW-12.9 RDWSD-46.5* Plt ___
___ 04:30AM BLOOD Neuts-44.2 ___ Monos-6.7 Eos-3.9
Baso-0.5 Im ___ AbsNeut-4.90 AbsLymp-4.91* AbsMono-0.74
AbsEos-0.43 AbsBaso-0.06
___ 04:30AM BLOOD Glucose-83 UreaN-18 Creat-1.0 Na-145
K-4.7 Cl-105 HCO3-26 AnGap-14
___ 10:50AM BLOOD ALT-16 AST-14 CK(CPK)-70 AlkPhos-75
TotBili-0.3
___ 04:30AM BLOOD Calcium-9.4 Phos-4.2 Mg-1.9
___ 10:50AM BLOOD Triglyc-275* HDL-35* CHOL/HD-6.1
LDLcalc-123
___ 10:50AM BLOOD %HbA1c-5.4 eAG-108
___ 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
=======
IMAGING
=======
- ___ MRI & MRA Brain WITHOUT Contrast, MRA Neck WITH
Contrast
1. No significant intracranial abnormality. No evidence of acute
infarction, hemorrhage or mass.
2. Patent intracranial and cervical vasculature without evidence
of
dissection, stenosis, occlusion or aneurysm formation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobazam 20 mg PO QHS
2. ZOLMitriptan 5 mg nasal ASDIR
3. TraZODone ___ mg PO QHS:PRN insomnia
4. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder
Discharge Medications:
1. Clobazam 20 mg PO QHS
2. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder
3. TraZODone ___ mg PO QHS:PRN insomnia
4. ZOLMitriptan 5 mg nasal ASDIR
5.Outpatient Physical Therapy
Cervical musculoskeletal pain
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
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 headache// acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is borderline enlarged, unchanged. The mediastinal and hilar
contours are normal. The pulmonary vasculature is normal. Mild atelectasis in
the right middle lobe is noted without focal consolidation. Remainder of the
lungs are clear. No pleural effusion or pneumothorax is seen. There are no
acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK.
INDICATION: History: ___ with headache and left arm weakness// Eval for
vascular/hemorrhagic etiology of headache and weakness.
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
intravenous administration of 70 mL of Omnipaque 350 nonionic contrast.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 32.4 mGy (Body) DLP =
16.2 mGy-cm.
3) Spiral Acquisition 5.4 s, 42.5 cm; CTDIvol = 15.3 mGy (Body) DLP = 649.7
mGy-cm.
Total DLP (Body) = 666 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: MRI MRA brain ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction, intracranial hemorrhage,edema,ormass. The
ventricles and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses demonstrate mild mucosal
thickening in the ethmoidal air cells, no air-fluid levels are seen,mastoid
air cells,and middle ear cavities are clear. Soft tissue density along the
external auditory canals is consistent with cerumen. 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:
The carotidandvertebral 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:
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.
The visualized portion of the lungs are clear. There is no lymphadenopathy by
CT size criteria.
IMPRESSION:
1. Essentially normal head and neck CTA.
2. Please note that MRI is more sensitive for evaluation of acute/subacute
ischemic changes.
3. Mild mucosal thickening identified in the ethmoidal air cells bilaterally,
no air-fluid levels are seen.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR HEAD NECK.
INDICATION: ___ year old man with hx of underlying undifferentiated
midochondrial disorder of adult onset, presenting with progressive headache
and L arm weakness, eval for stroke// eval for stroke.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration intravenous
contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: None.
FINDINGS:
MRI BRAIN:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. There are scattered T2/FLAIR hyperintensities in the cerebral
hemispheres bilaterally, a nonspecific finding and likely related to chronic
small vessel ischemic changes.
The ventricles and sulci are normal in caliber and configuration.
Major vascular flow voids are preserved. Major dural venous sinuses are
patent.
There is mucosal thickening along the ethmoid air cells. Note is made of
partial opacification of the right mastoid air cells. The left mastoid air
cells are clear.
MRA BRAIN:
The intracranial vertebral and internal carotid arteries and their major
branches appear normal without evidence of stenosis, occlusion, or aneurysm
formation. Note is made of a right fetal PCA, normal anatomic variant.
MRA NECK:
The common, internal and external carotid arteries appear normal. There is no
evidence of internal carotid artery stenosis by NASCET criteria. The origins
of the great vessels, subclavian and vertebral arteries appear normal
bilaterally.
IMPRESSION:
1. No significant intracranial abnormality. No evidence of acute infarction,
hemorrhage or mass.
2. Patent intracranial and cervical vasculature without evidence of
dissection, stenosis, occlusion or aneurysm formation.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Headache
Diagnosed with Headache, Weakness
temperature: 98.5
heartrate: 94.0
resprate: 18.0
o2sat: 97.0
sbp: 153.0
dbp: 90.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ year-old right-handed man with a history
of myoclonic and abdominal seizures, undifferentiated
mitochondrial disorder, migraines, and radiculoneuropathy,
recent prolonged hospitalization in ___ for perforated
diverticulitis s/p ___ repair and stomal retraction, now
s/p reversal of colostomy who presents for evaluation of an 11
day history of progressively severe headache and left arm
weakness. Given his history and constellation of symptoms, he
was admitted for neuroimaging to evaluate for central process.
MRI was negative for stroke or other CNS lesion. Exam was
notable for give-way weakness on left side with normal
proprioception and sensation. His headache improved moderately
with a migraine cocktail. He endorsed significant
musculoskeletal discomfort and was seen by ___. He will be
discharged home with a cervical soft collar and will follow-up
with Dr. ___ week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Portal vein thrombus
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F h/o HCC presenting from clinic with portal vein
thrombus. Pt presented to ___ oncology appt at ___ today.
Pt c/o non-radiating epigastric pain ___, worsening over the
past 2 weeks. Denies associated n/v/d. U/S in clinic showed new
non-occlusive portal vein thrombosis and was sent in to the ED.
.
Pt first diagnosed with HCC last year. She had been followed for
chronic hep C by GI. AFP noted to be elevated and pt had MRI
which demonstrated 18 mm liver mass. s/p cyberknife ___. AFP
has continued to rise. This was discussed with ___ GI who felt
this may be ___ thrombus vs infiltrative malignancy.
.
In the ED: af/vss. RUQ u/s with dopplers showed apparent
thrombus in the right anterior portal vein. ALT/AST 132/125, ap
143, tbili 0.6.Given lovenox and admitted to omed.
.
ROS: as above, otherwise complete ROS negative.
Past Medical History:
___
DM2 on insulin
CKD
Hypothyroidism
Hypertension
Hypercholesteremia
GERD
Social History:
___
Family History:
no known FH of cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
___ 140/70 61 20 96%ra
NAD
eomi, perrl
neck supple
no ___
chest clear
rrr
abd soft, non-ttp
ext w/wp
neuro: non-focal
no rash
DISCHARGE PHYSICAL EXAM:
VS: 97.7, 124/56, 59, 18, 95RA
GENERAL: Lying in bed and then walking around in NAD
HEENT: anicteric sclera, moist mucous membranes
CARDIAC: RRR, no MRG
LUNG: CTAB
ABD:soft, nondistended, +BS, mild tenderness to deep palpation
in superior epigastric area.
EXT: moving all extremities well, no peripheral edema
PULSES: 2+ DP and ___ pulses bilaterally
NEURO: alert and oriented, no asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 01:30PM BLOOD WBC-5.4 RBC-4.71 Hgb-15.4 Hct-48.4*
MCV-103* MCH-32.7* MCHC-31.8 RDW-13.6 Plt ___
___ 01:30PM BLOOD Neuts-69.8 ___ Monos-4.5 Eos-1.3
Baso-3.3*
___ 01:30PM BLOOD ___ PTT-42.5* ___
___ 01:30PM BLOOD Glucose-159* UreaN-27* Creat-1.4* Na-138
K-5.2* Cl-103 HCO3-24 AnGap-16
___ 01:30PM BLOOD ALT-132* AST-125* AlkPhos-143*
TotBili-0.6
___ 01:30PM BLOOD Lipase-44
___ 01:30PM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.7 Mg-2.4
___ 01:42PM BLOOD Lactate-2.2*
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-4.5 RBC-4.34 Hgb-14.4 Hct-44.1
MCV-102* MCH-33.1* MCHC-32.5 RDW-13.9 Plt ___
___ 06:20AM BLOOD ___ PTT-46.5* ___
___ 06:20AM BLOOD Glucose-91 UreaN-17 Creat-1.2* Na-139
K-4.5 Cl-103 HCO3-27 AnGap-14
___ 06:20AM BLOOD ALT-107* AST-98* AlkPhos-110* TotBili-0.5
___ 06:20AM BLOOD Albumin-3.7 Calcium-9.4 Phos-3.4 Mg-2.3
___ MRI ABDOMEN
1. Limited study due to non breath hold technique.
2. Cirrhotic liver. Treated segment V HCC, allowing for
differences in
technique is minimally smaller since ___.
3. Large wedge-shaped area of perfusion abnormality in the
anterior right
hepatic lobe, relates to new thrombus within the anterior branch
of the right portal vein.
4. A 10 mm segment ___ lesion with arterial hyperenhancement
and
questionable washout, minimally larger ___, is
worrisome for ___
but currently not meeting criteria for OPTN 5 lesion.
___ RUQ ULTRASOUND WITH DOPPLER
1. Reversal of flow in the right portal vein and apparent
thrombus in the
right anterior portal vein with either some peripheral flow in
the setting of non-occlusive thrombus or collateralization
around the thrombosed vessel.
2. Large gallstones in a prominent but otherwise normal
gallbladder.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 50 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. colestipol 2 grams oral daily
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Glargine 26 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Chlorthalidone 50 mg PO DAILY
4. colestipol 2 grams oral daily
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Glargine 26 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Portal vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Likely ___, found to have portal vein thrombosis on outpatient
MRI. Evaluate for presence of portal vein thrombosis, please assess with
Doppler flow.
COMPARISON: MRI abdomen ___.
TECHNIQUE: Grayscale, color and spectral Doppler ultrasound evaluation of the
liver.
FINDINGS: There is somewhat heterogeneous echogenicity throughout the liver
which is better evaluated on recent MRI; however, no large focal lesions are
detected. There is no intra- or extra-hepatic biliary duct dilation. The
main portal vein is patent with hepatopetal flow. The left portal vein is
patent with hepatopetal flow. There is reversal of flow in the right portal
vein. The right posterior portal vein appears patent with hepatopedal flow.
There is apparent thrombus in the right anterior portal vein with either some
peripheral flow in the setting of non-occlusive thrombus or collateralization
around the thrombosed vessel. The IVC and hepatic veins are patent. The main
hepatic artery is patent with normal spectral waveform.
The CBD measures 6 mm. The gallbladder is prominent containing numerous large
shadowing stones but without wall thickening or pericholecystic fluid to
suggest cholecystitis. Pancreas is normal without focal lesions or pancreatic
duct dilation. There is no ascites.
IMPRESSION:
1. Reversal of flow in the right portal vein and apparent thrombus in the
right anterior portal vein with either some peripheral flow in the setting of
non-occlusive thrombus or collateralization around the thrombosed vessel.
2. Large gallstones in a prominent but otherwise normal gallbladder.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: Abd pain, ABNL LABS
Diagnosed with PORTAL VEIN THROMBOSIS
temperature: 96.9
heartrate: 58.0
resprate: 16.0
o2sat: 99.0
sbp: 131.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | ___ with HCV cirrhosis and ___ s/p cyberknife sent in for
evaluation of portal vein thrombosis.
# PORTAL VEIN THROMBUS: Etiology of thrombus is either due to
tumor vs clot. She was initially started on anticoagulation x 1
(Lovenox and warfarin) which was stopped after review of images
revealed this could be tumor clot, which would not need
anticoagulation. Hepatology was consulted. She has also never
had an EGD despite known cirrhosis, and she will require
outpatient EGD to rule out varices prior to discussion of
anticoaguation. She will be discussed at upcoming Liver Tumor
conference.
# HCC: s/p cyberknife. There is concern for possible progression
of her tumor. LFTs were stable in obstructive pattern. She did
not have jaundice or asterixis on exam. She was asymptomatic and
will need outpatient hepatology followup.
# CIRRHOSIS FROM CHRONIC HEP C. No evidence of decompensation.
No ascites or asterixis on exam.
# DM2: Initially hypoglycemic in ___ and complained of
presyncope, which resolved after dextrose administration.
Continue home glargine and ISS.
# HYPERTENSION: Orthostatics negative. Continue home amlodipine
and atenolol.
# CKD: Cr stable in 1.0-1.2 range.
# HYPOTHYROIDISM: Cont home levothyroxine
#CODE: Full
#CONTACT: neighbor ___ (___)
### ___ ISSUES ###
-No medication changes
-Will need outpatient EGD to rule out varices
-Needs hepatology followup |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a right handed man with history of chronic
labyrinthitis, HLD, diabetes, R caudate infarct, CAD s/p CABG
who
presents with vertigo and a code stroke was called. Today, he
had laser eye surgery on the left at 1pm. At 3pm, he developed
dizziness. He describes a "wave like" sensation, not quite room
spinning. There was associated nausea, no vomiting. Symptoms
improved with closing his eyes. He took ativan (what he usually
takes) without relief. He denies associated diplopia,
clumsiness,
focal weakness, headache. There was gait unsteadiness but due
to
the dizziness. This was identical to his typical episodes of
dizziness in quality, but increased in severity. As his
symptoms
persisted, his great niece called ___. Here, he was treated
with
zofran and had improvement of symptoms.
Mr. ___ has had vertigo since ___ when he punctured his
right
ear drum during a dive. After surgery, he had some improvement
in vertigo. For the last several weeks, he has had increasing
bouts of vertigo compared to baseline. He has these episodes
daily and they are intermittent, occuring several times
throughout the day. The intensity of the vertigo has been more
severe lately as well. The episodes are spontaneous but can
also
be triggered by movement. Vertigo is worse with lying down,
and
he is lightheaded in mornings. He is rarely naueaous with
vertigo. He takes ativan as needed for vertigo at home, up to
4mg/day. Yesterday he took 2mg. At baseline, his gait is
somewhat unsteady, especially when he is dizzy. He does not
tend
to fall to one side or the other. A few weeks ago, he had a
fall. His wife passed away from a stroke 5 months ago and he
has
been under a lot of stress.
On neuro ROS, deaf in R ear; the pt denies headache, loss of
vision, blurred vision, diplopia, dysarthria, dysphagia,
tinnitus. Denies difficulties producing or comprehending speech.
Denies focal weakness, numbness, parasthesiae. No bowel or
bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria.
Past Medical History:
1. Chronic Labyrinthitis
2. Hypercholesterolemia
3. Coronary Artery Disease s/p CABG ___
4. History of recurrent vomiting in ___, normal EGD.
5. Macular degeneration
6. Type II Diabetes
7. Lightheadedness--autonomic testing was normal; was encouraged
to hydrate
8. Small R caudate infarct on MRI ___ seen incidentally
Social History:
___
Family History:
Significant for HTN, DM, heart disease. Father with prostate
cancer.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
Vitals: T 97.6 HR 71 BP 158/93 RR 16 O2 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT; head impulse test neg
Neck: Supple.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, ___, date. 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. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Pt. was able to register
3 objects and recall ___ at 5 minutes. There was no evidence
of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI. On upgaze, torsional nystagmus to the left.
Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch, proprioception throughout.
Decreased sensation to pin prick distally in feet. No extinction
to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor on right, equivocal on left.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Slightly wide-based, normal stride and
arm swing. Slightly unsteady, veered to the left (at home also
veers to right). Romberg with sway. ___ neg.
========================
DISCHARGE PHYSICAL EXAM
========================
Unchanged from admission physical exam apart from:
-Improvement in and stabilization of gait.
-On repeat sensory exam, pt was found to have a decrease in
proprioception and vibration in the right>left lower extremity.
Temperature and pinprick were intact.
Pertinent Results:
=========
LABS
=========
___ 04:35PM BLOOD VitB___* Folate-GREATER TH
___ 04:35PM BLOOD TSH-2.1
___ 06:35PM URINE Color-Straw Appear-Hazy Sp ___
___ 06:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
___ 06:35PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE.
=========
IMAGING
=========
NCHCT (___):
No acute intracranial abnormality.
MRI CERVICAL SPINE WITHOUT CONTRAST (___):
1. Multilevel, multifactorial degenerative changes as described
above.
At C5-6 a large disc osteophyte complex flattens the cord
without underlying cord signal change. In addition, there is
severe left neural foraminal narrowing and moderate to severe
right neural foraminal narrowing.
2. At C4-5, there is osteophyte which minimally remodels the
ventral aspect of the cord. There is severe right neural
foraminal narrowing and moderate left neural foraminal
narrowing.
3. At C6-7 there is severe left neural foraminal narrowing and
moderate right neural foraminal narrowing.
4. Additional less prominent multilevel and multifactorial
spondylosis as
described above.
5. Incompletely characterized are T2 hyperintense nodules within
expected
location of the thyroid gland measuring up to 1.2 cm on the
sagittal images. Correlation with clinical history and prior
imaging if available. Recommend further evaluation with thyroid
ultrasound if clinically indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fluoxetine 10 mg PO DAILY
3. Repaglinide 0.5 mg PO TIDAC
4. Atorvastatin 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Fluoxetine 10 mg PO DAILY
4. Repaglinide 0.5 mg PO TIDAC
5. Lorazepam 0.5 mg PO BID PRN vertigo
6. Restasis (cycloSPORINE) 0.05 % ophthalmic BID left eye
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
9. Outpatient Physical Therapy
ICD-9-CM 438.85 Vertigo
Will need ___ rehab.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: chronic vertigo, cervical stenosis, macular
degeneration
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: ___ man with acute onset vertigo.
TECHNIQUE: Contiguous multidetector CT scan through the head was performed
without intravenous contrast. Axial images displayed as separate 5 mm soft
tissue and 2.5 mm bone algorithm image series. Multiplanar reformation was
performed to construct coronal and sagittal images.
DOSE: DLP: 891.93 mGy-cm. CTDIvol: 55.75 mGy.
COMPARISON: MRI from ___.
FINDINGS:
There is no acute intracranial hemorrhage, edema, mass effect, or evidence of
large vascular territorial infarction. Prominence of the ventricles and sulci
is consistent with age-related involutional changes. There is atherosclerotic
calcification of the bilateral cavernous carotid arteries. There are
non-specific periventricular and subcortical white matter hypodensities which
can be seen in patients with chronic small vessel ischemia. There is no
fracture. The imaged paranasal sinuses, mastoid air cells, and middle ear
cavities are clear.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST
INDICATION: ___ year old man with loss of proprioception, falls //
?spondylosis
TECHNIQUE: Sagittal T1, T2 and sagittal IDEAL sequences were obtained through
the cervical spine, axial T2 and MERGE images were also obtained.
COMPARISON: MRI and MRA brain of ___.
FINDINGS:
Incidental note is made of ___ cisterna magna, unchanged appearance from
prior exam. The visualized posterior fossa is otherwise unremarkable.
The craniocervical junction is unremarkable.
Severe loss of disc height at C5-6 is noted. Moderate loss of disc height at
C6-7 is also seen. The remainder of the disc heights are preserved. Vertebral
body heights are maintained.
A prominent fat rest at the inferior endplate of C3 is noted; and also in the
articular process of T1.
Small 1 hypointense and Water-Ideal hyperintense foci are in the C4 and T1
spinous pocesses (se 3, im 10)-? Cystic foci or focal lesions.
There is mild 1-2 mm anterolisthesis of T2 on 3.
There are no cord signal abnormalities.
C2-3: Mild left uncovertebral arthropathy is identified as well as infolding
of the ligamentum flavum. There is no significant spinal canal or neural
foraminal narrowing.
C3-4: There is a central disc protrusion which minimally effaces the ventral
aspect of the thecal sac without contacting the cord. Infolding of the
ligamentum flavum is also noted. There is right greater than left
uncovertebral arthropathy and facet arthropathy resulting in moderate
bilateral neural foraminal narrowing.
C4-5: There is a right paracentral osteophyte which flattens the ventral
aspect of the thecal sac with suggestion of minimal remodeling of the ventral
aspect of the cord without underlying cord signal change. Infolding of the
ligamentum flavum is also noted. There is right greater than left
uncovertebral and facet arthropathy, resulting in moderate-severe right neural
foraminal narrowing and moderate left neural foraminal narrowing.
There is a 8 mm presumed to synovial cyst, which projects posteriorly into the
midline paraspinal soft tissues just inferior to the spinous process of C4
(series 6, image 22).
C5-6: There is a large disc osteophyte complex, eccentric to the left which
flattens the cord without underlying cord signal change. Infolding of the
ligamentum flavum is also noted. There is also superimposed left much greater
than right uncovertebral and facet arthropathy resulting in severe left neural
foraminal narrowing and moderate to severe right neural foraminal narrowing.
C6-7: There is a central disc osteophyte complex which effaces the ventral
aspect of thecal sac without contacting the cord. Left greater than right
uncovertebral and facet arthropathy results in severe left neural foraminal
narrowing and moderate right neural foraminal narrowing.
C7-T1: No significant spinal canal or neural foraminal narrowing.
On sagittal images, there are small central disk protrusions at the T2-3 and
T3-4 levels, without significant spinal canal or neural foraminal narrowing.
Other: Incompletely visualized are T2 hyperintense nodules measuring up to 1.2
cm on sagittal images, in the expected location of the thyroid gland. The
paraspinal soft tissues are unremarkable.
IMPRESSION:
1. Multilevel, multifactorial degenerative changes as described above.
At C5-6 a large disc osteophyte complex flattens the cord without underlying
cord signal change. In addition, there is severe left neural foraminal
narrowing and moderate to severe right neural foraminal narrowing.
2. At C4-5, there is osteophyte which minimally remodels the ventral aspect of
the cord. There is severe right neural foraminal narrowing and moderate left
neural foraminal narrowing.
3. At C6-7 there is severe left neural foraminal narrowing and moderate right
neural foraminal narrowing.
4. Additional less prominent multilevel and multifactorial spondylosis as
described above.
5. Incompletely characterized are T2 hyperintense nodules within expected
location of the thyroid gland measuring up to 1.2 cm on the sagittal images.
Correlation with clinical history and prior imaging if available. Recommend
further evaluation with thyroid ultrasound if clinically indicated.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Vertigo
Diagnosed with VERTIGO/DIZZINESS
temperature: 97.6
heartrate: 71.0
resprate: 16.0
o2sat: 97.0
sbp: 158.0
dbp: 93.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a right handed man with past medical history
including chronic labyrinthitis, hyperlipidemia, diabetes
mellitus (type 2), prior right caudate infarct, and coronary
artery disease status post CABG who presented to the ___ ED
___ with acute worsening of his chronic vertigo. NCHCT was
unremarkable. Due to pt's inability to ambulate independently,
he was admitted to the stroke neurology service for further
management.
While on the floor, pt was noted to have loss of vibration and
proprioception in the right > left lower extremity. He denied
any recent urinary incontinence or saddle anesthesia. Due to
these exam findings, pt underwent an MRI of the cervical spine
which showed cervical spondylosis. There was no cord
compression. Physical therapy worked with patient who
recommended home with outpatient physical therapy. TSH, RPR,
B12, and folate were all normal.
During hospital stay, pt's vertiginous symptoms greatly
improved. Pt will undergo ___ rehab as an outpatient to
further treat his chronic labyrinthitis.
Otherwise, pt was continued on home medications for his chronic
medical conditions while in the hospital.
==========================
TRANSITIONS OF CARE
==========================
-MRI cervical spine incidentally showed: "Incompletely
characterized are T2 hyperintense nodules within expected
location of the thyroid gland measuring up to 1.2 cm on the
sagittal images. Correlation with clinical history and prior
imaging if available. Recommend further evaluation with thyroid
ultrasound if clinically indicated."
-Will need ___ rehab and physical therapy as an
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left sided plegia, dysarthria.
Major Surgical or Invasive Procedure:
PICC line placement.
History of Present Illness:
The pt is a ___ year-old right-handed female with history of ADHD
on stratera who presents with onset of slurred speech and left
sided speech this afternoon.
She was in her usual state of health until this afternoon/this
morning when she was with friends in a car smoking K2. She felt
like she was having an "anxiety attack" and went home. ___
describes shortness of breath, palpitations and says she "felt
like [she] was going to die of a heart attack". She went home
and tried to take deep breaths, count backwards from 10, take a
drink of cold water which helped a little. The history is then
unclear as to when she developed the slurred speech and
weakness.
.
Per the history mom was given, her friend was at her apartment
with her and she came out of her room some time around 2 or 3pm.
At that time her speech was slurred and she had difficulty
standing up. He had her sit on the couch and she fell to the
ground. This friend then called her boyfriend who was at work
and
unable to come see her. He called another friend who picked her
up and took her to the ED in ___. Per mom, she thinks she
was left at the ED without much of a history being given.
.
In the ED at ___, she was combative and
agitated. Unable to perform NIHSS due to agitation. There she
had a CT head which was reportedly unremarkable. MRI performed
after ativan.
Past Medical History:
ADHD
Bipolar Disorder (?)
Borderline personality traits (?)
Social History:
___
Family History:
Patient is adopted.
Physical Exam:
ADMISSION EXAM
.
Physical Exam:
99.1 °F (37.3 °C), Pulse: 79, RR: 14, BP: 127/99, O2Sat: 100 RA,
Pain: 0.
General: Drowsy, dozes off to sleep but arouseable easily.
HEENT: NCAT, 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, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
HSM.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. LLE cool to touch but with strong pulse
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Alert, oriented to name, "hospital", ___
___. Able to relate history with constant stimulation and
repetitive questioning. Continuously dozes off to sleep but
wakes with minimal tactile stimulation. Inattentive, able to
name ___ backward without difficulty. Language is fluent with
intact. Following commands, with repetition. There were no
appreciated
paraphasic errors. Pt. was able to name high frequency objects.
Speech was mildly dysarthric. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF unable to be assessed.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI unreliably tested due to sedation, appears to
have full horizontal gaze. Normal saccades.
V: Facial sensation intact to light touch.
VII: Dense L facial droop in upper motor neuron pattern.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes with deviation to the left.
.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 2 2 2 0 0 0 0 0 2 2 0 0 0 0
R 5 5 5 ___ 5 5 5 5 5 5 5 5
.
-Sensory: Diminished sensation to all modalities. Extinction to
DSS.
.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response was upgoing on L, withdrawal on the R.
.
-Coordination: No intention tremor, no dysdiadochokinesia on the
R. No dysmetria on FNF or HKS bilaterally.
.
-Gait: deferred.
PERTINENT FINDINGS ON DISCHARGE:
Patient demonstrated wakefulness, attention, and improved speech
daily. She remains hemiplegic on the left with no movement on
the L side even to noxious stimuli. There is a left facial
droop. Reflexes are brisk, and upgoing on the left plantar. She
is inattentive to her left side. Mentation and mood are off for
the circumstance.
Pertinent Results:
LABS ON ADMISSION:
------------------
___ 08:50AM %HbA1c-5.3 eAG-105
___ 08:50AM TRIGLYCER-62 HDL CHOL-54 CHOL/HDL-3.4
LDL(CALC)-117
___ 08:50AM CRP-1.4
___ 08:50AM SED RATE-3
___ 02:02AM ASA, ETHANOL, ACETMNPHN, bnzo, barbit, tricyc
= NEG
___ 01:50AM URINE bnzo, bbit, opiat, cocain, amphetmn,
mthdone = NEG
___ 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 01:50AM URINE COLOR-Straw APPEAR-Clear SP ___
.
PERTINENT LABS DURING WORK-UP:
___ 08:50AM BLOOD ACA IgG-2.2 ACA IgM-4.4
___ 08:50AM BLOOD AT-108 ProtCFn-77 ProtSFn-96
___ 08:50AM BLOOD Lupus-NEG
___ 08:50AM BLOOD ALT-10 AST-15 LD(LDH)-140 AlkPhos-39
TotBili-0.2
___ 02:02AM BLOOD CK(CPK)-85
___ 02:02AM BLOOD cTropnT-<0.01
___ 02:02AM BLOOD CK-MB-2
___ 08:50AM BLOOD %HbA1c-5.3 eAG-105
___ 08:50AM BLOOD Triglyc-62 HDL-54 CHOL/HD-3.4 LDLcalc-117
___ 06:29AM BLOOD TSH-1.4
.
___ 04:21AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
___ 08:50AM BLOOD PROTHROMBIN MUTATION ANALYSIS-PND
___ 08:50AM BLOOD FACTOR V LEIDEN-PND
.
LABS ON DISCHARGE:
------------------
___ 04:34AM BLOOD WBC-8.7 RBC-4.36 Hgb-12.9 Hct-39.4 MCV-90
MCH-29.5 MCHC-32.6 RDW-14.1 Plt ___
___ 04:34AM BLOOD ___ PTT-35.3 ___
___ 04:34AM BLOOD Glucose-84 UreaN-15 Creat-0.6 Na-138
K-4.0 Cl-100 HCO3-28 AnGap-14
___ 04:34AM BLOOD Calcium-9.7 Phos-4.8* Mg-1.8
___ 04:34AM BLOOD Osmolal-285
.
IMAGING:
--------
CTA HEAD/NECK ___:
IMPRESSION:
1. Very large relatively acute infarct involving much of the
right middle
cerebral arterial distribution, with only slight mass effect
upon the
overlying gyri and subjacent body of the right lateral
ventricle, and no
subfalcine or more central herniation.
2. No evidence of hemorrhagic conversion.
3. Abrupt occlusion of the right MCA at its mid-M1 segment,
which may relate to thrombosis, given the hyperattenuating
material in the immediately more distal portion as seen on the
NECT or, alternatively, to focal dissection or vasospasm, or
some combination of these. There is minimal distal flow, largely
provided by meningeal collateral vessels.
4. Otherwise, unremarkable intracranial circulation and cervical
vessels;
specifically, there is a normal appearance to the right common
and internal carotid arteries, without significant plaque or
flow-limiting stenosis.
.
NCHCT ___:
IMPRESSION:
1. New mild (4 mm) leftward parafalcine herniation, with
associated mild
effacement of the right lateral ventricle.
2. Evolving large right MCA territory infarct, with no evidence
of
hemorrhagic conversion.
3. The suprasellar and quadrigeminal cisterns remain preserved.
.
ECHOCARDIOGRAM ___:
The left atrium and right atrium are normal in cavity size. A
patent foramen ovale is present. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). No masses or thrombi are seen in the left
ventricle. 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: Patent foramen ovale. Normal global and regional
biventricular systolic function.
.
NCHCT ___:
IMPRESSION: Unchanged appearance of a large right MCA territory
infarct, with continued mild effacement of the right lateral
ventricle. Slight deformity on the right uncus. Consider close
followup. No new mass effect or hemorrhagic conversion.
Asymmetry in the lateral atlanto-axial distances is likely
positional and can be correlated clinically for significance.
.
BILATERAL LOWER EXTREMITY DOPPLER U/S ___:
IMPRESSION: No evidence of lower extremity deep vein thrombosis.
.
NCHCT ___:
IMPRESSION: There is expected further evolution of the large
right MCA
territorial infarct with a minimal increase in leftward shift of
normally
midline structures and no evidence of significant central
herniation.
.
NCHCT ___:
IMPRESSION: Stable appearance of large right MCA infarct with
leftward shift of normally midline structures.
.
MRV PELVIS ___:
IMPRESSION:
1. No evidence for a pelvic venous thrombus.
2. 3.6 cm minimally complex right ovarian cyst, probably within
physiologic allowance in a patient of this age, followup pelvic
ultrasound suggested in six weeks to ensure stability or
resolution.
.
MR HEAD ___:
IMPRESSION: Redemonstration of the extensive subacute right
middle cerebral arterial territorial infarction, with similar
degree of subfalcine but no more central herniation. There is
evidence of hemorrhagic conversion in the involved deep gray
matter structures of the striatum, as well as likely early
dystrophic mineralization related to cortical pseudo-laminar
necrosis.
Medications on Admission:
-Stratera 50mg
-Minessa (OCP)
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right middle cerebral artery stroke.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
.
Neuro examination at discharge:
Patient demonstrated wakefulness, attention, and improved speech
daily. She remains hemiplegic on the left with no movement on
the L side even to noxious stimuli. There is a left facial
droop. Reflexes are brisk, and upgoing on the left plantar. She
is inattentive to her left side. Mentation and mood are off for
the circumstance.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with recent stroke and PFO. Evaluate for DVT.
COMPARISONS: None.
FINDINGS: There is no evidence of lower extremity DVT. The bilateral common
femoral veins have appropriate flow and normal response to Valsalva.
Bilateral common femoral veins, greater saphenous veins, superficial femoral
veins, popliteal veins, peroneal veins, and posterior tibial veins are patent
with normal compressibility. There is normal response to augmentation.
IMPRESSION: No evidence of lower extremity deep vein thrombosis.
Radiology Report
INDICATION: ___ woman with right MCA stroke; evaluate for midline
shift and increased swelling.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered.
COMPARISON: Comparison was made with CT head on ___ as well as a series
of studies dating back to ___.
FINDINGS: There is expected further evolution of the extensive subacute
infarction throughout the right MCA territory. Compared to study on ___,
there is no significant increase in extent of cytotoxic edema. The shift of
normally-midline structures is minimally increased, measuring 8.5 mm today
compared to ___, when it measured 7.0 mm. The effacement of the right
lateral ventricle is unchanged compared to ___, but increased compared to
___. The ventricular size is unchanged compared to ___. There are
several relatively hyperattenuating foci within the infarcted region, isodense
to surrounding brain (~25 ___ that likely represent "islands" of spared gray
matter, rather than hemorrhagic conversion. There is no significant central
herniation. There are no new regions of infarction.
IMPRESSION: There is expected further evolution of the large right MCA
territorial infarct with a minimal increase in leftward shift of normally
midline structures and no evidence of significant central herniation.
Radiology Report
INDICATION: ___ female with right MCA stroke.
___ at approximately 9:00 a.m.
TECHNIQUE: Axial CT images through the head were acquired without intravenous
contrast.
FINDINGS: Compared to examination approximately nine hours prior, there has
been little interval change. Infarct in the region of the right MCA territory
appears similar with a large area of hypodensity with interspersed
hyperdensity, which likely represents areas of spared gray matter. There is 9
mm of leftward shift of normally midline structures, which is stable compared
to prior. Mass effect on the right lateral ventricle, fourth ventricle, and
minimally on the basal cisterns on the right appears similar. There is no
evidence for large new hemorrhage. There is no evidence for significant
central herniation or new infarction.
Evaluation near the skull base is affected by motion artifact. Within this
limitation, the visualized portions of the paranasal sinuses and mastoid air
cells appear well aerated. No acute bony findings are detected.
IMPRESSION: Stable appearance of large right MCA infarct with leftward shift
of normally midline structures.
Radiology Report
HISTORY: ___ woman with right MCA stroke and patent foramen ovale,
assess for DVT in the pelvis.
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5
Tesla magnet including dynamic 3D imaging obtained prior to, during, and after
the uneventful intravenous administration of 0.1 mmol/kg (10 mL) of Ablavar.
COMPARISON: No prior studies available for comparison.
FINDINGS:
The IVC, bilateral common iliac, bilateral external and internal iliac veins
are all patent with normal directionality of flow. The uterus is anteverted
and anteflexed. There is a 3.5-cm cyst in the right ovary, this contains two
small internal septations superiorly (6:50) which may in fact represent
adjacent small cysts; however, followup ultrasound in six weeks is recommended
to ensure stability. The left ovary is normal in appearance. The urinary
bladder and rectum are unremarkable in appearance. No pelvic lymphadenopathy.
The visualized osseous structures are unremarkable.
IMPRESSION:
1. No evidence for a pelvic venous thrombus.
2. 3.6 cm minimally complex right ovarian cyst, probably within physiologic
allowance in a patient of this age, followup pelvic ultrasound suggested in
six weeks to ensure stability or resolution.
Radiology Report
MR EXAMINATION OF THE BRAIN WITHOUT CONTRAST, ___
HISTORY: ___ female status post right MCA stroke, six days earlier,
with left hemiplegia; evaluate for interval change.
TECHNIQUE: Routine ___ non-enhanced study, including axial T2-weighted and
FLAIR PROPELLER FSE sequences. In addition, high-resolution thin-section
diffusion tensor imaging (with 30 directions) was also performed, per the
attending neurologist's request.
FINDINGS: This study is compared with the most recent NECT, dated ___, as
well as a series of studies dating to the CTA of ___.
Again demonstrated is the large subacute infarct involving virtually the
entire right middle cerebral arterial territory. This demonstrates marked
gyriform intrinsic T1-hyperintensity, likely representing early dystrophic
mineralization related to cortical pseudo-laminar necrosis. The relatively
greater T1-hyperintensity involving the deep gray matter structures,
particularly the striatum, demonstrates "blooming" susceptibility artifact,
likely related to blood products reflecting hemorrhagic conversion. There is
a similar degree of mass effect with effacement of cortical sulci and the
ipsilateral lateral ventricle, and 6.5-mm leftward shift of the septum
pellucidum. There is no effacement of the suprasellar cistern or evidence of
more central herniation. There is no evidence of infarction in any additional
vascular territory. Though there is apparent loss of the normal flow-void
within the mid-right MCA, the remaining principal intracranial vascular flow
voids are preserved.
IMPRESSION: Redemonstration of the extensive subacute right middle cerebral
arterial territorial infarction, with similar degree of subfalcine but no more
central herniation. There is evidence of hemorrhagic conversion in the
involved deep gray matter structures of the striatum, as well as likely early
dystrophic mineralization related to cortical pseudo-laminar necrosis.
Radiology Report
CTA OF THE HEAD AND NECK WITH CONTRAST, ___
HISTORY: ___ female with left MCA stroke seen at OSH; evaluate for
clot, "conversion" (sic), or evolution.
TECHNIQUE: Routine ___ study with initial contiguous 5-mm axial MDCT
sections obtained from the skull base to the vertex, prior to IV contrast
administration. Subsequently, helical 1.25-mm axial MDCT sections were
obtained from the aortopulmonary window through the vertex, during dynamic
intravenous administration of 70 mL Omnipaque-350. Multiplanar thick-slab
reconstructions were performed on the console.
FINDINGS: There are no comparison studies on record; specifically the
prompting OSH (not specified) study has not been uploaded to PACS for
comparison. N.B. The rotational curved planar reformatted and volume-rendered
3D-reconstructed images are not available at time of this dictation.
The non-enhanced study demonstrates extensive cytotoxic edema throughout the
right frontal, parietal, and temporal lobes, involving much of that MCA
territory. There may be some sparing of its superior territory. This process
likely represents acute infarction and clearly involves more than one-third of
the MCA vascular territory. There are no hyperattenuating foci within to
specifically suggest hemorrhage. However, there are punctate hyperattenuating
foci within likely the more distal M2 segment, as well as its sylvian branches
(___), suspicious for thromboembolic material in this setting.
There is normal opacification and an unremarkable appearance to the aortic
arch and the great vessel origins with incidentally noted takeoff of the left
vertebral artery directly from the aortic arch, a normal variant. No
significant mural irregularity, calcification or flow-limiting stenosis
involves the vessels of the neck. Specifically, there is a completely
unremarkable appearance to the right common, internal and external carotid
arteries through that carotid terminus, with no evidence of steno-occlusive
disease or dissection. However, just distal to that bifurcation, there is an
abnormal appearance to the proximal-most portion of the M1 segment of the
right MCA, which demonstrates significant at least 50% stenosis (3:221). There
is an abnormal tapered appearance to the more distal 8-mm segment of this
vessel, with abrupt occlusion at the mid-M1 segment and scant distal flow,
which appears to be provided by meningeal collateral vessels. There is an
otherwise unremarkable appearance to the intracranial anterior and posterior
circulation with patent anterior and left posterior communicating vessels and
no other flow-limiting stenosis or significant mural irregularity. There is
no aneurysm larger than 3 mm. There is normal opacification of the principal
dural venous sinuses and deep cerebral veins, with no evidence of thrombosis.
There is no abnormality of the surrounding cervical soft tissues, including
the thyroid gland. The included portion of the lung apices is clear (allowing
for expiratory phase of acquisition), with prominent azygos fissure,
incidentally noted.
IMPRESSION:
1. Very large relatively acute infarct involving much of the right middle
cerebral arterial distribution, with only slight mass effect upon the
overlying gyri and subjacent body of the right lateral ventricle, and no
subfalcine or more central herniation.
2. No evidence of hemorrhagic conversion.
3. Abrupt occlusion of the right MCA at its mid-M1 segment, which may relate
to thrombosis, given the hyperattenuating material in the immediately more
distal portion as seen on the NECT or, alternatively, to focal dissection or
vasospasm, or some combination of these. There is minimal distal flow,
largely provided by meningeal collateral vessels.
4. Otherwise, unremarkable intracranial circulation and cervical vessels;
specifically, there is a normal appearance to the right common and internal
carotid arteries, without significant plaque or flow-limiting stenosis.
COMMENT: A preliminary interpretation to this effect was posted to RIS-web
and PACS by Dr. ___ at 5:51 a.m. on ___.
Radiology Report
PORTABLE CHEST FILM, ___ AT 10:20
CLINICAL INDICATION: ___ with stroke, evaluate for pneumonia or lung
process.
No comparison studies. Please note that comparison to old films can be
helpful to detect subtle interval change.
A single portable AP upright chest film, ___ at 10:20, is submitted.
IMPRESSION:
Lungs volumes are slightly diminished but no focal airspace consolidation,
pleural effusions, or pneumothorax is seen. Incidental note is made of an
azygos lobe. Overall, cardiac and mediastinal contours are within normal
limits given portable technique. No pneumothorax. No evidence of pulmonary
edema. No acute bony abnormality.
Radiology Report
INDICATION: Right MCA stroke with somnolence.
COMPARISON: CT available from ___.
TECHNIQUE: MDCT-acquired 5 mm axial images of the head were obtained without
the use of IV contrast.
FINDINGS:
Since ___, there has been new mild effacement of the anterior horn
of the right lateral ventricle, accompanied by a mild 4 mm leftward shift of
midline structures at this level (2:14). A large right MCA territorial
infarct is again seen, with a large hypodense area encompassing the right
parietal, frontal, and temporal lobes. No hemorrhagic conversion is detected.
The quadrigeminal and suprasellar cisterns remain preserved. There is no
evidence of tonsillar herniation.
There is no acute fracture. The middle ear cavities, mastoid air cells, and
included views of the paranasal sinuses remain clear.
IMPRESSION:
1. New mild (4 mm) leftward parafalcine herniation, with associated mild
effacement of the right lateral ventricle.
2. Evolving large right MCA territory infarct, with no evidence of
hemorrhagic conversion.
3. The suprasellar and quadrigeminal cisterns remain preserved.
Radiology Report
EXAM: CT of the head.
CLINICAL INFORMATION: Patient with right MCA infarct, for followup.
TECHNIQUE: Axial images of the head were obtained without contrast and
compared with the prior CT of ___ obtained at 2:00 a.m.
FINDINGS: There is mass effect on the right lateral ventricle seen secondary
to vasogenic edema at the site of the MCA infarct. There is no hemorrhage
seen. The mass effect remains unchanged accounting for differences in slice
selection. There is no evidence of dilatation of the left lateral ventricle
seen to indicate subfalcine herniation. No evidence of uncal herniation
identified. There is no hemorrhage seen.
IMPRESSION: Overall, no significant change in mass effect on the right
lateral ventricle compared to the prior study of ___. No hemorrhage
seen. No evidence of herniation.
Radiology Report
STUDY: Chest radiograph.
INDICATION: New left-sided PICC. Evaluate placement.
TECHNIQUE: A single chest radiograph was obtained.
COMPARISON: ___.
REPORT:
A left-sided PICC line lies in good position with its tip in the cavoatrial
junction region. Cardiomediastinal contours are normal. Lungs are clear. No
pneumothorax. Osseous structures are normal.
CONCLUSION:
No significant interval change from before. Good position of the PICC line.
Radiology Report
INDICATION: Right MCA territory infarct.
COMPARISON: CTs available from ___.
TECHNIQUE: MDCT-acquired 5-mm axial images of the head were obtained without
the use of IV contrast.
FINDINGS: Again seen is a very large right MCA territorial infarct with mild
effacement of the anterior horn of the right lateral ventricle (2:13). The
suprasellar and quadrigeminal cisterns remain preserved. There is slight
deformity on the right uncus. There is no evidence of new hemorrhage or mass
effect. The middle ear cavities, mastoid air cells, and paranasal sinuses
remain clear. Asymmetry in the lateral atlanto-axial distances is likely
positional and can be correlated clinically for significance.
IMPRESSION: Unchanged appearance of a large right MCA territory infarct, with
continued mild effacement of the right lateral ventricle. Slight deformity on
the right uncus. Consider close followup. No new mass effect or hemorrhagic
conversion. Asymmetry in the lateral atlanto-axial distances is likely
positional and can be correlated clinically for significance.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LMCA INFARCT
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, UNSPEC HEMIPLEGIA UNSPEC SIDE, DRUG ABUSE NEC-UNSPEC
temperature: nan
heartrate: 111.0
resprate: 20.0
o2sat: 100.0
sbp: 120.0
dbp: 40.0
level of pain: 0
level of acuity: 2.0 | This is the brief hospital course for a ___ year old woman with
ADHD on atomoxetine, on oral contraceptive therapy, and a
history of tobacco use who presented with dysarthria and left
sided weakness with a subsequent finding of a large right MCA
territory. This notably occurred in the setting of synthetic
cannabis abuse (smoking K2). She was found to have a mid-M1
occlusion of unknown etilogy with otherwise normal blood vessels
of the neck and head. She was initially admitted to the SDU but
overnight developed a headache. An NCHCT revealed 4mm of
parafalcine herniation and she was started on hyperosmolar
therapy with mannitol. She was transferred to the ICU for closer
monitoring.
.
Her NCHCTs remained stable for the next few days (except for
small amounts of hemorrhagic transformation), and her exam
continued to improve with more wakefulness, attention, and
improved speech. She remains hemiplegic with no movement on the
LEFT side, including to noxious stimuli.
.
She was found to have a PFO on her TTE, but negative lower
extremity dopplers and an MRI of her pelvic region did not
reveal any venous clots (anticoagulation is not an option for
her at this time). Hypercoagulability labs were sent, and some
remain pending at the time of discharge (see above results
section). These can be followed up at her appointment with Dr.
___ in a few weeks.
.
She conditionally passed her bedside dysphagia screen but
requires 1:1 supervision and soft consistency solids. She was
left-sided plegic when initially starting physical and
occupational therapy, and remained this way throughout her stay
with us.
.
At discharge, she will be continued on ASA 325mg daily, a daily
statin, and prozac. Until she is more mobile, Heparin SC 5000U
TID should be continued.
.
She was discharged to rehab for rigorous physical, speech, and
occupational therapy when medically stable by the neurology
team. She will have follow-up with Dr. ___ on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with reported h/o CAD, hypertension, hyperlipidemia, "CHF",
s/p AVR (per patient in ___ presenting with chest pain and
shortness of breath.
Chest pain was described as a retrosternal pressure without
radiation that started acutely the day prior to admission
associated with shortness of breath and ? hypotension. Pain
improved and completely went away when given NTG. Pain made
worse with position changes. Prior to this event, he said he
felt fine. He denies worsening of the chest discomfort on
exertion, any recent or current chest pain, lightheadedness,
dizziness, orthopnea, paroxysmal nocturnal dyspnea,
palpitations, pre-syncope, or syncope. He has had recent dyspnea
and was admitted for a COPD exacerbation, currently on
prednisone with improvement. He denies any localizing infectious
symptoms, including no increase in cough, dyspnea, or sputum
production.
In the ED initial vitals were: T 98.5 HR 73 BP 118/76 RR 20 SaO2
96% on RA. EKG: NSR, normal axis, incomplete RBBB, LVH with
secondary repolarization abnormalities, however compared with
prior, these were more widespread across the precordium with
borderline ST-Depression. Labs/studies notable for troponin-T
0.02, WBC of 22 (on prednisone).
The patient appeared to be a rather poor informant with multiple
inconsistencies on his history.
Past Medical History:
-S/P aortic valve replacement
-COPD
-Hyperlipidemia
-Hypothyroidism
-Depression
-H/O posterior-inferior pancreatico-duodnal artery
pseudoaneurym, S/P coiling by vascular surgery
Echocardiogram: ___ (___)
-Limited survey quality (portable study in ICU, poor patient
cooperation)
-Normal LV chamber size, mild concentric LVH, contractions
vigorous without appreciable regional wall motion abnormality.
-Bioprosthetic valve firmly seated,leaflets sclerotic/calcified,
mobility difficult to assess. Peak calculated pressure gradient
42 mmHg, mean28 mmHg. No paravalvular leak.
-Mild MAC, no MR.
-___ TR; estimated RVSP 38-40 mmHg.
-Proximal thoracic aorta inadequately seen.
-Dilated IVC with blunted inspiratory collapse c/w elevated RAP.
-No obvious intracavitary shunt.
-No significant pericardial fluid collection.
Social History:
___
Family History:
Patient unable to recall family history
Physical Exam:
On admission
GENERAL: WDWN middle aged white man in NAD. Oriented x3. Mood,
affect appropriate.
VS: T 98.4 BP 98/63 HR 68 RR 20 O2 SAT 95% on RA
Admission weight: 83.2 kg
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 6 cm.
CARDIAC: RRR, Loud ___ SEM with no S2. Delayed carotid pulsation
LUNGS: CTAB.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses delayed and symmetric
At discharge
GENERAL: Well appearing, in NAD
VITALS: Tc 98.2 BP 100s/50s HR ___ RR 20
WEIGHT: 81 kg <- 82.2 kG
WEIGHT ON ADMISSION: 83.2 kg
TELEMETRY: NSR
HEENT: Poor dentition
LUNGS: CTAB
HEART: JVP 7 cm. Loud ___ SEM with audible S2. Delayed carotid
pulsation
ABDOMEN: Soft non-tender, not distended
EXTREMITIES: warm and well perfused, no peripheral edema
Pertinent Results:
___ 05:00PM WBC-22.5*# RBC-4.77# HGB-13.9# HCT-42.0#
MCV-88 MCH-29.1 MCHC-33.1 RDW-14.3 RDWSD-46.2
___ 05:00PM GLUCOSE-86 UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
___ 05:00PM cTropnT-0.02*
___ 09:28PM CK-MB-6 cTropnT-0.02*
CXR ___
Sternotomy, valve prosthesis. Normal heart size, pulmonary
vascularity. Trace left pleural effusion or thickening. Chronic
rib fractures. Lungs are clear. No pneumothorax.
IMPRESSION: Trace pleural effusion or thickening.
Echocardiogram ___
The left atrial volume index is mildly increased. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. A bioprosthetic aortic valve prosthesis is present. The
prosthetic aortic valve leaflets are thickened. The transaortic
gradient is higher than expected for this type of prosthesis.
The effective orifice area/m2 is severely decreased (0.6 cm2/m2;
nl >0.9 cm2/m2) No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Prominent LVH with normal global and regional
biventricular systolic function. Thickened aortic valve
bioprosthesis with high gradients, functionally equivalent to
moderate to severe stenosis. Mild pulmonary hypertension.
Exercise Nuclear Stress Test ___
This ___ year old man with a h/o AS, HTN, HLD, smoking and
presumed CAD s/p AVR with recent TTE (___) showing ___ 1.2
cm2 and peak gradient of 45 mmHg and question of NSTEMI was
referred to the lab for evaluation of chest discomfort. The
patient exercised for 5.5 minutes of a modified Gervino protocol
and stopped for leg fatigue. The estimated peak MET capacity is
2.5, representing a poor functional capacity for his age. There
were no chest, neck, arm or back discomforts reported by the
patient throughout the study. ECG: sb, borderline short PR, wide
QRS, slurred upstroke upstroke consider IVCD lbbb block type
and/or WPW pattern. At peak exercise there appeared to be an
additional 0.5 mm downsloping ST segment depression in the
inferolateral leads, which returned to baseline by 3 minutes of
recovery. The rhythm was sinus with three isolated, somewhat
different wide complex beats A and/or VPDs during exercise.
There was blunted blood pressure and heart rate responses to
exercise in the setting of beta blockade. There was test
termination for leg fatigue.
IMPRESSION: No anginal type symptoms with an uninterpretable EKG
for ischemia in the setting of wide QRS with prominent voltage
and repolarization abnormalities. Blunted hemodynamic response
to exercise. Poor functional capacity.
IMAGING: Left ventricular cavity size is mildly enlarged.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium. Gated images reveal
normal wall motion. The calculated left ventricular ejection
fraction is 51%.
IMPRESSION: Mild left ventricular enlargement with normal
perfusion, wall
motion and systolic function.
DISCHARGE LABS
___ 05:40AM BLOOD WBC-16.5* RBC-4.47* Hgb-13.0* Hct-40.1
MCV-90 MCH-29.1 MCHC-32.4 RDW-14.6 RDWSD-48.1* Plt ___
___ 05:40AM BLOOD Glucose-84 UreaN-18 Creat-0.9 Na-139
K-3.8 Cl-99 HCO3-28 AnGap-16
___ 05:40AM BLOOD Calcium-8.3* Phos-4.0 Mg-1.9
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. FLUoxetine 40 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Nicotine Patch 21 mg TD DAILY
8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation 2 puffs BID for wheezing
10. Thiamine 100 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. Multivitamins 1 TAB PO DAILY
14. PredniSONE 60 mg PO DAILY
Tapered dose - DOWN
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. PredniSONE 20 mg PO DAILY Duration: 3 Doses
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
3. PredniSONE 10 mg PO DAILY Duration: 2 Days
4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. Aspirin 81 mg PO DAILY
7. FLUoxetine 40 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Nicotine Patch 21 mg TD DAILY
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation 2 puffs BID for wheezing
14. Thiamine 100 mg PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
- Moderate to severe stenosis of bio-prosthetic aortic valve
- Non-ST segment elevation myocardial infarction
- Chronic obstructive pulmonary disease
- Depression
- Hypothyroidism
- 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: ___ year old man with chest pain with decreased breath sounds and
crackles and elevated WBC// eval for pneumonia, pulmonary edema
TECHNIQUE: Chest two views
COMPARISON: None
FINDINGS:
Sternotomy, valve prosthesis. Normal heart size, pulmonary vascularity.
Trace left pleural effusion or thickening. Chronic rib fractures. Lungs are
clear. No pneumothorax.
IMPRESSION:
Trace pleural effusion or thickening.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.5
heartrate: 73.0
resprate: 20.0
o2sat: 96.0
sbp: 118.0
dbp: 76.0
level of pain: 2
level of acuity: 2.0 | This is a ___ with a reported h/o CAD (unknown anatomy),
hypertension, hyperlipidemia, "CHF," s/p AVR (severe stenosis of
a bicuspid AV that was repaired at ___ ___ with a 19 mm
___ Pericardial Magna Ease valve) who presented with
chest pain and shortness of breath with concern for worsening
prosthetic aortic stenosis. An echocardiogram revealed LVEF 70%,
AV peak gradient of 45 mm Hg, mean of 25 mm Hg and valve area of
1.2 cm2 consistent with moderate to severe prosthetic aortic
stenosis (vs. ___ ___ 0.8 cm2 with peak gradient
42 and mean gradient 28). Given level of AS so early after SAVR,
there is concern for early valve failure. Plan at discharge was
for the patient to follow up with outpatient cardiologist for
planning of revision/replacement at ___ of his bio-prosthetic
aortic valve.
Troponin-T 0.02 twice followed by 2 normal values with normal
CK-MB consistent with a tiny NSTEMI. Exercise MIBI provoked no
symptoms and showed no perfusion defects, but poor functional
capacity to only ___ METs. Based on patient's course and
exercise stress, patient's chest pain was deemed to be unlikely
a result of his aortic stenosis. Patient was discharged without
coronary angiography as there was no objective evidence of
residual ischemia. Dose of atrovastatin was increased from 40 mg
to 80 mg in light of his history and risk factors for CAD. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of ESRD from IgA
nephropathy s/p failed LRRT in ___ on HD ___ via tunneled
line (and previously on PD, stopped ___ and recent acute
necrotizing pancreatitis with pseudocysts in ___, who
presents to the ED with abdominal pain and nausea.
He has had multiple admissions in the last few months for
recurrent abdominal pain and nausea. During his most recent
hospitalization from ___, CT of the abdomen showed
overall improvement in the size of the pseudocyst along the
greater curvature. While he was inpatient, a liter of dialysate
was instilled into the existing PD catheter and the effluent was
sent for culture, which eventually was negative for growth.
Blood cultures were also all negative for growth. His tube feeds
were held with resulting improvement in his abdominal pain. He
was eventually restarted on tube feeds, which he tolerated and
he was discharged home. He received routine hemodialysis using
an existing tunneled dialysis catheter while inpatient. He
recently underwent replacement of his post-pyloric ___
___ feeding tube by ___ ___ because his old one had become
clogged. He returns to the ED again with band like abdominal
pain, vague nausea, and a few episodes of diarrhea.
Past Medical History:
PMH: IgA nephropathy and ESRD (he started peritoneal dialysis
for six months in ___ and then had a LRRT in ___, which
eventually failed; he was restarted on renal replacement since
___ with peritoneal catheter placement (___),
repositioned on ___ in ___, a tunneled R IJ HD
catheter was placed and PD was stopped due to development of
pancreatitis and intolerance to PD), HTN, R hip ___ ___,
osteoporosis, stable pulmonary nodule
PSH: LRRT ___, R hip screws, excision of non-malignant skin
lesions
Social History:
___
Family History:
No history of pancreatitis. An aunt with kidney disease, mother
with hypertension and atrial fibrillation, father with
hypertension. The sister who donated the kidney later developed
brain cancer and passed away. He has two brothers and another
sister. His two brothers passed away in their ___ from muscular
dystrophy, possibly ___.
Physical Exam:
98.2, 69, 127/80, 20, 100RA
NAD, AAOx3, nontoxic
CTA ___
RRR
dophoff feeding tube in place
abdomen soft nontender nondistended
RIJ tunneled line catheter site clean, no erythema
PD catheter site clean, no erythema
no peripheral edema
Pertinent Results:
___ 07:55AM BLOOD WBC-5.6 RBC-3.37* Hgb-10.5* Hct-34.2*
MCV-102* MCH-31.1 MCHC-30.7* RDW-15.5 Plt ___
___ 06:11AM BLOOD WBC-6.4 RBC-2.93* Hgb-9.1* Hct-29.7*
MCV-101* MCH-30.9 MCHC-30.5* RDW-15.2 Plt ___
___ 07:55AM BLOOD Glucose-96 UreaN-56* Creat-5.7* Na-134
K-3.7 Cl-94* HCO3-27 AnGap-17
___ 06:11AM BLOOD Glucose-141* UreaN-63* Creat-6.4* Na-136
K-4.3 Cl-98 HCO3-24 AnGap-18
___ 07:55AM BLOOD ALT-125* AST-91* AlkPhos-110 TotBili-0.2
___ 06:11AM BLOOD ALT-78* AST-42* AlkPhos-95 TotBili-0.3
___ 07:55AM BLOOD Lipase-294*
___ 06:11AM BLOOD Lipase-190*
___ 07:55AM BLOOD Albumin-4.1 Calcium-9.5 Phos-5.2* Mg-2.9*
___ 06:11AM BLOOD Calcium-8.8 Phos-5.8* Mg-2.9*
Cdiff negative
Peritoneal dialysis catheter culture - no organisms, no PMNs, no
growth to date
Blood culture - no growth to date
CXR/AXR - dophoff tube in proximal jejunum, no acute
cardiopulmonary process
Medications on Admission:
acetaminophen 650'''' prn, plavix 75', lasix 120', glargine 7U
qAM, lisinopril 5', nephrocaps 1', pravastatin 10', prednisone
5', flomax 0.4'
Discharge Medications:
1. Tamsulosin 0.4 mg PO HS
2. PredniSONE 5 mg PO DAILY
3. Pravastatin 10 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Glargine 7 Units Breakfast
7. Furosemide 120 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Diarrhea, abdominal pain. Evaluate nasogastric tube placement.
COMPARISON: Multiple prior radiographs of chest dated ___ through
___.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrate low lung volumes
results in bronchovascular crowding. The cardiomediastinal contours are
unchanged. There is no pneumothorax, pleural effusion, or consolidation. A
right subclavian central venous line terminates in the cavoatrial junction.
Nasogastric tube courses into the stomach and out of the field of view.
IMPRESSION:
Nasogastric tube courses into the stomach and out of the field of view.
Radiology Report
HISTORY: Evaluate Dobbhoff tube placement.
COMPARISON: Abdominal radiograph dated ___ and CT of the abdomen
pelvis dated ___.
FINDINGS:
Portable supine radiograph of the abdomen demonstrates normal bowel gas
pattern without evidence of ileus or obstruction. There is no pneumatosis or
secondary signs of free air. A nasogastric tube courses past the pylorus into
the region of the proximal jejunum. A peritoneal dialysis catheter projects
over the pelvis. Multiple metallic surgical clips project over the right
hemipelvis. Right femoral orthopedic hardware is partially visualized.
IMPRESSION:
The nasogastric tube courses past the pylorus likely into the region of the
proximal jejunum
Gender: M
Race: ASIAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ACUTE PANCREATITIS, KIDNEY TRANSPLANT STATUS, PANCREAS TRANSPLANT STATUS
temperature: 98.0
heartrate: 75.0
resprate: 18.0
o2sat: 95.0
sbp: 124.0
dbp: 71.0
level of pain: 7
level of acuity: 3.0 | Mr. ___ is a ___ year old male with prior failed LRRT
subsequently requiring peritoneal dialysis who is well-known to
our service after his recent episode of necrotizing pancreatitis
in ___ complicated by pseudocysts. Now on HD via RIJ
tunneled line and on tube feeds via a post-pyloric dophoff tube.
He is otherwise NPO. Recent imaging in late ___ showed
improvement in the size of his known pseudocyst and fluid
collections. He returned to the ED on ___ with band like
abdominal pain, vague nausea, and a few episodes of diarrhea.
His lipase was 290, minimal LFT elevation, normal WBC, and
normal vitals. He was admitted to the transplant surgery service
for hydration and observation. His pain resolved after one dose
of dilaudid in the ED. His cdiff specimen was negative and his
diarrhea stopped after an episode in the evening of hospital day
1. His vitals remained stable, his lipase came down to 190. His
peritoneal dialysis catheter and his blood were cultured, both
of which are no growth to date at the time of discharge.
On HD2, the patient underwent routine HD via his RIJ tunneled
line. He was run even for 3.5 hours. The session was stopped 30
minutes early because he had some heaviness in his chest that
lasted for about 3 minutes. It self resolved, he had normal
vitals during the episode, and an EKG was performed which was
within normal limits and stable in comparison to the EKG that he
had on ___. He was observed for a few hours and did not have
recurrence of the chest or abdominal pain. The patient notes
that he gets leg and chest symptoms on and off pretty regularly
during his HD sessions. After HD, his tube feeds were restarted
which he tolerated without difficulty and he was discharged home
to follow up with Dr. ___ week in clinic. No new
medications were prescribed during this admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ Afib, CAD, ___, CVA on aggrenox, HTN, and dementia who
presents with fatigue. Per assisted living, last night was
having acute AMS, confusing elevator for a bathroom and trying
to wear her bra on her feet. Reportedly staff found drops of
feces and blood on bedroom floor, but unknown source. Today,
more fatigue in the AM. No fever/chills/cough, no neuro
deficits, no chest pain, no abdominal pain. Almost couldn't wake
up this AM. Per patient report, she does endorse feeling more
fatigued this morning however does not recall any episodes of
confusion. Currently, she feels she is in her usual state of
health and surprised that she was taken to the hospital.
In ___, she did have an episode of syncope for which there was
reportedly a high suspicion of seizure given left arm posturing
and a post-ictal state. No documentation of neuro follow-up or
further work-up with EEG.
In the ED, initial VS were 99.5 84 110/60 18 96%4L. Initial exam
was notable for lethargy. Initial labs showed lactate of 2.3 and
Cr of 1.2 (at baseline). Otherwise, CBC, Chem10, UA, and trops
x1 were unremarkable. CT of the head showed no acute process but
was suggestive of chronic small vessel disease. CXR was
unremarkable. Urine and blood cultures were sent, and patient
received 1LNS before being admitted to medicine for further
management.
On further review of systems, endorses some increased colostomy
leakage over the past 6 months.
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-___ w/ 60% LVEF and trace AR
-CAD
-Atrial fibrillation on Aggrenox
-Hypertension
-CVA in ___ s/p CEA
-Dementia
-Peripheral neuropathy
-CKD
-Crohn's s/p ileostomy
-?Syncope ___
Social History:
___
Family History:
Father died on major CVA, no hx of HCM or SCD, multiple members
s/p ileostomy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.1 133/52 73 20 96%RA
GEN - well-developed, well-nourished elderly female lying
comfortably in bed, alert, appropriate, no acute distress
HEENT - NCAT, MMM, sclera anicteric
NECK - supple, no JVD, no LAD
PULM - mild crackles at bases bilaterally, no wheezes or rhonchi
CV - normal rate, regular rhythm, no m/r/g
ABD - erythematous area extending from colostomy site medially
towards umbilicus, minimal serosang drainage. non-tender, no
purulence. blanching. otherwise abdomen is soft, NT/ND,
normoactive bowel sounds, no guarding or rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO - PERRLA, EOMI, facial sensation equal b/l, face
symmetric, palate rises symmetrically, SCMs equal, tongue
protrudes midline. strength ___ in UE and ___ equally
bilaterally. sensation intact to light touch.
COGNITION: oriented to ___. knows it is ___
and ___. recalls year as ___ registers 3 objects
immediately. clock-face drawing completely intact and accurately
draws time 11:10, subsequently recalls ___ objects
Discharge physical exam
VS: 98.1 150/48 83 20 94%RA
GEN - well-developed, well-nourished elderly female lying
comfortably in bed, alert, appropriate, no acute distress
HEENT - NCAT, MMM, sclera anicteric
NECK - supple, no JVD, no LAD
PULM - mild crackles at bases bilaterally, no wheezes or rhonchi
CV - normal rate, regular rhythm, no m/r/g
ABD - erythematous area extending from colostomy site medially
towards umbilicus, minimal serosang drainage. non-tender, no
purulence. blanching. otherwise abdomen is soft, NT/ND,
normoactive bowel sounds, no guarding or rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO - PERRLA, EOMI, facial sensation equal b/l, face
symmetric, palate rises symmetrically, SCMs equal, tongue
protrudes midline. strength ___ in UE and ___ equally
bilaterally. sensation intact to light touch.
COGNITION: Grossly unchanged since admission
Pertinent Results:
Blood Work:
___ 12:25PM BLOOD WBC-9.8 RBC-4.18* Hgb-12.7 Hct-38.0
MCV-91 MCH-30.3 MCHC-33.3 RDW-13.9 Plt ___
___ 06:25AM BLOOD WBC-9.6 RBC-4.09* Hgb-12.4 Hct-37.1
MCV-91 MCH-30.4 MCHC-33.5 RDW-13.8 Plt ___
___ 12:25PM BLOOD Glucose-111* UreaN-18 Creat-1.2* Na-144
K-3.9 Cl-102 HCO3-28 AnGap-18
___ 06:25AM BLOOD Glucose-106* UreaN-21* Creat-1.1 Na-145
K-3.8 Cl-106 HCO3-26 AnGap-17
___ 12:25PM BLOOD cTropnT-<0.01
___ 12:25PM BLOOD Calcium-9.8 Phos-3.6 Mg-2.1
___ 06:25AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.0
___ 12:25PM BLOOD Digoxin-1.5
___ 12:25PM BLOOD TSH-2.0
Urine:
___ 01:30PM URINE Color-Straw Appear-Clear Sp ___
___ 01:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Reports:
___ Imaging CT HEAD W/O CONTRAST
FINDINGS: There is no evidence for intra- or extra-axial
hemorrhage. There is no mass effect, hydrocephalus, or shift
of the normally midline structures. Enlarged sulci, widened
extra-axial spaces and mildly prominent ventricles suggest
unchanged atrophy. Areas of a relative white matter hypodensity
in cerebral hemispheres are most consistent with chronic small
vessel ischemia. More focal small low-density areas in the
right basal ganglia aresuggestive of chronic unchanged lacunar
infarcts. Vascular calcifications are present. The visualized
paranasal sinuses and mastoid air cells appear clear.
IMPRESSION: No evidence of acute process.
___ Imaging CHEST (PA & LAT)
FINDINGS: The cardiac, mediastinal and hilar contours appear
unchanged,
including a left ventricular configuration to the heart. Mild
unfolding and calcification are similar along the aorta. A
streaky left basilar opacity is consistent with unchanged minor
atelectasis or scarring. There is no definite pleural effusion
or pneumothorax. The chest is hyperinflated. The bones appear
demineralized. Mild degenerative changes are similar along the
mid to lower thoracic spine.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Micro:
___ URINE URINE CULTURE-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 800 UNIT PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Metoprolol Succinate XL 200 mg PO DAILY
Hold for SBP<100 or HR<60
7. GlipiZIDE XL 2.5 mg PO DAILY
8. Simvastatin 10 mg PO DAILY
9. Clonazepam 0.5 mg PO QHS
10. Amitriptyline 50 mg PO HS
11. Dipyridamole-Aspirin 1 CAP PO BID
12. Captopril 50 mg PO TID
Hold for SBP<100
13. Ibuprofen 400 mg PO Q6H:PRN pain
14. Milk of Magnesia 30 mL PO DAILY:PRN constipation
15. Acetaminophen 650 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Captopril 50 mg PO TID
4. Digoxin 0.125 mg PO DAILY
5. Dipyridamole-Aspirin 1 CAP PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Simvastatin 10 mg PO DAILY
10. Vitamin D 800 UNIT PO DAILY
11. Amitriptyline 25 mg PO HS
12. Clonazepam 0.25 mg PO QHS:PRN insomnia
This medication will be tapered and discontinued as an
outpatient.
13. GlipiZIDE XL 2.5 mg PO DAILY
14. Milk of Magnesia 30 mL PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Confusion, self-resolved, possibly medication effect
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Lethargy.
COMPARISONS: ___.
TECHNIQUE: Chest, AP upright and lateral.
FINDINGS: The cardiac, mediastinal and hilar contours appear unchanged,
including a left ventricular configuration to the heart. Mild unfolding and
calcification are similar along the aorta. A streaky left basilar opacity is
consistent with unchanged minor atelectasis or scarring. There is no definite
pleural effusion or pneumothorax. The chest is hyperinflated. The bones
appear demineralized. Mild degenerative changes are similar along the mid to
lower thoracic spine.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Radiology Report
HEAD CT
HISTORY: Lethargy.
COMPARISONS: ___.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no evidence for intra- or extra-axial hemorrhage. There
is no mass effect, hydrocephalus, or shift of the normally midline structures.
Enlarged sulci, widened extra-axial spaces and mildly prominent ventricles
suggest unchanged atrophy. Areas of a relative white matter hypodensity in
cerebral hemispheres are most consistent with chronic small vessel ischemia.
More focal small low-density areas in the right basal ganglia are suggestive
of chronic unchanged lacunar infarcts. Vascular calcifications are present.
The visualized paranasal sinuses and mastoid air cells appear clear.
IMPRESSION: No evidence of acute process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LETHARGY
Diagnosed with ALTERED MENTAL STATUS
temperature: 99.5
heartrate: 84.0
resprate: 18.0
o2sat: 96.0
sbp: 110.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | PRINCIPLE REASON FOR ADMISSION:
___ w/ Afib, CAD, dCHF, CVA on aggrenox, HTN, and dementia who
presents with self-limited episode of fatigue and confusion.
# Fatigue/Confusion: Patient reported to have acute confusion
night prior to admission, and to be lethargic morning of
presentation. Apparently self-resolved spontaneously, as patient
was at her baseline cognitive status on arrival to the medicine
floor. Delirium in this patient with reported dementia has a
wide differential and most commonly may include medication
effect, infectious etiology, electrolyte abnormality or other
metabolic disturbances, seizures also considered. No new
medications per report, however patient is on clonazepam which
certainly could cause delirium in the elderly as well as
amitriptyline. These medications were held and should be used
cautiously or at decreased doses if indicated. Dig level was
also checked and was normal. She had no symptoms or signs of
infection including clean u/a and negative CXR along with any
clinical symptoms of infection. The rash on her abdomen appears
more consistent with irritation dermatitis or candidal rash
rather than cellulitis. Basic chem panel was all within normal
limits. Patient lacked any reported worrisome symptoms for
seizures such as myoclonus, tongue biting, urine incontinence,
though difficult to know whether post-ictal state was possible.
Given the past concern for seizure activity, could consider EEG
as outpatient to further evaluate.
# Ostomy leak: Patient noted to have some leakage from her
ostomy on arrival. Also with bright red rash around ostomy site
concerning for a irritation dermatitis or perhaps candidal rash.
Would recommend careful ostomy nursing to minimize leakage.
Could consider empiric topical antifungal if rash does not
improve with improved hygeine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide
Antibiotics) / Reglan / Latex / Ampicillin / Lactose / Soy,
Lentils, Beans / Neomycin
Attending: ___
Chief Complaint:
fever during dialysis
Major Surgical or Invasive Procedure:
interventional radiology hemodialysis catheter removal
interventional radiology tunneled hemodialysis catheter
placement
History of Present Illness:
___ yo F child psychiatrist w/ complicated PMH significant for
type 1 IDDM (s/p revision renal and pancreas transplants, ___
and ___, diastolic CHF (Echo 35-40%, ___, recurrent MDR E
coli UTIs, chronic anemia, currently on dialysis for repeated
hyperkalemia, who developed fevers during dialysis on ___.
.
Pt states that she was feeling completely normal up until
dialysis. Over the last three months, she has had a complicated
course w/ multiple admissions, most recently ___, w/
HCAP and worsening CHF during which she was intubated. Pt has
since been at ___ since than and recently discharged
to ___ in ___, where she has slowly been
making progress in her recovery.
.
Pt received dialysis on ___, as usual and was found
to be febrile and have chills. Dialysis was terminated early.
Per her most recent nephrology note from ___, her renal
graft seemed to be working better, with Cr 2.0, and a tentative
plan to wean off dialysis. Pt denies any localizing symptoms
prior to ___.
.
In the ED, Pt was initially not very responisve and triggered on
arrival for altered mental status with fever 103 and HR 130. UA
was bland, UCx and Blood Cx pending. Pt was given Vancomycin 1g,
Levofloxacin 750mg, and Metronidazole 500mg, stress dose
steroids (methylprednisolone 125mg) and fluid bolus (amount not
documented). Pt had a good response w/ lactate correcting from
2.9 to 2.2, HR 90, and marked improvement in mental status. By
report, she had nausea, lower abdominal pain and dysuria. Pt's
CXR was significnat for small bilateral pleural effusions and
interval marked enlargement of the cardiac silhouette. Bedside
Echo did not show any significant pericardial effusion. Pt had a
non-contrast CT abd which showed dilated fluid-filled loops of
small bowel in RLQ and midline pelvis w/ some fecalized loops
concerning for partial small bowel, colon full of stool, and
normal appearing LLQ transplanted kidney. Transplant surgery was
called and had low suspicion for obstruction w/ recommendation
of serial abdominal exams and repeat imaging w/ po contrast if
worsening exam or symptoms. Pt was admitted for fever of unknown
origin workup.
.
On arrival to the floor, Pt's vitals were 99.2F, 117/60, HR 94,
RR 18, sat 100% 2L. Pt has no pain at all, except for a "sharp
pain" near her urethra.
ROS: No fevers, no chills (aside from dialysis session on
___, no night sweats, no changes in weight. No cough, no
SOB, no chest pain, no palpitations. No nausea, no vomiting, no
diarrhea or constipation. Pt states that she normally has 3 BM
daily and that she has been regular. Her last BM was 4pm 1d
prior to admission.
Past Medical History:
1. diastolic CHF (preserved EF 35%, moderate regional
systolic dysfunction, ___
2. s/p renal transplant ___, complicated by chronic rejection,
second transplant ___
3. s/p pancreas transplant (with allograft pancreatectomy
___, redo transplant ___, acute rejection ___ which
resolved with increased immunosuppresion)
4. diabetes mellitus type I (complicated by neuropathy,
retinopathy, dysautonomia, no longer requires regular insulin
after pancreas transplant)
5. autonomic neuropathy
6. sleep-disordered breathing (on 2L NC nighttime, unable to
tolerate CPAP)
7. osteoporosis
8. hypothyroidism
9. pernicious anemia
10. cataracts
11. glaucoma
12. anemia from chronic kidney disease (on Aranesp previously)
13. Right foot fracture, complicated by RLE DVT
14. chronic LLE edema
15. Reucrrent MDR E.coli pyelonephritis
16. s/p anal polypectomy (___)
17. s/p bilateral trigger finger surgery (___)
18. s/p left BKA (___)
19. CAD s/p DES to LAD ___
Social History:
___
Family History:
Father with MI at ___ year old; denies family history of
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Physical Exam:
Vitals: 99.2F, 117/60, HR 94, RR 18, sat 100% 2L
General: sickly looking woman in bed in no acute distress
HEENT: PERRL, EOMI, normal oropharynx
Neck: no JVD, no LAD
Heart: RRR, nl S1, S2, ___ systolic blowing murmur heard best
at apex
dialysis port site looks normal.
Lungs: CTAB
Abdomen: soft, non-tender, normal bowel sounds,
Extremities: L below the knee amputation, R leg erythematous and
very tender to palpation over R shin. No obvious skin breaks, no
pus, no pedal edema. 2+ pulses.
Neurological: intermittently falling asleep during conversation.
A&O x 3. CN2-12 grossly intact. Pt ___ strength throughout.
.
Pertinent Results:
___ 09:00PM BLOOD WBC-1.8* RBC-4.18*# Hgb-12.0# Hct-38.5#
MCV-92 MCH-28.8 MCHC-31.2 RDW-16.2* Plt ___
___ 09:00PM BLOOD Neuts-66.1 ___ Monos-1.0* Eos-1.8
Baso-0.1
___ 09:54PM BLOOD ___ PTT-22.8 ___
___ 09:00PM BLOOD Glucose-100 UreaN-37* Creat-1.6*# Na-141
K-7.6* Cl-104 HCO3-27 AnGap-18
___ 09:00PM BLOOD ALT-25 AST-86* LD(LDH)-962* AlkPhos-62
TotBili-0.4
___ 08:02AM BLOOD Lipase-13
___ 08:02AM BLOOD Albumin-3.0* Calcium-8.3* Phos-2.1*
Mg-1.6 Iron-9*
___ 08:02AM BLOOD calTIBC-239* Ferritn-53 TRF-184*
___ 08:02AM BLOOD TSH-0.45
___ 05:20PM BLOOD Cortsol-15.1
___ 08:02AM BLOOD Vanco-22.4*
___ 08:02AM BLOOD tacroFK-2.3* rapmycn-3.1*
___ 05:44PM BLOOD ___ Temp-38.3 pH-7.42
___ 09:12PM BLOOD Lactate-2.9*
___ 10:43PM BLOOD Glucose-96 Lactate-2.2* K-3.4
___ 05:44PM BLOOD Lactate-1.9
___ 05:35AM BLOOD tacroFK-9.3
___ 09:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
___ 09:15PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
___ 09:15PM URINE CastHy-1*
___ 9:00 pm BLOOD CULTURE (2 of 2 bottles)
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___. ___ (___) @ ___
___.
___ URINE URINE CULTURE-FINAL
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI} ( 2 of 4 bottles)
___ CATHETER TIP-IV WOUND CULTURE-FINAL
No significant growth
___ BLOOD CULTURE Blood Culture, Routine-no
growth to date
___ BLOOD CULTURE no growth to date
___ Radiology CHEST (PORTABLE AP)
Small bilateral pleural effusions. Interval marked enlargement
of the cardiac silhouette relative to the most recent prior
exam. However, other more remote exams have demonstrated
enlargement of the silhouette, thereby suggesting the
possibility of waxing and waning pericardial effusion. Correlate
clinically.
.
___BD & PELVIS W/O CON
1. Fluid-filled dilated loopss of small bowel in the right lower
quadrant and midline pelvis with areas of fecalized small bowel
concerning for partial small-bowel obstruction, of uncertain
etiology. Clear transition point is difficult to identify given
the lack of both oral and intravenous contrast. 2. Small right
pleural effusion. 3. Normal appearance of the appendix. 4.
Normal appearance of the transplanted kidney in the left lower
quadrant.
.
___ Cardiology ECHO
The left atrium is moderately dilated. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is moderately depressed (LVEF= XX
%). [Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Severe
(4+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
IMPRESSION: No vegetation seen. Moderately dilated left
ventricular cavity with moderate global hypokinesis - the
anterior wall and septum have the worst function. Severe mitral
regurgitation. Small ASD/stretched PFO present with left to
right shunting at rest.
.
___ Radiology ART EXT (REST ONLY)
FINDINGS: The Doppler waveform in the right common femoral,
superficial femoral, and popliteal arteries is triphasic with
monophasic Doppler waveform at the level of the posterior tibial
and dorsalis pedis artery. The pressures are falsely elevated
due to calcified vessels; therefore, ABI index could not be
obtained. IMPRESSION: Findings consistent with significant
posterior tibial disease in the right lower extremity.
.
___ Radiology CHEST (PORTABLE AP)
FINDINGS: Removal of dialysis catheter with no evidence of
pneumothorax. Heart is mildly enlarged and is accompanied by
vascular engorgement and new septal lines consistent with
interstitial edema. Small pleural effusions have increased in
size in the interval.
Medications on Admission:
Medications - Prescription
ACYCLOVIR - (Prescribed by Other Provider) - 200 mg Capsule - 1
Capsule(s) by mouth every twelve (12) hours
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg
Tablet - 1 Tablet(s) by mouth once a day
BRIMONIDINE [ALPHAGAN P] - (Prescribed by Other Provider) -
0.15 % Drops - 1 drop both eyes tid
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day
CYCLOSPORINE [RESTASIS] - (Prescribed by Other Provider) - 0.05
% Dropperette - one drop both eyes daily
DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] -
(Prescribed by Other Provider) - 200 mcg/mL Solution - iv q 28
days
DORZOLAMIDE-TIMOLOL - (Prescribed by Other Provider) - 0.5 %-2
% Drops - one drop both eyes twice daily
ELBOW PADS - - use as tolerated
FAMOTIDINE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
GRAB BARS - - to be installed
HEPARIN (PORCINE) - (Prescribed by Other Provider) - 5,000
unit/mL Cartridge - SC three times a day
HYDROCORTISONE-PRAMOXINE - 2.5 %-1 % Cream - apply to itchy skin
as needed
LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005
% Drops - 1 gtt ___ at bedtime
LEVOTHYROXINE - (Prescribed by Other Provider) - 112 mcg Tablet
- 1 Tablet(s) by mouth every other day MWFsat
LEVOTHYROXINE [LEVOXYL] - 100 mcg Tablet - 1 Tablet(s) by mouth
qod alternating with 112 mcg qd
LIPASE-PROTEASE-AMYLASE [CREON] - 12,000 unit-38,000 unit-60,000
unit Capsule, Delayed Release(E.C.) - ___ Capsule(s) by mouth
three times a day
METHAZOLAMIDE - (Prescribed by Other Provider) - 50 mg Tablet -
1 Tablet(s) by mouth three times a day
PERSONAL EMERGENCY RESPONSE SERVICE (___) - - PATIENT LIVES
ALONE, FREQUENT HYPOGLYCEMIA AND FREQUENT FALLS; FOR HOME USE
FOR AT LEAST 12 MONTHS
PREDNISONE - (Dose adjustment - no new Rx) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
SEVELAMER CARBONATE [RENVELA] - (Prescribed by Other Provider)
- 800 mg Tablet - 1 Tablet(s) by mouth three times a day
SIROLIMUS [RAPAMUNE] - (Prescribed by Other Provider) - 1 mg
Tablet - 1.5 Tablet(s) by mouth once a day
SMOOTH EMOLIENT LUBRICANT FOR EYES - (Prescribed by Other
Provider) - Dosage uncertain
TACROLIMUS - (Dose adjustment - no new Rx; update) - 1 mg
Capsule - 3 Capsule(s) by mouth twice a day
TERIPARATIDE [FORTEO] - 20 mcg/dose (600 mcg/2.4 mL) Pen
Injector - ___very evening
TRAVOPROST [TRAVATAN Z] - (Prescribed by Other Provider) -
Dosage uncertain
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 0.5
(One half) Tablet(s) by mouth at bedtime
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply to itchy skin as
needed do not use longer than 2 weeks at a time
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth once a day
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - check
finger stick blood sugar four times a day before meals and at
bedtime
CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - (Prescribed by
Other Provider) - Dosage uncertain
LANCETS - Misc - test finger stick blood sugar four times a
day before meals and at bedtime
LOPERAMIDE [IMODIUM A-D] - (Prescribed by Other Provider) - 2
mg Tablet - 3 Tablet(s) by mouth PRN
MULTIPLE URINE TESTS [MULTISTIX 10 SG] - Strip - prn urinary
symptoms
SENNOSIDES - (Prescribed by Other Provider) - 8.6 mg Tablet - 2
Tablet(s) by mouth at bedtime
SYRINGE WITH NEEDLE (DISP) [SYRINGE 3CC/25GX1"] - 25 gauge X 1"
Syringe - use for vitamin B12 injection as directed
Discharge Medications:
1. acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic three
times a day.
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic daily ().
6. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic twice a day.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. hydrocortisone-pramoxine ___ % Cream Sig: One (1) Topical
once a day as needed for itching.
11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
12. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day): MWF ___.
13. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day): ___, Th, ___.
14. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: ___ Caps PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
15. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
16. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
17. sirolimus 1 mg Tablet Sig: 1.5 Tablets PO q am.
18. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a
day.
19. travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic once a
day.
20. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
21. triamcinolone acetonide 0.1 % Cream Sig: One (1) Topical
once a day: apply to itchy skin, no longer than 2 wks at a time.
22. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H
(every 48 hours) as needed for peripheral neuropathy.
23. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
24. Citracal + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO
twice a day.
25. senna 8.6 mg Capsule Sig: Two (2) Capsule PO at bedtime:
hold for loose stool.
26. ceftazidime 1 gram Recon Soln Sig: ___ g Intravenous with
dialysis for 9 days: Pt is to receive ___ w/ HD until ___.
Disp:*qs g* Refills:*0*
27. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
28. insulin regular human 100 unit/mL Solution Sig: as directed
Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
E coli septicemia (suspected HD line infection)
Secondary:
s/p pancreas and renal transplant
chronic renal failure
diastolic and systolic congestive heart failure
severe mitral regurgitation
peripheral neuropathy
glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with fever, altered mental status, and left lower
quadrant pain. Patient is status post renal transplant.
COMPARISON: CT abdomen and pelvis from ___.
TECHNIQUE: ___ MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness. No oral or intravenous
contrast was administered. Coronal and sagittal reformations were prepared.
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Subsegmental atelectasis is
identified in the lung bases. There is a small simple right pleural effusion.
Complete evaluation of the intra-abdominal viscera is limited by the non-
contrast technique. The liver appears homogeneous without focal lesion. No
intra- or extra-hepatic biliary ductal dilatation is identified. The hepatic
veins and portal venous system are normal in caliber. The gallbladder,
spleen, and pancreas appear normal. The adrenal glands are symmetric without
focal lesion. The native kidneys are markedly shrunken, findings consistent
stable chronic renal failure. The abdominal aorta and its branch vessels are
non-aneurysmal though severely calcified. Venous calcifications are also
identified throughout the abdomen and pelvis. There is no free fluid or free
air. The transplanted kidney in the left lower quadrant appears normal on
this non-contrast examination without evidence of hydronephrosis or
perinephric fluid collection.
GI: In the right lower quadrant and midline pelvis, there are multiple fluid-
filled loops of small bowel which are mildly dilated. A portion of the
terminal ileum measures 4.7 cm in craniocaudal dimension (301B:15).
Additionally, there are multiple loops of fecalized small bowel in the ileal
region (2:46, 2:67). A few decompressed loops of small bowel are visualized
in the midline pelvis (2:60). Findings are concerning for partial small-bowel
obstruction of uncertain etiology, A focal dilated loop appears to sit along
the ventral surface; however, no clear ventral defect or hernia is identified.
The colon remains well expanded and filled with stool. Complete evaluation
for a transition point is difficult given the lack of both intravenous and IV
contrast.
CT PELVIS WITHOUT INTRAVENOUS CONTRAST: A Foley catheter is identified within
the bladder which demonstrates small foci of air. There is no pelvic free
fluid. The uterus and adnexa are not clearly visualized possibly secondary to
prior surgical resection as clips are identified within the area.
OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture is
identified.
IMPRESSION:
1. Fluid-filled dilated loopss of small bowel in the right lower quadrant and
midline pelvis with areas of fecalized small bowel concerning for partial
small-bowel obstruction, of uncertain etiology. Clear transition point is
difficult to identify given the lack of both oral and intravenous contrast.
2. Small right pleural effusion.
3. Normal appearance of the appendix.
4. Normal appearance of the transplanted kidney in the left lower quadrant.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with history of kidney and
pancreas transplant and currently with sepsis and bacteremia and new oxygen
requirement.
Portable AP chest radiograph was compared to ___.
As compared to the prior study, there is interval minimal increase in vascular
congestion. Cardiomediastinal silhouette is stable. There is no change in
the appearance of the dialysis catheter. Small bilateral effusions are most
likely present. There is no pneumothorax. No new consolidations to suggest
infectious process demonstrated.
Radiology Report
NON-INVASIVE ARTERIAL STUDY AT REST
INDICATION: ___ female patient with left below-knee amputation and
longtime diabetes, status post pancreatic and renal transplant, currently on
dialysis for one month.
TECHNIQUE: Doppler waveforms, pulse volume recordings, and segmental blood
pressures were obtained from the right lower extremity.
FINDINGS: The Doppler waveform in the right common femoral, superficial
femoral, and popliteal arteries is triphasic with monophasic Doppler waveform
at the level of the posterior tibial and dorsalis pedis artery. The pressures
are falsely elevated due to calcified vessels; therefore, ABI index could not
be obtained.
IMPRESSION: Findings consistent with significant posterior tibial disease in
the right lower extremity.
Radiology Report
PROCEDURE: Right internal jugular tunneled hemodialysis catheter placement:
___.
INDICATION: ___ year-old woman with ESRD and recent line sepsis requiring
access for hemodialysis.
CLINICIANS: Dr. ___ Dr. ___.
TECHNIQUE/FINDINGS:
Following a detailed discussion regarding the risks and benefits of the
procedure, a signed informed consent was obtained from the patient. The
patient was brought to the angiography suite and positioned supine on the
imaging table. The right chest was prepped and draped in the usual sterile
fashion. A preprocedural timeout was performed using three separate patient
identifiers.
Local anesthesia was achieved using a 1% bicarbonate buffered lidocaine and
lidocaine/epinephrine. 4 mg of Zofran were administered at the beginning of
the procedure for nausea. 0.25 mg of IV Dilaudid were also given. The
patient's hemodynamic parameters were continuously monitored by a radiology
nurse.
Under ultrasound guidance, the right internal jugular vein was accessed using
a micropuncture needle, and a 0.018 inch wire was advanced into the SVC. A
permanent ultrasound image of the patent vessel was printed. A dermatotomy was
made with a #11 blade. The needle was exchanged for a micropuncture sheath.
The wire was then exchanged for a 0.035 ___ wire, which was used to
determine the catheter length. The ___ wire was then advanced into the IVC.
The tunnel exit site was then marked approximately 5-6 cm lateral and inferior
to the venotomy site, just medial to a prior tunneling site. This area was
anesthetized using 1% bicarbonate buffered lidocaine. A 1-cm incision was
then made with a #11 blade. The tunneling tract was anesthetized first with a
lidocaine/epinephrine mixture. A 15.5 ___ dual-lumen hemodialysis catheter
was then passed subcutaneously from the tunnel exit site to the venotomy site
using a metal tunneling device.
The micropuncture sheath was then removed. 12 and 14 ___ dilators were
passed over the wire to expand the venotomy site further. A 16 ___
peel-away sheath was then placed. The wire and inner stylet were then
removed, and the catheter was advanced through the peel-away. The peel-away
sheath was then removed. A final spot fluoroscopic image demonstrates the tip
of the catheter terminating at the right atrium.
The venotomy site was closed with a buried subcutaneous ___ Vicryl stitch, and
covered with Steri-Strips and dry dressings. The catheter was secured using
___ silk sutures. Sterile dressings were applied. Both ports aspirated and
flushed freely. The final tip-to-cuff length is 23 cm.
The patient tolerated the procedure well, and there were no immediate
post-procedural complications.
IMPRESSION:
Placement of a 15.5 ___ tunneled dual-lumen hemodialysis catheter via a
right IJ approach, with the tip terminating in the right atrium. The
tip-to-cuff length is 23 cm. The line is ready for use.
Radiology Report
PORTABLE CHEST X-RAY ___
COMPARISON: ___ chest x-ray.
FINDINGS: Removal of dialysis catheter with no evidence of pneumothorax.
Heart is mildly enlarged and is accompanied by vascular engorgement and new
septal lines consistent with interstitial edema. Small pleural effusions have
increased in size in the interval.
Gender: F
Race: ASIAN - ASIAN INDIAN
Arrive by AMBULANCE
Chief complaint: FEVER, CHILLS
Diagnosed with SEVERE SEPSIS , ADV EFF MEDICINAL NOS, DIABETES UNCOMPL ADULT, KIDNEY TRANSPLANT STATUS
temperature: 100.5
heartrate: 126.0
resprate: 18.0
o2sat: 100.0
sbp: 141.0
dbp: 104.0
level of pain: 13
level of acuity: 2.0 | ___ yo F child psychiatrist w/ complicated PMH significant for
type 1 IDDM (s/p revision renal and pancraes transplants, ___
and ___, diastolic CHF (Echo 35-40%, ___, recurrent MDR E
coli UTIs, chronic anemia, currently on dialysis for repeated
hyperkalemia, who developed fevers during dialysis and later
septic shock.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pyelonephritis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is reliable historian
___ Female presents with 1 day dizziness, low abdominal
discomfort, dysuria, polyuria. Awoke at 2Am with nausea/vomting
x 1 and lower abdominal discomfort without fever, chills,
sweats. She went to ED and had persistent lower anterior
abdominal pain and costovertebral angle tenderness, leukocytosis
and CT abdomen suggestive of acute pyelnonephritis. In the ER
she was given ibuprofen with good effect, and a dose of
Ciprofloxacin 500mg orally. She had no fever, but decision was
to observe her in hospital given ongoing nausea and vomiting.
ROS: toherwise (-) in 12 pt detail review
Past Medical History:
Ingrown toenail
No prior UTIs
Social History:
___
Family History:
Mo - DM2
Fa - deceased pancreatic/prostate cancer at ___
Physical Exam:
98.1, ___, 61, 18, 100% RA "pain = 0-1/10"
Well in NAD
Anicteric, OP clear and moist, neck supple, no ___ CTA bilat
Cor RRR, nl S1, S2 no MRG
Abd (+)suprapubic tenderness, (+) bilat CVA tenderness, no HSM,
no masses
EXT no C/C/edema
SKIN no rashes lesions
NEURO fluent speech, nl cognition, non-focal exam throughout
Pertinent Results:
___ 04:20AM WBC-16.2* RBC-4.50 HGB-12.9 HCT-40.6 MCV-90
MCH-28.7 MCHC-31.8 RDW-11.7
___ 04:20AM NEUTS-82.2* LYMPHS-12.2* MONOS-4.6 EOS-0.8
BASOS-0.2
___ 04:20AM PLT COUNT-179
___ 04:20AM GLUCOSE-106* UREA N-14 CREAT-1.3* SODIUM-137
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
___ 05:25AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 05:25AM URINE RBC-3* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 05:25AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:25AM URINE UCG-NEGATIVE
___ 5:25 am URINE Site: NOT SPECIFIED
ADDED TO ___ ON ___ AT 14:56.
URINE CULTURE (Pending):
___ PELVIS, NON-OBSTETRIC Clip # ___
Reason: torsion vs ovarian cyst
UNDERLYING MEDICAL CONDITION:
___ year old woman with acute onset suprapubic cramping,
nausea, vomiting
REASON FOR THIS EXAMINATION:
torsion vs ovarian cyst
Final Report
HISTORY: Acute onset suprapubic cramping and nausea.
COMPARISON: None.
LMP: ___.
FINDINGS: Transabdominal pelvic sonography was performed; the
internal
examination was deferred. The uterus measures 8.2 x 2.8 x 5.1
cm. The
endometrium is normal measuring 4 mm. The ovaries are normal
bilaterally with
preserved arterial and venous waveforms. No free fluid is seen.
IMPRESSION: Normal examination.
___ 11:___BD & PELVIS WITH CONTRAST Clip # ___
Reason: eval for appy
Contrast: OMNIPAQUE Amt: 130
UNDERLYING MEDICAL CONDITION:
+PO contrast; History: ___ with RLQ pain and tenderness,
leukocytosis. thin,
needs PO contrast
REASON FOR THIS EXAMINATION:
eval for appy
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: JRke MON ___ 2:18 ___
Acute pyelonephritis.
Wet Read Audit # 1
Final Report
HISTORY: Right lower quadrant pain and tenderness
COMPARISON: None available
TECHNIQUE: Axial helical MDCT images were obtained from the
lung bases to the pubic symphysis after administration of IV and
oral contrast. Coronal and sagittal reformations were
generated.
DLP: 407.31 mGy-cm
FINDINGS: The lung bases are clear and the visualized heart and
pericardium are unremarkable.
CT ABDOMEN: The liver enhances homogeneously, without focal
lesions or
intrahepatic biliary duct dilatation. The gallbladder is
unremarkable and the portal vein is patent. The pancreas,
spleen, adrenal glands are within normal limits.
Diffuse bilateral striated nephrograms are present indicative of
acute severe pyelonephritis. There is no discrete abscess,
however more confluent hypodensity in the right renal upper
(601b: 35) and inter-pole regions could represent phlegmon.
There is no hydronephrosis or perinephric abscess. No
nephrolithiasis is identified.
The small and large bowel are normal, without evidence of wall
thickening or obstruction. The appendix is visualized (601b:20)
and is normal. The aorta and its main branches are patent and
nonaneurysmal. There is no mesenteric or retroperitoneal lymph
node enlargement by CT size criteria. There is no ascites,
abdominal free air or abdominal wall hernia.
CT PELVIS: The urinary bladder and ureters are unremarkable.
There is no pelvic wall or inguinal lymphadenopathy. No pelvic
free fluid is observed.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions
concerning for
malignancy.
IMPRESSION: Acute severe bilateral pyelonephritis. No abscess.
Urine culture
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Orsythia (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg oral
daily
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*26 Tablet Refills:*0
2. Phenazopyridine 100 mg PO TID Duration: 3 Days
It may turn your urine orange. You can only take this for three
days
RX *phenazopyridine [Uristat] 95 mg 1 tablet(s) by mouth three
times a day Disp #*9 Tablet Refills:*0
3. Orsythia (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg oral
daily
4. Promethazine 12.5 mg PO Q6H:PRN nausea
RX *promethazine 12.5 mg 1 tablet(s) by mouth three times a day
Disp #*10 Tablet Refills:*0
5. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
It may make you drowsy
RX *acetaminophen-codeine [Tylenol-Codeine #3] 300 mg-30 mg 1
tablet(s) by mouth every 6 hours as needed for pain Disp #*10
Tablet Refills:*0
RX *acetaminophen-codeine [Tylenol-Codeine #3] 300 mg-30 mg ___
tablet(s) by mouth every 6 hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Acute onset suprapubic cramping and nausea.
COMPARISON: None.
LMP: ___.
FINDINGS: Transabdominal pelvic sonography was performed; the internal
examination was deferred. The uterus measures 8.2 x 2.8 x 5.1 cm. The
endometrium is normal measuring 4 mm. The ovaries are normal bilaterally with
preserved arterial and venous waveforms. No free fluid is seen.
IMPRESSION: Normal examination.
Radiology Report
HISTORY: Right lower quadrant pain and tenderness
COMPARISON: None available
TECHNIQUE: Axial helical MDCT images were obtained from the lung bases to the
pubic symphysis after administration of IV and oral contrast. Coronal and
sagittal reformations were generated.
DLP: 407.31 mGy-cm
FINDINGS: The lung bases are clear and the visualized heart and pericardium
are unremarkable.
CT ABDOMEN: The liver enhances homogeneously, without focal lesions or
intrahepatic biliary duct dilatation. The gallbladder is unremarkable and the
portal vein is patent. The pancreas, spleen, adrenal glands are within normal
limits.
Diffuse bilateral striated nephrograms are present indicative of acute severe
pyelonephritis. There is no discrete abscess, however more confluent
hypodensity in the right renal upper (601b: 35) and inter-pole regions could
represent phlegmon. There is no hydronephrosis or perinephric abscess. No
nephrolithiasis is identified.
The small and large bowel are normal, without evidence of wall thickening or
obstruction. The appendix is visualized (601b:20) and is normal. The aorta
and its main branches are patent and nonaneurysmal. There is no mesenteric or
retroperitoneal lymph node enlargement by CT size criteria. There is no
ascites, abdominal free air or abdominal wall hernia.
CT PELVIS: The urinary bladder and ureters are unremarkable. There is no
pelvic wall or inguinal lymphadenopathy. No pelvic free fluid is observed.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions concerning for
malignancy.
IMPRESSION: Acute severe bilateral pyelonephritis. No abscess.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN EPIGASTRIC
temperature: 97.8
heartrate: 95.0
resprate: 18.0
o2sat: 100.0
sbp: 123.0
dbp: 68.0
level of pain: 9
level of acuity: 3.0 | ___ F with no prior PMHx presents with 1 day suprapubic
discomfort (likely cystitis), polyuria, abd pain, N/V and CVA
tenderness (with ascending pyeloonephritis) with CT findings
suggestive of bilateral pylenopnephritis.
#Pyelonephritis:
-Treated with ciprofloxacin during her hospitalization, and her
symptoms of flank pain improved, as did her nausea. Although
final culture grew out 3 species of bacteria, ___ d/w ___
medical director continuation of antibiotics for now.
Discharged with oral anti-emetics, tylenol and oxycodone prn for
flank pain. She also had pain in her pelvis - ? from cystitis
or menstruation. Prescribed three days of pyridium
# ___: (Cr = 1.3, likely higher than baseline given weight, age,
build)
Creatinine improved to 1.0 on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ woman with a history of recurrent acute idiopathic
pancreatitis with extensive work up without clear cause,
followed by Drs. ___ who presents with
recurrent symptoms concerning for recurrent acute pancreatitis.
She reports that she has been suffering from recurrent acute
pancreatitis for more than ___ years. She has had an extensive
work up which has been unrevealing for an underlying cause
despite being followed by pancreas specialists here at ___.
She typically has ___ episodes per year and last admission was
this past ___ for the same symptoms. Her symptoms consistently
occur the same way. She has been doing well until last evening
when her typical symptoms began. She first experienced abdominal
pain located around her "naval" which then spreads in all
direction to her entire abdomen and finally begins radiating
diretly to her back. The pain is associated with nausea but no
vomiting. She was awake most of the night with worsening pain so
went to ___ for evaluation. What worries her this
time is that her pain recurred so quickly from her last attack
in ___ (was not admitted for this), usually she can be symptom
free for several months. Otherwise her symptoms are fairly
typical.
She denies fever, chills, vomiting, chest pain, shortness of
breath, diarrhea, recent travel. She does not drink nor has she
drank alcohol in ___ years, she maintains a strict low fat,
health diet.
She presented to ___ where her labs revealed a
lipase ___ (> assay). She was given IV Dilaudid, IVFs and
transferred to ___ for eval.
In the ED, initial vitals were: ___ pain 97.2 74 135/50 20 98%
RA. Exam was reassuring with mild abdominal tenderness. Labs
largely normal except for lipase >4000. CXR was negative. She
was given IV Dilaudid, IVFs and admitted to medicine.
On the floor, she reports her pain is reasonably controlled but
she does not " want to take anything else" she reports feeling
"queasy" but no vomiting. No SOB, chest pain, cough, sputum
production. No fevers or chills.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. No dysuria. Denies arthralgias or
myalgias. Otherwise ROS is negative.
Past Medical History:
Chronic idiopathic pancreatitis s/p extensive work up
Seizure disorder s/p temporal lobectomy
Social History:
___
Family History:
No family history of pancreatitis
Son with colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals:98.0 PO 142 / 68 73 18 96 RA
Pain Scale: ___ abdominal pain
General: Patient appears tired but stable, comfortable. Alert,
oriented and in no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, tender to palpation diffusely, slightly
distended, hypoactive bowel sounds throughout, no rebound or
guarding
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly intact in bilateral UE and ___, symmetric
DISCHARGE EXAM:
Pertinent Results:
Admission Labs:
___ 11:20AM BLOOD WBC-8.5 RBC-4.20 Hgb-13.3 Hct-39.8 MCV-95
MCH-31.7 MCHC-33.4 RDW-12.7 RDWSD-43.6 Plt ___
___ 11:20AM BLOOD Neuts-77.8* Lymphs-16.1* Monos-4.9*
Eos-0.5* Baso-0.5 Im ___ AbsNeut-6.62* AbsLymp-1.37
AbsMono-0.42 AbsEos-0.04 AbsBaso-0.04
___ 11:20AM BLOOD ___ PTT-29.6 ___
___ 11:20AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-141
K-6.2* Cl-104 HCO3-26 AnGap-17
___ 11:20AM BLOOD ALT-27 AST-49* LD(LDH)-685* AlkPhos-68
TotBili-0.3
___ 11:20AM BLOOD Albumin-4.1 Calcium-8.9 Phos-3.6 Mg-2.0
___ 11:20AM BLOOD Lipase-4680*
___ 11:26AM BLOOD Lactate-1.1
OSH Labs:
Lipase >22,000
Discharge Labs:
*******************
Imaging:
CXR PA/LAT: No acute cardiopulmonary abnormality
CTA Pancreas: Pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 150 mg PO QHS
2. LevETIRAcetam 1000 mg PO QHS
3. DiphenhydrAMINE 50 mg PO Q6H:PRN Insomnia
4. Viokace (lipase-protease-amylase) 20,880-78,300- 78,300 unit
oral TID W/MEALS
Discharge Medications:
1. DiphenhydrAMINE 50 mg PO Q6H:PRN Insomnia
2. Famotidine 20 mg PO DAILY
3. LamoTRIgine 150 mg PO QHS
4. LevETIRAcetam 1000 mg PO QHS
5. Viokace (lipase-protease-amylase) 20,880-78,300- 78,300 unit
oral TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Active:
- Acute idiopathic pancreatitis
- Chronic Pancreatic Insufficiency
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 pancreatitis// eval for pleural effusion
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.
Cholecystectomy clips are noted in the right upper quadrant of the abdomen.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CTA PANCREAS (ABDOMEN AND PELVIS)
INDICATION: ___ year old woman with recurrent idiopathic pancreatitis,
planning CT for pancreatectomy
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 2.4 s, 27.1 cm; CTDIvol = 5.0 mGy (Body) DLP = 131.9
mGy-cm.
2) Spiral Acquisition 6.9 s, 44.8 cm; CTDIvol = 6.8 mGy (Body) DLP = 301.3
mGy-cm.
Total DLP (Body) = 433 mGy-cm.
COMPARISON: CTA Abdomen and Pelvis ___
FINDINGS:
LOWER CHEST: There is scarring at the lung bases. There is mild pleural
thickening on the left, new from ___.
VASCULAR: There is no abdominal aortic aneurysm. There is moderate
atherosclerotic disease. Hepatic arterial anatomy is conventional. Portal
vein is patent.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. Mild central patent biliary duct dilation
has mildly increased. The gallbladder is surgically absent.
PANCREAS: There remains irregular dilation of the pancreatic duct, which has
progressed compared to ___, now measuring up to 9 mm. Focal narrowing of the
pancreatic duct in the head is again seen (series 4, image 45). No focal
pancreatic lesion is identified. Pancreatic parenchyma enhances normally.
There is atrophy of the pancreatic body and tail, progressed compared to ___.
There is mesenteric stranding centered around the pancreatic head, that
extends inferiorly. No walled-off collection is seen. There are no
pancreatic calcifications.
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 symmetrically. There is an extrarenal pelvis on
the right, as seen previously. There are no suspicious renal lesions. There
is a subcentimeter hypodensity in the upper pole the left kidney which is too
small to characterize. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. There is a large duodenal
diverticulum. There is no bowel obstruction. There is extensive
diverticulosis. There is no intra-abdominal free air.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The bladder is partially distended. There is no evidence of pelvic or
inguinal lymphadenopathy. There is moderate pelvic free fluid, new from
prior.
REPRODUCTIVE ORGANS: The uterus is unremarkable.
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. Progressive changes related to chronic pancreatitis since ___, with
increased irregular dilation of the pancreatic duct and increased atrophy of
the body and tail. Mesenteric stranding centered around the pancreatic head
suggests acute pancreatitis. No evidence of pancreatic necrosis. No
peripancreatic collection.
2. Moderate simple free fluid in the pelvis, likely reactive.
3. No focal pancreatic mass.
4. Conventional arterial anatomy.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Acute pancreatitis without necrosis or infection, unsp
temperature: 97.2
heartrate: 74.0
resprate: 20.0
o2sat: 98.0
sbp: 135.0
dbp: 50.0
level of pain: 7
level of acuity: 3.0 | ___ is a ___ woman with a history of recurrent acute
idiopathic pancreatitis with extensive work up without clear
cause, followed by Drs. ___ and ___ who presents
with recurrent symptoms concerning for recurrent acute
pancreatitis.
# Acute pancreatitis, idiopathic
# Chronic pancreatic insufficiency
# Post procedure pancreatitis
History of chronic recurrent acute pancreatitis with extensive
negative work up followed by Drs. ___ and ___.
At one point considered radical pancreatectomy though after
review with multi-disciplinary pancreas board decision not to
pursue that line of treatment given friable pancreas and her
chronic pain syndrome had resolved. On admission, BISAP score
was 1 (for age) portending favorable prognosis and lipase
downtending rapidly. With conservative care including NPO, IVFs,
pain and nausea control her symptoms abated and she was
tolerated a clear liquid diet. CTA showed widened PD that would
allow advanced endoscopic intervention. On ___, she underwent
ERCP and received a PD stent across the minor papilla in an
effort to keep the PD patent. Post-procedure on ___, she
developed abd pain and nausea with lipase elevated to 2400. The
pain has been waxing and waning since then with fluctating
lipase levels of unclear significance.
Continued Pancrelipase (usually on Viokace at home) at an
approximate dose, which she takes for pancreatic insufficiency
# Seizure disorder
s/p temporal lobectomy, without seizures for many years.
Continued Lamotrigine
and Levetiracetam |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Sore throat
Major Surgical or Invasive Procedure:
___ Fiberoptic nasopharyngeal intubation
___ Midline placement
History of Present Illness:
___ y.o lady with a history of hypothyroidism and depression, who
presented with 1 day history of sore throat, odynophagia and
difficulty with secretions. She denies any ear pain. She reports
she has to push on her TMJs bilaterally to assist with
swallowing due to the pain. No fever. No cough. No difficulty
breathing or SOB. Immunizations up to date (except Hep B. She
endorses chills at home over the last day.
In the ED, initial vitals: 99.1 107 151/85 18 99% RA
Physical exam significant for Oropharynx without significant
swelling, no stridor, left tender adenopathy.
Bedside laryngoscopy with erythema and inflammation of the vocal
chords. She was given 10 mg IV dexamethasone. ENT scoped and
agreed with epiglottitis. They recommended continuing 10 mg IV
dexamethasone q 8 hours, unasyn 3g q6h, Benadryl 25mg q6h,
continuous face mist/humidification at all times, page them for
stridor/stertor, inc WOB or worsening airway complaints/signs.
She should be in the ICU for airway monitoring.
ENT notes: "beefy, red and edematous epiglottis w/ edema and
erythema extending to AE folds and arytenoids. TVF still
visualized with no glottic edema. No stridor/stertor."
She received 30 mg IM ketorolac, 1 mg IM lorazepam, magic mouth
wash, 3g ampicillin-sulbactam, 10 mg dexamethasone, 25 mg
diphenhydramine, 2L NS.
Labs significant for lactate 2.1.
On arrival to the MICU, pt was initially stable, reporting no
worsening of symptoms or difficulty handling secretions. Within
~1 hr, pt had worsening symptoms, difficulty handling
secretions, and SOB. ENT, anesthesia and ACS were emergently
contacted to evaluate for airway mangament. She was taken to the
OR for a fiberoptic intubation with surgical backup for
impending airway occlusion.
Pt returned to the MICU stable, intubated and sedated.
Review of systems:
negative except per HPI
Past Medical History:
- depression
- prurigo nodularis
- hypothyroidism
Social History:
___
Family History:
Mother with breast cancer diagnosed in late ___ well.
Mother has hypertension, degenerative joint disease. Father MI
in at early ___, passed away. Two older sisters with fibroids,
hypertension, and sister with thyroid disorders. Colon cancer in
mother's 2 brothers.
Physical Exam:
======================
ADMISSION EXAM:
======================
Vitals: BP:125/80 P:116 R:11 O2:97%
GEN: NAD.
HEENT: muffled voice. Difficulty handling secretions. No stridor
or stertor. EOMI. Eye/eyelids wnl. MMM. No tonsillar
hypertrophy. No posterior pharyngeal erythema.
Neck: soft, supple. Mild L tender adenopathy.
Resp: CTAB. Nonlabored.
Card: RRR. No m/r/g.
Abd: Soft, NTND.
Ext: No edema, cyanosis or clubbing.
SKin: No rash
Neuro: Cn3-12 grossly intact. Gross sensorimotor intact.
======================
DISCHARGE EXAM:
======================
Vitals: 98.3, afebrile overnight 126/74 62 18 96% RA
GENERAL: no acute distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition, there are multiple small ulcers on the hard
palate again improved from prior, there is a healing ulcer of
the lateral lip
NECK: supple neck
CARDIAC: bradycardic but regular S1/S2, no murmurs, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, non-tender, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: moving all 4 extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
====================
ADMISSION LABS:
====================
___ 11:51AM BLOOD WBC-22.6*# RBC-4.70 Hgb-13.3 Hct-39.9
MCV-85 MCH-28.3 MCHC-33.3 RDW-18.0* RDWSD-55.9* Plt ___
___ 11:51AM BLOOD Neuts-91.3* Lymphs-3.2* Monos-4.6*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-20.65* AbsLymp-0.72*
AbsMono-1.04* AbsEos-0.01* AbsBaso-0.07
___ 11:51AM BLOOD Glucose-101* UreaN-15 Creat-0.7 Na-140
K-3.7 Cl-105 HCO3-20* AnGap-19
___ 11:56AM BLOOD Lactate-2.1*
====================
PERTINENT RESULTS:
====================
LABS:
====================
___ 04:06AM BLOOD TSH-1.5
====================
IMAGING:
====================
CXR (___): ET tube tip is relatively low, 2 cm above the
carina and should be pulled back. NG tube is coiled within the
stomach. Bibasal consolidations are present, might potentially
represent atelectasis due to low lung volumes but infectious
process is a possibility. Small bilateral pleural effusions are
most likely present as well.
====================
MICROBIOLOGY:
====================
___ 11:57 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
PASTEURELLA MULTOCIDA.
Sensitivity testing per ___ ___. FINAL
SENSITIVITIES.
sensitivity testing performed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PASTEURELLA MULTOCIDA
|
AMPICILLIN------------ S
CEFTRIAXONE----------- S
LEVOFLOXACIN---------- S
TRIMETHOPRIM/SULFA---- S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0435.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ 11:53 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
PASTEURELLA MULTOCIDA.
IDENTIFICATION PERFORMED ON CULTURE # ___
___.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0435.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ blood culture x 2 NGTD
___ blood culture x 1 NGTD
___ 10:09 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..
====================
DISCHARGE LABS:
====================
___ 06:15AM BLOOD WBC-15.9* RBC-3.87* Hgb-10.9* Hct-33.5*
MCV-87 MCH-28.2 MCHC-32.5 RDW-18.2* RDWSD-55.8* Plt ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 88 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Acyclovir 400 mg PO Q8H Duration: 6 Days
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*12 Tablet Refills:*0
3. CeftriaXONE 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV Q24h
Disp #*6 Intravenous Bag Refills:*0
4. PredniSONE 10 mg PO ONCE Duration: 1 Dose
30mg ___, 20mg ___, 10mg ___
Tapered dose - DOWN
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Pasteurella epiglottitis
Pasteurella bacteremia
Primary herpes simple I infection
Secondary diagnosis:
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with og placed after intubation for
epiglottitis // og placement og placement
COMPARISON: ___
IMPRESSION:
ET tube tip is relatively low, 2 cm above the carina and should be pulled
back. NG tube is coiled within the stomach. Bibasal consolidations are
present, might potentially represent atelectasis due to low lung volumes but
infectious process is a possibility. Small bilateral pleural effusions are
most likely present as well.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Sore throat
Diagnosed with Acute epiglottitis without obstruction
temperature: 99.1
heartrate: 107.0
resprate: 18.0
o2sat: 99.0
sbp: 151.0
dbp: 85.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ y/o woman who presented with sore throat and
was found to have pasteurella epiglottitis and bacteremia.
=================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
left hand pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with PMH of well controlled asthma presenting
with left hand pain and swelling. He was in his usual state of
health until he woke up on ___ at 5 AM with pain in his left
hand going up towards his left shoulder. The pain was worse
with extending his fingers and he was unable to fully extend his
fingers. He then developed swelling mostly of the left third
finger and forearm. He called his doctor and was instructed to
go to the ED. He denies any bites, scratches, trauma, sick
contacts, recent travel. In ED labs and upper extremity Doppler
were unremarkable, hand X-ray showed no fracture but did show
soft tissue swelling along long finger. Hand surgery was
consulted, concern for early flexor tenosynovitis, he was
started on Vancomcyin and Unasyn, was put in a splint and his
hand was kept elevated. He had improvement in the pain and
swelling and was able to fully extend his fingers but still had
some pain.
Currently he reports he feels well. With hand elevated and in a
splint he has no pain. Denies any numbness, tingling or
decreased motion. He does report having a sore throat ___ days
prior which resolved on its own but otherwise has been feeling
well. About ___ year ago he developed an infection of his right
thumb requiring incision and drainage, he reports no obvious
cause of the infection was found.
ROS: As above, ten point ROS otherwise negative.
Past Medical History:
well controlled asthma, eczema, seasonal allergies.
Social History:
___
Family History:
Mother died at ___ from a car accident. Father has DM, HTN and
CAD. Aunt recently diagnosed with unknown cancer.
Physical Exam:
Admission PE
VS: T: 97.3 BP: 124/76 HR 59 RR 18 96% RA
Gen: NAD, resting comfortably in bed
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
GU: no foley
Ext: left hand in splint, mild erythema of third finger, normal
sensation throughout, full range of motion of fingers, mild
swelling and erythema in forearm.
Neuro: CN II-XII intact, ___ strength throughout
Psych: pleasant, normal affect
Skin: warm, dry no other rashes
Discharge PE:
VS: T: 97.7 BP: 124/79 HR 62 RR 18 98% RA
Gen: NAD, resting comfortably in bed
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
GU: no foley
Ext: improved mild erythema and swelling of left third finger,
normal sensation throughout, full range of motion of fingers, no
swelling or erythema of forearm
Neuro: CN II-XII intact, ___ strength throughout
Psych: pleasant, normal affect
Skin: warm, dry no other rashes
Pertinent Results:
___ 04:13PM GLUCOSE-93 UREA N-13 CREAT-0.9 SODIUM-139
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
___ 04:13PM CALCIUM-9.6 PHOSPHATE-4.3 MAGNESIUM-2.2
___ 04:13PM WBC-6.5# RBC-5.25 HGB-15.8 HCT-45.1 MCV-86
MCH-30.1 MCHC-35.0 RDW-12.3 RDWSD-37.5
___ 04:13PM NEUTS-65.4 ___ MONOS-8.0 EOS-2.9
BASOS-0.6 IM ___ AbsNeut-4.25 AbsLymp-1.49 AbsMono-0.52
AbsEos-0.19 AbsBaso-0.04
Left Hand X-ray:
IMPRESSION:
No fracture or focal osseous abnormality. Soft tissue swelling
involving the long finger.
Left Upper extremity Doppler:
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. beclomethasone dipropionate 80 mcg/actuation inhalation
BID:PRN SOB
3. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN hand rash
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Multivitamins 1 TAB PO DAILY
4. beclomethasone dipropionate 80 mcg/actuation inhalation
BID:PRN SOB
5. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN hand rash
6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 14 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left third finger flexor tenosynovitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with L palmar hand pain, mild swelling // Eval for acute
abnormality
TECHNIQUE: AP, lateral, and oblique views of the left hand.
COMPARISON: None.
FINDINGS:
There is no fracture or focal osseous abnormality. Joint spaces are
preserved. There is soft tissue swelling involving the long finger. There is
no radiopaque foreign body or subcutaneous gas.
IMPRESSION:
No fracture or focal osseous abnormality. Soft tissue swelling involving the
long finger.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL LEFT
INDICATION: ___ man with left upper extremity swelling
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None relevant
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: L Arm pain
Diagnosed with Other synovitis and tenosynovitis, left forearm
temperature: 97.9
heartrate: 79.0
resprate: 16.0
o2sat: 100.0
sbp: 190.0
dbp: 92.0
level of pain: 8
level of acuity: 2.0 | ___ year old male with PMH of well controlled asthma presenting
with left hand pain and swelling.
#Flexor tenosynovitis of left hand. Hand surgery was consulted
in the ED. No obvious inciting cause of inflammation.
Significant improvement on Vanc/Unasyn and elevation. With
Vancomycin he developed some redness at the injection site and
some tingling in his mouth/throat, Vancomycin was discontinued.
-Transitioned to Bactrim DS for a 14 day course
-Follow with hand surgery in ___ days.
#Asthma: No signs of exacerbation, continue PRN albuterol
#FEN/PPX: regular, ambulatory
Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is an ___ with history of A. fib on Coumadin,
hypertension, presenting with an unwitnessed fall today. Patient
himself has no recollection of the fall. Per ED documentation,
the patient was found by security on the ground immediately
outside of his apartment unit where he lives with his wife. He
states that he woke up this morning, went to a meeting
downstairs and was in his usual state of health until he found
himself on stretcher by EMS. Has no recollection of intervening
events. States that occasionally gets lightheaded when he takes
his BP meds (sometimes takes QDay vs BID, one pill or two
pills), but does not recall feeling so this morning. He denies
CP, palpitations, SOB. No h/o seizures. Reports possible URI a
few days ago but no persistent cough or fevers. Denies HA, focal
weakness, numbness, HA, blurry vision, dysphagia, abd pain, n/v,
poor PO intake, dysuria, hematuria (past hx but no recent
issues), melana/hematochezia, paresthesias.
Spoke with ___ from ___ in ___ who
explains that patient was found by another resident on the floor
in front of appartment in left lateral recumbant position and
confused at the time. ? report of urinary incontinence, no stool
incontinence noted. Noted to have bruise on forehead. Patient
taken by EMS to ED.
On arrival to the ED, initial vitals were: 98, ___,
100% RA. Per ED nursing notes, pt unable to answer to date but
states place as hospital and able to state his name and what
school he attended - pt initially combative but eventually more
responsive to commands. FSBS = 107. EKG: SR with LBBB (new
compared to ___, NCHCT negative. CT ___ negative. FAST
negative. U/A notable for pyuria, bacteriuria, + nitirate. Given
CTX and TD. Admit for fall, AMS and UTI. Hemolyzed K 6.5. repeat
:5.5. ___: <0.01, Cr 1.3, INR 1.6, urine tox neg. VS prior to
transfer: 97.6, 96, 179/78, 17, 96% RA
.
Currently, patient feeling well. Denies any HA, blurry vision,
lightheadedness, CP, palpitations, SOB.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
+ chronic LLE>RLE edema, unchanged. No recent
travel/immobilization.
Past Medical History:
- Hypertension.
- BPH status post TURP.
- Afib (on warfarin)
- Congestive heart failure (per records, pt denies)
- Diverticulosis.
- shingles
- h/o Hematuria
- CKD stage III (baseline ~1.3)
- neuritis NOS
- acne rosacea
- macular degeneration R
- hemorrhoids
- colitis
Social History:
___
Family History:
- sister with lung cancer, then brain cancer ~ age ___
- mother with colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97kg 98.4 190/90 90 20 99ra
General: NAD
HEENT: no scleral icterus, left scalp hematoma w/ superficial
abrasion
Neck: supple, no cervical ___. No carotid bruits.
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: CTABL
Abdomen: soft, NT/ND. No organomegaly. +BS.
GU: foley with yellow urine
Ext: cool extremities but 2+ pulses. 1+ edema LLE, neg ___,
no palpable cords.; right knee with swelling medially, normal
ROM.
Neuro: A+Ox3, attentive. days of the week backwards. CN ___
intact. Motor and sensory function grossly intact. no pronator
drift. finger to nose intact. reflexes brisk and equal
bilaterally, downgoing babinski.
Skin: scattered superfical abrasions
DISCHARGE PHYSICAL EXAM:
VS - 98.1 161/85 70 18 96RA 84.7KG
General: NAD
HEENT: no scleral icterus, left scalp hematoma
Neck: supple
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: CTABL
Abdomen: soft, NT/ND. No organomegaly. +BS.
GU: no foley
Ext: normal distal pulses, 1+ edema LLE
Neuro: A+Ox3, attentive. grossly intact.
Skin: scattered superficial abrasions and echymoses
Pertinent Results:
ADMISSION LABS:
___ 01:10PM BLOOD ___
___ Plt ___
___ 01:10PM BLOOD ___
___
___ 01:10PM BLOOD ___ ___
___ 01:10PM BLOOD ___
___
___ 01:10PM BLOOD ___
.
PERTINENT LABS:
___ 06:45AM BLOOD ___
___ 09:05PM BLOOD ___
___ 01:10PM BLOOD ___
___
___ 01:10PM BLOOD cTropnT-<0.01
___ 09:05PM BLOOD ___ cTropnT-<0.01
___ 06:45AM BLOOD ___ cTropnT-<0.01
___ 06:45AM BLOOD ___
.
DISCHARGE LABS:
___ 05:45AM BLOOD ___ ___
___ 05:45AM BLOOD ___
___
___ 06:45AM BLOOD ___
.
IMAGING:
.
___ W/O CONTRAST
1. No fracture or traumatic malalignment of the cervical spine.
Mild degenerative changes.
2. Enlarged heterogeneous ___ left thyroid gland.
___ thyroid ultrasound would be helpful for further
evaluation if not previously done.
3. Pulmonary edema noted at the lung apices. Chest ___ may
be performed if clinically indicated for further evaluation.
.
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION: No evidence of acute intracranial process. Small
left frontal scalp hematoma.
.
___ Imaging CHEST (PA & LAT)
IMPRESSION: No acute cardiopulmonary process.
.
___ Cardiovascular ECHO
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Doppler parameters
are most consistent with Grade I (mild) left ventricular
diastolic dysfunction. The gradient increased with the Valsalva
manuever. No ___ gradient is identified. No apical
intracavitary gradient is present. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. There
is systolic anterior motion of the mitral valve leaflets.
Trivial mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function.
Systolic anterior motion of the MV leaflet with mild increase of
outflow tract gradient with Valsalva only. Mild pulmonary artery
systolic hypertension.
.
MICROBIOLOGY
___ 2:20 pm URINE Site: NOT SPECIFIED
CHM S# ___ ADDED ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
2. Warfarin 2.5 mg PO 4X/WEEK (___)
3. Warfarin 5 mg PO 3X/WEEK (___)
4. Finasteride 5 mg PO DAILY
5. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Outpatient Lab Work
please check INR on ___ and fax results to:
Name: ___.
Location: ___
Address: ___, ___
Phone: ___
Fax: ___
and
___ clinic
Fax: ___
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX ___ 800 ___ mg 1 (One)
tablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0
3. Atenolol 100 mg PO DAILY
4. Doxycycline Hyclate 100 mg PO Q12H
5. Finasteride 5 mg PO DAILY
6. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST TWO VIEWS, ___
HISTORY: ___ male status post fall.
COMPARISON: None.
FINDINGS: There are streaky bibasilar opacities, left greater than right,
suggestive of atelectasis. The lungs are otherwise clear. There is no
pneumothorax. The cardiomediastinal silhouette is within normal limits. No
acute osseous abnormality is identified.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: Status post fall with limited with altered mental status and
perseveration, evaluate for intracranial hemorrhage.
COMPARISON: None available.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm-reconstructed images were acquired.
DLP: 1449 mGy-cm
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large vascular
territorial infarction. Prominent ventricles and sulci suggesting age related
a global atrophy. There is evidence of a prior lacunar infarct of the left
caudate head. The basal cisterns appear patent and there is preservation of
gray-white matter differentiation.
No fracture is identified. A left frontal scalp hematoma is noted. A small
mucous retention cyst is seen within the left frontal sinus. The remaining
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear.
IMPRESSION:
No evidence of acute intracranial process. Small left frontal scalp hematoma.
Radiology Report
HISTORY: Status post fall and now with altered mental status and
perseveration.
COMPARISON: None available.
TECHNIQUE: Helical axial MDCT sections were obtained from the skullbase
through the T2 vertebral level. Reformatted images in sagittal and coronal
axes were obtained.
DLP: 1104 mGy-cm
FINDINGS:
There is no sign of a fracture or traumatic malalignment of the cervical
spine. There is no prevertebral soft tissue swelling. Mild multilevel
degenerative changes are noted with end plate osteophytes and disc space
narrowing, especially at the C6-C7 level. CT is not able to provide
intrathecal detail comparable to MRI, but the visualized outline of thecal sac
appears unremarkable.
No lymphadenopathy is present by CT size criteria. There is asymmetric
enlargement of the left thyroid lobe with heterogeneous hypodensities. The
imaged lung apices demonstrate smooth septal thickening and ground-glass
opacities suggestive of pulmonary edema.
IMPRESSION:
1. No fracture or traumatic malalignment of the cervical spine. Mild
degenerative changes.
2. Enlarged heterogeneous multi-nodular left thyroid gland. Non-emergent
thyroid ultrasound would be helpful for further evaluation if not previously
done.
3. Pulmonary edema noted at the lung apices. Chest x-ray may be performed if
clinically indicated for further evaluation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Altered mental status
Diagnosed with SYNCOPE AND COLLAPSE, URIN TRACT INFECTION NOS, TETANUS TOXOID INOCULAT, UNSPECIFIED FALL
temperature: 98.0
heartrate: 100.0
resprate: nan
o2sat: 100.0
sbp: 202.0
dbp: 110.0
level of pain: nan
level of acuity: 1.0 | Mr ___ is an ___ with history of A. fib on Coumadin,
hypertension, presenting with an unwitnessed fall/syncope.
# Fall
Patient with syncopal episode of unclear etiology. No clear
mechanical cause for fall and no h/o prior falls. Patient denied
any ___ symptoms. No neurologic deficits on exam to
suggest CVA and NC head CT neg for bleed or acute stroke. No h/o
seizures. ___ revealed LBBB on EKG, which was later
confirmed to be present on EKG in ___. Cardiac enzymes were neg
x 3. Monitored on telemetry with no arrhythmias. Echocardiogram
with normal EF, no e/o valvular disease and no wall motion
abnormalities. Syncope likely occurred in setting of UTI for
which patient will complete a ten day course of antibiotics. If
recurrent episode, would consider event monitor. Patient
evaluated by ___ who recommended regular use of a cane and home
___ for balance training.
# UTI
Patient reported h/o BPH and prior UTIs. Denied dysuria or
recent difficulty urinating. Urinalysis for w/u of fall showed
pyuria and bacteriuria. Initially treated with Ceftriaxone IV,
then transitioned to PO Bactrim to complete a ten day course.
Urine culture grew ___ E.coli. (Of note, patient had
foley placed in ED as part of trauma protocol. Removed on
arrival to the floor with few subsequent self limited episodes
of hematuria. Reported clear urine prior to discharge. Has had
h/o intermittent hematuria in past and this is not uncommon for
him).
# PAfib
In SR throughout course. Continued Atenolol. Patient
anticoagulated on warfarin with INR 1.6 on admission. Patient
reported goal ___, confirmed with ___
___ clinic that goal has been ___. Given above
antibiotics, discharged on lower dose of warfarin 2.5mg daily
with INR ___ on ___. INR on day of discharge 1.5.
# Incidental finding:
CT noted ___ left thyroid gland. TSH WNL. Recommend
outpatient ultrasound for further evaluation.
# HTN
BP elevated on arrival to 190/90. Treated acutely with
Labetolol, then resumed home Atenolol.
# CKD III
___ ~ 1.3. GFR 53. Remained at baseline.
# BPH
Continued finasteride. |
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:
___ yo female who reports that yesterday morning she had oatmeal
w/ milk as she usually does; around noon had some popcorn and
then 15 minutes later, started having periumbilical pain, as if
someone tied a knot at the belly button and was pulling it down
but pain more diffuse as well. Took Tums and still wasn't
feeling well; then took some Motrin 400 mg, continued to feel
pain. Improved w/ lying down but feeling nauseous the whole
time. Loss of appetite. Vomited up water when tried to drink.
Around 9pm took more Motrin. Then today, vomited all day. Tried
to drink apple cider, vomited this 10 minutes later along with
medication. Middle of the night--no one to take care of kids as
husband was away--tossing and turning--finally around ___ am
made toast with jam, this finally stayed; took some Tums; felt
better; slept from 3 to 7. Took more medication, vomited this
again. Called HCA around noon, ate half an avocado, took a
couple of Motrin. Staying in one position as much as possible.
Pain continues unabated. Hurt to go over bumps in the car, even
little bumps. Hurts to change position. Family history of
gallstones, cholecystectomy among several of her female
relatives.
Past Medical History:
HTN
PSH: Csection x3
Social History:
___
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
T 98.1 HR 90 132/70 RR 17 98% RA
Gen: Non-toxic appearing. Staying still while in chair. Moves
gingerly. Interacting with examiner easily and appropriately.
Abd: RUQ pain to palpation with some guarding. Not much pain to
direct
palpation elsewhere. However has immediate and dramatic tap
tenderness diffusely in all four quadrants
On discharge:
AVSS
Gen: In NAD
CV: RRR, no m/r/g
Abdomen: soft, NTND
Ext: No c/c/e
Pertinent Results:
___ 06:30PM GLUCOSE-119* UREA N-14 CREAT-1.0 SODIUM-134
POTASSIUM-5.8* CHLORIDE-98 TOTAL CO2-26 ANION GAP-16
___ 06:30PM ALT(SGPT)-17 AST(SGOT)-45* ALK PHOS-63 TOT
BILI-0.3
___ 06:30PM LIPASE-21
___ 06:30PM ALBUMIN-4.2
___ 06:30PM WBC-11.4*# RBC-4.83 HGB-12.8 HCT-38.5 MCV-80*
MCH-26.6* MCHC-33.3 RDW-14.2
___ 06:30PM PLT COUNT-357
CT ABD & PELVIS WITH CONTRAST
IMPRESSION:
1. Acute uncomplicated appendicitis.
2. Intestinal malrotation
Medications on Admission:
HCTZ 25mg', enalapril 40mg'
Discharge Medications:
1. enalapril maleate 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*24 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with sudden onset severe abdominal pain, most
notably in the right lower quadrant, and positive peritoneal signs.
COMPARISON: MR dated ___. No CT comparison available.
TECHNIQUE: Axial CT images through the abdomen and pelvis were acquired after
administration of intravenous contrast. Coronal and sagittal reformatted
images were reviewed.
FINDINGS:
ABDOMEN: The lung bases are clear without pleural or pericardial effusion.
The liver, spleen, gallbladder, pancreas, adrenal glands, right kidney are
unremarkable. A 1-cm hypodensity in the left kidney likely corresponds to the
angiomyolipoma seen on prior MR. ___ is made of intestinal malrotation
without evidence for volvulus; no bowel obstruction or bowel wall thickening
is seen. Stool is seen throughout the colon. There is reversal of the
relationship between the superior mesenteric artery and veins. Slight superior
indentation on the celiac artery may be secondary to median arcuate ligament.
Visualized vasculature is otherwise unremarkable.
The appendix is dilated up to 13 mm and fluid filled with haziness of the
surrounding fat. There is no adjacent fluid collection or free
intraperitoneal air. There is no ascites.
PELVIS: The uterus is bulky and heterogeneous, most likely secondary to
fibroids. The urinary bladder is unremarkable. No adnexal abnormalities are
detected within the limitations of CT. The rectum contains stool and is
otherwise unremarkable.
No lymphadenopathy is detected. No concerning lytic or sclerotic osseous
lesions are seen. Sclerosis along the sacroiliac joints bilaterally is noted.
IMPRESSION:
1. Acute appendicitis. No drainable fluid collection or extraluminal gas.
2. Intestinal malrotation without current midgut volvulus.
These findings were discussed with Dr. ___ by Dr. ___
by telephone at 9:30 p.m. on ___ and by Dr. ___ by telephone
at 10:25 p.m. on ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ACUTE APPENDICITIS NOS, INTESTINAL FIXATION ANOM, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.5
heartrate: 99.0
resprate: 16.0
o2sat: 99.0
sbp: 133.0
dbp: 83.0
level of pain: 9
level of acuity: 3.0 | The patient was admitted to the Acute Care Surgery team and
underwent CT imaging of her abdomen showing acute appendicitis
with intestinal malrotation. She was consented and taken to the
operating room for laparoscopic appendectomy. There were no
complications. Reader referred to operative note for full
details. Postoperatively she progressed well; her diet was
advanced on the morning following her surgery and her home
medications were restarted. She was able to tolerate her diet
without problems and is ambulating independently with adequate
pain control. She is being discharged to home and will follow up
with her PCP and in ___ Care Surgery clinic in the next few
weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
___ with unknown PMH found down with a bottle of alcohol at side
with pinpoint pupils on the side walk with heavy odor of EtOH
per EMS. He was given 2 mg of Narcan x2 in ED without response.
Pt became hypoxic to ___ with episodes of apnea and was
intubated. There was a queston of trauma from OG tube placement
d/t blood vs GI blood. Pt was guaiac negative in ED. He is being
transferred intubated and sedated.
In the ED, VS: Unknown.
Notable labs: Initial blood gas: pH 7.21 pCO2 65 pO2 141 HCO3 27
BaseXS -3, Lactate 3.2, Tox screen negative, serum EtOH level
131, H&H ___, WBC 9.9, Normal Coags, WNL Chem 7, and normal
lipse. LFT's not sent. UA with 30 protein but otherwise
unremarkable.
EKG showed NSR with normal intervals.
In the ED, patient was given 4L NS, 80 mg pantoprazole and
started on pantaprazole drip, intubated and started on propofal
gtt, and given 2 mg IV lorazepam X 1.
After intubation:
pH 7.39 pCO2 37 pO2 276 HCO3 23 BaseXS -1
Imaging:
Chest Xray: ET tube in satisfactory position. NG tube with the
tip in the stomach but the side hole in the lower esophagus.
Retrocardiac opacity may reflect atelectasis, aspiration or
pneumonia.
Head CT Without contrast: No acute intracranial process.
Vitals prior to transfer Temp. 97.9 HR 75 BP 101/61 RR 20 100%
Intubation. Of note prior to transfer patient was agitated
requiring ativan administration and propofal bolus.
On arrival to the ___, patient is intubated and sedated.
Past Medical History:
Prior seizure not related to alcohol
Right lower extremity fracture
Social History:
___
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
Vitals: T: afebrile BP: 117/71 P: 69 CMV, PEEP 5, TV 500, RR 20,
FiO2 0.35
GENERAL: Intubated and sedated, not following commands. OG tube
in place. No echymosis or other evidence of trauma appreciated.
HEENT: Pinpoint pupils, reactive to light, no evidence of trauma
or defects to palpation
NECK: JVP not elevated
LUNGS: Clear to auscultation anteriorly
CV: RRR, no murmurs
ABD: soft, normal bowel sounds, non-tender to palpation in all
4 quadrants. Scar approximately 3 cm in length in RLQ,
well-healed.
EXT: No edema, 2+ peripheral pulses, extremities warm and
well-perfused. Multiple tattoos including one on right upper
forearm, left upper forearm, and right and left hands.
PHYSICAL EXAM ON DISCHARGE:
=============================
Pertinent Results:
LABS ON ADMISSION:
=====================
___ 11:26PM BLOOD WBC-9.2 RBC-4.26* Hgb-12.2* Hct-36.8*
MCV-86 MCH-28.6 MCHC-33.2 RDW-13.7 RDWSD-43.0 Plt ___
___ 09:28AM BLOOD WBC-3.9*# RBC-3.37* Hgb-9.9* Hct-28.7*
MCV-85 MCH-29.4 MCHC-34.5 RDW-13.9 RDWSD-42.9 Plt ___
___ 09:28AM BLOOD Glucose-83 UreaN-13 Creat-0.7 Na-141
K-3.4 Cl-110* HCO3-21* AnGap-13
___ 11:26PM BLOOD Glucose-151* UreaN-17 Creat-1.1 Na-141
K-4.0 Cl-102 HCO3-26 AnGap-17
___ 09:28AM BLOOD Calcium-7.4* Phos-2.3* Mg-1.7
___ 11:26PM BLOOD CK(CPK)-151
___ 09:28AM BLOOD ALT-13 AST-23 AlkPhos-54 TotBili-0.2
___ 11:26PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:40PM BLOOD pO2-141* pCO2-65* pH-7.21* calTCO2-27
Base XS--3 Comment-GREEN TOP
___ 12:47AM BLOOD pO2-276* pCO2-37 pH-7.39 calTCO2-23 Base
XS--1
___ 11:40PM BLOOD Glucose-144* Lactate-3.4* Na-144 K-3.9
Cl-102
___ 09:47AM BLOOD Lactate-1.1
IMAGING:
==========
Chest Xray: ET tube in satisfactory position. NG tube with the
tip in the stomach but the side hole in the lower esophagus.
Retrocardiac opacity may reflect atelectasis, aspiration or
pneumonia.
Head CT Without contrast: No acute intracranial process.
ED EKG reviewed:
Normal sinus rhythm, rate of 88 bpm. Normal intervals.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with unresponsive found down pinpoint pupils***
WARNING *** Multiple patients with same last name! // eval for intracranial
hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.9 cm; CTDIvol = 47.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: UNRESPONSIVE
Diagnosed with ALTERED MENTAL STATUS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ with unknown PMH found unresponsive with serum EtOH level of
131 now intubated and sedated after apneic episode with
respiartory failure likely secondary to toxic metabolic
encephalopathy.
#Hypercarbic Respiratory Failure
Patient with respiratory failure secondary to altered mental
status and inability to protect the airway. Hypercarbia now
improved with intubation with normal pH and pCO2. Patient was
quickly weaned from mechanical ventilation and extubated
successfully and on RA prior to discharge.
#Toxic Metabolic Encephalopathy
Patient found down with bottle of EtOH with pinpoint pupils
unresponsive to narcan. Serum EtOH level of 131 supports EtOH
intoxication. Tox screen otherwise negative with negative CT
head. Upon awakening patient endorsed taking a half tab of
suboxone with alcohol. Infectious etiology also less likely
given absence of leukocytosis, normal UA, and normal CXR. Mental
status improved post-extubation.
#Alcohol intoxication
Patient with elevated serum EtOH level to 131. LFT's and INR all
within normal range. Patient denied history of DT's or
complicated alcohol withdrawel. Social work evaluated patient.
Additionally patient monitored with CIWA scale for withdrawal.
Thiamine, folate, and MVI given. Counseled regarding ETOh abuse
and also seen by SW prior to discharge.
#Pancytopenia
Patient noted to develop pancytopenia on labs while in the ICU
likely secondary to bone marrow suppression from alcohol use and
dilutional effect from IVF since all counts were down.We
requested that patient stay to have repeat CBC to ensure
stability but patient refused to stay for blood draw. Otherwise
was stable without bleeding so recommended he should have this
rechecked upon follow up as outpatient if not willing to stay.
#Hematemesis
Questionable hematemsis vs. trauma from OG tube placement in ED.
Differential included gastritis and ___ tear though
patient was without any evidence of ongoing bleeding in the ICU.
#Lactic Acidosis
Patient with evidence of lactic acidosis initially with lactate
of 3.4 on arrival. Elevated lactate likely secondary to poor PO
intake in addition to EtOH effect favoring preferential
conversion of pyruvate to lactate. Lactate improved with IVF to
1.1 prior to discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Black Stool and Weakness
Major Surgical or Invasive Procedure:
bone marrow biopsy on ___
History of Present Illness:
___ yo F with hx of weakness and guaiac positive stools. She
presented to her PCPs office after feeling weak for 4 days. A
few days ago she had some stomach discomfort after drinking old
milk and had subsequent n/v. She had some abdominal cramping and
noticed that her stools were black today (___). She went to
her PCPs office and was noted to have a hgb of 11 down from 14
and black guaiac positive stool. Her BP was noted to be in the
___. She was transferred to the ED for further care. She was
unable to get EGD done, as platelets result was 22.
She reports that she has been taking NSAIDs recently for
shoulder pain. She does have heartburn and takes ranitidine. She
has never had any GI bleeding in the past. No EGD before. Last
colonoscopy was in ___ and showed diverticulosis but was
otherwise normal to the cecum. She denies chest pain or
shortness of breath.
ROS: A 10 point review of systems was performed in detail and
negative except as noted in the HPI.
In the ED, initial VS were 99.4 91 98/42 16 96% ra
Exam notable for Heme Positive, dark stools, not tarry
Labs showed WBC 3.3, Plts 20 3.3 10.1 20 32.0
Ret-Aut: 0.7 Abs-Ret: 0.02 ___: 11.0 PTT: 34.0 INR: 1.0
Lactate:2.2
Heme/onc was consulted. Decision was made to admit to medicine
for further management, with heme/onc following and BM biopsy
performed
Past Medical History:
ASTHMA
OSTEOPOROSIS
SPINAL STENOSIS
SLEEP APNEA
HYPERLIPIDEMIA
GERD
Social History:
___
Family History:
No known history of colon cancer, no other known significant
medical history
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.5 F, 105/60 92 18 95%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Good air entry bilaterally, scattered basilar wheezes,no
rales, rhonchi, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO:conversation, repeats plan back
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS - T 98.4 F HR71 BP ___ RR 16 98 02 sat on RA
GENERAL: NAD ,appears comfortable but anxious, reassured of
constant communication of plan
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: nontender supple neck, no palpable LAD, no JVD
CARDIAC: RRR, S1/S2,systolic ejection murmur best heard at RUSB
LUNG: Good air entry bilaterally, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO:conversation, repeats plan back
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 07:40PM ALT(SGPT)-33 AST(SGOT)-73* LD(LDH)-389* ALK
PHOS-58 TOT BILI-1.0
___ 07:40PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
___:40PM HIV Ab-NEGATIVE
___ 07:40PM WBC-3.4* RBC-3.35* HGB-10.2* HCT-31.2* MCV-93
MCH-30.4 MCHC-32.7 RDW-13.7 RDWSD-46.6*
___ 07:40PM NEUTS-77* BANDS-7* LYMPHS-14* MONOS-1* EOS-0
BASOS-1 ___ MYELOS-0 AbsNeut-2.86 AbsLymp-0.48
AbsMono-0.03 AbsEos-0.00 AbsBaso-0.03
___ 07:40PM PARST SMR-POSITIVE
___ 07:40PM PLT SMR-VERY LOW PLT COUNT-19*
___ 05:30PM BONE MARROW CD23-DONE CD45-DONE ___
___ KAPPA-DONE CD2-DONE CD7-DONE CD10-DONE CD19-DONE
CD20-DONE LAMBDA-DONE CD16/56-DONE CD5-DONE
___ 05:30PM BONE MARROW CD3-DONE CD4-DONE CD8-DONE
___ 10:25AM GLUCOSE-103* UREA N-26* CREAT-1.3* SODIUM-135
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17
___ 10:52AM LACTATE-2.2*
___ 10:25AM cTropnT-<0.01
___ 10:25AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
DISCHARGE LABS:
___ 08:50AM BLOOD WBC-5.1 RBC-3.42* Hgb-10.3* Hct-32.2*
MCV-94 MCH-30.1 MCHC-32.0 RDW-13.9 RDWSD-47.5* Plt Ct-25*
___ 08:50AM BLOOD Neuts-77* Bands-10* Lymphs-10* Monos-2*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-4.44 AbsLymp-0.51
AbsMono-0.10 AbsEos-0.00 AbsBaso-0.00
___ 08:50AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 08:50AM BLOOD Plt Smr-VERY LOW Plt Ct-25*
___ 08:50AM BLOOD Glucose-121* UreaN-24* Creat-0.9 Na-138
K-3.3 Cl-107 HCO3-24 AnGap-10
___ 08:50AM BLOOD Calcium-8.1* Phos-1.6* Mg-2.1 UricAcd-3.9
IMAGING:
Echocardiogram ___: The left atrium is mildly dilated. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a mild resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. Mild (1+) 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 a
trivial/physiologic pericardial effusion.
IMPRESSION: Hyperdynamic left ventricular systolic function.
Mild resting outflow tract gradient. Mild aortic regurgitation.
Mild mitral regurgitation. Moderate pulmonary hypertenson.
CT Abdomen/Pelvis with Contrast ___: Multiple
pathologically enlarged retrocrural, retroperitoneal, and
mesenteric lymph nodes are concerning for lymphoma. 13.4 cm
simple appearing left adnexal cystic structure displaces the
uterus to the right. This was likely present in ___, but was
incompletely imaged and smaller. If clinically indicated,
consider MRI of the pelvis for further evaluation. Top-normal
spleen size, with 2 wedge-shaped hypodensities concerning for
splenic infarcts. Compression fracture of the T10 vertebral body
was also present on the MR
___ from ___
CXR ___: Cardiac silhouette size is normal. Aorta remains
tortuous. Moderate hiatal hernia is noted. Pulmonary
vasculature is not engorged. Lungs are hyperinflated without
focal consolidation. No pleural effusion or pneumothorax is
present. There are no acute osseous abnormalities. Mild loss
of height of a low thoracic vertebral body remains unchanged.
Multiple clips are demonstrated overlying the midline lower neck
PATHOLOGY and CYTOGENETICS:
Bone Marrow Aspirate ___:
CELLULAR MARROW WITH MARKED LYMPHOCYTOSIS CONSISTENT WITH
CHRONIC
LYMPHOCYTIC LEUKEMIA. INTRACELLULAR ORGANISMS WITHIN NEUTROPHILS
IN
PERIPHERAL BLOOD AND BONE MARROW CONSISTENT WITH ANAPLASMOSIS
(ANAPLASMA PHAGOCYTOPHILUM).
Note: Concurrent flow cytometry studies reveal a population of
CD20 positive lymphocytesthat co-expresses CD5 and CD23 and
exhibits dim monoclonal kappa surface membrane immunoglobulin,
which is consistent with Correlation with flow results for
further characterization of marrow lymphocytosis is recommended.
Immunophenotyping ___:
Immunophenotypic findings consistent with involvement by a
CD20(+) B-cell lymphoma with co-expression of CD5 and CD23. The
differential diagnosis includes small lymphocytic lymphoma
versus mantle cell lymphoma. Based on morphology and
immunophenotypic features, small lymphocytic lymphoma is
favored. Correlation with clinical, morphologic (see ___
and cytogenetic findings recommended.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
2. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Multivitamins 1 TAB PO DAILY
6. Ranitidine 150 mg PO BID
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*24 Tablet Refills:*0
2. Atorvastatin 10 mg PO QPM
3. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
4. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Ranitidine 150 mg PO BID
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
9. Outpatient Lab Work
Please draw CBC + diff on ___ and fax results to Dr. ___
___ at ___. ICD 9: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
anaplasma
lymphadenopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: 2
INDICATION: History: ___ with weakness
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiac silhouette size is normal. Aorta remains tortuous. Moderate hiatal
hernia is noted. Pulmonary vasculature is not engorged. Lungs are
hyperinflated without focal consolidation. No pleural effusion or
pneumothorax is present. There are no acute osseous abnormalities. Mild loss
of height of a low thoracic vertebral body remains unchanged. Multiple clips
are demonstrated overlying the midline lower neck.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with right sided abdominal pain, nausea, vomiting, melena.
Evaluate for diverticulitis, small bowel obstruction, or mass.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
No oral contrast was administered.
DOSE: This study involved 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
4) Spiral Acquisition 4.2 s, 46.4 cm; CTDIvol = 12.9 mGy (Body) DLP = 597.1
mGy-cm.
Total DLP (Body) = 605 mGy-cm.
IV Contrast: 130 mL Omnipaque
COMPARISON: MR ___ from ___ and MR ___ from ___.
FINDINGS:
LOWER CHEST: There is bibasilar dependent atelectasis. No pleural effusion or
pericardial effusion. Mild aortic valve calcifications and a moderate hiatal
hernia identified.
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. There is a small amount of pericholecystic
fluid, which may be due to third-spacing, and the gallbladder is nondistended
without evidence of cholecystitis.
PANCREAS: A 1.0 cm rounded hypodensity in the pancreatic tail may be a small
side branch IPMN (2:25). The pancreas otherwise has normal attenuation
throughout, without evidence of focal lesions or main pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen is top normal in size, measuring 12.5 cm. Two wedge-shaped
hypodensities are concerning for splenic infarcts (2:13, 18).
ADRENALS: The left adrenal gland appears nodular and bulky in morphology, but
this is unchanged compared with the MRI from ___. The right
adrenal gland is unremarkable.
URINARY: Multiple bilateral renal hypodensities are likely simple cysts, as
seen on the prior MRI lumbar spine. The kidneys are otherwise of normal and
symmetric size with normal nephrogram. There is no evidence of
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Diverticulosis of the sigmoid colon is noted,
without evidence of wall thickening and fat stranding. Appendix contains air,
has normal caliber without evidence of fat stranding.
LYMPH NODES: There are multiple pathologically enlarged retrocrural,
retroperitoneal, and mesenteric lymph nodes (2:15, 37, 38), concerning for
lymphoma.
VASCULAR: There is no abdominal aortic aneurysm. There is mild 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: A 13.4 cm simple appearing left adnexal cystic structure
displaces the uterus to the right (2:58). This was likely present, but
smaller and incompletely characterized, on the MR ___ from ___.
BONES AND SOFT TISSUES: Severe degenerative changes of the lower lumbar spine,
including vacuum disc phenomena and disc space narrowing identified. There is
grade 2 anterolisthesis of L5 on S1. A compression deformity of the T10
vertebral body was also present on the MR ___ from ___.
Abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Multiple pathologically enlarged retrocrural, retroperitoneal, and
mesenteric lymph nodes are concerning for lymphoma.
2. 13.4 cm simple appearing left adnexal cystic structure displaces the uterus
to the right. This was likely present in ___, but was incompletely imaged
and smaller. If clinically indicated, consider MRI of the pelvis for further
evaluation.
3. Top-normal spleen size, with 2 wedge-shaped hypodensities concerning for
splenic infarcts.
4. Compression fracture of the T10 vertebral body was also present on the MR
___ from ___.
RECOMMENDATION(S): If clinically indicated, consider MRI of the pelvis for
further evaluation of the 13.4 cm simple appearing left adnexal cystic
structure.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Melena, Weakness
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 99.4
heartrate: 91.0
resprate: 16.0
o2sat: 96.0
sbp: 98.0
dbp: 42.0
level of pain: 2
level of acuity: 2.0 | PRIMARY PRESENTATION:
___ yo woman with hx of GERD who presented with weakness and
fatigue, with melena in setting of likely UGIB with associated
pancytopenia. She has elevated LDH with lymphadenopathy seen on
CT abdomen concerning for lymphoma, along with heme workup
revealing anaplasma. She also likely had gastritis from NSAIDS
use, leading to bleeding in setting of severe thrombocytopenia.
She underwent bone marrow biopsy on ___ that showed anaplamsa
with final stains for lymphoma pending at time of discharge.
ACTIVE ISSUES
#Lymphocytosis and Thrombocytopenia, concerning for CLL vs
Mantle cell: Per ___ report, the lymphocytosis is concerning for
CLL, however may need further investigation. Patient was aware
of working diagnosis, and had follow up with oncology
outpatient. Patient did not have any repeat episodes of melena
after initial admission ___ and on ___, with her Hgb/Hct
remaining stable and thrombocytopenia remained stable with
slight improvement during hospitalization. It was recommended
that she remain hospitalized until final pathology was
determined, in the event that an aggressive lymphoma were
identified and needed to be treated urgently. The patient, her
husband, and in consultation with her PCP preferred discharge
home with follow-up with hematology/oncology once her final
pathology was back. These results were communicated over the
phone by the resident physician and confirmed her follow-up
appointment with heme/onc.
# Anaplasma: Anaplasmosis or other tick borne illness could
explain thrombocytopenia and subsequent bleeding, but prominent
lymphadenopathy was thought to be less likely due to the
infection. Her CBC was closely trended, and she was treated with
Doxycycline 100mg TID, Day 1: ___, with plan for a ___ day
course on discharge.
#Upper GI Bleed from gastritis in setting of severe
thrombocytopenia: Patient's Hgb/Hct remianed stable over
admission. Patient was on Pantoprazole 40 mg IV twice a day
inpatient. An upper endoscopy was not performed given presenting
symptoms and thrombocytopenia. On discharge, she was given
ranitidine 150 mg PO BID and Pantoprazole 40 mg PO twice a day.
H. pylori antibody was negative, checked prior to admission.
CHRONIC ISSUES
#Cough/Asthma: Patient complained of mild cough, and audible
"wheezing", correlated with physical exam. Patient was continued
on home Symbicort, with sympotamtic relief with Guaifenesin. She
remained stable on room air and did not require any supplemental
oxygen therapy.
#Osteoporosis: Patient was continued on home medications of
Calcium Carb-Vit D3 600mg-400mg, with advil held in setting od
inpatient GI bleeding.
#Hyperlipidemia: Patient continued on home Lipitor 10 mg daily
TRANSITIONAL ISSUES
--------------------
- Follow up H. pylori serum antibody: negative
- Follow up bone marrow biopsy: report as of ___ consistent
with Chronic Lymphocytic Leukemia
- Continue doxy for total 14 day course
- Please recheck CBC + diff on ___
- Full code |