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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Bactrim / Codeine / Penicillins
Attending: ___.
Chief Complaint:
shortness of breath, food getting stuck in chest
Major Surgical or Invasive Procedure:
EGD with Botox injection for achalasia
History of Present Illness:
___ y/o F female with PMHx of severe COPD (FEV1=0.67
27%predicted), HTN, hypothyroidism who was recently discharged
from ___ on ___ for a COPD exacerbation who presents
with dyspnea.
Of note, the patient was discharge on ___ for COPD
exacerbation on 2L NC after completing a course of steroids and
azithromycin. During that hospitalization her work up included
CTA that was negative for PE, but did show severe emphsyema
along with dilated pulmonary artery. She subsequently underwent
an echo that showed mild pulmonary arterial hypertension.
She reported that she was feeling well when being discharged and
she being weaned down from 2L to 1L with oxygen saturation of
94% oxygen saturation. She reports that her symptoms slowly
began with dyspnea on exertion making it difficult for her to
walk around her house and has progressively worsened. She
reports that these symptoms are identical to when she presented
in ___. Yesterday when she was walking to the bathroom, she
did develop acute onset shortness of breath with oxygen
saturation decreasign to 70%. She turned up the oxygen to 2L
with improvement. Due to concern of worsening breathing, she
came to the Emergency Department for further evaluation. She
also reports that for many years that she has had orthopnea
because of post-nasal drip and this has not changed. She denies
any fevers, chills, N/V/D, Chest pain, pleuritic chest pain.
Her only other symptom is dysuria that started on day of
admission. She denies any suprapubic pain. She also reports that
since ___ she has had a band like muscle spasm on her lower
back wrapping around her stomach.
Vitals in the ED: 97 82 101/58 20 94% 2L
Labs notable for: CBC WNL. Chem 7 WNL. VBG 7.___. UA was
grossly positive. CXR showed Severe emphysema with mild
bibasilar atelectasis and small bilateral pleural effusions,
slightly increased in size on the right compared to prior.
Patient symptomatically felt better. When attempting to do an
ambulatory saturation when walking to the bathroom, patient
desaturated to mid 60% on 2L. A trigger was called. She was
placed on facemask with return of oxygen saturation to 94% on
2L. Due to acute drop in oxygen saturation, CTA was ordered.
However CTA could not be completed as the patient could not lie
flat for dyspnea and back pain despite being given
cyclobenzprine, tramadol and fentanyl.
Patient given: ipratroprium-albuterol nebs, 1L NS. methypred
125mg, azithromycin 500 in addition to cyclobenzaprine and
tramadol for back spasms to help her lie flat for the CT scan.
Vitals prior to transfer:95 110/61 18 100% nebulizer
On the floor, she reports her symptoms improved with her
nebulizer.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Hypertension
Hypothyroidism
COPD
Lower extremity edema
back pain
Social History:
___
Family History:
Mother deceased at ___ with AAA, father deceased in ___ with CAD,
brother alive with diabetes, sister deceased at ___ with cancer.
Physical Exam:
ON ADMISSION:
Vitals - T97.1 119/66 93 22 96% 3L
GENERAL: NAD, AOx3, converstational dyspnea
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, dry mucus membranes
NECK: nontender supple neck, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: decrease breath sounds throughout, prolonged expiratory
phase, minimal wheezing
ABDOMEN: NABS, NT/ND, No suprapubic tenderness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
ON DISCHARGE:
Pertinent Results:
ON ADMISSION:
___ 11:56PM ___ PO2-64* PCO2-56* PH-7.32* TOTAL
CO2-30 BASE XS-0
___ 11:56PM LACTATE-1.6
___ 11:56PM O2 SAT-92
___ 11:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 11:40PM URINE BLOOD-MOD NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 11:40PM URINE RBC-14* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-<1
___ 11:40PM URINE HYALINE-3*
___ 11:40PM URINE MUCOUS-OCC
___ 08:10PM GLUCOSE-101* UREA N-8 CREAT-0.6 SODIUM-133
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14
___ 08:10PM estGFR-Using this
___ 08:10PM WBC-6.9 RBC-4.24 HGB-13.9 HCT-38.9 MCV-92
MCH-32.7* MCHC-35.7* RDW-13.0
___ 08:10PM NEUTS-61.4 ___ MONOS-8.7 EOS-2.1
BASOS-0.5
___ 08:10PM PLT COUNT-165
ON DISCHARGE:
EKG:
ECGStudy Date of ___ 8:21:08 ___
Sinus rhythm. Short P-R interval. Otherwise, normal ECG.
Compared to the previous tracing of ___ no change.
___
___
ECGStudy Date of ___ 5:01:38 ___
Sinus tachycardia. Intra-atrial conduction abnormality.
Extensive baseline artifact. Premature atrial contractions.
Compared to the previous tracing of ___ sinus rate is
faster. Other findings are similar.
___
___
ECGStudy Date of ___ 1:42:48 ___
Sinus rhythm with atrial ectopy. Borderline low precordial lead
voltage. Compared to the previous tracing of ___ atrial
ectopy persists without diagnostic interim change.
___
___
IMAGING:
CHEST (PA & LAT)Study Date of ___ 9:24 ___
Severe emphysema with mild bibasilar atelectasis and small
bilateral pleural effusions, slightly increased in size on the
right compared to prior. Enlarged pulmonary arteries suggestive
of underlying pulmonary arterial hypertension. No new focal
consolidation.
CHEST (PORTABLE AP)Study Date of ___ 1:57 ___
In comparison with the study of ___, there is again
substantial emphysema with bilateral pleural effusions and
compressive atelectasis at the bases. Otherwise little change.
___ CXR:
IMPRESSION:
Patient has severe emphysema. On ___, mild congestive
heart failure
increased heart size and pleural effusions and engorged the
pulmonary
vasculature. Subsequently patient has developed heterogeneous
pulmonary
opacification, most severe in the right lower lobe. I think
this is more
likely to be pneumonia than asymmetric edema. On the left is
even more severe
consolidation, indicated by air bronchograms projecting over the
heart. This
could be more pneumonia or severe left lower lobe atelectasis.
Currently the
heart is normal size, smaller than it was at its largest. There
is no
pneumothorax.
ESOPHAGUSStudy Date of ___ 3:51 ___
Limited exam, however beak like narrowing of the distal
esophagus with slow passage of contrast into the stomach is
concerning for achalasia.
___ ESOPHAGUS:
IMPRESSION:
Persistent distal esophageal dilation with beak-like tapering.
However,
compared to the prior study, thin barium now passes promptly
through the
increased caliber lumen at the GE junction.
___ EGD:
Upon entering the esophagus, large amount of undigested food was
noted. The procedure was aborted given the high risk of
aspiration and poor respiratory reserve.
Otherwise normal EGD to middle third of the esophagus
___ EGD:
Upon entering the esophagus there was liquid and food particles.
About 70 percent of the esophageal mucosa was obscured with
food. The distal esophageal mucosa and GE junction were examined
closely. The Z line was slightly irregular. There was no mass
concerning for malignancy. The lumen appeared slightly narrowed
but the scope could easily pass without resistance.
Normal mucosa in the stomach
Not examined in order to limit procedure time and aspiration
risk in the setting of food contents in the esophagus.
Given the high suspicion for achalasia and poor surgical
candidacy, the decision was made to proceed with botox
injection. (injection)
Otherwise normal EGD to stomach
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
6. mometasone 50 mcg/actuation nasal daily
7. ClonazePAM 0.5 mg PO QHS
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose 1
puff INH twice a day Disp #*3 Disk Refills:*3
2. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 puff
INH once a day Disp #*3 Capsule Refills:*3
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
4. Isosorbide Dinitrate 2.5 mg SL TID W/MEALS
RX *isosorbide dinitrate 2.5 (s) sublingually three times a day
Disp #*90 Tablet Refills:*3
5. Isosorbide Dinitrate 2.5 mg SL TID:PRN sensation of food
being stuck
6. ClonazePAM 0.5 mg PO QHS
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
RX *albuterol sulfate 90 mcg ___ puff INH every six (6) hours
Disp #*2 Inhaler Refills:*3
10. mometasone 50 mcg/actuation nasal daily
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL
0.5mg-3mg mg INH every four (4) hours Disp #*40 Ampule
Refills:*3
12. Device
Nebulizer ___
Diagnosis: COPD
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
COPD exacerbation
Achalesia
UTI
SECONDARY DIAGNOSES:
Back pain
Anxiety
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 history of severe COPD with newly
developed cough and acute onset shortness of breath
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CTA and chest radiograph ___
FINDINGS:
Lungs remain hyperinflated with flattened diaphragms and extensive
emphysematous changes again noted. The heart size is normal. Enlargement of
the pulmonary arteries bilaterally is re- demonstrated suggestive of
underlying pulmonary arterial hypertension. Mediastinal contour is unchanged.
Pulmonary vasculature is not engorged. Small bilateral pleural effusions are
demonstrated, mildly increased in size on the right since the prior study.
Patchy opacities in the lung bases likely reflect areas of atelectasis.
Multiple pulmonary nodules seen on prior chest CT are not as well demonstrated
on the current exam. No pneumothorax or new focal consolidation is present.
Mild loss of height of a mid thoracic vertebral body is similar.
IMPRESSION:
Severe emphysema with mild bibasilar atelectasis and small bilateral pleural
effusions, slightly increased in size on the right compared to prior.
Enlarged pulmonary arteries suggestive of underlying pulmonary arterial
hypertension. No new focal consolidation.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old woman with severe COPD complaing of food getting
stuck in the chest. // Barium swallow - Eval for cause of dysphagia
TECHNIQUE: Barium esophagram.
COMPARISON: CTA chest from ___.
FINDINGS:
A limited esophagram was performed administering thin barium in the upright
position and in the right anterior oblique position at 30 degrees. Barium
passed freely through the esophagus without evidence of proximal obstruction.
At the gastroesophageal junction there is a beak like a narrowing of the
esophagus with very slow passage of contrast. This resulted in holdup of
barium within the esophagus even after a 5 min delay. There is no evidence of
gastroesophageal reflux or a hiatal hernia.
IMPRESSION:
Limited exam, however beak like narrowing of the distal esophagus with slow
passage of contrast into the stomach is concerning for achalasia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with severe COPD, achalasia, s/p endoscopic
botox injection, now desating to ___. // Evaluate for aspiration Evaluate
for aspiration
IMPRESSION:
In comparison with the study of ___, there is again substantial
emphysema with bilateral pleural effusions and compressive atelectasis at the
bases. Otherwise little change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with severe COPD, HTN, hypothyroidism now with
increasing oxygen requirement and dsypnea // ? infiltrate ?acute lung process
? infiltrate ?acute lung process
COMPARISON: Chest radiographs since through ___.
IMPRESSION:
Large lung volumes are due to COPD. Heterogeneous interstitial abnormality in
the lungs is similar in appearance to ___, probably atypical pulmonary
edema since small bilateral pleural effusions are slightly larger as is
moderate cardiomegaly. Given the asymmetric distribution of edema,
concurrent early pneumonia would be hard to detect.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with severe COPD with interval worsening of
hypoxemia likely due to aspiration pneumonitis, evaluating for worsening
opacities/pneumonia evidence // eval for interval change in opacities eval
for interval change in opacities
COMPARISON: Chest radiographs since ___, most recently ___.
IMPRESSION:
Patient has severe emphysema. On ___, mild congestive heart failure
increased heart size and pleural effusions and engorged the pulmonary
vasculature. Subsequently patient has developed heterogeneous pulmonary
opacification, most severe in the right lower lobe. I think this is more
likely to be pneumonia than asymmetric edema. On the left is even more severe
consolidation, indicated by air bronchograms projecting over the heart. This
could be more pneumonia or severe left lower lobe atelectasis. Currently the
heart is normal size, smaller than it was at its largest. There is no
pneumothorax.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old woman with severe COPD with flare with new diagnosis
of severe achalasia s/p EGD with botox therapy. pt is aspirating which is
severely worsening her respiratory status. ? improvement in achalasia with
botox vs persistent achalasia leading to aspiration.
TECHNIQUE: Barium esophagram.
DOSE: Fluoroscopy time: 2 min 57 seconds
Skin dose: 29 mGy
Accumulated DAP: 93.53 uGy-m2
COMPARISON: Esophagram from ___.
FINDINGS:
A limited esophagram was performed due to the patient's respiratory status and
inability to tolerate supine/prone positions. Images of the esophagus and
gastroesophageal junction were obtained in the upright frontal and lateral
posterior oblique positions. Thin barium passes freely through the esophagus
without proximal obstruction. There is increased caliber of the lumen at the
GE junction, and barium now passes promptly through into the stomach without
delay. Persistent dilation of the esophagus with beak-like tapering at the GE
junction. No evidence of reflux or hiatal hernia.
IMPRESSION:
Persistent distal esophageal dilation with beak-like tapering. However,
compared to the prior study, thin barium now passes promptly through the
increased caliber lumen at the GE junction.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with asthma, copd, pnemonia // 47 left basilic
picc placed. ? tip position. Contact name: ___: ___ left
basilic picc placed. ? tip position.
COMPARISON: Chest radiographs since ___ most recently ___.
.
IMPRESSION:
Left PIC line ends in the low SVC. Moderate bilateral pleural effusions are
unchanged. Interstitial edema minimal, unchanged. Severe left lower lobe
consolidation which developed between ___ and ___ is unchanged,
and although this could be atelectasis, it should be investigated clinically
for possible pneumonia.
Heart size top-normal unchanged.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with SHORTNESS OF BREATH, HYPOXEMIA
temperature: 97.0
heartrate: 82.0
resprate: 20.0
o2sat: 94.0
sbp: 101.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | ___ with h/o severe COPD (FEV1 27% predicted, on home oxygen,
widely diffuse emphysematous changes on chest CT), HTN,
hypothyroidism presenting with worsened dyspnea and increased
oxygen requirement consistent with COPD flare.
# COPD exacerbation: Patient has a h/o of COPD for ___ year,
however she was very functional and without O2 requirement until
her most recent admission earlier this year. She experienced
worsening SOB recently with desatting to ___ and ___ on
ambulation and now even at rest requiring increased oxygen. Last
FEV1=27% predicted. Found to have severe and diffuse
emphysematous changes on imaging as well. Flu swab was negative.
CXR negative for pneumonia, and she had no leukocytosis. No
evidence of PE or CHF. ___ was consulted and agreed with COPD
exacerbation. There was no role for volume reduction surgery
given diffuse emphysema bylaterally. Lung transplant also was
not an option, given age and likely high risk of mortality. She
was treated with standing duonebs, steroids, and completed 5 day
course of azithromycin. She is on prednisone 40mg PO qd with
plan of ___ wk taper. Additionally, she is using her home
nebulizers (was provided a nebulizer machine) including advair,
tiotropium, and duonebs (confirmed covered by her insurance).
# Achalasia: During her hospital course she endorsed a very
uncomfortable sensation of food being stuck in her chest. Barium
swallow study showed bird's beak sign and significant distal
esophageal dilation consistent with achalasia. She was trailed
on SL isosorbide dinitrite before each meal, however it did not
help appreciably. GI performed EGD on ___ but was limited due
to significant food material in the esophagus. She was re-scoped
on ___ again, and botox injection of her GE junction was done
given the appearance consistent with achalasia and her
respiratory status precluding other more invasive options
(pneumatic dilation, surgery, etc.). She was slowly advanced on
a diet however did experience an aspiration even leading to
acute hypoxemia which resolved with a non-rebreather and empiric
IV antibiotics (see below). After recovering from this, she was
re-advanced with her diet initially on pureed and tolerated this
well. She will follow-up with GI as an outpatient and will
likely require regular EGD with Botox therapy every 4 or so
months. Alternative options were discussed but given the
morbidity of pneumatic dilation or surgical options, pt and team
agreed these were not appropriate at this time. Additionally, pt
was not interested in tube feeding option at this time either.
# Aspiration vs HCAP: On ___, pt developed acute hypoxemia
respiratory failure requiring non-rebreather. CXR revealed new
multifocal opacities. This episode occurred shortly after a
reported vomiting event, so the presumed etiology was
aspiration. Given a concomitant and persistent leukocytosis
along with persistent opacities and her severe underlying COPD,
she was treated empirically with IV vancomycin/meropenem for
possible HCAP. She tolerated a 7-day course well and had no
further aspiration events.
# Goals of care: In extensive discussion with patient, she was
very clear in her wishes not to escalate care above a
non-rebreather and medications should her severe hypoxemia recur
- very specifically this includes NO non-invasive positive
pressure ventilation, and in the event of recurrent severe
hypoxemia not response to non-rebreather the goal would be to
keep her comfortable.
# Urinary Tract Infection: Uncomplicated. Culture grew E-coli,
s/p bactrim (___).
# Back pain: Likely muscle spasm. Pain was managed with
cyclobenzaprine, tramadol, and acetaminophen for pain control |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Vancomycin / Gluten / xanthan gum / Benefiber (guar gum)
Attending: ___
Chief Complaint:
Diplopia ___ headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ YO M with PMH of Type 1 DM, HTN, Celiac
disease, Alopecia, mood disorder presented to the ED with
complaints of double vision.
Patient reports that he was in ___ normal state of health until
3
days ago. He woke up on ___ with a headache located on the
left temporal bone, behind the left eye with associated blurry
vision ___ dizziness which lasted a few minutes. He went to take
a shower ___ symptoms resolved during that time ___ reports
that it may have lasted a total of 15 to 30 minutes. ___
headache
was on off that morning but resolved with in the hour. He felt
fine until last night when he noticed double vision. He was
looking into ___ phone ___ when he suddenly looked up he saw
distant objects being double. He tried to adjust ___ gaze but
___ symptoms persisted. ___ blood sugars during this episode
were okay ___ he went to bed late in the night. He woke up this
morning with persistent double vision ___ also felt left
temporal
headache similar to the one he had on ___. ___ headache
remained stable throughout, rates it as ___ in severity ___
sharp in nature. He notes that double vision is present only
when he looks to the left ___ is worse with farther compared to
near. he did not have any associated blurry vision or dizziness
today. Denies any focal weakness or sensory problems or trouble
breathing or chest pain. He did have difficulty walking but he
attributes it to double vision. He did not have any similar
complaints in the past.
Of note, he was taken off of ___ Lasix(he was taking for
hypertension) by ___ nephrologist about a month ago ___
cardiologist asked him to monitor ___ blood pressure at home.
He
has been checking ___ blood pressure daily for the past week ___
noticed it to be high(systolic around 180 ___ diastolic in ___.
He is supposed to review these readings with ___ cardiologist to
changing ___ antihypertensives. Wife also adds that ___ insulin
pump sensor has been going off more frequently in the past month
due to high or low readings ___ they have been adjusting ___
bolus doses. He decided to wear a glucometer after ___
episode ___ blood sugars yesterday were fluctuating. ___
blood glucose was 50 around 6 ___ yesterday but he did not have
any associated symptoms, he ate ___ dinner ___ the episode of
diplopia occurred late in the night. ___ blood sugar in the ED
today was 53 ___ he received oral supplement with improvement
but
diplopia persisted.
On neurologic review of systems, the patient denies difficulty
with producing or comprehending speech. Denies loss of vision,
vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies focal muscle weakness, numbness, parasthesia. Denies loss
of sensation. Denies bowel or bladder incontinence or retention.
He did have difficulty with gait associated with double vision.
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:
BACK PAIN
CELIAC SPRUE
DEPRESSION
DIABETES TYPE I
GASTROESOPHAGEAL REFLUX
OTITIS EXTERNA
PNEUMONIA
STRESS TEST
TRANSAMINITIS
URINARY FREQUENCY
Discharge Summary Past Medical History form MON ___:
Type 1 diabetes
HTN
Celiac sprue - recently diagnosed with serology but having
biopsy ___
Depression
Hyperlipidemia
Elevated LFTs (?NAFLD)
Partial factor V Leiden deficiency (although patient says
actually it's factor VII partial deficiency . . . no h/o clots
or bleeding though)
GERD
Social History:
___
Family History:
Relative Status Age Problem Comments
Other FAMILY HISTORY FAMILY HISTORY:
___ mother is ___
___ healthy.
___ died of a
___ ___ ___ also
___ MI in ___
___. Sister had a
___, age ___, ___
___ passed away at
___. ___ also has
diabetes type 1 ___
___
grandmother died of
___
maternal side 64.
___ gmother had
stomach cancer.
___ had liver
___ with
melanoma.
Physical Exam:
PHYSICAL EXAMINATION admission:
Vitals: reviewed in omr:
General: Awake, alert cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds.
Extremities: No ___ edema.
Skin: no rashes or lesions noted. Noted minimal scalp
tenderness palpation over the left temporal, no prominent
vessels
to palpation.
Neurologic:
-Mental Status: Alert, awake, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
___
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high ___ low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline ___ appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm ___ brisk. EOMI without
nystagmus except trace visible sclera on lateral side in the
left
eye on the left abduction(left gaze). Diplopia elicited on left
gaze(slightly past midline) in the horizontal plane ___ noted
some worsening in the left upper quadrant ___ similar diplopia
in
the left lower quadrant. Noted worsening diplopia(objects
apart)
when looking at farther objects compared to closer.
L eye appears isodeviated. With binocular diploplia. Goes away
with eye covering. Worsening double vision the left. Resolves
with looking right.
Normal saccades. VFF to confrontation. Visual acuity ___
bilaterally with corrective lenses. Fundoscopic exam revealed no
papilledema (except left optic disc not completely visualized),
exudates, or hemorrhages. evidence of diabetic retinopathy L>R.
Left retinal drusen
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 ___ SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. Decreased vibratory sense -6 seconds
in the toes bilaterally. no extinction to DSS.
-DTRs:
Bi Tri ___ ___ Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride ___ arm
swing.
Physical exam at discharge:
Vitals: 24 HR Data (last updated ___ @ 445)
Temp: 97.6 (Tm 98.4), BP: 164/96 (164-186/74-96), HR: 71
(67-71), RR: 16 (___), O2 sat: 96% (96-98), O2 delivery: Ra
General: Awake, alert cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds.
Extremities: No ___ edema.
Skin: no rashes or lesions noted. Noted minimal scalp
tenderness palpation over the left temporal, no prominent
vessels
to palpation.
Neurologic:
-Mental Status: Alert, awake, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
___ comprehension. Normal prosody. There were no paraphasic
errors.
Pt was able to name both high ___ low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline ___ appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm ___ brisk. EOMI without
nystagmus except trace visible sclera on lateral side in the
left
eye on the left abduction(left gaze). Diplopia elicited on left
gaze(slightly past midline) in the horizontal plane with
appearance of 2 objects next to each other, resolved with
looking to the right, ___ worsened with looking to the left,
also resolved with covering one eye. Visual field grossly
intact ___ acuity intact with with glasses on. Normal saccades.
VFF to confrontation. Unable to differentiate if I positioning
was abnormal, with the right eye appearing more medial.
V: Facial sensation intact to light touch, ___ cold sensation.
VII: No facial droop, facial musculature symmetric, ___
strength full.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii ___ SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
throughout bilaterally in both upper ___ lower extremities. No
adventitious movements, such as tremor, noted. No asterixis
noted.
-Sensory: No deficits to light touch, or cold sensation,
-Coordination: no dysdiadochokinesia noted. No dysmetria on
FNF bilaterally. rapid alternating movement symetric
bilaterally, finger tap within normal limits.
-Gait: Differed as above.
Pertinent Results:
___ 06:40AM BLOOD WBC-8.2 RBC-5.28 Hgb-15.3 Hct-45.1 MCV-85
MCH-29.0 MCHC-33.9 RDW-13.1 RDWSD-40.7 Plt ___
___ 12:07PM BLOOD WBC-8.7 RBC-5.39 Hgb-15.5 Hct-45.5 MCV-84
MCH-28.8 MCHC-34.1 RDW-13.0 RDWSD-40.2 Plt ___
___ 12:07PM BLOOD Neuts-57.9 ___ Monos-9.0 Eos-3.4
Baso-0.6 Im ___ AbsNeut-5.05 AbsLymp-2.52 AbsMono-0.79
AbsEos-0.30 AbsBaso-0.05
___ 12:07PM BLOOD ___ PTT-28.0 ___
___ 12:07PM BLOOD Glucose-53* UreaN-15 Creat-0.9 Na-142
K-4.4 Cl-105 HCO3-26 AnGap-11
___ 06:40AM BLOOD Glucose-66* UreaN-12 Creat-1.0 Na-141
K-4.0 Cl-105 HCO3-26 AnGap-10
___ 06:40AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.0 Cholest-125
___ 12:07PM BLOOD Calcium-9.4 Phos-3.3 Mg-1.9
___ 06:40AM BLOOD %HbA1c-7.3* eAG-163*
___ 06:40AM BLOOD Triglyc-57 HDL-42 CHOL/HD-3.0 LDLcalc-72
___ 12:07PM BLOOD TSH-2.7
___ 12:07PM BLOOD CRP-9.5*
ECG: Sinus rhythm Probable left atrial enlargement When compared
with ECG of ___, No significant change was found
Electronically signed by MD ___ (20) on ___
9:57:11 ___
=============
___ HEAD W & W/O CONTRAS
TECHNIQUE: Sagittal ___ axial T1 weighted imaging were
performed. After
administration of intravenous contrast, axial imaging was
performed with
gradient echo, FLAIR, diffusion, ___ T1 technique. Sagittal
MPRAGE imaging was
performed ___ re-formatted in axial ___ coronal orientations.
COMPARISON: CT dated ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift
or infarction. The ventricles ___ sulci are normal in caliber
___
configuration. There are few scattered T2/FLAIR hyperintensity
in the
periventricular subcortical white matter compatible with chronic
microangiopathy. There is no abnormal enhancement after
contrast
administration. The visualized vascular flow voids are grossly
unremarkable.
No evidence of dural venous sinus thrombosis. There is mild
mucosal
thickening of the ethmoid air cells, otherwise the paranasal
sinuses are
clear. Mild effusion in the bilateral mastoid air cells. There
is no
abnormal marrow signal.
IMPRESSION:
1. No acute intracranial abnormality. No evidence of acute
stroke,
intracranial mass, or hemorrhage.
___ HEAD ___ CTA NECK
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction,hemorrhage,edema,ormass. The
ventricles
___ sulci are mildly prominent suggesting involutional changes.
There is mild mucosal thickening in the inferior aspect of the
left maxillary
sinus. Otherwise, the visualized paranasal sinuses, mastoid air
___
middle ear cavities are clear. The visualized portion of the
orbits are
normal.
CTA HEAD:
The vessels of the circle of ___ ___ their principal
intracranial branches
appear patent without stenosis, occlusion, or aneurysm.
Atherosclerotic
calcification of the cavernous ___ supraclinoid internal carotid
arteries is
noted as well as the petrous internal carotid arteries, left
greater than
right. However, there is no significant stenosis. Posterior
communicating
artery not definitely seen on the left. There is a small patent
posterior
communicating artery on the right. There is a patent anterior
communicating
artery. Early branching of the left middle cerebral artery.
The dural venous
sinuses are patent.
CTA NECK:
Conventional three-vessel aortic arch. Proximal great vessels
___ subclavian
arteries are widely patent. Minimal calcification noted in the
proximal right
subclavian artery without stenosis
Bilateral carotid ___ vertebral artery origins are patent.
There is calcified ___ noncalcified atherosclerotic plaque at
the bilateral
carotid bifurcations, right greater than left, but this causes
no measurable
stenosis of the internal carotid arteries by NASCET criteria.
The carotidandvertebral arteries ___ their major branches
otherwise appear
normal with no evidence of stenosis or occlusion. The left
vertebral artery
is slightly dominant.
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. Multilevel degenerative changes of the cervical spine
noted.
IMPRESSION:
1. No acute intracranial abnormality.
2. Patent circle of ___ without evidence of
stenosis,occlusion,or aneurysm.
3. Patent bilateral cervical carotid ___ vertebral arteries
without evidence
of hemodynamically significant stenosis, occlusion,or dissection
Medications on Admission:
The Preadmission Medication list is accurate ___ complete.
1. Lisinopril 30 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Simvastatin 40 mg PO QPM
4. tadalafil 20 mg oral as directed
5. Venlafaxine XR 150 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Ranitidine 150 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: 80-180
Discharge Medications:
1. eye patch 1 Patch miscellaneous DAILY
Alternate eyes that are wearing the patch daily
RX *eye patch [Opticlude Eye Patch] 1 Patch Daily, alternating
eyes once a day Disp #*60 Each Refills:*0
2. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: ___
Fingersticks: QAC ___ HS
3. Aspirin 81 mg PO DAILY
4. Lisinopril 30 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Ranitidine 150 mg PO DAILY
7. Simvastatin 40 mg PO QPM
8. tadalafil 20 mg oral as directed
9. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left Peripheral ___ Nerve Palsy.
Discharge Condition:
Mental Status: Clear ___ coherent.
Level of Consciousness: Alert ___ interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with horizontal diplopia, no discernable gaze palsy
// eval aneurysm
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 15.0 mGy (Body) DLP =
7.5 mGy-cm.
3) Spiral Acquisition 5.3 s, 41.7 cm; CTDIvol = 15.2 mGy (Body) DLP = 635.1
mGy-cm.
Total DLP (Body) = 643 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction,hemorrhage,edema,ormass. The ventricles
and sulci are mildly prominent suggesting involutional changes.
There is mild mucosal thickening in the inferior aspect of the left maxillary
sinus. Otherwise, the visualized paranasal sinuses, mastoid air cells,and
middle ear cavities are clear. The visualized portion of the orbits are
normal.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear patent without stenosis, occlusion, or aneurysm. Atherosclerotic
calcification of the cavernous and supraclinoid internal carotid arteries is
noted as well as the petrous internal carotid arteries, left greater than
right. However, there is no significant stenosis. Posterior communicating
artery not definitely seen on the left. There is a small patent posterior
communicating artery on the right. There is a patent anterior communicating
artery. Early branching of the left middle cerebral artery. The dural venous
sinuses are patent.
CTA NECK:
Conventional three-vessel aortic arch. Proximal great vessels and subclavian
arteries are widely patent. Minimal calcification noted in the proximal right
subclavian artery without stenosis
Bilateral carotid and vertebral artery origins are patent.
There is calcified and noncalcified atherosclerotic plaque at the bilateral
carotid bifurcations, right greater than left, but this causes no measurable
stenosis of the internal carotid arteries by NASCET criteria.
The carotidandvertebral arteries and their major branches otherwise appear
normal with no evidence of stenosis or occlusion. The left vertebral artery
is slightly dominant.
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. Multilevel degenerative changes of the cervical spine noted.
IMPRESSION:
1. No acute intracranial abnormality.
2. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm.
3. Patent bilateral cervical carotid and vertebral arteries without evidence
of hemodynamically significant stenosis, occlusion,or dissection.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: History: ___ with horizontal diplopia, ? L CNVI palsy vs R CNIII
palsy // MR brain stroke protocol and MR with contrast to rule out occult
neoplasm.
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 dated ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There are few scattered T2/FLAIR hyperintensity in the
periventricular subcortical white matter compatible with chronic
microangiopathy. There is no abnormal enhancement after contrast
administration. The visualized vascular flow voids are grossly unremarkable.
No evidence of dural venous sinus thrombosis. There is mild mucosal
thickening of the ethmoid air cells, otherwise the paranasal sinuses are
clear. Mild effusion in the bilateral mastoid air cells. There is no
abnormal marrow signal.
IMPRESSION:
1. No acute intracranial abnormality. No evidence of acute stroke,
intracranial mass, or hemorrhage.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Hypertension
Diagnosed with Diplopia
temperature: 97.2
heartrate: 77.0
resprate: 16.0
o2sat: 98.0
sbp: 176.0
dbp: 78.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ is a ___ year old right handed man with past medical
history most pertinent for DMI, hypertension, celiac sprue, ___
autoimmune blistering skin disorder who presented with
horizontal double vision ___ found on examination to have left
___ nerve palsy.
Mr. ___ was admitted for workup of central vs peripheral
etiology of left ___ nerve palsy. Exam supported a peripheral L
___ Nerve Palsy. Workup included labs, which found hypoglycemia,
but otherwise no signs of infection or metabolic source. HbA1C
7.3%, CRP 9.5, TSH 2.7. LDL 72. EKG was normal sinus. MRI brain
without evidence of acute stroke. CTA without any concerning
abnormalities.
Mr. ___ has an ischemic left sixth nerve palsy. He does not
have an examination consistent with a central sixth nerve palsy
___ MRI brain was without pontine stroke. Mr. ___ has been
told that ___ double vision will improve, but that he needs to
work to improve management of DMI ___ hypertension. I have
recommended that while he has double vision that he wear an eye
patch ___ alternate it between eyes. I have told him that ___
headache is likely because of the double vision ___ that the
headache will improve also with the eye patch. I will have Mr.
___ follow up in ___ clinic in ___ weeks to
consider prism lenses if he continues to have double vision. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F presents with history of HTN, hypothyroidism, no prior
cardiac hx who presented to ___ ED with chest pain.
Patient endorses right sided chest pain for the last 2 days
which
worsened today to ___, at which point she started having nausea
and vomiting. Chest pain both at rest and on exertion. At
baseline she walks with a walker throughout her house. No
shortness of breath or leg swelling. Denies any anginal
symptoms,
pre-syncope, or syncope.
She had 2 falls in ___ and was treated at outside hospitals.
Per
patient, injured her pelvis and R leg but unsure of specifics.
Hospital course c/b aspiration PNA.
Otherwise no recent falls or hospitalizations.
No family history of cardiac disease known to patient. Her
granddaughter passed away yesterday from breast cancer.
In the ED initial vitals were: 96.7 70 163/78 18 97% RA weight:
88lb height: 5ft
EKG: ST depressions in V2-V4
Labs/studies notable for: Trop-T: 0.09, lactate 2.9, K 6.0, WC
11.5
Patient was given: ASA 300, metop tartrate 12.5, nitro SL,
atorva
80, Lasix 20, insulin 10u+ 25 gm dextrose 50%, hep gtt
Vitals on transfer: 65 120/61 21 99% RA
On the floor, denies any current CP, dyspnea, N/V. Feels at her
baseline overall.
REVIEW OF SYSTEMS:
10 point ROS otherwise negative.
Past Medical History:
Gathered from OMR notes and some from pt.
- "Irregular heart rhythm, for a long time" per pt for which she
takes Toprol XL
- Hyperlipidemia
- H/o Cdiff per recent OMR notes
- Esophageal strictures s/p several dilations in the past, last
one ___
- Temporal arteritis --> she states she's been taking Prednisone
for ___ years now
- Hypothyroidism
- History of lower GI bleed
- DJD
- Lumbar stenosis, lumbar radiculopathy, hip pain
- Osteoporosis
- Recurrent Cdiff, seen in ___ clinic ___, last noted ___
- Admitted to ___ in ___ with
n/v/d/rectal bleeding, found to have a portal vein thrombosis,
which was felt to be
likely due to ascending thrombophlebitis from a UTI. Abdominal
pelvic CT scan with contrast on ___ which shows a
persistent thrombosis in her superior right portal vein with
evidence of partial degradation of clot; there is no longer
filling defect with the right main portal vein as was seen on
prior study.
- Large hiatal hernia
- She denies any AMI's/CABG/caths, CVA's, DM, HTN, or other
heart/lung/kidney/liver/GI major diseases
- ___ admission for pan sensitive Ecoli urosepsis treated
with IV Ceftriaxone, d/c'd home with 2wk course of PO Cipro.
Bladder defects again seen on CT scan, but repeat bladder u/s
normal.
Social History:
___
Family History:
F deceased ___ from ___ deceased ___ of old age
Physical Exam:
Admission Physical Exam:
=======================
VS: 97.5PO 127 / 70 56 18 99 ra
GENERAL: NAD Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP 12
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. soft ___ systolic cresc/decresc
murmur.
No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Discharge Physical Exam:
========================
GENERAL: frail elderly female. pleasant and conversant.
comfortably lying in bed. nad. Oriented x3.
HEENT: NCAT. Sclera anicteric. no conjunctival pallor.
oropharynx
dry. poor dentition.
NECK: Supple with JVP 12 cm at 45 deg
CARDIAC: RRR, +S1/S2. ___ systolic cresc/decresc murmur heard
best at RUSB.
LUNGS: good inspiratory effort, no accessory muscle use. CTABL.
No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No peripheral edema
SKIN: No stasis dermatitis, ulcers.
PULSES: 2+ Distal pulses b/l
Pertinent Results:
Admission Labs:
================
___ 03:30PM BLOOD WBC-11.5* RBC-3.91 Hgb-11.6 Hct-36.2
MCV-93 MCH-29.7 MCHC-32.0 RDW-15.2 RDWSD-51.2* Plt ___
___ 03:30PM BLOOD Neuts-66.3 ___ Monos-10.1 Eos-1.4
Baso-0.7 Im ___ AbsNeut-7.62* AbsLymp-2.41 AbsMono-1.16*
AbsEos-0.16 AbsBaso-0.08
___ 03:30PM BLOOD ___ PTT-22.3* ___
___ 03:30PM BLOOD Glucose-124* UreaN-14 Creat-0.5 Na-137
K-6.0* Cl-99 HCO3-17* AnGap-21*
___ 03:30PM BLOOD ALT-15 AST-40 AlkPhos-39 TotBili-0.8
___ 03:30PM BLOOD cTropnT-0.09*
___ 09:55PM BLOOD CK-MB-25* cTropnT-0.55*
___ 07:25AM BLOOD CK-MB-19* cTropnT-0.66*
___ 02:20AM BLOOD CK-MB-8 cTropnT-0.38*
___ 06:20AM BLOOD cTropnT-0.38*
___ 03:38PM BLOOD Lactate-2.9*
Imaging:
========
Chest Xray ___
IMPRESSION:
Moderate to large hiatal hernia with mild bibasilar atelectasis.
No
subdiaphragmatic free air or cardiomegaly.
ECHO ___
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction. Mild-moderate mitral
regurgitation. Moderate tricuspoid regurgitation. Increased
PCWP.
Compared with the prior study (images reviewed) of ___,
very mild regional LV dysfunction is now seen and the severity
of mitral regurgitation is increased.
Discharge Labs:
===============
___ 07:30AM BLOOD WBC-12.1*# RBC-4.05 Hgb-11.7 Hct-36.2
MCV-89 MCH-28.9 MCHC-32.3 RDW-14.9 RDWSD-48.7* Plt ___
___ 09:50PM BLOOD ___ PTT-55.2* ___
___ 07:30AM BLOOD Glucose-135* UreaN-17 Creat-0.5 Na-141
K-3.7 Cl-103 HCO3-23 AnGap-15
___ 06:20AM BLOOD cTropnT-0.38*
___ 07:30AM BLOOD Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
1. NSTEMI
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 chest pain, nausea, vomiting//eval
cardiomegaly, free air
TECHNIQUE: Upright AP view of the chest
COMPARISON: None.
FINDINGS:
Heart size is normal. The aorta is somewhat tortuous. The mediastinal and
hilar contours are unchanged with a moderate to large hiatal hernia noted.
Lungs are hyperinflated with patchy opacities in the lung bases. No pleural
effusion or pneumothorax is seen. The pulmonary vasculature is not engorged.
Levoscoliosis of the thoracic spine is present. No subdiaphragmatic free air
is seen.
IMPRESSION:
Moderate to large hiatal hernia with mild bibasilar atelectasis. No
subdiaphragmatic free air or cardiomegaly.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Essential (primary) hypertension
temperature: 96.7
heartrate: 70.0
resprate: 18.0
o2sat: 97.0
sbp: 163.0
dbp: 78.0
level of pain: nan
level of acuity: 2.0 | Ms. ___ is a ___ year old female with a history of HTN who
presented to ___ with right sided chest pain x 2d, with
associated nausea, and vomiting, who was found to have ST
depressions on ECG and elevated cardiac enzymes, which were
concerning for an NSTEMI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracyclines
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary Angiography ___
History of Present Illness:
___ yo M with HLD, HTN, CAD s/p 3v CABG ___ LIMA to the
diagonal and reverse saphenous vein graft to the posterior
descending artery and obtuse marginal artery) presenting with
chest pain.
Patient presented to ___ on ___ with chest pressure and
left-sided arm and face numbness associated with nausea and
diaphoresis. Troponin was negative x3 and ECG did not show any
ischemic changes. Patient had a stress echo that showed no
stress-induced wall motion abnormalities.
Patient notes occasional post-prandial heartburn, particularly
at
nighttime after eating spicy foods. After dinner last night,
patient had heartburn with chest pressure radiating to the
abdomen, jaw pain, and diaphoresis, leading him to call EMS. He
was seen by EMS and given sublingual nitro spray with no
improvement.
He was brought to the ___ where he was found to have negative
troponin x2. ECG revealed RBBB, unchanged from prior. He
underwent exercise tolerance test today, which was terminated
due
to fatigue. He had lightheadedness and discomfort in his teeth
towards the end of the protocol, which resolved with rest.
Biphasic T waves in V4-5 were noted early during the recovery
period, which resolved by ~9 min recovery. There were no
significant ST changes; however, pt has underlying right bundle
branch block. There was a blunted heart rate response to
exercise
in the presence of beta blockade.
In the ED
- Initial vitals: T98.6, HR78, BP126/82, RR18, PO298% RA
- EKG: NRS rate 70, TWI lead 3, normal intervals, RBBB
- Labs/studies notable for: trop negative x2, CBC/chem10
unremarkable
- Patient was given:
PO Pantoprazole 40 mg ___
PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
___
PO Lidocaine Viscous 2% 10 mL ___
PO Acetaminophen 1000 mg ___
PO Venlafaxine XR 75 mg ___
___ Pantoprazole 40 mg ___
- Vitals on transfer: HR78, BP144/92, RR16, PO2 100% RA
On the floor the patient has no complaints. Is not having any
chest pain or jaw discomfort currently. Understands plan for
cath
on ___. Mildly anxious about cath, worried that he will need
open heart surgery again. Also noted that in addition to history
given above, had one or two similar episodes over the summer
with
reflux symptoms accompanied by shortness of breath while outside
doing work in the hot weather. Symptoms were relieved with rest
and he did not seek medical care.
Past Medical History:
Allergic rhinitis
Anxiety
Depression
Gastroesophageal Reflux Disease
Hemorrhoids
Hyperlipidemia
Hypertension
Pre-diabetes
Social History:
___
Family History:
Father had rheumatic fever and died at age ___ of MI
Maternal grandfather died of "heart disease" at ___
Physical Exam:
ADMISSION EXAMINATION:
======================
VITALS: ___ Temp: 98.3 PO BP: 165/91 R Sitting HR: 72
RR: 16 O2 sat: 97% O2 delivery: Ra
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate, lying comfortably in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8cm, no HJR.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAMINATION:
======================
GENERAL: Comfortable, NAD
NECK: JVP not elevated, no HJR.
CARDIAC: RRR, no MRG
LUNGS: Breathing comfortably on RA, CTAB except mildly
diminished
at bases.
ABDOMEN: Soft, non-tender, not distended. Small, reducible
umbilical hernia.
EXTREMITIES: Warm, no peripheral edema
SKIN: No apparent rashes
Pertinent Results:
ADMISSION:
___ 10:52PM BLOOD WBC-8.0 RBC-4.36* Hgb-13.3* Hct-39.6*
MCV-91 MCH-30.5 MCHC-33.6 RDW-12.6 RDWSD-41.7 Plt ___
___ 10:52PM BLOOD Neuts-51.3 ___ Monos-9.5 Eos-2.9
Baso-0.5 Im ___ AbsNeut-4.12 AbsLymp-2.86 AbsMono-0.76
AbsEos-0.23 AbsBaso-0.04
___ 10:52PM BLOOD ___ PTT-26.3 ___
___ 10:52PM BLOOD Glucose-134* UreaN-18 Creat-1.0 Na-141
K-4.3 Cl-104 HCO3-25 AnGap-12
___ 03:30AM BLOOD cTropnT-<0.01
___ 10:52PM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.2
DISCHARGE:
___ 06:10AM BLOOD WBC-9.4 RBC-4.75 Hgb-14.6 Hct-43.8 MCV-92
MCH-30.7 MCHC-33.3 RDW-12.4 RDWSD-42.0 Plt ___
___ 06:10AM BLOOD Glucose-139* UreaN-16 Creat-0.9 Na-142
K-4.5 Cl-103 HCO3-25 AnGap-14
___ 06:10AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.1
___ ___ MD ___
Left main and three vessel native coronary artery disease.
3 of 3 bypass grafts are widely patent although LIMA touches
down onto lower pole branch of
D2.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Venlafaxine XR 75 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 40 mg PO QPM
6. Venlafaxine XR 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
- Coronary artery disease status post 3 vessel coronary artery
bypass graft
SECONDARY
=========
- Gastroesophageal reflux disease
- Hypertension
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 CAD s/p CABG presenting w/ chest pain// r/o PNA
other etiology of CP
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs with the most recent from ___
FINDINGS:
Median sternotomy wires are intact. Anterior mediastinal surgical clips are
noted. The lung volume is small, exaggerating bronchovascular markings. No
focal consolidation. No pulmonary edema. No pleural abnormalities. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Jaw pain
Diagnosed with Chest pain, unspecified
temperature: 98.6
heartrate: 78.0
resprate: 18.0
o2sat: 98.0
sbp: 126.0
dbp: 82.0
level of pain: 8
level of acuity: 2.0 | SUMMARY
=======
___ yo M with HLD, HTN, CAD s/p 3v CABG ___ LIMA to the
diagonal and reverse saphenous vein graft to the posterior
descending artery and obtuse marginal artery) presenting with
chest pain. Possibly GERD, but underwent coronary angiography
to rule out CAD progression or graft failure.
ACUTE ISSUES
============
# CAD:
# Chest pain:
History of CAD, s/p CABG in ___. LIMA to the diagonal artery
and reverse SVGs to PDA and OM artery. Given non-exertional
symptoms, questionable improvement with nitro, atypical pain,
suspect GI-related rather than cardiac. That said, patient had
tooth discomfort during stress and EKG changes in recovery
period of stress test and atypical symptoms during first
presentation prior to CABG (including jaw discomfort), merits
further testing for new obstructive coronary disease. Continued
Rosuvastatin 40mg PO QPM, Metop succinate 50mg PO TID, and ASA
81mg PO daily. Coronary angiography on ___ showed stable
native CAD and ___ patent bypass grafts.
CHRONIC ISSUES
==============
# HTN:
Continued metop succinate 50mg PO daily and Lisinopril 10mg PO
daily.
# Pre-diabtes:
A1C of 6.1 in ___. Outpatient recheck and consider Metformin if
persistently in pre-diabetes range.
# Nutrition:
Patient mentioned that he has put on 30 pounds since quitting
smoking last year. Would like to meet with nutritionist to talk
over recommendations for a hear healthy diet. Consult placed.
TRANSITIONAL ISSUES
===================
Discharge WT: 112.9 kg
Discharge Cr: 0.9
[ ] A1C of 6.1 in ___. Transitional issue to recheck and
consider Metformin.
[ ] Chest pain more likely GI in nature than cardiac, given
stable CAD and patent bypass grafts on coronary angiography.
Consider GI referral to further evaluate.
[ ] Consider nutrition consult as outpatient to help with diet
planning
# CONTACT: HCP: ___ (___)
# DISPO: ___, pending above |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amoxicillin / Penicillins
Attending: ___
Chief Complaint:
diffuse leptomeningeal disease
Major Surgical or Invasive Procedure:
Lumbar Puncture ___ Radiation Therapy Sessions to L1-sacral spine daily
___ session planned ___
History of Present Illness:
=============================================================
ONCOLOGY HOSPITALIST ADMISSION NOTE
=============================================================
___
PRIMARY ONCOLOGIST: ___
PRIMARY CARE PHYSICIAN: ___, MD
PRIMARY DIAGNOSIS: metastatic NSCLC
TREATMENT REGIMEN: nivolomab
CC: diffuse leptomeningeal disease
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ year-old gentleman with a history of
PVR,
COPD and NSCLC metastatic to cerebellum and leptomeninges s/p
WB-C2 XRT currently on palliative intent nivolumab who is
transferred from ___ after fall with transient loss of
lower extremity strength and finding of diffuse spinal
leptomeningeal disease.
Per record review and verbal signout he was at the supermarket
and had fall without LOC or headstrike after transiently losing
strength in both lower extremities. He recovered his strength
but
as he fell on his knees he went to ___ where he had
MRI T/L-spine with the finding of leptomeningeal disease from
the
cervical spine to the conus. He was transferred at the request
of
his primary oncologist for placement of ___ to start
intrathecal chemotherapy.
ED initial vitals were 98.5 92 156/92 18 95% RA
Prior to transfer vitals were 98.3 93 122/83 18 93% RA
Exam in the ED showed : "Normal strength and sensation in the
lower extremities, No saddle anesthesia"
ED work-up significant for:
-CBC: WBC: 6.4. HGB: 12.6*. Plt Count: 328. Neuts%: 75.2*.
-Chemistry: Na: 135 . K: 4.6 . Cl: 97. CO2: 22. BUN: 9. Creat:
0.7.
-Coags: INR: 1.2*. PTT: 26.5.
ED management significant for:
-Medications:APAP 1g
-Consult:___ - admit to ___ follow
On arrival to the floor, patient reports feeling well and having
regained all his strength in his lower extremities. His knee
pain
has resolved. He asks if he could get bowel regimen since he has
not had a bowel movement in 6 days in spite of polyethylene
glycol.
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, shortness of breath, cough,
hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ ___
___ - ___ XRT-paclitaxel-carboplatin by Drs. ___
___ Paclitaxel-carboplatin x2 cycles
___ HA, vertigo, N/V started
___ CT torso
___ Brain MRI showed left cerebellar mass
___: WB-C2 RT, 10x300cGy
___: Nivolumab 480mg
PAST MEDICAL HISTORY (Per OMR, reviewed):
-Polycythemia ___
-COPD
-Chemotherapy-related neuropathy
-Right MCA anurysm
-Lumbar spine DJD
-IBS
-Dyslipidemia
-Right eye macular degeneration
-Retinal detachment
-s/p Knee replacement
-BPH
-Depression
Social History:
___
Family History:
He has two healthy daughters. Of his three siblings, one sister
died at age ___ with meningitis. One brother is in poor health and
in a nursing home. One other brother is healthy.
Physical Exam:
General: 98.2 PO 133 / 77 L Lying ___ RA
HEENT: MMM
CV: RR, NL S1S2 no S3S4, no MRG
PULM: CTAB, respirations unlabored
ABD: BS+, soft, NTND
LIMBS: No ___
SKIN: bright pink erythema with scattered macules on upper back
and proximal upper ext, pruritic, scaly now fading away
NEURO: CNIII-XII intact
Speech is clear and fluent but at times confused about
dates/times
assessed his gait at bedside and requires assistance to stand
and requires walker to ambulate.
on admission was able to stand independently. strength ___
b/l upper and lower ext w/ exception of R extensor hallucis
longus 3+/5, 4+/5 on L
Pertinent Results:
___ CT head: "Compared with ___ there has been regression
of the mass in the left cerebellar hemisphere with decrease in
the amount of edema with resolution of the mass effect."
___ MRI T-spine: "Abnormal nodularity and enhancement along the
surface of the cervical and thoracic cord consistent with
leptomeningeal spread of tumor. No evidence of focal cord
compression. Additional suspicious focus of enhancement within
the T5 vertebral body suggestive of a metastasis."
___ MRI L-spine: "Diffuse leptomeningeal spread of tumor along
the conus and roots of the cauda equina consistent with
metastatic disease. No evidence of focal cord compression."
___ MRI C-spine
1. Diffuse leptomeningeal enhancement with few discrete small
leptomeningeal nodules in the cervical and visualized upper
thoracic thecal sac, extending into the intracranial
compartment. Concurrent brain MRI is reported separately. These
findings are consistent with leptomeningeal carcinomatosis in
the setting of underlying lung cancer. 2. Questionable small
faint ill-defined T2 signal abnormality and contrast enhancement
in the ventral spinal cord at the level of C5 on sagittal
images, not seen on axial images. Additional patchy T2
hyperintensity and contrast enhancement in the cord from C6-C7
through mid C7 levels. The absence of associated cord edema and
expansion are atypical for parenchymal metastatic disease.
Alternative diagnostic considerations include cord
edema/ischemia on the basis of venous congestion in the setting
of diffuse leptomeningeal metastatic disease, versus a
paraneoplastic process. 3. Multilevel degenerative disease with
mild spinal canal narrowing and mild-to-moderate neural
foraminal narrowing, as detailed above.
___ MRI Brain
1. Decreased bulk of leptomeningeal lesions in the left
cerebellar hemisphere and left vermis. No significant change in
thin leptomeningeal enhancement within bilateral superior
vermis. Increased conspicuity of leptomeningeal enhancement
along the ventral brainstem. 2. Decreased edema in the left
cerebellar hemisphere and left vermis with re-expansion of the
fourth ventricle. Stable size of the third and lateral
ventricles. 3. Nonenhancing confluent periventricular white
matter T2/FLAIR hyperintensity appear slightly increased, but
this could be secondary to differences in technique and MR
scanners. 4. Apparent 4 x 2 mm aneurysm projecting posteriorly
from the origin of the right middle cerebral artery is again
noted. 5. Paranasal sinus disease.
___ CSF Cytology (PRELIMINARY REPORT AS OF ___
POSITIVE FOR MALIGNANT CELLS. Metastatic carcinoma. See note.
Note: The cell block demonstrates scant cellularity. Rare cells
in the cellblock are weakly positive for TTF-1, suggestive of
metastasis from the ___ known lung adenocarcinoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob/wheeze
2. Omeprazole 40 mg PO BID
3. PARoxetine 10 mg PO DAILY
4. budesonide 0.5 mg/2 mL inhalation BID
5. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob/wheezing
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Dronabinol 2.5 mg PO BID
10. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Enoxaparin Sodium 40 mg SC QPM
3. Glycerin Supps ___AILY:PRN constipation
usually produces a response in around 20 minutes. administer
just prior to a cleaning
4. Magnesium Citrate 300 mL PO EVERY OTHER DAY PRN no bm >4
days
5. Ondansetron 8 mg PO Q8H:PRN nausea
take one dose one hour prior to radiation therapy
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
take 1 hour prior to your radiation therapy session
RX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn pain Disp #*14
Tablet Refills:*0
7. Senna 17.2 mg PO BID
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN rash on
arms and back Duration: 10 Days
do not exceed 2 weeks at a time. do not apply to face, palms,
nor skin folds
9. Polyethylene Glycol 17 g PO BID
10. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob/wheeze
11. budesonide 0.5 mg/2 mL inhalation BID
12. Dronabinol 2.5 mg PO BID
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob/wheezing
15. Omeprazole 40 mg PO BID
16. PARoxetine 10 mg PO DAILY
17. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Spinal leptomeningeal disease
Cauda Equina Syndrome
Metastatic Non-Small Cell Lung Cancer
Discharge Condition:
Mental Status: Clear and coherent, but sometimes confused
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with lung cancer, ataxia, falls, new
leptomeningeal disease. Re-evaluate brain metastases
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: Limited postcontrast brain MRI from ___
Complete brain MRI with and without contrast from ___.
Head CT from ___
FINDINGS:
Images are mildly limited by motion artifact. Dominant area of enhancement in
the left cerebellum centered along the horizontal fissure, likely
leptomeningeal, has decreased in bulk, now 4.5 x 1.6 cm on image 5:4, and
previously 5.3 x 2.6 cm on ___. Additional areas of leptomeningeal
enhancement in the anterolateral left cerebellar hemisphere on image 5:5, in
the left vermis on images 4:51 and 401:117, have also decreased in bulk.
Linear leptomeningeal enhancement within bilateral superior vermis is not
significantly changed. There is also diffuse leptomeningeal enhancement along
the ventral brainstem, which appears more conspicuous. No new focal enhancing
lesion is seen.
The extent of edema in the left cerebellar hemisphere and left vermis has
decreased. The fourth ventricle has re-expanded and is no longer shifted to
the right. There is no dilatation of the third a lateral ventricles.
Nonenhancing confluent periventricular white matter T2/FLAIR hyperintensity
appears slightly increased, but this could be secondary to differences in
technique given the different MR scanners. Discrete foci of T2/FLAIR
hyperintensity in the deep and subcortical white matter of the cerebral
hemispheres not significantly changed, nonspecific but likely sequela of
chronic small vessel ischemic disease in this age group. Mild age-related
prominence of the sulci is again seen. No evidence for intracranial blood
products. No acute infarction.
Major vascular flow voids are preserved. Apparent 4 x 2 mm aneurysm
projecting posteriorly from the origin of the right middle cerebral artery is
again noted, images 400:92, 4:73.
Status post bilateral cataract surgery.
Paranasal sinus disease is similar to prior. This includes opacification of
multiple anterior/middle right ethmoid air cells, mucosal thickening within
left anterior/middle and bilateral posterior ethmoid air cells, fluid and
mucosal thickening should opacifying the frontal sinus, and mild mucosal
thickening and small mucous retention cysts along the floors of the maxillary
sinus. There is also partial right mastoid air cell opacification, increased
compared to ___, but present on ___.
IMPRESSION:
1. Decreased bulk of leptomeningeal lesions in the left cerebellar hemisphere
and left vermis. No significant change in thin leptomeningeal enhancement
within bilateral superior vermis. Increased conspicuity of leptomeningeal
enhancement along the ventral brainstem.
2. Decreased edema in the left cerebellar hemisphere and left vermis with
re-expansion of the fourth ventricle. Stable size of the third and lateral
ventricles.
3. Nonenhancing confluent periventricular white matter T2/FLAIR hyperintensity
appear slightly increased, but this could be secondary to differences in
technique and MR scanners.
4. Apparent 4 x 2 mm aneurysm projecting posteriorly from the origin of the
right middle cerebral artery is again noted.
5. Paranasal sinus disease.
Radiology Report
EXAMINATION: MRI CERVICAL SPINE WITH/WITHOUT CONTRAST
INDICATION: Patient with history of lung cancer, left cerebellar lesion, now
with new leptomeningeal disease. Evaluate for metastatic disease to the
cervical spinal cord.
TECHNIQUE: Sagittal T1 weighted, T2 weighted, and IDEAL images of the
cervical spine with axial gradient echo and T2 weighted images. Following
intravenous administration of 9 cc Gadavist, sagittal and axial T1 weighted
images were obtained.
COMPARISON: No prior cervical spine MRI.
Thoracic spine MRI from ___.
FINDINGS:
Vertebral body heights are preserved. There is manage retrolisthesis of C3 on
C4 and of C4 on C5, and minimal anterolisthesis of C7 on T1. No suspicious
bone marrow lesions are seen. There are T1 hyperintense hemangiomas within C7
and T1 vertebral body. There are discogenic bone marrow changes in the
endplate from C4-C5 through C6-C7, in association with loss of disc height and
endplate osteophytes.
There is no evidence for an epidural mass. There is diffuse leptomeningeal
contrast enhancement throughout the cervical and visualized upper thoracic
thecal sac, extending into the intracranial compartment. Concurrent brain MRI
is reported separately. Discrete leptomeningeal nodules along the right
ventral cord measures 6 mm at the level of C2-C3 on image 9:5 and 3 mm at the
level of C3 on image 9:7.
In addition, there is a small, faint, ill-defined hyperintensity in the
ventral spinal cord at the level of C5 on sagittal T2 weighted and
fat-suppressed IDEAL images, with contrast enhancement on sagittal
postcontrast T1 weighted images (image 9 of series 3, 4, 8), but without
evidence for parenchymal enhancement on the axial postcontrast T1 weighted
images. There also apparent small foci of high T2 signal in the left ventral
cord at C7 on axial image 06:26, and apparent patchy contrast enhancement
within the cord from C6-C7 through mid C7 levels on sagittal image 8:8 and
axial images ___. However, there is no evidence for associated cord
edema or expansion to clearly indicate parenchymal metastatic disease.
C2-C3: Small central disc protrusion without spinal canal narrowing. Mild
right neural foraminal narrowing by facet osteophytes. Left facet arthropathy
is also present without neural foraminal narrowing.
C3-C4: Small central disc protrusion without spinal canal narrowing. Mild
bilateral facet arthropathy without significant neural foraminal narrowing.
C4-C5: Mild retrolisthesis and broad-based posterior endplate osteophytes
mildly narrow the spinal canal. Moderate to severe bilateral neural foraminal
narrowing by uncovertebral and facet osteophytes.
C5-C6: Minimal retrolisthesis and broad-based central disc protrusion with
endplate osteophytes mildly narrow the spinal canal. Moderate to severe
bilateral neural foraminal narrowing by uncovertebral and facet osteophytes.
C6-C7: Small central disc protrusion and posterior endplate osteophytes mildly
narrow the spinal canal. Mild bilateral neural foraminal narrowing by
uncovertebral and facet osteophytes.
C7-T1: Minimal anterolisthesis. No spinal canal narrowing. Moderate right
neural foraminal narrowing by uncovertebral and facet osteophytes. Advanced
left facet arthropathy without neural foraminal narrowing.
IMPRESSION:
1. Diffuse leptomeningeal enhancement with few discrete small leptomeningeal
nodules in the cervical and visualized upper thoracic thecal sac, extending
into the intracranial compartment. Concurrent brain MRI is reported
separately. These findings are consistent with leptomeningeal carcinomatosis
in the setting of underlying lung cancer.
2. Questionable small faint ill-defined T2 signal abnormality and contrast
enhancement in the ventral spinal cord at the level of C5 on sagittal images,
not seen on axial images. Additional patchy T2 hyperintensity and contrast
enhancement in the cord from C6-C7 through mid C7 levels. The absence of
associated cord edema and expansion are atypical for parenchymal metastatic
disease. Alternative diagnostic considerations include cord edema/ischemia on
the basis of venous congestion in the setting of diffuse leptomeningeal
metastatic disease, versus a paraneoplastic process.
3. Multilevel degenerative disease with mild spinal canal narrowing and
mild-to-moderate neural foraminal narrowing, as detailed above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Transfer
Diagnosed with Weakness
temperature: 98.5
heartrate: 92.0
resprate: 18.0
o2sat: 95.0
sbp: 156.0
dbp: 92.0
level of pain: 4
level of acuity: 2.0 | ___ w/ polycythemia ___, COPD and NSCLC metastatic to
cerebellum
and leptomeninges s/p WB-C2 XRT currently on palliative
nivolumab
who is transferred from ___ after fall with transient
loss of lower extremity strength and finding of diffuse spinal
leptomeningeal disease.
# Diffuse spinal leptomeningeal disease
# Cauda Equina Syndrome
Likely explains recent fall event. He is at risk for compressive
radiculopathy and continues having a very good functional status
in spite of his advanced disease. Strength is largely intact on
exam but otherwise able to ambulate w/ walker w/ ataxia. Was
discussed at tumor board. No ommaya indicated at this time. Due
to sx
worrisome for cauda equina syndrome (due to increasing urinary
hesitation, ongoing constipation), he was started urgently
on XRT, 20 gy in 5 fractions to the lumbar-sacral spine, on
___.
He did not improve while he was inpatient, and had worsening
torso
ataxia.
- last XRT session ___ (time TBD by Rad-Onc)
- premed w/ zofran (offer oxycodone as well) 1 hr prior to XRT
- will need rehab placement
- pt and family aware that unfortunately LMD portends a poor
prognosis
# Rash
Limited to upper torso. Has had similar rash associated w/
chemo.
Improved with topical triamcinolone, ___, BID. Not to exceed
2 weeks.
# Metastatic NSCLC:
Unfortunately with significant progression. Received first
dose of palliative intent nivolumab ___. Goals of care
discussion initiated with Dr ___ continue with Dr
___.
# Constipation:
Chronic. Potentially neurogenic associated with his cauda equina
disease
He may may have loss of some vagal tone or rectal innervation.
Moves bowels q5 days at baseline.
- cont bowel regimen (including miralax BID, senna BID, and
suppository PRN)
# COPD: stable, cont home nebs
# GERD: continue omeprazole
# Weight loss
# Severe Protein calorie malnutrition
Nutrition consulted. Severe malnutrition related to malignancy
as evidenced by 11% weight loss in ~4 months and <=75% energy
intake compared to estimated energy needs for >=1 month.
- Encourage PO intake and adequate protein at all meals
- Oral nutrition supplement: Ensure Enlive Frappe TID
- Add multivitamin w/ minerals as medically able
# BPH: Continue tamsulosin
# Depression: Continue paroxetine
FEN: Regular diet
DVT PROPH: HSC
ACCESS: PIV
CODE STATUS: FC (confirmed on admission)
DISPO: Life Care ___
BILLING: >30 min spent coordinating care for discharge
______________
___, D.O.
Heme/___ Hospitalist
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine Sulfate
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with severe AS ___ 0.6, mean gradient 39, peak vel 4.0),
home 2L O2 requirement, Afib (not on anticoagulation), s/p PPM
for SSS, HFpEF (EF >60%), who was brought in by EMS with
dyspnea. Her daughter is her primary caretaker and reports that
her mother has been feeling stronger since her last
hospitalization and she has noticed she has more energy and is
eating better, but then over the last couple weeks she has
noticed more leg swelling, so she had received additional
torsemide for ___ days (80 daily instead of 60 daily). She also
reports that one of her mother's doctors started ___ on
metoprolol succinate 25 daily recently because of tachycardia to
the 120s.
Before she left the house yesterday she noticed her mother was
breathing faster but her oxygen saturation and other vitals were
ok, but by the time she returned home the patient was very short
of breath. SHe denies any sick contacts, fevers, cough,
congestion, or diet changes.
The patient was recently admitted to ___ from ___ for
CHF exacerbation, requiring BiPAP and admission to the CCU.
Hospitalization was complicated by HCAP and symptomatic NSVT
with one episode of VT with HR>200. EKG showed prolonged QTc
(>600). As a result, all QTc prolonging medications including
amiodarone, were discontinued. The patient was overdrive paced
at 80bpm with improvement of QTc (430-470s). Goals of care were
also discussed and the decision was made to change code status
to DNR/DNI. Palliative care was involved and patient was sent
home with liquid oxycodone for emergencies, but was never used.
THe daughter reports she is still having a lot of difficulty
being comfortable using that medication because she feels like
she would be "killing my mother".
In the ED, initial vitals were 99.0 81 132/76 36 95% CPAP. Exam
was notable for elevated JVD, bilateral crackles, and 1+ pitting
edema. Labs were significant for Cr 1.5 (baseline), BNP 13,393,
Trop <0.01, and lactate 2.0. VBG showed 7.27/___/34. CXR
showed pulmonary edema and large pleural effusions bilaterally.
Initial EKG showed ventricular pacing with underlying Afib. The
patient was given lasix 40mg IV with about 600 cc UOP in her
foley and then was admitted to the CCU for BiPAP requirement,
however she continually tried to remove the mask and was
transferred upstairs 97% on 6L NC.
On review of systems, she reports feeling like she "needs to
cough something up" but no fevers, chills, sweats, sore throat,
nasal congestion, chest pain, palpitations, abdominal pain,
N/V/D, dysuria, rash, syncope, presyncope.
Past Medical History:
1. CAD - 3 Vessel, medically managed
2. Severe aortic stenosis ___ 0.6, peak velocity 4, mean
gradient 39), AVR was considered but the pt refused surgery, and
preferred to continue on medical therapy.
3. Paroxysmal atrial fibrillation, s/p pacemaker placement in
___ for tachy-brady syndrome, followed by generator change in
___. Amiodarone was re-initiated in ___ d/t increased
frequency of AF, d/c'd on last hospitalization ___ QTc
prolongation
4. HTN
5. HFpEF (EF>60%)
6. Hypothyroidism
7. Chronic lung nodules
Social History:
___
Family History:
Multiple family members with CAD
Physical Exam:
ADMISSION EXAM:
======================
VS: Wt=80kg T= 98.1F BP=115/63 HR=81 RR=38 O2 sat= 97% on 6L NC
General: elderly woman appears younger than chronologic age, in
no distress
HEENT: EOMI, PERRL, MM dry, OP clear
Neck: JVP 8cm, no ___ or thyroid abnormality
CV: RRR, crescendo-decrescendo systolic murmur best over RUSB
Lungs: Crackles throughout bilateral lung fields
Abdomen: obese, benign, +BS, ?flank dullness
GU: foley with yellow urine draining
Ext: 2+ edema to thighs
Neuro: A&Ox3, CN II-XII intact, symmetric, moving all
extremities with purpose, symmetrically
Skin: Dry, no rashes
DISCHARGE EXAM:
=======================
VS: 97.3; 80-100/80s; 80; ___ 95%2L O2 (home amount)
Wt: 87.1kg (bed weight)
I/Os: ___ 120/200
Tele: No events
GENERAL: NAD. Mood, affect appropriate. Coughing
HEENT: NCAT.
NECK: JVP < 8cm
CARDIAC: RRR, SEM
LUNGS: bibasilar crackles in bases
ABDOMEN: obese. Soft, non-tender, non-distended
EXTREMITIES: trace peripheral edema
SKIN: No stasis dermatitis, ulcers
Pertinent Results:
ADMISSION LABS:
=====================
___ 07:29AM BLOOD WBC-5.7# RBC-3.76* Hgb-11.3* Hct-34.5*
MCV-92 MCH-30.2 MCHC-32.8 RDW-16.1* Plt ___
___ 07:29AM BLOOD Neuts-59.3 ___ Monos-4.9 Eos-1.6
Baso-0.4
___ 07:29AM BLOOD ___ PTT-27.8 ___
___ 07:29AM BLOOD Glucose-147* UreaN-21* Creat-1.5* Na-141
K-4.1 Cl-104 HCO3-26 AnGap-15
___ 07:29AM BLOOD ALT-9 AST-29 AlkPhos-184* TotBili-0.5
___ 07:29AM BLOOD ___
___ 07:29AM BLOOD cTropnT-<0.01
___ 07:29AM BLOOD Calcium-8.0* Phos-4.5 Mg-1.9
___ 07:42AM BLOOD ___ pO2-33* pCO2-71* pH-7.27*
calTCO2-34* Base XS-1 Comment-PERIPHERAL
___ 07:42AM BLOOD Lactate-2.0
___ 07:45AM URINE Color-Yellow Appear-Clear Sp ___
___ 07:45AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:45AM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 07:45AM URINE CastHy-72*
DISCHARGE LABS:
=======================
___ 06:10AM BLOOD WBC-5.7 RBC-3.50* Hgb-10.6* Hct-31.8*
MCV-91 MCH-30.2 MCHC-33.2 RDW-15.8* Plt ___
___ 06:10AM BLOOD Plt ___
___ 07:50AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.9
IMAGING:
=======================
CXR (___):
1. Interstitial edema likely a developing into alveolar edema
similar to ___.
2. Large bilateral pleural effusions.
MICROBIOLOGY:
=======================
Blood Cx - Now growth
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Ascorbic Acid ___ mg PO BID
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Senna 8.6 mg PO QHS constipation
9. Simvastatin 20 mg PO QPM
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Torsemide 60 mg PO DAILY
12. OxycoDONE Liquid 2.5-10 mg PO Q2H:PRN shortness of breath
13. Ipratropium Bromide Neb 1 NEB IH Q6H
14. Miconazole Powder 2% 1 Appl TP QID:PRN fungus under breast
15. Potassium Chloride 20 mEq PO EVERY OTHER DAY
16. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Ascorbic Acid ___ mg PO BID
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Ipratropium Bromide Neb 1 NEB IH Q6H
8. Miconazole Powder 2% 1 Appl TP QID:PRN fungus under breast
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO QHS constipation
12. Simvastatin 20 mg PO QPM
13. Torsemide 60 mg PO DAILY
14. Colchicine 0.3 mg PO DAILY
RX *colchicine 0.6 mg 0.5 (One half) tablet(s) by mouth once a
day Disp #*5 Tablet Refills:*0
15. Metoprolol Succinate XL 25 mg PO DAILY
16. OxycoDONE Liquid 2.5-10 mg PO Q2H:PRN shortness of breath
17. Potassium Chloride 20 mEq PO EVERY OTHER DAY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- acute decompensated heart failure with preserved ejection
fraction
Secondary Diagnosis:
- Severe Aortic Stenosis
- Gout
- Atrial Fibrillation
- Chronic Kidney Disease
- Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with severe resp distress on bipap. Hx of CHF. //
eval for PNA, pulm edema
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest radiograph from ___.
FINDINGS:
There is prominence of the pulmonary vasculature and interstitial opacities
compatible with interstitial edema and developing into alveolar edema. There
are large bilateral pleural effusions. There is no pneumothorax. The
cardiomediastinal silhouette is unchanged. A left chest wall pacemaker leads
are present in the right atrium and right ventricle.
IMPRESSION:
1. Interstitial edema likely a developing into alveolar edema similar to ___.
2. Large bilateral pleural effusions.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 99.0
heartrate: 81.0
resprate: 36.0
o2sat: 95.0
sbp: 132.0
dbp: 76.0
level of pain: 0
level of acuity: 1.0 | ___ with severe AS ___ 0.6, mean gradient 39, peak vel 4.0),
home 2L O2 requirement, Afib (not on anticoagulation), s/p PPM
for SSS, and HFpEF (EF >60%) who presents with dyspnea, now
admitted for CHF exacerbation.
# Acute Decompensated Diastolic Heart Failure: Patient with a
history of HFpEF and critical AS, on home O2 with frequent
hospitalizations and palliative care involvement with no plan
for valve replacement. This acute episode possibly due to
dietary indescretion with daughter reporting increased PO
intake. Last discharge weight 74.2 kg with current admission
weight at 80kg. Patient was diuresed with lasix gtt with
intermittent boluses with symptomatic response. Transitioned
patient to home torsemide 60mg qD. Several discussion held with
patient and family this admission regarding overall prognosis.
While the patient remains DNR/DNI, she and her family are not
yet intersted in persuing hospice but are beginning to realize
that frequent hospitalizations may not be avoidable given her
AS.
# L Great Toe Pain - pt with hx of gout flares while
hospitalized on diuretics. Started on Colcicine in CCU and
continued this admission. Also offered low dose tramadol,
however patient's daughter refused. Discharged on continued
short course of colcicine.
# Severe AS: valve area 0.6, mean gradient 39. Family has
declined AVR in the past. She was diuresed as above.
# Afib: CHADS = 3. Has declined anticoagulation in the past.
Amiodarone discontinued due to concern for QTc prolongation. HRs
were well controlled while in-house. She was discharged on her
home metoprolol dose xL 25mg.
# CAD: Known 3VD in ___, no recent cardiac cath. Medically
managed. Continued home ASA 81mg and simvastatin 20mg qD
# Hypothyroidism: Continued levothyroxine this admission.
# Goals of care: Patient was seen by palliative care previously,
with plans for DNR/DNI/no CCU transfer (though interestingly she
was admitted to the CCU for BiPAP initially this admission).
However patient was seen again this admission with by palliative
care with discussions re: hospice. Patient stated that she
wished to be home, however patient's family declined hospice at
this time. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache, shortness of breath
Major Surgical or Invasive Procedure:
tunneled HD line placement (___)
History of Present Illness:
___, with no significant medical history, with the exception of
recent anabolic steroid use, presents as a transfer from OSH
with headache, nausea/vomiting, anasarca, and dyspnea.
Patient first began feeling unwell around five days ago, when he
developed heightened sense of smell. Subsequently developed a
pressure like headache and nausea, with one episode of vomiting.
Headache was located in frontal region bilaterally, persistently
present, but not associated with focal neuro deficits, such as
weakness or sensation, photophobia, phonophobia, facial
weakness, or slurring of speech. Did not awaken him at night. No
clear
triggers. Initially attributed headache to "allergies" and tried
pseudoephedrine and Clarityn without relief. As the week
progressed, patient was unable to tolerate PO intake secondary
to nausea, and noticed he was becoming more short of breath,
especially on exertion. He climbed three flights of stairs to
his apartment and was very short of breath, requiring over an
hour of rest to fully recover. That night, he felt very short of
breath when lying flat and had to elevate the head of the bed
with extra pillows. Over the same time period, patient noted he
was not urinating as much as previous.
With regards to his anabolic steroid use, patient has used these
intermittently, in addition to testosterone, over the last ___
years, without issues. He does develop total body swelling and
fluid retention, as he currently has, when taking them but says
it resolves when he finishes his cycles. He started his current
cycle a week and a half ago; oxandrolone 100mg and stanozol 75mg
daily. Also reports taking a daily testosterone supplement
daily, but unable to quantify dose.
Presented to an OSH ED where he was found to be hypertensive, to
have 2+ pitting edema of the lower extremities, creatinine >12
and BNP ~25,000, prompting transfer to ___.
On arrival to the ED, initial VS were;
Temp 98.1 HR 108 BP 197/164 RR 18 SaO2 99% RA
Examination was notable for 2+ pitting edema to shins, clear
lungs, and regular heart rhythm.
Bedside echo showed EF 45-50%, mild MR, no RWMA, and trivial
effusion.
Labs were notable for;
WBC 11.1 Hgb 10.7
Creatinine 12.8 BUN 76 HCO3 14 BNP 27229 trop 0.04
LFTs normal but albumin 2.7 CK 500
Coags normal and serum toxicology negative
VBG ___
UA with 9 WBC, few bacteria, 600 protein, and moderate blood
Renal US demonstrated no hydronephrosis and no evidence of
obstruction. Internal echogenic debris within the bladder is
nonspecific and of uncertain significance. CXR showed low lung
volumes with mild cardiomegaly and moderate pulmonary edema.
Cardiology and nephrology were consulted. Nephrology recommended
UA, urine protein/creatinine ratio, urine lytes, renal
ultrasound, CXR, and BP control. Cardiology recommended formal
TTE and BP reduction.
Patient was started on a nitroglycerin drip and given Zofran,
dilaudid, and Tylenol.
Transfer vital signs;
HR 83 BP 162/96 RR 21 SaO2 98% 2L NC
On arrival to the floor, patient repeats the above story.
Currently his most concerning symptoms are headache and nausea.
States he has vomited bilious material twice since arriving to
the floor, and has noticed occasional blood clots in his vomit,
but no large volume hematemesis. Denies light-headedness,
dizziness, BRBPR or melena. Per discussion with his girlfriend,
patient had an abnormal creatinine six months ago at ___
___, for which he was supposed to follow-up with a PCP, but
never did.
Past Medical History:
anabolic steroid use
Social History:
___
Family History:
Father with early onset hypertension in his ___, and suffered an
MI in his ___. Subsequently diagnosed with "multiple cancers"
and has passed away. Brother also with a history of hypertension
and rhabdomyolysis. Otherwise no other significant family
history.
Physical Exam:
ADMISSION EXAM
===========================
VS: Temp 97.4 BP 174/92 HR 113 RR 22 SaO2 95% RA
GENERAL: fatigued appearing man, diaphoretic, no acute distress
HEENT: AT/NC, EOMI, PERRL, no conjunctival pallor, anicteric
sclera, MMM
NECK: supple, no LAD, difficult to visualize JVP
CV: RRR, S1 and S2 normal, no murmurs/gallops/rubs, ecchymosis
on left chest
RESP: poor air entry, no clear wheeze/crackles
___: soft, non-tender, no distention, BS normoactive
EXTREMITIES: warm, well perfused, 2+ lower extremity edema to
knees, with 1+ edema in upper extremities, ecchymosis on right
lateral thigh
PULSES: 2+ pulses bilaterally
NEURO: A/O x3, strength ___ in all extremities, sensation
intact, CN II-XII intact
DISCHARGE EXAM
===========================
VITALS: ___ Temp: 98.0 PO BP: 145/83 L Sitting HR: 70
RR: 18 O2 sat: 97% O2 delivery: Ra
GENERAL: Well appearing man in no acute distress. Comfortable.
NEURO: AAOx3. Moving all four extremities with purpose.
HEENT: NCAT. EOMI. MMM.
CARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
PULMONARY: Clear to auscultation bilaterally.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. 2+ edema bilaterally to knees,
mildly improved.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
===========================
___ 02:08AM BLOOD WBC-11.1* RBC-3.66* Hgb-10.7* Hct-32.9*
MCV-90 MCH-29.2 MCHC-32.5 RDW-11.9 RDWSD-38.9 Plt ___
___ 02:08AM BLOOD Neuts-77.6* Lymphs-14.5* Monos-5.6
Eos-1.4 Baso-0.4 Im ___ AbsNeut-8.60* AbsLymp-1.61
AbsMono-0.62 AbsEos-0.15 AbsBaso-0.04
___ 02:08AM BLOOD ___ PTT-27.6 ___
___ 02:08AM BLOOD Glucose-82 UreaN-76* Creat-12.8* Na-141
K-5.0 Cl-110* HCO3-14* AnGap-17
___ 02:08AM BLOOD ALT-10 AST-20 CK(CPK)-500* AlkPhos-43
TotBili-0.2
___ 02:08AM BLOOD Lipase-40
___ 02:08AM BLOOD ___
___ 02:08AM BLOOD cTropnT-0.04*
___ 02:08AM BLOOD Albumin-2.7*
___ 02:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ URINE Color: Straw Appear: Hazy* Sp ___: 1.020
___ URINE Blood: MOD* Nitrite: NEG Protein: 600* Glucose:
NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.5 Leuks: NEG
___ URINE RBC: 14* WBC: 9* Bacteri: FEW* Yeast: NONE Epi: 1
ASA: NEG Ethanol: NEG Acetmnp: NEG Tricycl: NEG
PERTINENT LABS
===========================
___ 03:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 03:00PM BLOOD ANCA-NEGATIVE B
___ 03:00PM BLOOD ___
___ 03:00PM BLOOD PEP-NO SPECIFI IgG-327* IgA-218 IgM-118
IFE-NO MONOCLO
___ 03:00PM BLOOD C3-108 C4-36
___ 03:00PM BLOOD HIV Ab-NEG
___ 02:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 03:00PM BLOOD HCV Ab-NEG
MICRO
===========================
___ Urine culture - no growth
PERTINENT STUDIES
===========================
___ RENAL US
No hydronephrosis. No evidence of obstruction. Internal
echogenic debris within the bladder is nonspecific and of
uncertain significance.
___ CXR
Hazy opacities of the bilateral lungs with a nodular component
may represent pulmonary edema, however a nodular component
raises concern for an infectious process. Hemorrhage could be an
alternate consideration. Clinical correlation. This should be
followed by imaging to resolution.
Small bilateral pleural effusions.
___ CT Torso Second Opinion
Extensive parenchymal involvement by ___ opacities,
multifocal,
consolidations and ground-glass opacities. In conjunction with
mediastinal and hilar lymphadenopathy it is most likely
concerning for multifocal infection. Vasculitis would be
possible but less likely. The findings do not have an
appearance of neoplasm.
===============
DISCHARGE LABS:
===============
___ 10:34AM BLOOD WBC-19.6* RBC-3.15* Hgb-9.3* Hct-27.3*
MCV-87 MCH-29.5 MCHC-34.1 RDW-11.9 RDWSD-38.0 Plt ___
___ 10:34AM BLOOD Glucose-119* UreaN-134* Creat-15.5*
Na-136 K-4.6 Cl-95* HCO3-19* AnGap-22*
___ 10:34AM BLOOD Calcium-7.7* Phos-11.0* Mg-2.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. stanozolol (bulk) 75 mg PO DAILY
2. oxandrolone (bulk) 100 mg PO DAILY
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 1500 mg by mouth once a day
Refills:*0
2. Famotidine 20 mg PO Q24H
RX *famotidine 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Labetalol 800 mg PO TID
RX *labetalol 200 mg 4 tablet(s) by mouth three times a day Disp
#*360 Tablet Refills:*2
4. NIFEdipine (Extended Release) 60 mg PO DAILY
RX *nifedipine 60 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
5. PredniSONE 80 mg PO DAILY
RX *prednisone 20 mg 4 tablet(s) by mouth once a day Disp #*120
Tablet Refills:*0
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
RX *sevelamer carbonate [___] 800 mg 2 tablet(s) by mouth
three times a day Disp #*180 Tablet Refills:*0
7. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Renal Failure
IgA Nephropathy
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with chf// eval pulm edema
TECHNIQUE: Single AP view of the chest.
COMPARISON: Outside CT ___.
FINDINGS:
Lung volumes are low. Hazy opacities of the bilateral lungs with a nodular
component may represent pulmonary edema, however nodular component raises
concern for an infectious process. Clinical correlation. The
cardiomediastinal silhouette is within normal limits given technique. Small
bilateral pleural effusions.
IMPRESSION:
Hazy opacities of the bilateral lungs with a nodular component may represent
pulmonary edema, however a nodular component raises concern for an infectious
process. Hemorrhage could be an alternate consideration. Clinical
correlation. This should be followed by imaging to resolution.
Small bilateral pleural effusions.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: History: ___ with Cr 12// eval obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10.6 cm. The left kidney measures 11.8 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and demonstrated bilateral ureteral
jets. However, there was punctate internal echogenic debris which is
nonspecific.
IMPRESSION:
No hydronephrosis. No evidence of obstruction.
Internal echogenic debris within the bladder is nonspecific and of uncertain
significance. Correlation with urinalysis is recommended.
Radiology Report
EXAMINATION: Ultrasound-guided kidney biopsy
INDICATION: ___ year old man with ___ and possible pulmonary hemorrhage//
Renal biopsy for etiology ___
TECHNIQUE: Real-time grayscale ultrasound imaging for biopsy guidance.
COMPARISON: ___
OPERATORS: Dr. ___ and Dr. ___ sonographic guidance for
biopsy that was performed by the Nephrology team. Dr. ___
radiologist, was present and supervising throughout the guidance and reviewed
and agrees with the trainee's findings
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 left 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 of 35 minutes
during which the patient's hemodynamic parameters were continuously monitored
by an independent, trained radiology nurse.
IMPRESSION:
Ultrasound guidance for percutaneous left kidney biopsy.
Radiology Report
EXAMINATION: SECOND OPINION CT TORSO
INDICATION: ___ READ
TECHNIQUE: MD CT of the chest was obtained from thoracic inlet to upper
abdomen after administration of IV contrast. Axial images were reviewed in
conjunction with coronal and sagittal reformats.
COMPARISON: None
FINDINGS:
Aorta and pulmonary arteries are normal in diameter. Pathologically enlarged
mediastinal, hilar lymph nodes are demonstrated. No pathologically enlarged
supraclavicular or axillary lymph nodes seen.
Heart size is normal. There is no pericardial effusion. There is small
amount of bilateral pleural effusion.
Image portion of the upper abdomen reveals no appreciable abnormality.
Airways are patent to the subsegmental level bilaterally.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
No central pulmonary embolism demonstrated although this study is suboptimal
for assessment of mid and distal level of pulmonary arteries. Extensive
___ opacities, nodular consolidations are demonstrated in left and
right upper lobes as well as in the right middle lobe, lingula and both lower
lobes for. If findings are extensive. There is no substantial bronchial wall
thickening associated with the findings.
IMPRESSION:
Extensive parenchymal involvement by ___ opacities, multifocal,
consolidations and ground-glass opacities. In conjunction with mediastinal
and hilar lymphadenopathy it is most likely concerning for multifocal
infection. Vasculitis would be possible but less likely. The findings do not
have an appearance of neoplasm.
Radiology Report
INDICATION: ___ year old man with acute renal failure// tunneled HD line
placement
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: Sedation was provided by administrating divided doses of 2.5 mg of
midazolam while the patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. 1% lidocaine was injected
in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 1.6 minutes, 15 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right upper chest was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short Amplatz wire
was advanced to make appropriate measurements for catheter length. The short
Amplatz 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. ___ subcuticular Vicryl sutures and Steri-strips were also used to
close the venotomy incision site. Final spot fluoroscopic image demonstrating
good alignment of the catheter and no kinking. The tip is in the right atrium.
The catheter was flushed and both lumens were capped. Sterile dressings were
applied. The patient tolerated the procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing tunneled
dialysis catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled dialysis line.
The tip of the catheter terminates in the right atrium. The catheter is ready
for use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypertension, N/V, Transfer
Diagnosed with Heart failure, unspecified, Acute kidney failure, unspecified, Dyspnea, unspecified
temperature: 98.1
heartrate: 108.0
resprate: 18.0
o2sat: 99.0
sbp: 197.0
dbp: 164.0
level of pain: 0
level of acuity: 2.0 | This is a ___ man with history notable only for recent
anabolic steroid use who presented in acute renal failure s/p
renal biopsy most consistent with IgA nephropathy and
super-imposed contrast-induced injury. Required placement of
tunneled HD catheter with initiation of inpatient hemodialysis.
# ACUTE RENAL FAILURE
Initially presented with symptoms of nausea, vomiting, and
oliguria with initial workup notable for acute renal failure.
Renal US without evidence obstruction or hydronephrosis. Urine
studies most consistent with intrinsic cause without clear
etiology. Started on high-dose steroids and underwent renal
biopsy with preliminary results most consistent with
crescenteric glomerulonephritis with superimposed contrast
induced injury. Overall concerning for IgA nephropathy. Given
persistently low GFR with associated volume overload and rising
BUN, underwent tunneled HD line placement with initiation of
inpatient hemodialysis. The patient underwent HD on ___,
___, and ___ without complications. Received three days of
high dose steroids followed by prednisone 80mg daily, PCP ppx
was started. Considered cyclophophamide for IgA process however,
given evidence of significant chronicity on renal biopsy, risks
outweighed the benefits. Per renal recommendations, the patient
was discharged on Torsemide 40mg PO QD. Plan for follow up as an
outpatient with nephrology for evaluation for possible steroid
taper if no improvement in renal function.
# MULTIFOCAL PULMONARY OPACITIES
# POSSIBLE HEMATEMESIS VS. HEMOPTYSIS
On initial presentation to OSH the patient had possible
hematemesis vs. hemoptysis. Underwent CTA chest which
demonstrated multifocal opacities with broad differential. Low
suspicion for infection, more likely related to pulmonary edema
given profound volume overload. Continued to optimize volume
status with diuresis and HD as above.
# HYPERTENSIVE URGENCY
# HEADACHE (resolved)
On presentation, the patient had a BP elevated to 197/164 in ED,
overall most likely due to severe volume overload. Improved with
diuresis/HD and initiation of nifedipine and labetalol.
CHRONIC / STABLE ISSUES
=======================
# HYPOXIA (resolved)
Noted at outside hospital. Most likely from pulmonary edema.
Resolved with diuresis.
# ANABOLIC STEROID USE
Unclear if related to acute renal failure though cannot be ruled
out.
# NORMOCYTIC ANEMIA
Stable, no evidence of acute blood loss. Suspect related to
evolving CKD given prior abnormal Cr several months ago.
TRANSITIONAL ISSUES
===================
[] Follow up renal function and UOP. Will need long term follow
up with nephrology and decision regarding long term need for
HD/renal recovery.
[] Follow up blood pressure-- presented w/HTN urgency which
improved with initiation of nifedipine and labetalol. Titrate
nifedipine and labetalol PRN.
[] Follow up volume status-- being managed with HD and
Torsemide.
[] Follow up HgB/Hct-- had normocytic anemia on presentation
(likely in setting of CKD)
[] D/c Cr: Cr 15.5 and BUN 134.
[] D/c weight: 123 kg (271.16 lb) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left heel ulcer
Major Surgical or Invasive Procedure:
___ lower extremity angiogram
History of Present Illness:
___ w/ HTN, HLD, DM2 presents with increased left heel pain. He
reports the pain started one week with a dry crack on his heel.
This slowly progressed in sized and became ulcerated. He does
not describe any surrounding erythema. He denies any
fevers/chill, chest pain, or shortness of breath. He denies a
history of claudication and reports he walks regular and is not
limited walking up a flight of stairs by either shortness of
breath or pain. Of note he has not taken any medications or
seen a doctor in several years.
Past Medical History:
PMH: HTN, HLD, DM2, PVD
PSH: RLE angiogram w/ SFA stent ___, debridement of
right heel ulcer and removal of foreign body by podiatry in ___
Social History:
___
Family History:
Mother has DM, asthma, HTN. Father died of prostate cancer.
Grandmother had ovarian cancer.
Physical Exam:
AVSS
Alert and oriented x3, NAD
Chest: RRR, Unlabored respirations
Abd soft NTND
Ext warm, well perfused.
LLE with mild edema. Incisions with staples in placed, clean,
dry and intact.
Heel ulcer debrided with VAC dressing in place.
L: p/p/d/p Graft-p
R: p/d/d/d
Pertinent Results:
___ 03:52AM %HbA1c-17.3* eAG-450*
___ 04:48AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:57AM GLUCOSE-588* UREA N-14 CREAT-1.2 SODIUM-129*
POTASSIUM-4.4 CHLORIDE-91* TOTAL CO2-21* ANION GAP-21
___ 11:00AM GLUCOSE-289* UREA N-9 CREAT-1.0 SODIUM-135
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-23 ANION GAP-16
___ 04:48AM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 04:48AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:48AM URINE COLOR-Straw APPEAR-Clear SP ___
IMAGING:
Left Foot X-ray: ___:
Ulceration of the left heel without definite radiographic
evidence of
osteomyelitis. MRI is more sensitive for the evaluation of
osteomyelitis.
MRI Left Foot ___:
1. Cutaneous ulcer overlying the posterior lateral aspect of the
calcaneus measuring at least 11 mm.
2. Subcutaneous edema overlying the lateral and inferolateral
calcaneus. No underlying marrow signal abnormality to suggest
osteomyelitis. No subcutaneous abscess.
3. 4 x 5 mm T1 hypointense, T2 hypointense structure in the
subcutaneous tissue immediately lateral to the Achilles
insertion site raises question of foreign body versus small
amount of air tracking from ulcer.
Arterial Non-Invasive Studies: ___:
Occlusion of the proximal and mid segments of the stent in the
right
superficial femoral artery.
Occlusion of the distal segment of the left superficial femoral
artery.
Patent bilateral common femoral, popliteal and posterior tibial
arteries.
Moderate to severe bilateral superficial femoral and tibial
arterial
insufficiency at rest.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ibuprofen 400 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ibuprofen 400 mg PO Q6H:PRN pain
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
DAILY Disp #*30 Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
6. Clopidogrel 75 mg PO DAILY
RX *clopidogrel [Plavix] 75 mg 1 tablet(s) by mouth DAILY Disp
#*30 Tablet Refills:*0
7. Glargine 18 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Lisinopril 40 mg PO DAILY
Please continue follow up with your PCP for blood pressure check
on a week basis
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*15 Tablet Refills:*0
12. Metoprolol Tartrate 12.5 mg PO BID
Please continue follow up with your PCP on ___ weekly basis unless
he says otherwise
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Non-healing left heel ulcer, peripheral
vascular disease, uncontrolled type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ male with pain and wound.
TECHNIQUE: Three views of the left foot.
COMPARISON: None available.
FINDINGS:
Apparent ulceration of the left heel is seen. There is no subjacent cortical
irregularity, periosteal reaction or subcutaneous gas to suggest
osteomyelitis. No fracture or dislocation is seen, and a os perineum is
noted. Degenerative change is noted at the first MTP joint great toe
interphalangeal joint and talonavicular joint. Somewhat diminutive distal
phalanges of the third and fourth toes may be chronic morphology.
IMPRESSION:
Ulceration of the left heel without definite radiographic evidence of
osteomyelitis. MRI is more sensitive for the evaluation of osteomyelitis.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ year old man with left heel ulcer, DM, PVD. // please assess
for peripheral vascular disease BILATERAL legs
TECHNIQUE: Noninvasive evaluation of the arterial system of the lower
extremities was performed with Doppler signal recordings, pulse volume
recordings and segmental limb the pressure measurements.
COMPARISON: Study from ___.
FINDINGS:
Triphasic Doppler waveforms were seen in the right common femoral artery.
However, monophasic Doppler waveforms were seen at the right superficial
femoral, popliteal, posterior tibial and dorsalis pedis arteries.
On the left side, triphasic Doppler waveforms were seen in the left common
femoral artery. However, monophasic Doppler waveforms were seen and the left
superficial femoral, popliteal, posterior tibial and dorsalis pedis arteries.
The right ABI is 0.58 and the left ABI is 0.55.
Pulse volume recordings showed decreased amplitudes bilaterally at the levels
of the calf, ankles and the metatarsals.
IMPRESSION:
Moderate to severe bilateral superficial femoral and tibial arterial
insufficiency at rest.
Radiology Report
EXAMINATION: ART DUP EXT LOW/BILAT COMP
INDICATION: ___ year old man with left heel ulcer, uncontrolled DM, PVD. //
please assess peripheral vascular disease, please check toe pressures with
ABI/PVR's as well
TECHNIQUE: The lower extremity arterial system was evaluated with B-mode,
color and spectral Doppler ultrasound.
COMPARISON: None
FINDINGS:
The right common femoral artery is patent with mild atherosclerotic plaque and
the peak systolic velocity of 133 cm/sec. There is a stent in the right
superficial femoral artery. There is no evidence of flow within the proximal
portion of the right superficial femoral artery stent. The mid/distal segments
of the right superficial femoral artery are patent with peak systolic
velocities ranging between 26 and 32 centimeters/second. The right popliteal
artery is patent with peak systolic velocities ranging between 41 and 55
cm/sec. The right posterior tibial artery is patent with peak systolic
velocities ranging between 45 and 53 centimeters/second. The right peroneal
artery was not visualized.
The left common femoral artery is patent and demonstrates significant
atherosclerotic plaque. The peak systolic velocity in the left common femoral
artery is 183 centimeters/second. The proximal segments of the left
superficial femoral artery are patent with peak systolic velocities of 44
centimeters/second in the proximal segment and 55 centimeters/second in the
mid segment. There is no evidence of flow in the distal segment of the left
superficial femoral artery. The left popliteal artery is patent with peak
systolic velocity of 59 cm/sec. The left posterior tibial artery is patent
with peak systolic velocities ranging between 70 and 155 cm/sec. The left
peroneal artery was not visualized.
IMPRESSION:
Occlusion of the proximal and mid segments of the stent in the right
superficial femoral artery.
Occlusion of the distal segment of the left superficial femoral artery.
Patent bilateral common femoral, popliteal and posterior tibial arteries with
peak systolic velocities as described above. ---
Radiology Report
EXAMINATION: MR FOOT ___ CONTRAST LEFT
INDICATION: ___ year old man with deep left heel ulcer. // r/o osteomyelitis
TECHNIQUE: A contrast enhanced MRI of the left ankle/hindfoot was performed
on a 1.5 Tesla magnet using a quad foot coil. The following sequences were
obtained: Axial and sagittal T1, axial and sagittal STIR, axial T1 fat
saturated precontrast and axial and sagittal T1 fat saturated postcontrast
images after the uneventful intravenous administration of 9 mL Gadovist.
Subsequent subtraction images were obtained in the axial plane.
COMPARISON: Radiographs of the left foot ___.
FINDINGS:
There is a 2.2 x 1.8 cm skin defect over the lateral aspect of the heel
(series 3, image 22 and series 5, image 4) with adjacent skin thickening and
loss of the normal underlying subcutaneous fat signal. There is associated
subcutaneous edema and mild reticular subcutaneous soft tissue enhancement
within this region. There is no discrete linear sinus tract extending from
the skin defect. There is a 7 mm focus of susceptibility artifact just
superior to the skin defect within the subcutaneous soft tissues likely
corresponding to a small amount of subcutaneous emphysema as seen on recent
radiography (series 11, image 15). There is no soft tissue fluid collection.
The underlying bone marrow signal is within normal limits without evidence of
osteomyelitis. There is no evidence of fracture or avascular necrosis.
There is no evidence of an osteochondral lesion.
There is mild diffuse fusiform thickening of the Achilles tendon which is
otherwise intact and normal in signal.
The tibialis anterior, extensor hallucis longus and extensor digitorum tendons
are intact and normal in signal.
The tibialis posterior, flexor digitorum and flexor hallucis longus tendons
are intact and normal in signal.
The peroneus longus and brevis tendons are intact and normal in signal.
The anterior talofibular, posterior talofibular and calcaneofibular ligaments
are intact and normal in signal.
The visualized medial compartment ligaments are intact and normal in signal.
The articular cartilage is preserved at the visualized joints. There is no
joint effusion.
No ganglion or mass is seen.
Normal fat is preserved within the sinus tarsi.
There is mild thickening of the central band of the plantar fascia with
superficial subcutaneous soft tissue edema.
IMPRESSION:
1. 2.2 x 1.8 cm region of skin ulceration over the lateral aspect of the heel
with underlying subcutaneous soft tissue changes consistent with cellulitis.
No evidence of underlying osteomyelitis or soft tissue abscess.
2. Mild Achilles tendinosis.
3. Thickening of the central band of the plantar fascia with associated
superficial subcutaneous soft tissue edema which can be seen in the setting of
plantar fasciitis.
Radiology Report
INDICATION: ___ poorly controlled DM2 h/o right SFA stent ___ here w/ left
non-healing heel ulcer // please evaluate for possible conduit
TECHNIQUE: Real-time grayscale imaging of bilateral saphenous veins was
performed.
COMPARISON: None available.
FINDINGS:
The right great saphenous vein is patent with diameters ranging between 0.34
and 0.57 cm.
The left great saphenous vein is patent with diameters range between 0.29 and
0.59 cm.
IMPRESSION:
Patent bilateral great saphenous veins with diameters as described above.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT BILATERAL
INDICATION: ___ poorly controlled DM2 h/o right SFA stent ___ here w/ left
non-healing heel ulcer // please evaluate for possible conduit
TECHNIQUE: Grey scale evaluation was performed on the bilateral upper
extremity veins.
COMPARISON: None.
FINDINGS:
The distal segment of the right cephalic vein at the level of the forearm is
patent with diameters ranging between 0.24 and 0.39. Proximally the vessel was
not visualized. The right basilic vein is patent with diameters ranging
between 0.11 and 0.34 cm.
The left cephalic vein is patent with diameters ranging between 0.13 and 0.27
cm. Intravenous access was noted in the distal left cephalic vein at the level
of the wrist. The left basilic vein is patent with diameters ranging between 0
point 12 and 0.23 cm.
IMPRESSION:
Patent bilateral basilic veins and left cephalic vein with diameters as
described above. The proximal segments of the right cephalic vein were not
visualized.
Radiology Report
INDICATION: ___ poorly controlled DM2 h/o right SFA stent ___ here w/ left
non-healing heel ulcer s/p LLE angio now s/p L ___ bypass w/ NRSVG //
Please evaluate LLE ABIs, PVRs including metatarsal
TECHNIQUE: Non-invasive evaluation of the arterial system in the lower
extremities was performed with Doppler signal recording, pulse volume
recordings and segmental limb pressure measurements.
COMPARISON: Not available
FINDINGS:
On the right side, monophasic Doppler waveforms are seen in the dorsalis pedis
artery. The right ABI was 0.59.
On the left side, monophasic Doppler waveforms are seen at the posterior
tibial and dorsalis pedis arteries. The left ABI was 0.90.
Pulse volume recordings showed symmetric but decreased amplitudes bilaterally.
IMPRESSION:
Evidence of moderate to severe arterial insufficiency to the lower extremities
bilaterally.
Radiology Report
INDICATION: ___ s/p LLE ___ bypass w/ NRSVG // ? patent graft
TECHNIQUE: The left femoral to posterior tibial artery bypass was evaluated
using duplex ultrasound.
FINDINGS:
The graft was difficult to visualize at the proximal anastomosis due to
overlying staples. Common femoral artery velocity was 182 centimeters/second.
Velocity at the proximal anastomosis increased at 320 centimeters/second. It
then decreased to 70 cm/sec throughout the distal thigh and proximal calf
level. There was another elevation at the distal anastomosis of 289 cm/sec
but this could be the native artery distal to the bypass graft.
IMPRESSION:
Patent left fem-pop bypass with velocities as shown. Elevated velocities at
the proximal and distal anastomoses.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: L Foot ulcer
Diagnosed with NIDDM W/OTHER MANIF UNCONTR, ULCER OF HEEL AND MIDFOOT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 99.0
heartrate: 117.0
resprate: 18.0
o2sat: 100.0
sbp: 177.0
dbp: 80.0
level of pain: 1
level of acuity: 3.0 | ___ w/ HTN, HLD, DM2 presented with non-healing LLE heel ulcer,
elevated white count, and fevers in the setting of poorly
controlled diabetes. He was admitted under the medical service
for diabetes control, hydration. The patient was treated with
vancomycin, ciprofloxacin, and flagyl while hospitalized for his
infected foot ulcer and wound care was initiated with santyl,
BID dressing changes to optimize healing. Non invasive vascular
studies were obtained with subsequent angiography of the left
lower extremity revealing a high grade stenosis of the left SFA
and patent posterior tibial. It was decieded to proceed with a
femoral to posterior tibial artery bypass using translocated
nonreversed greater saphenous vein. His postoperative course was
uncomplicated. He continued on antibiotics that were
transitioned to PO augmentin to complete a total of ___ate. He was cleared to go home with services by physical
therapy. His left heel ulcer was further debrided and dressed
with a VAC. During the hospitalization, the patient had several
transitional issues summrized below:
1. Follow up: The patient was lost to follow up for several
years and was not taking any medications for his diabetes. A
referral was made by the medical team to establish care with a
PCP (referral made).
2. Uncontrolled type 2 diabetes mellitus: The patient was
initiated on insulin treatment per ___ recommendations and
strated on metformin 500 mg BID. He was sent home with a follow
up arranged to continue his care.
3. Hypertension: The patient's blood pressure was occasionally
elevated to SBP 180's while hospitalized, he requires
anti-hypertensive medication as an outpatient and blood pressure
checks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Penicillins / Sulfa (Sulfonamide Antibiotics) /
lisinopril / latex / Strawberry / adhesive on monitor leads /
Feraheme
Attending: ___
Chief Complaint:
Severe right knee pain s/p right total knee arthroplasty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ y/o female who presented to ED after
being
seen by her PCP for severe right knee pain s/p R total knee
arthroplasty on ___, with concern for septic joint.
She reports severe pain since her knee surgery, and rates her
pain as ___. She has tried oxycodone without any relief. Pain
is worse after movement, especially with extension. She is not
able to bear any weight on her RL extremity. She has been
working
with ___ 3x/week at her house since the surgery.
She went to the ED on ___ [see ED note] and states her knee
was not tapped; she states her knee pain on ___ was as
severe
as it is today. She attempted to schedule an appointment with
Dr.
___ reports she was unable to secure an appointment prior
to ___.
In the ED, initial vitals: Pain ___ T97.8, HR97, 146/94, RR18,
100%RA
- Exam notable for: Swollen R knee. Very tender to light touch.
No obvious redness. Staples closing wound. No sensation lateral
to incision. Sensation intact distally. Palpable distal pulses.
<2sec cap refill. ROM flexes to 50 degrees.
- Labs notable for:
CRP 16
UA Blood Sm, Leuks Sm
UCx pending
H/H 9.___.0
WBC 7.7
INR 1.2
- Imaging notable for:
Knee AP/Oblique/Lateral XR: Soft tissue swelling may reflect
infection in the correct clinical setting. Small joint
effusion,
no signs of osteomyelitis.
She was evaluated in the emergency department by ortho who felt
her presentation did not warrant tapping the joint to check for
infection. They suggested she f/u with an outpatient appointment
later in the week.
- Pt given:
___ 10:49 IV Morphine Sulfate 4 mg
___ 10:49 IV Ondansetron 4 mg
___ 11:42 IV Morphine Sulfate 4 mg
___ 12:58 IVF NS 1 L
___ 13:15 IV Morphine Sulfate 4 mg
___ 15:43 IV Ketorolac 15 mg
___ 16:18 PO Aspirin 324 mg
- Vitals prior to transfer: Pain ___ HR74 BP146/91 RR17 98% RA
On the floor, patient gave history consistent with above. She
also mentioned that she has both epileptic and non-epileptic
seizures, and that stress can trigger both. She takes keppra and
her last epileptic seizure was in ___. She also experiences
constipation likely ___ her opioid regiment.
Review of systems:
(+) Per HPI
(-) 10 Point review of systems otherwise negative
Past Medical History:
- KNEE PAIN (___) L meniscal disease, R knee patellofemoral
syndrome, S/P several knee surgeries. She is followed by Dr.
___.
- NARCOTICS AGREEMENT (___) For chronic knee pain
- ATRIAL SEPTAL DEFECT (___) - Echo at ___ in ___ showed atrial
septal aneurysm w/ small ASD, mild TR and no RV overload. Echo
in
___ did not demonstrate ASD, but did show mild interatrial
aneusym w/o thrombus. Will be seeing Dr. ___
- HYPERTENSION (___)
- IRREGULAR MENSES
- IRON DEFICIENCY ANEMIA Due to menorrhagia Colonscopy and EGD
in
___ did not show obvious bleeding source. Occult blood cards
were negative x 3 in ___
- HYPERACTIVE BLADDER - with stress/urge incontinence
- MIGRAINE HEADACHES
- VENTRICULAR TACHYCARDIA - RVO paroxysmal ventricular
tachycardia, S/P ablation, asympt on B-blocker, followed at ___
- SLEEP APNEA - CPAP at home
- SEIZURE DISORDER - started ___. Epileptic and non-epileptic
seizures. Followed by Dr. ___. On Keppra
- H/O HEMATURIA - Urology work-up ___: Negative pelvic CT,
cystoscopy
- BREAST REDUCTION
- CARPEL TUNNEL SURGERY B/L
Social History:
___
Family History:
HTN, MIs, Blood cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.3 149 / 83 HR89 RR16 97%Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. ROM in R knee decreased. R knee with staples down
midline, edematous, TTP and warm to touch. No discharge noted
from scar.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, deferred.
DISCAHRGE PHYSICAL EXAM:
Vital Signs: 98.1 130/85 79 16 97 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: RRR no M/G/R
Lungs: CTAB no W/R/R
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, no edema. R knee with staples down
midline, mild-to-moderately edematous, TTP and warm to touch. No
drainage noted.
Neuro: Normal conversation and speech. Symmetric face. Numbness
to touch on lateral aspect of knee. Otherwise sensation intact
in
lower extremities.
Pertinent Results:
==============================
ADMISSION LABS
==============================
___ 10:54AM BLOOD WBC-7.7 RBC-4.15 Hgb-9.6* Hct-31.0*
MCV-75* MCH-23.1* MCHC-31.0* RDW-15.9* RDWSD-42.0 Plt ___
___ 10:54AM BLOOD Neuts-68.4 ___ Monos-4.4* Eos-1.2
Baso-0.4 Im ___ AbsNeut-5.29# AbsLymp-1.92 AbsMono-0.34
AbsEos-0.09 AbsBaso-0.03
___ 10:54AM BLOOD ___ PTT-28.0 ___
___ 06:30AM BLOOD Glucose-86 UreaN-15 Creat-1.0 Na-140
K-3.6 Cl-98 HCO3-29 AnGap-17
___ 06:30AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.2
___ 10:54AM BLOOD CRP-16.3*
==============================
DISCHARGE LABS
==============================
___ 06:30AM BLOOD WBC-6.4 RBC-4.06 Hgb-9.2* Hct-30.8*
MCV-76* MCH-22.7* MCHC-29.9* RDW-15.9* RDWSD-43.0 Plt ___
___ 06:30AM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-139
K-3.9 Cl-99 HCO3-26 AnGap-18
___ 06:30AM BLOOD Calcium-9.8 Phos-3.9 Mg-2.2
==============================
MICROBIOLOGY
==============================
Urine - culture contaminated
==============================
IMAGING
==============================
___ KNEE (AP/LAT/OBLIQUE)
Findings as above. Soft tissue swelling may reflect infection
in the correct clinical setting. Small joint effusion, no signs
of osteomyelitis.
___ UNILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right lower
extremity veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. LevETIRAcetam 1000 mg PO BID
3. Vitamin D ___ UNIT PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Senna 8.6 mg PO BID
6. Aspirin 325 mg PO BID
7. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
- Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*112 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 10 mg PO Q4H
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*84 Tablet Refills:*0
3. Aspirin 325 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. LevETIRAcetam 1000 mg PO BID
7. Senna 8.6 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Post-operative hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Followup Instructions:
___
Radiology Report
INDICATION: ___ 2 weeks s/p TKA with severe R knee pain
COMPARISON: Prior from ___
FINDINGS:
AP, lateral and oblique views of the right knee provided. Anterior skin
staples are again noted. Previously noted soft tissue drain is been removed.
There is evidence of recent right knee arthroplasty with no evidence of
hardware failure or migration. Soft tissues remain diffusely prominent
without soft tissue gas or radiopaque foreign body. There is a small joint
effusion noted. No bony erosions.
IMPRESSION:
Findings as above. Soft tissue swelling may reflect infection in the correct
clinical setting. Small joint effusion, no signs of osteomyelitis.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with recent knee surgery, 2 weeks later now
with increased ___ pain// DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the 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 lower extremity veins.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: R Knee pain
Diagnosed with Pain in right knee
temperature: 97.8
heartrate: 97.0
resprate: 18.0
o2sat: 100.0
sbp: 146.0
dbp: 94.0
level of pain: 10
level of acuity: 3.0 | ___ y/o female patient of Dr. ___ presented to ED for
pain-out-of-proportion to expected post-op arthroplasty pain
found to have a soft tissue post-operative hematoma.
# Severe right knee pain.
No evidence of septic joint. Believed to be incisional
hematoma-related. Will proceed with pain management. Monitored
off antibiotics without fever, tachycardia or other issues. DVT
US was negative for clot. Discharged on PO 10mg oxycodone q 4
and acetaminophen PO 650mg q6 hr. This was discussed and agreed
upon with Dr. ___.
# Non-epileptic seizures continued at her baseline. No
intervention or treatment required.
=======================================
TRANSITIONAL ISSUES
=======================================
- ongoing close monitoring of pain and pain treatment in
coordination with Dr. ___
- ongoing ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fentanyl / midazolam / bacitracin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Endoscopic Retrograde Cholangiopancreatography (ERCP) with
sphincterotomy
History of Present Illness:
___ with ___ HTN p/w epigastric/mid abd pain for one week. She
presented to an outside hospital and had a CT scan showing
dilated common bile duct with likely stone. Her lipase was
elevated. She received Unasyn at 4 ___. She was not febrile.
Was also seen at ___ on ___ for same complaint;
their imaging did not see stone, so they d/c'd her home with
zofran and ultram after treatign with Toradol and GI cocktail
and IVF.
In the ED intial vitals were: 98.7 101 189/80 16 96%
- Labs were significant for Lactate:1.5, ALT 56, AST 48, ALP
172, TB 0.7, lipase 150. Seen by ERCP in ED who recommend MRCP.
Vitals prior to transfer were: 98.2 73 162/81 16 97% RA
On the floor, pt feels well, no abdom pain without any nausea or
vomiting. No chest pain or shortness of breath. Decreased PO
intake past few days.
Review of Systems:
(+) per HPI
Past Medical History:
HTN
Allergic rhinitis
Hiatal hernia
Hearing loss
Asymptomatic carotid artery stenosis
Cholelithiasis
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission exam:
Vitals - T: 99.6 BP: 150/54 HR: 60-100s RR: 16 02 sat: 98%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, nontender
supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Physical Exam on Discharge:
Vitals: T 97 BP 156/85 HR 57 RR 18 SpO2 96/RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, dry lips
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
CHEST: mild tenderness to palpation on left chest wall.
ABDOMEN: soft, nondistended, +BS, nontender, voluntary guarding
but no rigidity.
EXTRMITIES: no peripheral edema, 2+ DP pulses bilaterally, large
bruise on left elbow and forearm. No tenderness to palpation.
Full ROM
NEURO: CN II-XII intact
Pertinent Results:
Admission labs:
___ 08:25AM BLOOD WBC-6.3 RBC-4.80 Hgb-14.3 Hct-43.2 MCV-90
MCH-29.7 MCHC-33.0 RDW-12.6 Plt ___
___ 07:55PM BLOOD ___
___ 08:25AM BLOOD Glucose-134* UreaN-20 Creat-0.6 Na-134
K-3.4 Cl-94* HCO3-32 AnGap-11
___ 07:55PM BLOOD ALT-56* AST-48* AlkPhos-172* TotBili-0.7
Imaging:
RUQ US (___):
1. Distended gallbladder with mobile stone. No definite
sonographic evidence of acute cholecystitis.
2. Diffuse intra- and extra-hepatic biliary ductal dilatation
concerning fora distal obstructing stone or lesion. Recommend
MRCP or ERCP for further evaluation.
CT abd/pelvis (OSH, ___:
-obstructing lesion at papilla of vater, resulting biliary
dilatation
-pancreas atrophic, no gross e/o pancreatic duct dilation
-moderately large stool burden
MRCP (___)
IMPRESSION:
1. Mild intra and extrahepatic bile duct dilation, secondary to
an
obstructing 9 mm stone in the distal CBD. Single gallstone in
the
gallbladder, without evidence for acute cholecystitis.
2. Multiple cystic pancreatic lesions in the distal body/ tail,
likely
represent side branch IPMN's. Follow-up MRCP in 6 months to ___
year is
recommended.
3. Extensive abdominal aortic atherosclerosis, with severe
stenosis at the origin of the celiac trunk.
4. Mild compression of a mid thoracic vertebral body, acuity
unknown
ERCP (___)
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Excavated Lesions A few non-bleeding diverticula with large
opening were found in the second part of the duodenum and third
part of the duodenum.
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Fluoroscopic Interpretation of the Biliary Tree: The common bile
duct, common hepatic duct, right and left hepatic ducts, and
biliary radicles were filled with contrast and well visualized.
The CBD and CHD were dilated to 10mm and there was a distal CBD
filling defect.
Procedures:
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
A large 1cm black stone was extracted successfully using
retrieval balloon catheter. Occlusion cholangiogram showed
dilated CBD and CHD without any filling defects.
Impression: Multiple large duodenal diverticula.
Successful biliary cannulation with sphincterotome.
Successful sphincterotomy.
Extraction of 1cm large black stone using balloon retrieval
catheter.
No filling defects seen on subsequent occlusion cholangiogram.
Recommendations:
- No aspirin, Plavix, NSAIDS, Coumadin for 5 days
- Surgical consultation for cholecystectomy.
- Repeat MRI abdomen in 6 months to follow-up on the dilated
cystic lesions of the pancreas.
********************
Rib Xray (___)
- Frontal and oblique views show no definite acute abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Potassium Chloride 8 mEq PO DAILY
6. Lovastatin 40 mg oral QD
7. Multivitamins 1 TAB PO DAILY
8. TraZODone 50 mg PO HS:PRN insomnia
9. Hydrochlorothiazide Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Lovastatin 40 mg oral QD
4. Multivitamins 1 TAB PO DAILY
5. TraZODone 50 mg PO HS:PRN insomnia
6. Acetaminophen 650 mg PO Q8H:PRN pain
7. Aspirin 325 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Potassium Chloride 8 mEq PO DAILY
10. Artificial Tears ___ DROP BOTH EYES PRN eye irritation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: 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
INDICATION: ___ female with right upper quadrant discomfort and
recent CT concerning for choledocholithiasis.
COMPARISON: Outside hospital CT abdomen and pelvis from ___
___ on ___.
RIGHT UPPER QUADRANT ULTRASOUND: The liver is homogeneous in echogenicity
without focal lesion. The main portal vein is patent with hepatopetal flow.
The gallbladder is distended and contains a single mobile stone. There is no
gallbladder wall edema or pericholecystic fluid. The sonographic ___
sign is negative. There is intra- and extra-hepatic biliary ductal dilatation
with the common bile duct measuring 7 mm. The distal portion of the common
duct at the level of pancreatic head cannot be visualized due to overlying
bowel gas. The spleen is normal in echotexture and size. No ascites is
identified. Pancreatic parenchyma is difficult to evaluate due to bowel gas.
IMPRESSION:
1. Distended gallbladder with mobile stone. No definite sonographic evidence
of acute cholecystitis.
2. Diffuse intra- and extra-hepatic biliary ductal dilatation concerning for
a distal obstructing stone or lesion. Recommend MRCP or ERCP for further
evaluation.
Radiology Report
HISTORY: ___ woman with epigastric pain and biliary obstruction seen
on outside hospital CT.
COMPARISON: Reference CT from outside hospital ___.
TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the abdomen were
performed in a 1.5 tesla magnet, including dynamic 3D imaging performed prior
to, during and after uneventful intravenous administration of 5 mL of
Gadavist. 1 mL of Gadavist mixed with 50 cc of water was administered as
negative oral contrast.
FINDINGS:
The liver is normal in signal intensity. Small focus of arterial
hyperenhancement in segment VII (1301:40), likely represents a transhepatic
intensity difference. Small biliary hamartomas are seen, the largest in the
left hepatic lobe measuring 8 mm. There is mild to moderate intra and
extrahepatic bile duct dilation, with CBD maximally measuring 10 mm. A 9 mm
stone is seen in the distal CBD (06:27). A single gallstone is seen within
the gallbladder, which otherwise appears unremarkable, without evidence of
cholecystitis. The pancreas is diffusely atrophic, with multiple cystic
lesions in the distal body and tail, with the largest measuring 12 x 12 mm
(8:3). The main pancreatic duct is not dilated.
A 6 mm hemorrhagic cyst is seen in the interpolar region of the right kidney
(10:87). A few additional simple cysts are seen in both kidneys, the largest
in the left upper pole measuring 2.5 cm. The adrenal glands and spleen are
normal. There is trace perihepatic free fluid.
The abdominal aorta has extensive atherosclerotic disease, without aneurysmal
dilation. There is severe stenosis of the origin of the celiac trunk and
moderate stenosis of the origin of the SMA and right renal artery. The left
renal and inferior mesenteric arteries are patent. The portal, splenic and
superior mesenteric veins are patent.
There is a moderate dextroconvex scoliosis of the lumbar spine with
superimposed degenerative changes. Mild compression of a lower thoracic
vertebral body(likely T8) is noted. No worrisome focal bone lesion is
identified.
IMPRESSION:
1. Mild intra and extrahepatic bile duct dilation, secondary to an
obstructing 9 mm stone in the distal CBD. Single gallstone in the
gallbladder, without evidence for acute cholecystitis.
2. Multiple cystic pancreatic lesions in the distal body/ tail, likely
represent side branch IPMN's. Follow-up MRCP in 6 months to ___ year is
recommended.
3. Extensive abdominal aortic atherosclerosis, with severe stenosis at the
origin of the celiac trunk.
4. Mild compression of a mid thoracic vertebral body, acuity unknown
Radiology Report
HISTORY: Left rib pain.
FINDINGS: Frontal and oblique views show no definite acute abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with CHOLEDOCHOLITHIASIS NOS
temperature: 98.7
heartrate: 101.0
resprate: 16.0
o2sat: 96.0
sbp: 189.0
dbp: 80.0
level of pain: 5
level of acuity: 3.0 | ___ with ___ HTN p/w epigastric/mid abd pain for one week, has a
CT scan and RUQ US showing dilated common bile duct with
possible CBD stone.
# Abdominal pain, ___ choledocholithiasis: The patient presented
with epigastric/mid abd pain for one week. She initially went to
an outside hospital where a CT scan showed dilated common bile
duct with likely stone. She was started on Unasyn and
transferred to ___ for possible intervention.
At ___, her initial U/S showed CBD dilation but no stone.
Follow-up MRCP revealed CBD dilation and 9mm stone obstruction.
She subsequently underwent ERCP with sphincterotomy that
released a 1cm black stone. She tolerated the procedure well and
her abdominal pain resolved. She was on Unasyn for 2 days, but
that was dc'd on ___ as she showed no evidence of infection.
She remained afebrile after and did not require any additional
antibiotics.
# Rib pain - patient complained of left sided rib pain and had a
large bruise on her left elbow due to a fall a few days prior to
admission.
- Rib xrays were negative for fracture. Patient was treated
with Tylenol for pain with adequate relief.
#HTN: patient was continued on home amlodipine
- there was a question as to whether HCTZ was also a home
medication. BP remained controlled without restarting.
# pancreatic cysts - seen on MRCP
- will need repeat imaging in 6 months to follow-up
- will notify PCP
# ___ falls at home
- patient was evaluated by ___ and OT who recommended rehab for
balance training.
***************** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Compazine / Compazine Tablets / Reglan
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none this admission
History of Present Illness:
Ms. ___ is a ___ with history of SBOs s/p multiple
laparotomies and AFib (lovenox transitioning to coumadin) who
presented with 3 days of abdominal pain. She was last admitted
on
___ for worsening SBO and had a laparotomy, loop of small
bowel resection, and gastrostomy on ___. She was discharged to
rehab on ___ with a gastrostomy tube. Since then, she had
improved with persistent discomfort, tolerating pureed food
since
___ with G-tube clamped, passing flatus and having BMs. Starting
on ___, she started noticing sharp LUQ pain over the G-tube
region with sneezing and movements, ___ on top of baseline
constant ___ pain. Today at 3am, she woke up with nausea and
had
one episode of NBNB emesis. She denies nausea besides this
episode. At that time, she reportedly had a temperature measured
at 101.3. Her last meal was last ___ dinner, last BM was 2 days
ago, and was passing flatus this AM. She reports chills, denies
CP, SOB, or urinary frequency.
Past Medical History:
PMH: Multiple small bowel obstructions, atrial fibrillation (not
on anticoagulation), SMA atherosclerosis, blindness secondary to
juvenille glaucoma, OA, neurogenic bladder requiring straight
caths 5x/day at home
PSH: exploratory laparotomy/LOA ___ - Dr. ___,
exploratory laparotomy/LOA ___ - Dr. ___,
exploratory laparotomy/LOA (___), exploratory laparotomy
(___), open appendectomy (___), open cholecystectomy (___), R
shoulder surgery, bilateral hip surgery, multiple eye surgeries
Social History:
___
Family History:
Sisters with breast ___, both parents with CAD
Physical Exam:
GEN: A&O, NAD, non-toxic appearing
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, ND, minimally tender to palpation in LUQ, no rebound,
no guarding, no palpable masses.
Ext: Mild b/l ___ edema, ___ warm and well perfused
Pertinent Results:
___ 06:50AM BLOOD WBC-5.5# RBC-2.87* Hgb-8.5* Hct-27.5*
MCV-96 MCH-29.7 MCHC-31.0 RDW-15.8* Plt ___
___ 01:29PM BLOOD WBC-12.9*# RBC-3.53* Hgb-10.5*#
Hct-34.5*# MCV-98 MCH-29.8 MCHC-30.4* RDW-15.7* Plt ___
___ 01:29PM BLOOD Neuts-75.7* ___ Monos-5.5 Eos-0.4
Baso-0.3
___ 11:50AM BLOOD ___
___ 08:21AM BLOOD ___
___ 06:50AM BLOOD ___
___ 01:29PM BLOOD ___ PTT-40.1* ___
___ 06:50AM BLOOD Glucose-85 UreaN-22* Creat-0.5 Na-139
K-3.9 Cl-111* HCO3-25 AnGap-7*
___ 06:50AM BLOOD ALT-44* AST-24 AlkPhos-140* TotBili-0.3
___ 06:50AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.7
___ 01:39PM BLOOD Lactate-1.4
___ ___ ___ ___
Radiology Report PORTABLE ABDOMEN Study Date of ___ 3:56
___
___ ___ 3:56 ___
PORTABLE ABDOMEN Clip # ___
Reason: eval for SBO
UNDERLYING MEDICAL CONDITION:
___ year old woman with hx of SBOs presents with abd pain and
vomiting
REASON FOR THIS EXAMINATION:
eval for SBO
Final Report
HISTORY: History of small bowel obstructions now presenting
with abdominal
pain and vomiting.
TECHNIQUE: Supine AP view of the abdomen.
COMPARISON: ___.
FINDINGS:
A percutaneous gastrostomy tube is noted with several adjacent
clips. The
bowel gas pattern is nonspecific. There are mildly prominent
colonic loops of
bowel in the left lower quadrant. No pneumatosis or free
intraperitoneal air
is seen on this supine exam. Partially imaged are 2 screws
within the right
femoral head and an intramedullary rod within the left proximal
femur.
IMPRESSION:
Nonspecific bowel gas pattern. If there is continued concern
for small bowel
obstruction, consider a CT exam.
___. ___
___: TUE ___ 5:07 ___
Imaging Lab
There is no report history available for viewing.
Medications on Admission:
acetazolamide 500', digoxin 250', enoxaparin 100'', esomeprazole
magnesium 40', lisinopril 10'', metoprolol succinate 25',
aspirin 325', colace 100', protonix 40', oxycodone 5 Q4H PRN,
zofran 4''' PRN, coumadin 7.5'
Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
1 ml iv as needed Disp #*1 Bottle Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily
Disp #*30 Packet Refills:*0
3. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
4. AcetaZOLamide 500 mg PO Q24H
5. esomeprazole magnesium 40 mg oral daily
6. Digoxin 0 mg PO DAILY
7. Lisinopril 10 mg PO BID
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Aspirin 325 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 8.6 mg by mouth bid prn Disp #*30
Capsule Refills:*0
12. Pantoprazole 40 mg PO Q24H
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr prn Disp #*30
Tablet Refills:*0
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Warfarin 7.5 mg PO DAILY
hold for today and tomorrow (___), and have pcp
check INR ___ before re-dosing
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Recurrent SBO, and abdominal pain. Evaluate for abdominal free air.
TECHNIQUE: Single AP frontal upright view of the chest.
COMPARISON: ___.
FINDINGS:
No focal consolidation, large pleural effusion or evidence of pneumothorax is
seen. The aorta is tortuous. The cardiac silhouette is not enlarged. A
left-sided PICC is seen terminating in the mid to lower SVC. Surgical clips
are noted overlying the upper abdomen. No evidence of free air is seen
beneath the diaphragms.
IMPRESSION:
No acute cardiopulmonary process. No evidence of free air beneath the
diaphragms.
Radiology Report
HISTORY: History of small bowel obstructions now presenting with abdominal
pain and vomiting.
TECHNIQUE: Supine AP view of the abdomen.
COMPARISON: ___.
FINDINGS:
A percutaneous gastrostomy tube is noted with several adjacent clips. The
bowel gas pattern is nonspecific. There are mildly prominent colonic loops of
bowel in the left lower quadrant. No pneumatosis or free intraperitoneal air
is seen on this supine exam. Partially imaged are 2 screws within the right
femoral head and an intramedullary rod within the left proximal femur.
IMPRESSION:
Nonspecific bowel gas pattern. If there is continued concern for small bowel
obstruction, consider a CT exam.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 99.1
heartrate: 79.0
resprate: 20.0
o2sat: 98.0
sbp: 139.0
dbp: 75.0
level of pain: 5
level of acuity: 2.0 | The patient was admitted to the General Surgical Service for
abdominal pain. She has a history of small bowel obstructions
and was treated conservatively with bowel rest, IV fluids, and
pain medication.
Neuro: The patient received iv and then po pain medications with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Initially, the patient was made NPO with IV fluids.
Diet was advanced when the patient was passing gas, having bowel
movements, and experiencing less pain and abdominal distention,
which was well tolerated. Patient's intake and output were
closely monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required. Her coumadin was
initially held as she was supratherapeutic. When she came back
down into a therapeutic range she was again given her home
coumadin dose of 7.5. The following day she was supratherapeutic
again and her coumadin was held. She was discharged with the
instruction to hold her coumadin for 2 days, and then to have
her PCP ___ her INR on that second day before restarting.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / Demerol / Percodan / Keflex / Claritin / Advair Diskus
/ Ciprofloxacin / Levaquin / IV Dye, Iodine Containing Contrast
Media / Valtrex
Attending: ___.
Chief Complaint:
Abdominal Pain/Distension
Major Surgical or Invasive Procedure:
___: exploratory laparotomy, lysis of adhesions for closed
loop obstruction, appendectomy
History of Present Illness:
Ms. ___ is a ___ year old female with a history of
R-en-y gastric bypass in ___ who's post operative course was
complicated by a ventral hernia and recurrence. She is now POD 9
from her ventral hernia repair with mesh, she was discharged POD
2 and was off narcotic pain medication by POD 4. She reports
normal bowel function returning by POD 6, followed by cessation
of normal bowel function the AM prior to admission. She noticed
increasing abdominal distension over the days prior to admission
but suddenly developed abdominal pain on ___ after a small
late lunch. She called into the surgical clinic and was advised
to present to the ED. She denies any history of vomiting, but
she has felt nauseated and increasingly distended, she hasn't
passed flatus for at least 24 hours, and hasn't had a bowel
movement during that time either. She denies, fevers, chills, or
SOB.
Past Medical History:
PMH: arthritis, GERD, obesity, stress urinary incontinence,
MRSA, migraines, left leg phlebitis, hamstring tendonitis &
sinus headaches
PSH: gastric bypass surgery & hiatal hernia repair (___),
abdominoplasty and ventral herniorrhaphy w/ mesh overlay (___),
three
classical C-sections, laparoscopic cholecystectomy (___), bilat
knee replacements, and surgery for left ulnar nerve impingement
X2.
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
96.6 95 129/97 22 98%
GEN: NAD, anxious AAO x 3
CV: RRR, no m/r/g
PULM: CTAB
ABD: Midline incision open to air with steri strips and c/d/i.,
NO right upper quadrant pain, or tenderness, NO right lower
quadrant pain or tenderness, NO left lower quadrant tenderness,
NO left upper quadrant tenderness. No rebound or guarding NO
recurrence of hernia appreciated, NO recurrence appreciated on
valsalva. Distended. Moderately tender near midline incision.
Abdominal binder in place.
EXTR: Warm
DISCHARGE PHYSICAL EXAM
Tm98.3 Tc 98.0 HR 80 BP 120/65 RR 18 96% on RA
Gen: awake, alert, no apparent distress
HEENT: MMM
CV: RRR
Pulm: CTAB
Abd: midline incision c/d/i w staples in place, mildly ttp,
nondistended, mild to scant serosang discharge, ABD binder in
place, no induration or erythema
Ext: no ___
Pertinent Results:
ADMISSION LABS:
___ 11:10PM GLUCOSE-150* UREA N-12 CREAT-0.8 SODIUM-138
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-22 ANION GAP-24*
___ 11:10PM ALT(SGPT)-58* AST(SGOT)-31 ALK PHOS-285* TOT
BILI-0.7
___ 11:10PM LIPASE-19
___ 11:10PM ALBUMIN-4.4
___ 11:10PM WBC-11.6*# RBC-4.63 HGB-14.2 HCT-41.7 MCV-90
MCH-30.7 MCHC-34.0 RDW-13.3
___ 11:10PM NEUTS-85.4* LYMPHS-9.0* MONOS-4.1 EOS-1.3
BASOS-0.1
___ 11:10PM PLT COUNT-340
___ 11:10PM ___ PTT-33.1 ___
___ 11:40PM LACTATE-1.9
IMAGING STUDIES:
ABDOMEN (SUPINE & ERECT) ___
IMPRESSION:
Markedly dilated loops of small bowel with air-fluid levels and
a paucity of colonic air, concerning for high grade small bowel
obstruction.
Findings discussed with Dr. ___ by Dr. ___ by telephone at
5:28 a.m. on ___ at the time of discovery.
CT ABD & PELVIS W/O CONTRAST ___
IMPRESSION:
1. Findings consistent with high grade small bowel obstruction
with a swirling configuation of the mesenteric root suggestive
of mesenteric volvulus; transmesenteric hernia could be an
additional contributing factors. Transition point in the distal
ileum with additional loops appearing stretched and narrowed
proximally consistent with closed loop obstruction. Tapering of
the superior mesenteric vein due to the volvulus and mesenteric
edema are worrisome for vascular compromise. No pneumatosis is
seen, and evaluation for ischemia is limited without IV contrast
material.
2. Hiatal hernia containing both the gastrojejunal anastamosis
and the
excluded stomach.
3. Ground-glass opacitiy in the left lower lung base could
represent atypical infection or aspiration.
4. Left adrenal nodule, stable compared to ___.
MICROBIOLOGY:
___ GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
PATHOLOGY:
PATHOLOGIC DIAGNOSIS:
Appendix, appendectomy:
- Fibrous obliteration of the appendiceal lumen; no histologic
evidence of appendicitis.
DISCHARGE LABS:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN SOB
2. budesonide 90 mcg/actuation inhalation BID
3. Diazepam 10 mg PO Q8H:PRN pain
4. Vitamin D 50,000 UNIT PO 2X/WEEK (MO,TH)
5. Fexofenadine 60 mg PO PRN allergy
6. azelastine 137 mcg nasal QAM
7. Docusate Sodium (Liquid) 100 mg PO DAILY
8. Nasonex (mometasone) 50 mcg/actuation nasal HS
9. Promethazine 25 mg PO BID:PRN pain
10. Ascorbic Acid ___ mg PO DAILY
11. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral
DAILY
12. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
13. Ferrous Sulfate 50 mg PO DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Magnesium Oxide 250 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Nephrocaps 1 CAP PO DAILY
18. Pseudoephedrine 30 mg PO Q8H:PRN allergies
19. TraMADOL (Ultram) 50 mg PO BID pain
20. Acetaminophen 1000 mg PO Q8H
21. alcaftadine 0.25 % ophthalmic DAILY
22. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN rash
23. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
24. Patanol (olopatadine) 0.1 % ophthalmic DAILY
25. Polyethylene Glycol 17 g PO DAILY:PRN constipation
26. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Diazepam 10 mg PO Q8H:PRN pain
3. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
4. Fexofenadine 60 mg PO PRN allergy
5. Nasonex (mometasone) 50 mcg/actuation nasal HS
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. TraMADOL (Ultram) 50 mg PO BID pain
8. alcaftadine 0.25 % ophthalmic DAILY
9. Ascorbic Acid ___ mg PO DAILY
10. azelastine 137 mcg nasal QAM
11. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral
DAILY
12. Budesonide 90 mcg/actuation INHALATION BID
13. Ferrous Sulfate 50 mg PO DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN rash
16. Magnesium Oxide 250 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Nephrocaps 1 CAP PO DAILY
19. Patanol (olopatadine) 0.1 % OPHTHALMIC DAILY
20. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4H:PRN SOB
21. Promethazine 25 mg PO BID:PRN pain
22. Pseudoephedrine 30 mg PO Q8H:PRN allergies
23. Simethicone 40-80 mg PO QID:PRN bloating
24. Vitamin D 50,000 UNIT PO 2X/WEEK (MO,TH)
25. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Status post ventral hernia repair 10 days ago, abdominal pain and
distention on KUB. Evaluate for small bowel obstruction.
TECHNIQUE: Contiguous axial MDCT images were obtained from the lung bases to
the pubic symphysis following the administration of oral contrast material.
Reformatted coronal and sagittal axes images were obtained.
Detail peak: 902 mGy-cm.
COMPARISON: CT from ___ and radiograph from ___.
FINDINGS:
Patchy left lower lung basilar ground-glass opacity could represent atypical
infection or aspiration, and atelectasis is noted in the visualized lung
bases. Coronary calcifications are noted.
Evaluation of solid organs are limited without the use of intravenous contrast
material. The liver does not have any gross hepatic lesions. Surgical clips
are seen within the gallbladder fossa and the gallbladder has been surgically
removed. The spleen is normal in size and shape. The pancreas does not have
ductal dilation or peripancreatic stranding.
Nodularity of the left adrenal gland appears similar to ___
(2:25). The right adrenal gland is unremarkable. An angiomyolipoma is noted
in the right kidney (2:22). The kidneys are normal in size and shape without
evidence of hydronephrosis or perinephric stranding.
The patient is status post hiatal hernia repair and gastric bypass. A hiatal
hernia containing both the gastrojejunal anastamosis and excluded stomach are
noted, and a nasointestinal tube is seen terminating within the efferent limb.
The small bowel opacifies with oral contrast. Multiple dilated loops of small
bowel, some with fecalized contents, are present in the abdomen with a
swirling configuration of the mesenteric root consistent with mesenteric
volvulus or possibly transmesenteric hernia. A transition point is noted in
the distal ileum (2:45, 301b:31) with additional stretched and narrowed
appearing loops traversing the region (301b:35). Tapering / severe narrowing
of the superior mesenteric vein is noted due to the mesenteric volvulus
(2:34). Mesenteric edema in conjunction with the tapering of the SMV is
worrisome for vascular compromise although lack of contrast limits assessment
of the vasculature. The large bowel is decompressed distal to this
aforementioned transition point. Mild amount of free fluid is also noted
around the liver and spleen. No pneumatosis is seen.
The visualized aorta is of normal caliber throughout without aneurysmal
dilation. Moderate atherosclerotic calcifications are noted. No
retroperitoneal or mesenteric lymph nodes are enlarged by CT size criteria.
The bladder is moderately distended and unremarkable. A mild amount of
pelvic free fluid is seen. The rectum contains stool. There are no pelvic
sidewall or inguinal lymph nodes enlarged by CT size criteria.
Multiple compression deformities are noted in the spine, similar to ___, and there are no suspicious osteolytic or osteoblastic lesions
seen to suggest malignancy.
IMPRESSION:
1. Findings consistent with high grade small bowel obstruction with a swirling
configuation of the mesenteric root suggestive of mesenteric volvulus;
transmesenteric hernia could be an additional contributing factors.
Transition point in the distal ileum with additional loops appearing stretched
and narrowed proximally consistent with closed loop obstruction. Tapering of
the superior mesenteric vein due to the volvulus and mesenteric edema are
worrisome for vascular compromise. No pneumatosis is seen, and evaluation for
ischemia is limited without IV contrast material.
2. Hiatal hernia containing both the gastrojejunal anastamosis and the
excluded stomach.
3. Ground-glass opacitiy in the left lower lung base could represent atypical
infection or aspiration.
4. Left adrenal nodule, stable compared to ___.
Findings were discussed with Dr. ___ by Dr. ___ telephone at 2:15
___ on ___ immediately following review.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by UNKNOWN
Chief complaint: ABD PAIN
Diagnosed with PARALYTIC ILEUS, ABDOMINAL PAIN OTHER SPECIED
temperature: 96.6
heartrate: 95.0
resprate: 22.0
o2sat: 98.0
sbp: 129.0
dbp: 97.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ was admitted to the ___ Surgical Service on
___ after suffering a closed loop small bowel obstruction.
She went urgently to the OR for an exploratory laparotomy,
lysis of adhesions, and appendectomy. The procedure 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 in good condition.
Neuro: The patient received IV diluadid with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications. She did complain of
suicidal ideation on admission, and was put on a 1:1 sitter
immediately post-operatively. She was evaluated by psychiatry
who recommended discontinuing the 1:1 sitter, felt the event was
related to an acute event, and did not recommend starting new
medications. Outpatient followup with psychiatry was offered
and refused by the patient, and she denied any suicidal thoughts
thereafter.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: She presented with acute onset nausea/vomiting and a
CT scan demonstrated a closed loop internal hernia. She
underwent the procedure listed above. Post-operatively, the
patient was made NPO with IV fluids. Diet was advanced when
appropriate, which was well tolerated. Patient's intake and
output were closely monitored, and IV fluid was adjusted when
necessary. Electrolytes were routinely followed, and repleted
when necessary. She had no NGT placed. She had a JP placed the
subcutaneous tissues which was low-output, serosanguinous, and
discontinued on POD 5. She will be discharged with an abdominal
binder in place.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The wound dressings
were changed daily.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RUQ pain, depression
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old postpartum female (delivered
___ with depression who presented to ___ with acute
worsening of depression and was transferred to ___ for
management of incidentally found acute hepatic injury.
She originally presented to ___ with depression, which
has
been worse since the birth of her child. She reports frequent
crying and thoughts of suicide and attempted to cut her wrists
using a dull knife without success on ___. Screening labs at
___ showed acute hepatitis, but without synthetic dysfunction
(INR 1.1, albumin 3.8) and no encephalopathy. APAP was negative.
She was transferred from ___ on a ___ for acute
liver injury management by hepatology.
The patient has a history of taking Tylenol following delivery
(up to 4g/day) but denies APAP overdose, or other overdose
attempt. She last took APAP 1g 2 days prior to admission.
In the ED:
- Initial vital signs were notable for: T 98.3, BP 111/68, HR
58,
RR 18, SPO2 98% RA
- Exam notable for: normal mental status
- Labs were notable for: WBC 4.4, Hgb 12.6, plts 199, INR 1.2,
ALT 1601, AST ___, Alk phos 128, T bili 0.3, albumin 3.5, serum
tox screen negative for ASA, ethanol, APAP, tricyclics. U tox
positive for opiates
- Studies performed include: RUQUS (mild central intrahepatic
biliary ductal dilatation)
- Patient was given: N-acetylcysteine, morphine 2 mg, clonazepam
0.5 mg
- Consults: Hepatology - potentially AIH, recs admission to ET
for hepatitis w/u
Vitals on transfer: T 97.6, BP 117/75, HR 67, RR 18, SPO2 98%
RA.
Upon arrival to the floor, the patient confirms the above
history. She reports 1 prior suicide attempt in her teens, also
by trying to cut her wrists. Her depression is chronic but
became
more severe during her recent pregnancy. She re-started
sertraline during her second trimester, and her sertraline was
increased to 200 mg from 100 mg 1 week after delivery. She
denies
other new medications. No recent eating undercooked foods,
drinks
besides water and soda, new restaurants, supplements, wild
mushrooms. She has history of heavy EtOH use ___ bottles of
wine/day) but has only had 2 drinks since delivery, most
recently
a glass of wine ___.
She has noticed several episodes of sharp, stabbing RUQ pain
over
the past few days that lasted 10 seconds each. She reports
several days of fatigue, anorexia since the beginning of her
last
pregnancy, intermittent postprandial non-bloody/non-bilious
vomiting since her gastric bypass (last episode 2 days ago). She
also reports arm/neck pruritus 3 days ago that improved with
Aquaphor. She denies nausea, yellowing of skin/eyes, abdominal
distention, leg swelling.
Past Medical History:
back pain, sleep apnea, hyperlipidemia.
Social History:
___
Family History:
No history ___ disease, autoimmune hepatitis, liver
diseases. Mother with Grave's disease s/p thyroidectomy, sister
with unknown thyroid condition
Physical Exam:
ADMISSION EXAM:
================
VITALS: T 97.6, BP 117/75, HR 67, RR 18, SPO2 98% RA
GENERAL: Alert and interactive. In no acute distress. Not
confused.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Supple. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. Mild bilateral flank
tenderness.
ABDOMEN: Normal bowels sounds, non distended, tender on deep
palpation of RUQ. No organomegaly. No rebound/guarding.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rashes or vesicles appreciated. Not jaundiced.
NEUROLOGIC: CN2-12 intact grossly. Moves all extremities with
purpose. AOx3. No asterixis. Speech fluent
DISCHARGE EXAM:
================
Vitals: ___ 2331 Temp: 97.4 PO BP: 115/68 R Sitting HR: 76
RR: 18 O2 sat: 98% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress. Not
confused.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Supple. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. Mild bilateral flank
tenderness.
ABDOMEN: Normal bowels sounds, non distended, abdomen with
tenderness to palpation over RUQ. No organomegaly. No
rebound/guarding.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rashes or vesicles appreciated. Not jaundiced.
NEUROLOGIC: CN2-12 intact grossly. Moves all extremities with
purpose. AOx3. No asterixis. Speech fluent
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 200 mg PO DAILY
2. ClonazePAM 0.5 mg PO BID:PRN anxiety
Discharge Medications:
1. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *bisacodyl 10 mg 1 suppository(s) rectally nightly as needed
Disp #*12 Suppository Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Nicotine Patch 7 mg/day TD DAILY
RX *nicotine 7 mg/24 hour daily Disp #*28 Patch Refills:*0
4. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*24 Packet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablet by mouth twice daily Disp
#*60 Tablet Refills:*0
6. TraZODone 50 mg PO QHS:PRN sleep
RX *trazodone 50 mg 1 tablet(s) by mouth Nightly as needed Disp
#*15 Tablet Refills:*0
7. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
8. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily
Disp #*8 Capsule Refills:*0
9. ClonazePAM 0.5 mg PO BID:PRN anxiety
10. Sertraline 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Acute liver injury
Secondary diagnosis: Depression with suicide attempt
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with w/ post partum depression admitted to
medicine for abnormal LFTs and RUQ pain of unknown etiology. Per CT A/P: Mild
central biliary dilation is again noted, with no significant progression
relative to the ultrasound from yesterday. MRCP may be helpful if biliary
cause of pain is suspected.// assess for biliary cause of pain, LFT
abnormalities
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Abdominal pelvis CT from ___
FINDINGS:
Lower Thorax: Unremarkable. Bilateral breast prosthesis.
Liver: The liver is not dysmorphic. There is no hepatic steatosis. No focal
lesion. The hepatic vein, portal vein and portal splenic confluence are
patent.
Biliary: Again seen is a mild to moderate intra and extrahepatic biliary duct
dilatation with the CBD measured at 9 mm. The CBD tapers smoothly to the
ampulla. No mass is seen in the pancreatic head. There is no cholelithiasis
nor any choledocholithiasis. The gall bladder is slightly distended however
there is no gallbladder wall edema or pericholecystic fluid.
Pancreas: Unremarkable.
Spleen: Unremarkable.
Adrenal Glands: Unremarkable.
Kidneys: Unremarkable.
Gastrointestinal Tract: Status post gastric bypass. No bowel obstruction.
In the interim, a small amount of ascites is noted.
Lymph Nodes: No abdominal adenopathy.
Vasculature: Normal aortic aneurysm.
Osseous and Soft Tissue Structures: Unremarkable.
IMPRESSION:
1. Biliary duct dilatation without choledocholithiasis or obstructing lesion
seen. Potentially sphincter of Oddi dysfunction could have this appearance.
If there is ongoing clinical concern for biliary obstruction, ERCP may be
helpful.
2. New small amount of ascites in the abdomen.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:43 pm, 5 minutes after
discovery of the findings.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, SI, Transfer
Diagnosed with Other mental disorders complicating the puerperium, Postpartum depression, Oth complications of the puerperium, NEC, Disorder of kidney and ureter, unspecified
temperature: 98.3
heartrate: 58.0
resprate: 18.0
o2sat: 98.0
sbp: 111.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old postpartum female with depression
who presented to ___ with acute worsening of depression
and was transferred to ___ for management of incidentally
found
acute hepatic injury; LFTs are improving. |
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