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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. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levaquin in D5W / iodine
Attending: ___.
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with complex pmhx (stroke s/p carotid
dissection on asa), asplenia, long smoking history, past ptx
from shrapnel wounds in ___, recent pneumonia and sepsis,
who was discharged 1 week ago to rehab, now presenting with
fevers to 102, L sided "rib" pain and decreased oxygen
saturation. He notes that he was having "low grade fevers" at
rehab around 99 degrees. Then was doing well at home, until x2
days ago when he began having congestion in his chest. He also
fell off the toilet 2 days ago, hurting his right and left rib
cage. He is unsure if these falls are related to the left sided
latearl sharp chest pain that he has been having for last 2
days. It is near where his shrapnel scars and retained shrapnel
exists. In the ED, initial vitals were: ___ 18 88%
RA. Work up was notable for WBC of 27 (89% neutrophils), Cret
1.8, and lactate of 2. He had a difficult to interpret CXR in
the setting of recent severe pneumonia. He was empirically
started on vancomycin and cefepime for presumed HCAP as he was
febrile and reported that his symptoms were similar to those
during his last PNA flare. There was concern about a possible
PE (given hypoxia, tachycardia, fever, and chest pain) however
the because his h/o ___ in the setting of IV contrast CT could
not be done. Of note he has had 3 PNAs requiring hospitalization
in the last year. Workup at last admission for ?underlying
illness which could be predisposing him to infection was notable
for normal IgG, IgA and negative HIV. On the floor, the patient
reports that he is having ongoing difficulties breathing and
feels like there is "stuff in his chest." He reports that his L
sided chest pain is worse with inspiration and movement.
Past Medical History:
- Recurrent PNA c/b sepsis: multiple hospitalizations in past
couple of years
- Asplenia: ___ trauma, up to date of pneumococcal and
meningococcal vaccines.
- h/o ___ esophagus: s/p multiple EGDs and Botox injections
to ___
- ___: s/p mechanical fall in ___ causing R ICA dissection;
residual L-sided weakness
- HTN
- h/o shrapnel: MRI contraindicated
- diverticulitis: s/p partial colectomy 1990s
- PTSD
- ADHD
- Depression/Anxiety
- h/o Alcohol abuse
- Migraines
- Status post C5-C6 laminectomy and fusion
- Scrotal hematoma s/p radical orchiectomy ___ c/b phantom pain
syndrome, on chronic narcotics
- h/o provoked DVT ___ s/p several months of warfarin
- h/o MRSA wound infection from peripheral nerve stimulator in
___ for chronic groin pain
- s/p hernia repair
Social History:
___
Family History:
Adopted - no known family history.
Physical Exam:
ADMISSION:
Vitals: 98.8 121/71 95 18 95%RA
General: Alert, oriented, mildly ill appearing
HEENT: MMM, poor dentition, EOMI, PERRL
Neck: supple, JVP not appreciated
CV: Regular rate and rhythm, no murmurs and gallops; + chest
tenderness over L rib cage
Lungs: no accessory muscle use,Bibasilar rales R > L
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, multiple healed scars
Ext: warm, well perfused, 2+ pulses, no clubbing, trace edema on
L foot is chronic
Neuro: facial droop on L, ___ strength on R, ___ on L, grossly
normal sensation
DISCHARGE:
98.7 150/75 82 20 95%RA
General: Alert, oriented
HEENT: MMM, poor dentition, EOMI, PERRL
Neck: supple, JVP not appreciated
CV: Regular rate and rhythm, no murmurs and gallops; + chest
tenderness over L rib cage improved from prior exams
Lungs: CTAB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, multiple healed scars
Ext: warm, well perfused, 2+ pulses, no clubbing, trace edema on
L foot is chronic
Neuro: facial droop on L, ___ strength on R, ___ on L, grossly
normal sensation
Pertinent Results:
ADMISSION LABS:
___ 02:00PM BLOOD WBC-27.1*# RBC-4.75 Hgb-13.1* Hct-40.2
MCV-85 MCH-27.7 MCHC-32.7 RDW-14.4 Plt ___
___ 02:00PM BLOOD Neuts-89.6* Lymphs-4.7* Monos-5.0 Eos-0.3
Baso-0.5
___ 05:26AM BLOOD ___ PTT-30.3 ___
___ 02:00PM BLOOD Glucose-143* UreaN-18 Creat-1.8* Na-139
K-3.8 Cl-102 HCO3-25 AnGap-16
___ 07:00AM BLOOD Calcium-8.6 Phos-2.7# Mg-1.9
DISCHARGE LABS:
___ 06:38AM BLOOD WBC-11.1* RBC-4.31* Hgb-12.1* Hct-36.7*
MCV-85 MCH-28.0 MCHC-32.9 RDW-14.2 Plt ___
___ 06:38AM BLOOD Glucose-96 UreaN-10 Creat-1.2 Na-140
K-3.8 Cl-104 HCO3-27 AnGap-13
PERTINENT LABS:
___ 06:50AM BLOOD Vanco-21.3*
___ 06:38AM BLOOD Vanco-23.6*
IMAGING:
CXR ___:
FINDINGS: Frontal and lateral views of the chest were obtained.
There are perihilar opacities which may be due to mild edema;
however, resolving infection is not excluded in the appropriate
clinical setting. The opacities are decreased as compared to
the prior study. No pleural effusion or pneumothorax is seen.
The cardiac and mediastinal silhouettes are stable. No
displaced fracture is seen.
CT CHEST ___:
IMPRESSION:
Improving multifocal ground-glass opacities and decreased foci
of
consolidation, likely due to a slowly resolving infectious
process and less likely an infection complicated by cryptogenic
organizing pneumonia.
New areas of ground-glass opacity in right apex and extensive
lower-lobe predominant small airways disease.
Given these findings and apparent recent worsening of opacities
on chest radiographs between ___ and ___, these
findings likely reflect resolving multifocal pneumonia with
superimposed acute process such as aspiration. This is
supported by debris seen within the right mainstem bronchus.
Mediastinal lymphadenopathy, likely reactive, has improved.
Bronchial dilation within the lower lobes may be transient given
the ongoing infection or could reflect long-standing
bronchiectasis.
___ LENIs:
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremities. The calf veins, particularly on the left, were not
well seen.
___ EGD:
Impression:
-The GEJ was widely patent without scope hang up - it was
diffcult at first to determine where the GEJ laid given the
patency of the junction and the hiatus hernia
-Medium hiatal hernia
-Linear granularity, friability and erythema in the antrum
compatible with gastritis (biopsy)
-Otherwise normal EGD to third part of the duodenum
Recommendations:
-Await pathology results
-Given the patency of the GEJ, there was no indication for
empiric botox injection at this time. Recommend outpatient
evaluation of esophageal motility. The gastritis was incidental
and must be treated with antisecretory therapy
-PPI BID for 2 weeks and PPI daily thereafter.
-hpylori ab test and treat
-follow up pathology report
-follow up with outpatient GI for evaluation of esophageal
motility
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Baclofen 10 mg PO TID:PRN muscle spasms
3. BuPROPion (Sustained Release) 150 mg PO BID
4. Clonazepam 0.5 mg PO BID:PRN anixety
5. Methylphenidate SR 20 mg PO BID
6. Morphine SR (MS ___ 45 mg PO Q8H
7. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN breakthrough
pain
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 1 TAB PO BID:PRN constipation
10. Sertraline 150 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Gabapentin 300 mg PO BID
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
14. Guaifenesin ER 600 mg PO Q12H
15. Ipratropium Bromide Neb 1 NEB IH Q6H
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Aspirin 325 mg PO DAILY
3. Baclofen 10 mg PO TID:PRN muscle spasms
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Clonazepam 0.5 mg PO BID:PRN anixety
6. Gabapentin 300 mg PO BID
7. Guaifenesin ER 600 mg PO Q12H
8. Ipratropium Bromide Neb 1 NEB IH Q6H
9. Methylphenidate SR 20 mg PO BID
10. Morphine SR (MS ___ 45 mg PO Q8H
RX *morphine [MS ___ 15 mg 3 tablet extended release(s) by
mouth every 8 hours Disp #*99 Tablet Refills:*0
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN breakthrough
pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every ___ hours as need
for pain Disp #*50 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 1 TAB PO BID:PRN constipation
15. Sertraline 150 mg PO DAILY
16. CefePIME 2 g IV Q12H Duration: 9 Days
17. Multivitamins 1 TAB PO DAILY
18. Pantoprazole 40 mg PO Q12H Duration: 12 Days
19. Vancomycin 1500 mg IV Q 24H Duration: 9 Days
20. Pantoprazole 40 mg PO Q24H
To start after completion of pantoprazole BID dosing.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Health care associated pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAM: Chest, frontal and lateral views.
CLINICAL INFORMATION: Fall, hypoxia.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. There are
perihilar opacities which may be due to mild edema; however, resolving
infection is not excluded in the appropriate clinical setting. The opacities
are decreased as compared to the prior study. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. No
displaced fracture is seen.
Radiology Report
HISTORY: ___ male with fall. Evaluate for rib fracture.
COMPARISON: Multiple prior chest radiographs, most recently of the same day.
FINDINGS:
LEFT RIBS, 3 VIEWS: BB markers are placed over the patient's left flank at
the site of symptoms. There is no displaced rib fracture. Metallic foreign
bodies are seen within the left lateral soft tissues, similar to ___. For further description of chest findings, please refer to the same day
radiographs.
IMPRESSION:
No displaced rib fracture.
Radiology Report
PORTABLE CHEST RADIOGRAPH DATED ___
COMPARISON: Chest x-ray of one day earlier.
FINDINGS: Cardiac silhouette is mildly enlarged and accompanied by pulmonary
vascular congestion and minimal interstitial edema. New more confluent
opacities have developed in the right upper and both lower lungs, and may
reflect asymmetrical edema, multifocal aspiration, or rapidly developing
pneumonia. Additional linear areas of atelectasis are noted in both lung
bases. No visible pneumothorax.
Radiology Report
HISTORY: ___ man with hypoxia left-sided pleuritic chest pain,
concern for pulmonary embolism.
COMPARISON: None.
FINDINGS:
Grayscale and color Doppler ultrasonography of the bilateral common femoral
veins as well as the bilateral femoral, popliteal, posterior tibial, and
peroneal veins were performed. All imaged vessels demonstrated normal
compressibility, flow, and augmentation. The calf veins on the left side well
seen but color flow was demonstrated.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremities. The
calf veins, particularly on the left, were not well seen.
Radiology Report
HISTORY: Multifocal pneumonia with a recent chest x-ray suggestive of non
clearance. Further characterize pneumonia.
TECHNIQUE: MDCT axial images were acquired through the chest without the
administration of IV contrast secondary to acute kidney injury. Coronal and
sagittal reformations were provided and reviewed. Maximum intensity
projection images were created and reviewed as well. Images were displayed in
1.25 mm and 5 mm slice thicknesses.
DLP: 601.91 mGy/cm.
COMPARISON: Chest radiographs ___ and ___. CT chest ___.
FINDINGS: There are diffuse, bilateral peribronchovascular ground-glass
opacities which appear less confluent than the prior CT of ___. New
areas of ground-glass opacity, particularly in the right lung apex, are
appreciated. The peribronchiolar consolidations have nearly resolved.
Predominate within the lower lobes, and to a lesser extent within the right
middle lobe, there are extensive ___ opacities. There is no
pneumothorax. The trachea is normal in caliber. Secretions are seen within
the right mainstem bronchus. Within the right middle lobe and lower lobes
there is bronchial dilation. The pleural effusions have resolved.
Mild changes from emphysema noted at the lung apices. There is no axillary or
hilar lymphadenopathy. Multiple mediastinal lymph nodes are smaller than
prior and are likely reactive. The largest is a 1.3 cm left paratracheal node
(2:23). The heart is normal in size and there is no pericardial effusion.
The imaged portion of the thyroid is normal. The esophagus is unremarkable.
This study was not designed to evaluate the subdiaphragmatic contents. Simple
appearing liver cysts are unchanged from the prior CT abdomen pelvis.
There are no concerning lytic or blastic osseous lesions.
IMPRESSION:
Improving multifocal ground-glass opacities and decreased foci of
consolidation, likely due to a slowly resolving infectious process and less
likely an infection complicated by cryptogenic organizing pneumonia.
New areas of ground-glass opacity in right apex and extensive lower-lobe
predominant small airways disease.
Given these findings and apparent recent worsening of opacities on chest
radiographs between ___ and ___, these findings likely reflect
resolving multifocal pneumonia with superimposed acute process such as
aspiration. This is supported by debris seen within the right mainstem
bronchus.
Mediastinal lymphadenopathy, likely reactive, has improved. Bronchial
dilation within the lower lobes may be transient given the ongoing infection
or could reflect long-standing bronchiectasis.
Radiology Report
HISTORY: New PICC.
TECHNIQUE: Portable frontal chest radiograph.
COMPARISON: Chest radiograph ___. CT chest ___.
FINDINGS: A right upper extremity PICC terminates in the upper to mid superior
vena cava.
Diffuse ground-glass opacifications are unchanged from yesterday. There is no
pleural effusion, pneumothorax or focal airspace consolidation. Cardiac
silhouette is top-normal in size. The mediastinal contours are normal.
IMPRESSION: Satisfactory right PICC position.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: S/P FALL
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOXEMIA
temperature: 103.0
heartrate: 118.0
resprate: 18.0
o2sat: 88.0
sbp: 125.0
dbp: 62.0
level of pain: 7
level of acuity: 1.0 | ___ year old gentleman with h/o recent admission for pneumonia,
asplenia ___ trauma in ___, CVA w/ L-sided deficits,
depression, presents with new fevers, cough, and L rib pain.
Patient was treated for health care associated pneumonia.
# Health care associated pneumonia: Recently discharged from
___ after sepsis thought to be due to aspiration pneumonia,
requiring stay in the MICU. He recently completed 14 day course
of vancomycin and zosyn with subjective improvement symptoms.
However, shortly after stopping antibiotics he developed a dry
cough that progressed over several days. At the time of this
admission his cough, fevers, and lung exam was consistent with
recurrent pneumonia, so he was started on vancomycin and
cefepime, given that he was recently hospitalized. ID was
consulted and agreed with these antibiotics. Of note, the
patient has had 3 pneumonias within past ___ months, possibly
due to worsening/recurrent aspiration. Chest CT performed during
prior hospital stay did not identify any anatomic lesions in the
lungs which would predispose patient to recurrent pneumonias.
Likely his history of recurrent pneumonias are related to
recurrent aspiration events. ID recommended a repeat chest CT,
which was notable for resolving multifocal pneumonia with
superimposed acute process such as aspiration. A PPD was placed
on ___ to rule out latent TB, although there was very low
concern for TB given chest CT findings. Pulmonary was consulted
and did not recommend bronchoscopy at this time. In the
following days his fevers resolved, his WBC trended down, and
his lung exam improved. On the day of discharge ID recommended
completing a 14 day course of vancomycin and cefepime for his
pneumonia.
# Aspiration risk: He has a h/o oropharyngeal dysfunction,
esophageal dysmotility, and hypertonic lower esophageal
sphincter (treated with botox in the past). The patient's most
prominent symptoms involve the sensation of food getting stuck
after swallowing and a delay in the movement of food in the
setting of both solids and liquids. Speech and Swallow
recommended continued aspiration precautions and also
recommended the patient be seen by ENT (for assessment of vocal
cords) and GI (for evaluation of lower esophageal sphincter), as
the patient demonstrated prolonged hold up of barium tablet
during the evaluation. ENT found no evidence of a contributing
vocal cord paralysis, but recommended that the patient be seen
an outpatient clinic for further evaluation. GI evaluated the
patient and recommended an EGD. EGD demonstrated patency of the
GE junction, and there was no indication for empiric botox
injection. The patient should be continued on aspiration
precautions in the future.
# L rib pain: Patient reported recent falls which could be
source of his recent L rib pain. Pain was worse with palpation
and thought to be related to muscleskelatal injury. He was
continued on his home medications and given a lidoderm patch for
additional pain relief.
# Acute kidney injury, improving: Creatinine has been
downtrending since last admission. ___ was thought to have
occurred during last admission due to contrast. Creatinine was
1.8 at admission. On the day of discharge creatinine downtrended
to 1.2.
# Chronic pain: Continued on home doses of MS ___ 45 mg q8h
and oxycodone for breakthrough pain.
# Depression: Continued on wellbutrin, clonazepam,
methylphenidate, sertraline. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Ms. ___ is a ___ y/o female with a history of FSGN s/p renal
transplant in ___, DVT/PE previously on coumadin but stopped
due to hemarthrosis, and CAD s/p multiple NSTEMIs without
interventions who presented with acute substernal chest pain.
She graduated from cardiac rehab in ___ at which time she
was able to walk 45 min w/o any chest discomfort or SOB. On the
evening prior to admission she was driving back from ___
when she developed ___ dull, squeezing retrosternal chest pain
radiating to L neck and L arm. This came in the context of a
couple of days of general malaise. Her pain was not positional
or pleuritic (unlike her prior PE which was pleuritic in
nature). There was no associated upper resp symptoms, no nausea,
abd pain, no black stools. No SOB, palpitations, PND, orthopnea,
or decrease in exercise tolerance. She finished driving back
from ___ and went straight to the ED.
To recap her recent cardiac hx: In ___, she went to
___ with chest pain, found to have trop 0.05, <1mm STE in
III but no true ST elevations. Managed medically w/ metoprolol
and atorvastatin. Patient had a PMIBI which showed fixed defect
in area of LCx and EF 45%. An echo hypokinesis consistent with
the stress test and an EF of 50%. She was started on plavix on
discharge.
She was admitted in ___ and ___ for NSTEMIs. During her
___ admission she had chest pain, underwent cardiac cath on ___
which
showed LAD 30%, LCx 50% mid stenosis, OM1 occluded, OM2
occluded, RCA ___ 40% and mid 50% stenosis. No interventions
performed. She was started on imdur and metoprolol increased.
Exercise stress test was negative.
In ___ she presented with 3 episodes of isolated substernal
chest pain 2 days ago associated with SOB. These episodes were
relieved by SL nitro and lasted for less than 15 minutes. EKG
was without
changes, troponin negative. Ranolazine was started. Other
concerns were recurrent PE, gastritis or musculoskeletal origin.
PE was ruled
out with VQ scan (obtained to prevent renal injury), gastritis
was unlikely as no improvement noted with GI cocktail. Given
lack of response to nitroglycerin and improvement with
anti-inflammatories and narcotics, concern was increased for
musculoskeletal origin of
chest pain.
Of note troponins were negative during her ___ and ___
admissions for CP. She did have mildly positive trop in ___.
Her only other pos troponin in our system was ___: she had a
trop >3.0 and nonspecific EKG changes. She was seen by cards;
this was thought to be demand ischemia in setting of admission
for HCAP and ___.
In the ED initial vitals were: 97.2 69 148/80 16 100% RA.
Past Medical History:
- CAD with h/o NSTEMI
- FSGN status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- History of EBV viremia ___
- h/o C. diff (___)
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA
- Hypertension
- Hyperlipidemia
- Gout
- Nephrolithiasis with ureteral stent placements
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
- Left cataract surgery in ___
- Right cataract surgery in ___
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Cervical dysplasia
- HyperPTH secondary to renal failure
- Appendectomy
- Endometrial ablation for menorrhagia in ___
- ___ laparoscopy
Social History:
___
Family History:
Brother ___ had MI, Dad was ___ and had MI.
Sister with FSGS s/p transplant and avascular necrosis.
Uncle with RA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.7 114/72 57 18 97 RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace edema. 2+ ___ and DP pulses
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
VS: 98.3 100s-110s/60s ___ 99 RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace edema. 2+ ___ and DP pulses
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
___ 04:45AM PLT COUNT-299
___ 04:45AM NEUTS-51.9 ___ MONOS-10.0 EOS-2.2
BASOS-0.4 IM ___ AbsNeut-4.83 AbsLymp-3.28 AbsMono-0.93*
AbsEos-0.20 AbsBaso-0.04
___ 04:45AM WBC-9.3# RBC-3.89* HGB-11.1* HCT-33.3* MCV-86
MCH-28.5 MCHC-33.3 RDW-13.9 RDWSD-43.3
___ 04:45AM calTIBC-277 FERRITIN-247* TRF-213
___ 04:45AM ALBUMIN-4.3 CALCIUM-10.3 PHOSPHATE-4.0
MAGNESIUM-1.8 IRON-44
___ 04:45AM LIPASE-52
___ 04:45AM ALT(SGPT)-18 AST(SGOT)-22 ALK PHOS-91 TOT
BILI-0.3
___ 04:45AM estGFR-Using this
___ 04:45AM GLUCOSE-131* UREA N-52* CREAT-2.7* SODIUM-140
POTASSIUM-3.0* CHLORIDE-96 TOTAL CO2-26 ANION GAP-21*
___ 05:24AM ___ PTT-31.9 ___
___ 10:40AM PTT-150*
___ 10:33PM URINE MUCOUS-RARE
___ 10:33PM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-2
___ 10:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 10:33PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:33PM URINE HOURS-RANDOM CREAT-65 SODIUM-17
POTASSIUM-14 CHLORIDE-LESS THAN TOT PROT-<6 PROT/CREA-<0.1
TROPONIN TREND:
___ 04:45AM BLOOD cTropnT-<0.01
___ 10:40AM BLOOD cTropnT-<0.01
DRUG LEVELS:
___ 09:30AM BLOOD tacroFK-3.9* rapmycn-7.3
DISCHARGE LABS:
___ 06:50AM BLOOD Glucose-95 UreaN-40* Creat-2.1* Na-141
K-4.0 Cl-106 HCO3-24 AnGap-15
___ 06:50AM BLOOD tacroFK-6.1
___ 06:50AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.0
**STUDIES**
___ RENAL US
IMPRESSION:
1. Mild ectasia of the upper renal pole of the right lower
quadrant
transplant kidney is unchanged from the prior exam. No mass or
stone.
2. Patent renal vasculature with segmental arterial resistive
indices ranging
from 0.67-0.71.
___ CXR
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.5 mcg PO DAILY
5. Citalopram 40 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Febuxostat 120 mg PO DAILY
8. Metoprolol Succinate XL 75 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Sirolimus 2 mg PO DAILY
11. Tacrolimus 2 mg PO QAM
12. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
13. Docusate Sodium 100 mg PO BID
14. Famotidine 20 mg PO DAILY
15. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
16. Pantoprazole 40 mg PO Q12H
17. Furosemide 40 mg PO DAILY
18. Tacrolimus 1 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcitriol 0.5 mcg PO DAILY
4. Citalopram 40 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Famotidine 20 mg PO DAILY
8. Febuxostat 120 mg PO DAILY
9. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
10. Metoprolol Succinate XL 75 mg PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
14. Amlodipine 10 mg PO DAILY
15. Sirolimus 2 mg PO DAILY
16. Tacrolimus 2 mg PO QAM
17. Tacrolimus 1 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
coronary artery disease
end stage renal disease s/p LURT
acute allograft renal dysfunction
SECONDARY DIAGNOSES:
depression
gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ female with acute chest pain // Eval for acute CP
process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The lungs are well-expanded and clear. No focal consolidation, effusion,
edema, or pneumothorax. The heart is normal in size. The mediastinum is not
widened. The pleura and hila are grossly unremarkable. No acute osseous
abnormality. Bilateral shoulder prostheses.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ female with increasing creatinine, status post renal
transplant. Evaluate renal function.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal transplant ultrasound dated ___.
FINDINGS:
The right lower quadrant transplant renal morphology is normal. Renal cortex
thickness and echogenicity is similar to the prior exam. The renal sinus fat
is normal. Mild fullness of the transplant pelvis in the upper renal pole
(series 1, image 10) is similar to the prior exam and appears chronic. No
echogenic shadowing stone. No perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.67 to 0.71, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 65.4 cm/s. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
The bladder is distended and grossly unremarkable. No free fluid in the
pelvis. No distal ureteral dilatation.
IMPRESSION:
1. Mild ectasia of the upper renal pole of the right lower quadrant
transplant kidney is unchanged from the prior exam. No mass or stone.
2. Patent renal vasculature with segmental arterial resistive indices ranging
from 0.67-0.71.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 97.2
heartrate: 69.0
resprate: 16.0
o2sat: 100.0
sbp: 148.0
dbp: 80.0
level of pain: 7
level of acuity: 1.0 | Ms. ___ is a ___ y/o female with a history of FSGN s/p renal
transplant in ___, DVT/PE previously on coumadin but stopped
due to hemarthrosis, and CAD s/p multiple NSTEMIs without
interventions who presented with acute substernal chest pain.
Ruled out for ACS with 2 neg trops and no EKG changes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
latex
Attending: ___
Chief Complaint:
Right ankle fracture
Major Surgical or Invasive Procedure:
Right ankle open reduction and internal fixation
History of Present Illness:
From ED Admission Note:
___ w/ hypothyroidism, s/p partial colectomy, multiple SBOs,
HLD, p/w R ankle injury after she got in a tiffle with another
patron over cell phone use at ___. She then
fell down four steps -HS -LOC -anticoagulant use, with immediate
pain at her right ankle. No numbness, weakness, tingling. No
presyncopal component to the fall. No cp, sob, abd pain, naus,
vom, diarrhea.
Enroute received 50mcg fent. Still endorsing pain at her right
ankle laterally and medially.
Past Medical History:
hypothyroidism
s/p partial colectomy
multiple SBOs
HLD
depression
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION:
General: well appearing well nourished female lying in bed NAD
Vitals:
98.0
84
120/72
16
100% RA
Right upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Right lower extremity:
- Skin intact
- Gross deformity at the ankle with partial lateral displacement
of the foot
- No other deformity, erythema, edema, induration or ecchymosis
- Tender to palp over the distal fibula and tibia
- Soft, non-tender thigh and leg otherwise
- painful ROM of ankle
- Full, painless AROM/PROM of hip, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Left lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
DISCHARGE PHYSICAL EXAM:
Vitals: Afebrile, all vital signs stable
Gen: AOx3, NAD
CV: RRR
Pulm: CTAB
Right lower extremity:
- Operative splint in place, toes intact
- Soft, non-tender thigh and knee
- Full, painless AROM/PROM of hip, and ankle
- ___ fire, unable to assess GSC/TA
- SILT SPN/DPN/TN, unable to assess saphenous/sural nerve
distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 02:20AM WBC-9.7 RBC-3.87* HGB-12.4 HCT-38.0 MCV-98
MCH-32.0 MCHC-32.6 RDW-13.8 RDWSD-50.0*
___ 02:20AM NEUTS-49.2 ___ MONOS-8.3 EOS-3.6
BASOS-0.3 IM ___ AbsNeut-4.75 AbsLymp-3.70 AbsMono-0.80
AbsEos-0.35 AbsBaso-0.03
___ 02:20AM PLT COUNT-134*
___ 02:20AM ___ PTT-30.3 ___
___ 02:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
Ankle XR ___:
FINDINGS:
Complete transverse intra-articular fracture of distal fibula
with slight
posterior lateral displacement of the distal fragment. Mildly
displaced
intra-articular distal tibial malleolar fracture. There is
medial widening of
the ankle mortise which measures 10 mm. No other fractures are
identified.
IMPRESSION:
Bimalleolar fracture with medial widening of the ankle mortise.
NOTIFICATION: The findings were discussed with ___, M.D.
by ___
___, M.D. on the telephone on ___ at 12:44 AM, 2 minutes
after
discovery of the findings.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Misoprostol 200 mcg PO BID
3. Nefazodone 350 mg PO BID
4. Colchicine 1.2 mg PO BID
5. Lubiprostone 16 mcg PO QPM
6. Lubiprostone 24 mcg PO QAM
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*14 Syringe
Refills:*0
3. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Colchicine 1.2 mg PO BID
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Lubiprostone 16 mcg PO QPM
7. Lubiprostone 24 mcg PO QAM
8. Misoprostol 200 mcg PO BID
9. Nefazodone 350 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
right ankle bimalleolar fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX TIB/FIB AND ANKLE
INDICATION: ___ s/p reduction bimal fx
TECHNIQUE: AP and lateral views of the right knee and AP, lateral, and
oblique views of the right ankle.
COMPARISON: Right ankle radiographs from ___.
FINDINGS:
Knee: No joint effusion or fracture identified.
Ankle: Evaluation is mildly limited by overlying splint. The right distal
fibular and medial tibial malleolar fractures appear overall unchanged.
Persistent 7 mm of medial widening of the ankle mortise is unchanged from
previous examination.
IMPRESSION:
1. Evaluation mildly limited by overlying splint.
2. Overall unchanged right bimalleolar fracture and ankle mortise widening.
3. No fracture or joint effusion in the right knee.
Radiology Report
INDICATION: ___ s/p reduction bimal fx
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
The lungs are well expanded and clear. Mediastinal contours, hila, and
cardiac silhouette are normal. The aorta is tortuous. There is no pleural
effusion or pneumothorax. No osseous abnormality identified within limits of
plain radiography.
IMPRESSION:
No pneumonia or evidence of traumatic injury within the limits of plain
radiography.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ with bimall fx // ankle pain, worsening of fx
TECHNIQUE: Three views the right ankle.
COMPARISON: Right ankle radiographs from ___.
Right ankle and tib-fib radiographs from ___ at 01:22
FINDINGS:
Evaluation is mildly limited by overlying splinting material. Bimalleolar
fracture appears overall unchanged from previous examinations. There is
persistent 7 mm of medial widening of the ankle mortise.
IMPRESSION:
Little overall change in appearance of bimalleolar fracture.
Radiology Report
EXAMINATION: ANKLE (AP, LAT AND OBLIQUE) RIGHT
CLINICAL HISTORY ORIF RT ANKLE IN THE OR
COMPARISON: None
FINDINGS:
Intraoperative fluoroscopy was performed for 20.7 seconds. Multiple spot
views demonstrate open reduction and internal fixation of fractures of the
distal tibia and fibula.
IMPRESSION:
Intraoperative fluoroscopy. See procedure note.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Ankle injury
Diagnosed with Displaced bimalleolar fracture of right lower leg, init, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: 98.0
heartrate: 84.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 72.0
level of pain: 1
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight bearing in the right lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. The patient
requested a urology consult prior to her discharge and it was
explained that at her rehab facility, an appointment could be
made for her. She was amenable to this plan. She also requested
a medication list to go through prior to her discharge. All her
medications were reconciled per the patient on ___ at
4PM. She was given a printed list to bring with her to rehab as
per her request. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
blurry vision and headache
Major Surgical or Invasive Procedure:
___ lumbar puncture
History of Present Illness:
___ is a ___ y/o RHM with a PMH of HTN, HL, renal
insufficiency, and hypertensive retinopathy who presented ___
with headache and visual changes.
He was in his USOH until last ___, when he developed an
acute onset headache while at work. The headache started within
seconds and immediately progressed to a ___ pain (worst
headache of his life). He felt the pain ___ in his temple region
and across the forehead. Patient denies nausea, vomiting, or
sensitivity to light and sound. He was unable to do anything to
make the pain better, including taking medication at home. His
headache was not remitting; he felt it constantly at the same
intensity and was unable to sleep, due to pain. On ___,
patient presented from his PCP to the ___. At that time, his SBP
was >210. The patient also reports a simultaneous onset of
visual changes, which began on the same day as the headache. He
experienced blurry vision in his right eye along with horizontal
diplopia and sparkles across his visual field. He denied that
any part of his visual field was missing, but rather that
acuity was diminished. Patient has not noticed that anything
made his vision better or worse. However, he noted that acuity
in his R eye has improved since his admission.
Of note, patient has a history of visual disturbances,
associated with hypertensive episodes, that dates back to ___.
He was only able to recall episodes in the past ___ years at a
frequency of about 1 every few months, but states that these
episodes have all been similar in character (i.e., blurriness in
R eye). On ___, he was evaluated by opthamology after an episode
of blurry vision, diplopia, and sparkles across his visual
field. There were no acute findings. It imporved with eyedrops
prescribed at that time. Vision remained normal until the most
recent onset of visual disturbances last ___.
The patient also reports a history of mild headache over the
past couple of months, in the same location as the most recent
severe headache that led up to this admission.
On neuro ROS, the pt denies dysarthria, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Patient denies difficulties
in naming objects, trouble executing tasks at work, or any
changes in memory. Denies focal weakness, numbness,
parasthesiae. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss. Denies shortness
of breath. Denies chest pain or tightness, but endorses
palpitations, which have happened about 1x/week for the past
___ years when his blood pressure is high. The palpitations
last for less than a day. Check chart. 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:
- HTN
- HL
- renal insufficiency
- hypertensive retinopathy
Social History:
___
Family History:
Patient's grandfather: CAD, diabetes ___ (living, age ___
Patient's father: diabetes ___, hypertension
Reports pterygia in most of family members
Physical Exam:
Physical Exam:
Vitals: BP: 145/88
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 2, says ___ for date.
Unable to name ___ backward. Intact repetition of shoprt, but
not longer sentences, problemns following complex commands.
Can
naem high, but no low frequency objects neither in ___ nor
___. Speech was not dysarthric. Able to follow both
midline and appendicular one-step commands. Pt. was able to
register 3 objects but recalled ___ at 5 minutes. There was no
evidence of apraxia. Calculated $1.25 from 7 quarters, able to
write name well, unable to ___ (appears illiterate at
baseline).
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL R ___, L 3 to 2mm and brisk. R visual field cut
bilaterally. Visual acuity ___ bilaterally, no RAPD, no red
destauration. Unable to visualize fundi due to noncompliance.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, vibratory
proprioception throughout. Mildly reduced vibration sense in
toes
b/l.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3+ 1
R 2 2 2 3+ 2
Plantar response was flexor on L, extensor on R, ___ beat
clonus.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: deferred
DISCHARGE EXAM:
MS: -Mental Status: Alert, oriented x 2, not conisistently
correct date.
Unable to name ___ backward. Difficulty following complex
commands. Pt. was able to register 3 objects but recalled ___
at 5 minutes. Reports improved ___ headache
I: Olfaction not tested.
II: PERRL R ___, L 3 to 2mm and brisk. R visual field cut
bilaterally. Visual acuity ___ bilaterally, no RAPD, no red
destauration. Unable to visualize fundi due to noncompliance.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, vibratory
proprioception throughout. Mildly reduced vibration sense in
toes
b/l.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3+ 1
R 2 2 2 3+ 2
Plantar response was flexor on L, extensor on R, ___ beat
clonus.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait:stable at baseline
Pertinent Results:
___ 10:50AM GLUCOSE-138* UREA N-41* CREAT-3.9* SODIUM-137
POTASSIUM-5.6* CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
___ 10:50AM CALCIUM-9.8 PHOSPHATE-3.2 MAGNESIUM-2.1
___ 10:50AM WBC-9.2 RBC-4.59* HGB-13.0* HCT-41.4 MCV-90
MCH-28.3 MCHC-31.4 RDW-13.4
___ 10:50AM NEUTS-86.6* LYMPHS-6.8* MONOS-4.6 EOS-1.3
BASOS-0.7
___ 10:50AM PLT COUNT-222
DIABETES MONITORING %HbA1c eAG
___ 06:20 6.5*1 140*2
___ RECOMMENDATIONS:; <7% GOAL OF THERAPY; >8% WARRANTS
THERAPEUTIC ACTION
ESTIMATED AVERAGE GLUCOSE, CALCULATED FROM A1C USING ADAG
EQUATION.
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
___ 06:20 ___ 29 4.2 68
___ CT Head
In the posterior left parietal lobe there is a region of
relative hypodensity, with both gray and white matter
involvement and components of both vasogenic and cytotoxic
edema. This may represent a subacute infarct of the left PCA
territory, however underlying mass cannot be excluded. There is
no shift of the normally midline structures.
There is volume loss in the bilateral posterior cerebellar
hemispheres,
which is chronic in appearance, but is new from the prior CT,
and raises
concern for chronic infarct.
___ MRI/MRA
BRAIN MRI: There is slow diffusion involving the left temporal
and occipital lobes with corresponding ADC hypointensity and
FLAIR hyperintensity indicative of an acute infarct. There is
also concern for punctate foci of infarct within the left
parietal lobe (series 302, image 21), and the left frontal lobe
(series 302, image 23). There is encephalomalacia within the
bilateral cerebellar hemispheres with associated gliosis on the
and FLAIR sequence. There is no hemorrhage, or mass effect.
There are nonspecific periventricular and subcortical white
matter FLAIR hyperintensities.
BRAIN MRA: The intracranial internal carotid, and anterior
cerebral arteries are unremarkable. There are multiple focal
areas of narrowing involving the M1 and M2 segments of the
middle cerebral arteries, left greater than right. Prominent
bilateral posterior communicating arteries are identified. There
is markedly decreased flow signal within the vertebrobasilar
system which may relate to combination of slow flow and
hypoplasia. There are multiple focal areas of high-grade
stenosis involving right posterior cerebral artery. There
is loss of flow signal within the distal P2 segment of the left
PCA.
NECK MRA: The right vertebral artery is hypoplastic and
portions of it has loss of normal flow signal. The left
vertebral artery is also diminutive in size but has normal flow
signal throughout its course.
___ CAROTID ULTRASOUND
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is no plaque in the ICA. On the
left there is no plaque seen in the ICA. findings are
consistent with no stenosis.
___ ECHO showed no PFO or hypokinesis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Bumetanide 0.5 mg PO DAILY
4. Calcitriol 0.5 mcg PO BID
5. CloniDINE 0.15 mg PO BID
6. Labetalol 600 mg PO BID
7. Minocycline 100 mg PO Q12H
8. valsartan 80 mg oral daily
9. Spironolactone 25 mg PO DAILY
10. Carbamide Peroxide 6.5% ___ DROP AD BID
11. Vitamin D 4000 UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Bumetanide 0.5 mg PO DAILY
3. Calcitriol 0.5 mcg PO BID
4. Carbamide Peroxide 6.5% ___ DROP AD BID
5. CloniDINE 0.15 mg PO BID
6. Minocycline 100 mg PO Q12H
7. Spironolactone 25 mg PO DAILY
8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
RX *dextran 70-hypromellose [Artificial Tears] 0.1 %-0.3 % ___
drop2 ophth every 4 hours Refills:*3
9. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
10. Vitamin D 4000 UNIT PO DAILY
11. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
12. Verapamil SR 120 mg PO Q24H
RX *verapamil [Calan SR] 120 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
13. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice per day Disp
#*60 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: left posterior cerebral artery stroke,
concern for possible reversible cerebral vasoconstriction
syndrome (RCVS)
Secondary diagnoses: HTN retinopathy, HTN nephropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Headache. Evaluate for intracranial hemorrhage.
COMPARISON: CT of the head dated ___.
TECHNIQUE: Multi detector CT images of the head were obtained without the
administration of intravenous contrast material. Multiplanar reformatted
images in coronal and sagittal planes are provided.
DLP: 891.93 mGy-cm
FINDINGS:
There is a region of hypodensity involving the left occipital lobe, left
temporal lobe, and possibly small portion of the posterior left parietal lobe.
Difficult to discern if truly cytotoxic or vasogenic edema, but felt to
involve the cortex, suggesting cytotoxic. Findings raise concern for a
subacute infarct of the left PCA territory, however underlying mass cannot be
excluded. There is no shift of the normally midline structures. There is no
hemorrhage.
Additionally, there is volume loss in the bilateral posterior cerebellar
hemispheres, which is chronic in appearance, but is new from the prior CT, and
raises concern for chronic infarct.
The basal cisterns appear patent. No fracture is identified. The globes are
unremarkable. The mastoid air cells, middle ear cavities, and visualized
paranasal sinuses are clear.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Region of relative hypodensity involving the left occipital lobe, left
temporal lobe, and possibly small portion of the posterior left parietal lobe.
Difficult to discern if truly cytotoxic or vasogenic edema, but felt to
involve the cortex, suggesting cytotoxic. Findings raise concern for a
subacute infarct of the left PCA territory, however underlying mass cannot be
excluded. No midline shift. MRI of the brain could be performed for additional
evaluation.
3. Volume loss in the bilateral posterior cerebellar hemispheres, which is
chronic in appearance, but is new from the prior CT, and raises concern for
chronic infarct.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old man with hypodensity in L parietal area on head CT
// further characterize hypodensity in L parietal area, evaluate for
underlying mass
TECHNIQUE: Multi sequence, multiplanar brain MRI was performed without
intravenous contrast utilizing the following sequences: Axial FLAIR, axial
GRE, axial T2 trace, axial T2 and sagittal T1.
Three dimensional time of flight MR arteriography of the head and two
dimensional time-of-flight MR arteriography of the neck was performed with
rotational reconstructions.
COMPARISON: Noncontrast head CT dated ___.
FINDINGS:
BRAIN MRI: There is slow diffusion involving the left temporal and occipital
lobes with corresponding ADC hypointensity and FLAIR hyperintensity indicative
of an acute infarct. There are also punctate foci of infarct within the left
parietal lobe (series 302, image 21), and the left frontal lobe (series 302,
image 23). There is encephalomalacia within the bilateral cerebellar
hemispheres with associated gliosis on the and FLAIR sequence.
There is no hemorrhage, or mass effect. There are nonspecific periventricular
and subcortical white matter FLAIR hyperintensities. The ventricles, sulci and
cisterns are appropriate for age.
The orbits, mastoid air cells and visualized soft tissues are unremarkable.
There is mild ethmoid and bilateral maxillary sinus mucosal thickening.
BRAIN MRA: The intracranial internal carotid, and anterior cerebral arteries
are unremarkable. There are multiple focal areas of narrowing involving the M1
and M2 segments of the middle cerebral arteries, left greater than right.
Prominent bilateral posterior communicating arteries are identified. There is
markedly decreased flow signal within the vertebrobasilar system which may
relate to combination of slow flow and hypoplasia. There are multiple focal
areas of high-grade stenosis involving right posterior cerebral artery. There
is loss of flow signal within the distal P2 segment of the left PCA.
NECK MRA: The common carotid and internal carotid arteries are unremarkable
without evidence of significant stenosis based on NASCET criteria.
The right vertebral artery is hypoplastic and portions of it has loss of
normal flow signal. The left vertebral artery is also diminutive in size but
has normal flow signal throughout its course.
IMPRESSION:
Acute infarct involving the left temporal and occipital lobes. Also punctate
foci of infarct within the left parietal and left frontal lobes. There is
encephalomalacia within bilateral cerebellar hemispheres likely related to
prior infarcts. There is no hemorrhage or mass effect. There are also
nonspecific white matter changes and multiple areas of intracranial vessel
narrowing as described above. There is also loss of flow signal within the
distal left PCA. Findings are unusual for atherosclerotic disease given
patient's age and other etiologies such as vasculitis, RCVS, or sequelae of
chronic hypertension should be considered.
NOTIFICATION: Discussed with Dr. ___ telephone by Dr. ___ at 08:00
on ___, immediately after the findings were made.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with new visual field cut, tumor vs stroke //
infiltrates?
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the lung volumes have slightly
decreased. As a consequence, the cardiac silhouette appears slightly larger
than before. Moderate cardiomegaly. Normal hilar and mediastinal structures.
No pleural effusions. No pneumonia, no pulmonary edema.
Radiology Report
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: 41 with HTN, CKD, and left PCA thrombus
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is no plaque in the ICA. On the left there is no plaque seen
in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 58/15, 61/20, 50/20 cm/sec. CCA peak systolic
velocity is 104 cm/sec. ECA peak systolic velocity is 90 cm/sec. The ICA/CCA
ratio is .6. These findings are consistent with no stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 85/29, 49/20, 50/24 cm/sec. CCA peak systolic velocity
108 cm/sec. ECA peak systolic velocity is 73 cm/sec. The ICA/CCA ratio is .8.
These findings are consistent with no stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA no stenosis.
Left ICA no stenosis.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Headache
Diagnosed with VISUAL DISTURBANCES NEC, HEADACHE
temperature: 97.8
heartrate: 67.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 75.0
level of pain: nan
level of acuity: 1.0 | ___ is a ___ year old RHM with hyperlipidemia and HTN
complicated by nephropathy/retinopathy, seen in the ___ this past
week with right visual field floaters and hypertesive emergency
(BP 200s) presents with a headache and right VF cut. On CT he
was found to have a left posterior inferior hypodensity on CT
scan without midline shift. MRI/MRA confirms an area of
restricted diffusion in the left PCA territory with ADC
correlate. MRA shows evidence of diminutive basilar artery
with decreased caliber of the R MCA and irregularity of P1 with
a PCA cutoff at P2.
The initial differential diagnosis includes embolic L PCA
stroke, RCVS, vasculitis or asymmetric PRES. Based on the
constellation of clinical history of severe sudden headache,
imaging findings showing multivessel pathology and absence of
clear cardioembolic source, suspicion is for a reversible
cerebral vasconstriction syndrome versus less likely
intracranial atherosclerosis. The fact that his LDL was only 68
(in the setting of taking atorvastatin 40mg qhs) and his young
age argues against the underlying process being intracranial
atherosclerosis.
#NEURO:
- MRI/MRA: Acute infarct involving the left temporal and
occipital lobes in the PCA territory. Questionable punctate foci
of infarct within the left parietal and left frontal lobes.
Encephalomalacia within bilateral cerebellar hemispheres likely
related to prior infarcts. There is no hemorrhage or mass
effect. There are also
nonspecific white matter changes and multiple areas of
intracranial vessel narrowing as described above. There is
also loss of flow signal within the distal left PCA.
- Added full dose aspirin 325mg daily
- Continue home atorvastatin 40mg daily
- concern for RCVS, adding trial of verapamil 120mg daily
- Workup for RCVS: ESR, CRP, ___, SSA/SSB, pANCA/cANCA, C3/C4,
cryo, lyme, VDRL, S/Utox screens, hepatitis panels
- echocardiogram showed no PFO or vegetation
- LP was without evidence of inflammation (2WBC, glucose 82,
protein 22)
- normal lipid panel, A1c (6.5%)
- BP autoregulation with goal SBP <180
- ___ consults
- artificial tears q4prn for eyes
- Repeat MRI/MRA imaging in 3 months to determine response to
verapamil
#CV:
- On telemetry without evidence of arrhythmia
- BP goals 130-180
- Keeping him on home CloniDINE 0.15 mg PO BID to prevent
rebound HTN
- Will restart amlodipine 5mg daily.
- Holding valsartan, labetolol. ___ continue to hold, will
discuss plan to restart as outpatient
#ENDO:
- borderline A1c, added low dose metformin 500mg BID
#RENAL
- Follow up daily creatinine, lytes
- Reviewed extensive outpatient secondary HTN workup, no obvious
gaps in that workup. Normal renal US, pheo labs, adrenal
function
#TOX/METABOLIC
-Pulm: CXR normal
-ID: UA
-FEN: diabetic, heart healthy
-PPX: pneumoboots, SQ heparin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amlodipine-benazepril
Attending: ___.
Chief Complaint:
abdominal pain, dyspnea
Major Surgical or Invasive Procedure:
Right and left sided cardiac catheterization ___
TEE with cardioversion ___
History of Present Illness:
___ yo M w/ stage IIIB DLBCL (dx ___, most recently s/p EPOCH
x6
cycles in ___, Afib and DVT on Xarelto, HFrEF (EF 40%
___,
chronically recurrent L pleural effusion w/ PleurX catheter in
place, who presents for dyspnea.
In terms of recent history, ___ was discharged on ___ after
a
3 day admission for similar symptoms. During that admission, he
required TPA to be instilled by IP on ___. He was stable at home
for a few days, and then over the last day started to develop
increasing dyspnea and orthopnea accompanied with cough
productive of scant beige/clear sputum. ___ states sputum
production has not worsened, but cough worse. ___ without
any
hemoptysis. These symptoms were associated with decreased
drainage from 200-300 cc/d to 30 cc/d (done by home ___.
No fevers, chills, hemoptysis. Denies chest pain, abdominal
pain,
nausea, vomiting, or diarrhea.
He last took his Xarelto day prior to admission.
___ has a history of L recurrent pleural effusion dating
back
to ___, cytology has been negative for lymphoma x4. Etiology
thought to be malignancy-related vs allergic(eosinophilia in
pleural fluid) vs CHF. Tunneled pleural catheter placed ___,
followed by Dr. ___ in ___ clinic, with unclear etiology of
recurrent effusion.
In the ED, initial vitals were: 97.4F, HR 81, BP 152/110, RR18,
100% RA
Exam was notable for irregular heart sounds, crackles
bilaterally, absent lung sounds at L lung base. PleurX in place
over LLL, no erythema or exudate. RUE with stable swelling, LLL
with stable 1+ pitting edema, no calf tenderness.
Labs were notable for:
UA negative
Lactate wnl
Negative trop
CBC: 5.3>12.___.5<159
BMP wnl
Studies were notable for:
CXR ___:
No substantial interval change in size of small to moderate left
pleural effusion which is partially loculated with left basilar
chest tube in place. Associated left basilar opacity may reflect
compressive atelectasis, as seen previously.
CXR ___:
Unchanged partly loculated left pleural effusion with subjacent
opacities. New ill-defined opacities in the right lower lung
could reflect layering pleural fluid or possibly pneumonia.
- The ___ was given: Metoprolol Succinate XL 25 mg,
Simvastatin 20 mg
IP was consulted and is following. Recs below.
On arrival to the floor, ___ states that the drain has not
been draining since last hospitalization discharge. He was told
that the chemotherapy made him "leaky" and prone to the
recurrent
pleural effusions. He otherwise, feels well. He clarifies that
he
sometimes has mild intermittent orthopnea. He states he's able
to
walk for 30min and do about 15min of work outside. He feels a
little nauseous. No vomiting or diarrhea.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Large B Cell lymphoma ___
DVT (both left and right arms, also occlusive thrombus in the
right subclavian, axillary, and basilic veins)
Hypertension
Hypercholesterolemia
Atrial fibrillation
PSH: L inguinal hernia repair ___
Social History:
___
Family History:
- His father had an MI, died and at ___ of heart-related
complications.
- Mother died at age ___ she had no major medical problems, had
diverticulitis.
- He has one brother. He is not aware of any medical problems
that he might have.
- He has 2 biological children, although he is not in close
contact with them, and 4 grandchildren, and does not believe
that they have any significant medical problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Temp: 97.5 (Tm 97.5), BP: 153/101 (132-153/93-101),
HR:
105 (95-105), RR: 18, O2 sat: 96% (95-96), O2 delivery: Ra, Wt:
202.1 lb/91.67 kg
**100cc of clear yellow fluid from chest tube
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Irregularly irregular rhythm, normal rate. Audible S1
and S2. ___ Systolic ejection murmur. No rubs/gallops.
LUNGS: Decreased lung sounds on left side. No wheezes, rhonchi
or rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis. R leg with 1+ pitting edema
around ankles, L leg pitting edema up to knees. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAMINATION: '
===============================
24 HR Data (last updated ___ @ 802)
Temp: 97.5 (Tm 97.5), BP: 133/84 (97-133/62-84), HR: 75
(61-75), RR: 18, O2 sat: 98% (96-98)
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. JVP 7cm.
CARDIAC: Normal rate and regular rhythm. Audible S1
and S2. ___ Systolic ejection murmur over the cardiac apex. No
rubs/gallops.
LUNGS: Decreased lung sounds on left side with crackles. No
wheezes, rhonchi or rales. No increased work of breathing. L
pleurx c/d/I - to water seal draining serous fluid
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis. R leg with 1+ pitting edema
around ankles, L leg pitting edema up to knees. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:50AM BLOOD WBC-5.3 RBC-4.09* Hgb-12.8* Hct-39.5*
MCV-97 MCH-31.3 MCHC-32.4 RDW-15.5 RDWSD-54.5* Plt ___
___ 11:50AM BLOOD Neuts-84.3* Lymphs-5.8* Monos-8.5
Eos-0.4* Baso-0.6 Im ___ AbsNeut-4.47 AbsLymp-0.31*
AbsMono-0.45 AbsEos-0.02* AbsBaso-0.03
___ 07:50AM BLOOD ___ PTT-31.3 ___
___ 11:50AM BLOOD Glucose-104* UreaN-14 Creat-0.9 Na-139
K-4.5 Cl-106 HCO3-29 AnGap-4*
___ 11:50AM BLOOD cTropnT-<0.01
___ 11:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.1
___ 12:33PM BLOOD Lactate-1.1
DISCHARGE LABS:
===============
___ 04:42AM BLOOD WBC-4.8 RBC-4.09* Hgb-12.4* Hct-39.6*
MCV-97 MCH-30.3 MCHC-31.3* RDW-15.5 RDWSD-54.5* Plt ___
___ 04:42AM BLOOD Glucose-96 UreaN-17 Creat-0.9 Na-142
K-4.8 Cl-103 HCO3-28 AnGap-11
___ 04:42AM BLOOD Phos-3.5 Mg-2.0
PERTINENT LABS:
===============
___ 11:50AM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD cTropnT-<0.01
___ 01:15PM URINE Blood-SM* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:56AM PLEURAL TNC-365* RBC-1136* Polys-13* Lymphs-47*
Monos-9* Meso-11* Macro-20*
___ 07:56AM PLEURAL TotProt-1.1 Glucose-114 LD(LDH)-37
Cholest-11 ___
___ 07:58AM PLEURAL TNC-306* RBC-9063* Polys-1* Lymphs-83*
Monos-15* Other-1*
___ 07:58AM PLEURAL TotProt-0.9 Glucose-65 LD(___)-69
Albumin-0.8 Cholest-11 proBNP-4386
___ 04:44AM BLOOD TSH-3.0
MICROBIOLOGY:
=============
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
PLEURAL FLUID CYTOLOGY FROM ___: NO EVIDENCE OF MALIGNANT
CELLS
====================================
IMAGING:
========
CXR - ___
No substantial interval change in size of small to moderate left
pleural
effusion which is partially loculated with left basilar chest
tube in place. Associated left basilar opacity may reflect
compressive atelectasis, as seen previously.
CT SCAN - ___
1. Left PleurX catheter terminates in the posterior pleural
space. Small left.
pleural effusion has decreased in size from prior, with
associated pleural
thickening. New locules of pleural gas and small anterior
pneumothorax.
2. Simple moderate right pleural effusion has increased from
prior.
3. Few new peripheral patchy opacities are seen in the right
upper lobe,
which could be infectious or inflammatory nature.
CXR - ___
Lungs are low volume with a stable small left pleural effusion
with
subsegmental atelectasis in the left lung base. Parenchymal
opacity in the
right midlung could also represent atelectasis.
Cardiomediastinal silhouette
is stable. No pneumothorax. Left-sided chest tube remains in
place.
CXR - ___
-Slight interval worsening of small to moderate left pleural
effusion with adjacent compressive atelectasis.
-Mild pulmonary vascular congestion, unchanged.
TTE - ___
The left atrial volume index is SEVERELY increased. The right
atrium is moderately enlarged. There is normal left ventricular
wall thickness with a normal cavity size. Overall left
ventricular systolic function is severely depressed secondary to
global hypokinesis with inferior akinesis. The visually
estimated left ventricular ejection fraction is 25%. There is no
resting left ventricular outflow tract gradient. Tissue Doppler
suggests an increased left ventricular filling pressure (PCWP
greater than 18 mmHg). Normal right ventricular cavity size with
low normal free wall motion. The aortic sinus diameter is normal
for gender with normal ascending aorta diameter for gender. The
aortic arch is mildly dilated with a normal descending aorta
diameter. The aortic valve leaflets are moderately thickened.
There is low flow/low gradient SEVERE aortic valve stenosis
(valve area 1.0 cm2 or less). There is trace aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is moderate mitral
annular calcification. There is moderate to severe [3+] mitral
regurgitation. Due to acoustic shadowing, the severity of mitral
regurgitation could be UNDERestimated. The pulmonic valve
leaflets are normal. The tricuspid valve leaflets appear
structurally normal. There is moderate [2+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION:
severe left ventricular systolic dysfunction with
moderate-to-severe mitral regurgitation
Compared with the prior TTE (images reviewed) of ___ ,
mitral regurgitation is increased, left ventricular ejection
fraction is decreased, and severe low flow/low gradient aortic
stenosis now present.
TEE - ___
There is mild spontaneous echo contrast in the body of the left
atrium and in the left atrial appendage. No thrombus/mass is
seen in the body of the left atrium/left atrial appendage. The
left atrial appendage ejection velocity is mildly depressed. No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium/right atrial appendage. The right atrial appendage
ejection velocity is normal. There is
no evidence for an atrial septal defect by 2D/color Doppler.
Overall left ventricular systolic function is depressed. There
are simple atheroma in the aortic arch with simple atheroma in
the descending aorta to 37 cm from the incisors. The aortic
valve leaflets (3) are severely thickened. No masses or
vegetations are seen on the aortic valve. No abscess is seen.
Aortic valve stenosis cannot be excluded. There is a centrally
directed jet of mild [1+] aortic regurgitation. The mitral valve
leaflets are moderately thickened
with no mitral valve prolapse. No masses or vegetations are seen
on the mitral valve. No abscess is seen. There is mild [1+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. No mass/ vegetation are seen on the
tricuspid valve. No abscess is seen. There is mild [1+]
tricuspid regurgitation. EMR ___-P-IP-OP (___) Name:
___ MR___ Study Date: ___ 15:25:00
p. ___
IMPRESSION: Mild spontaneous echo contrast but no thrombus in
the left atrium and left atrial appendage. No spontaneous echo
contrast or thrombus in the body of the left atrium/right
atrium/ right atrial appendage. Depressed LV systolic function.
Calcified aortic valve with mild aortic regurgitation. Mild
mitral regurgitation. Mild tricuspid regurgitation.
RIGHT AND LEFT SIDED CARDIAC CATHETERIZATION - ___
Elevated left heart filling pressure.
Moderate pulmonary hypertension.
Most significant coronary artery disease in the proximal LAD
(eccentric 70% stenosis)
Minimal gradient across aortic valve
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO BID
2. Metoprolol Succinate XL 25 mg PO BID
3. Simvastatin 20 mg PO QPM
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
5. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO BID
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day ___ #*5
Tablet Refills:*0
2. Amiodarone 400 mg PO ONCE Duration: 1 Dose
RX *amiodarone 400 mg 1 tablet(s) by mouth once a day ___ #*7
Tablet Refills:*0
3. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth once a day ___ #*60
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day ___ #*60 Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth Nightly ___ #*60
Tablet Refills:*0
6. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day ___ #*60
Tablet Refills:*0
7. Spironolactone 25 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 1 tablet(s) by mouth once a
day ___ #*60 Tablet Refills:*0
8. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day ___ #*60
Tablet Refills:*0
9. Metoprolol Succinate XL 12.5 mg PO BID
RX *metoprolol succinate [Kapspargo Sprinkle] 25 mg 0.5 (One
half) capsule(s) by mouth ___ #*60 Capsule
Refills:*0
10. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day
___ #*60 Tablet Refills:*0
11. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
Bilateral pleural effusion
Heart failure with reduced ejection fraction
SECONDARY DIAGNOSES:
===================
Atrial fibrillation
Hyperlipidemia
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 lymphoma, SOB// dyspnea
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___, CT torso ___
FINDINGS:
Heart size is mildly enlarged, unchanged. The mediastinal and hilar contours
are unremarkable. The pulmonary vasculature is normal. Left basilar chest
tube is re-demonstrated. There is a persistent small to moderate left pleural
effusion, not substantially changed in the interval, a component of which is
partially loculated laterally. Similar appearance of left basilar
opacification which may reflect compressive atelectasis. Right lung appears
clear. No pneumothorax. There are no acute osseous abnormalities.
IMPRESSION:
No substantial interval change in size of small to moderate left pleural
effusion which is partially loculated with left basilar chest tube in place.
Associated left basilar opacity may reflect compressive atelectasis, as seen
previously.
Radiology Report
EXAMINATION: ___ large cell lymphoma s/p EPOCH x6 cycles in ___, Afib
and DVT on Xarelto, HFrEF (EF 40% ___, recurrent L pleural effusion PleurX
catheter in place, presents for dyspnea, found to have recurrent effusion, now
s/p chest tube insertion and tpa, please re-evaluate and compare interval
imagin
INDICATION: ___ large cell lymphoma s/p EPOCH x6 cycles in ___, Afib and
DVT on Xarelto, HFrEF (EF 40% ___, recurrent L pleural effusion PleurX
catheter in place, presents for dyspnea, found to have recurrent effusion, now
s/p chest tube insertion and tpa, please re-evaluate and compare interval
imaging.// ___ large cell lymphoma s/p EPOCH x6 cycles in ___, Afib and
DVT on Xarelto, HFrEF (EF 40% ___, recurrent L pleural effusion PleurX
catheter in place, presents for dyspnea, found to have recurrent effusion, now
s/p chest tube insertion and tpa, please re-evaluate and compare interval
imaging
TECHNIQUE: MDCT axial images were acquired through the chest without
intravenous contrast administration.
Coronal and sagittal reformations were performed and reviewed on PACS.
COMPARISON: CT chest from ___
FINDINGS:
The thyroid is unremarkable.
Subcentimeter mediastinal lymph nodes are not enlarged by CT size criteria.
There is no axillary lymphadenopathy. Evaluation of the hila is limited in
the absence of intravenous contrast. There is no bulky hilar lymphadenopathy.
There are moderate atherosclerotic calcifications of the thoracic aorta,
without aneurysmal dilatation. The pulmonary artery measures 3.2, which is
borderline enlarged and can be seen in the setting of pulmonary hypertension.
Heart size is normal. There are severe triple vessel coronary calcifications.
Pericardial thickening versus trace effusion is similar to prior.
A simple moderate right pleural effusion is seen, increased from prior.
A left PleurX catheter terminates in the posterior pleural space. There is a
small left pleural effusion, decreased in size from prior. A small loculated
component is seen series 302, image 110, measuring 4.2 cm x 2.8 cm. There are
new locules of pleural gas and small anterior pneumothorax. There is
associated pleural thickening.
There is moderate atelectasis, including rounded atelectasis, in the left
lower lobe. A few new peripheral patchy opacities are seen in the right upper
lobe, which could be infectious or inflammatory nature.
Central airways are patent. There is occlusion of small airways in the left
lower lobe.
This study is not tailored for subdiaphragmatic evaluation. There is a 2.2 cm
exophytic cyst in the upper pole of the left kidney. There is cortical
scarring in the posterior upper pole of the left kidney. A 1.9 cm lipoma is
seen in the colonic hepatic flexure.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Stable mild compression fracture of T12.
IMPRESSION:
1. Left PleurX catheter terminates in the posterior pleural space. Small left
pleural effusion has decreased in size from prior, with associated pleural
thickening. New locules of pleural gas and small anterior pneumothorax.
2. Simple moderate right pleural effusion has increased from prior.
3. Few new peripheral patchy opacities are seen in the right upper lobe,
which could be infectious or inflammatory nature.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleural effusion with recent chest tube
placement with SOB.// ?worsening effusion, PTX
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with a stable small left pleural effusion with
subsegmental atelectasis in the left lung base. Parenchymal opacity in the
right midlung could also represent atelectasis. Cardiomediastinal silhouette
is stable. No pneumothorax. Left-sided chest tube remains in place.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with bilateral pleural effusions// s/p right
chest tube placement s/p right chest tube placement
IMPRESSION:
Comparison to ___. Right pleural pigtail catheter in correct
position. No pneumothorax. The pleural effusion on the right is almost
completely resolved. The left pleural drain is in stable position. Minimal
decrease in extent of the left pleural effusion. Stable retrocardiac
atelectasis. No left pneumothorax. Stable borderline size of the cardiac
silhouette.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with recurrent l pleural effusion// eval pleural
effusion, has b/l chest tubes
TECHNIQUE: Portable AP radiograph the chest
COMPARISON: Radiograph from ___
FINDINGS:
Lung volumes are lower compared to the exam performed on the day prior. Small
to moderate left pleural effusion appears slightly increased compared to the
prior exam with adjacent opacities, likely secondary to worsening compressive
atelectasis. Pigtail catheter in the right lung base appears similar in
position and left-sided chest tube also is similar position. No evidence of
pneumothorax. Mild pulmonary vascular congestion is seen.
IMPRESSION:
-Slight interval worsening of small to moderate left pleural effusion with
adjacent compressive atelectasis.
-Mild pulmonary vascular congestion, unchanged.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with hx of bilateral pleural effusion// r/o
reaccumulation- interval changes
IMPRESSION:
In comparison with the study of ___, the patient has taken a better
inspiration and this is an upright view. There is still a mild to moderate
left pleural effusion with atelectatic changes at the base. On the lateral
view, the right posterior costophrenic angle is sharply seen.
The cardiomediastinal silhouette is stable and there is no evidence of
appreciable vascular congestion or acute focal pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Dyspnea
Diagnosed with Breakdown (mechanical) of internal prosth dev/grft, init, Exposure to other specified factors, initial encounter, Unspecified abdominal pain, Pleural effusion, not elsewhere classified, Shortness of breath
temperature: 97.4
heartrate: 81.0
resprate: 18.0
o2sat: 100.0
sbp: 152.0
dbp: 110.0
level of pain: 0
level of acuity: 3.0 | SUMMARY:
Mr. ___ is a ___ gentleman with history of stage
IIIB DLBCL (dx ___, most recently s/p EPOCH x6 cycles in
___, Afib and DVT on Xarelto, HFrEF (EF 40% ___,
chronically recurrent left pleural effusion with PleurX catheter
in place, presents for dyspnea in setting of reaccumulated
effusion in setting of clogged PleurX and new right pleural
effusion.
ACUTE/ACTIVE ISSUES:
==================
# Dyspnea:
# Recurrent left effusion:
# Right pleural effusion:
___ with shortness of breath on presentation but able to
maintain sats on room air. CXR in the ED showed persistent L
pleural effusion with partial loculation with new right pleural
effusion without evidence of pulmonary edema. Less likely
empyema or pneumonia given lack of fever and negative CXR. Left
pleurX was found to be clogged, with drainage improved following
administration of tPA. A right chest tube was inserted by
interventional pulmonology team on ___ and removed on
___. Pleural fluid was found to be transudative with pro-BNP
initially in 10 K range. It is noteworthy that all pleural fluid
cytology samples were negative in the past and current admission
(x4). ___ underwent TTE (see below) and was found to have
heart failure with new reduced ejection fraction (EF). ___
breathing improved after drainage of pleural fluid and was sent
home with capped left pleurX.
# HFrEF
# CAD
Bilateral pleural effusion that is transudative with pro-BNP in
the 10,000s. ___ with known global systolic dysfunction on
TTE in ___ with EF of 40%. TTE from ___ showed further
reduction in EF to 25% with low flow, low gradient AS and mild
to moderate MR. ___ underwent right and left-sided cardiac
catheterization on ___. There was an eccentric 70% stenosis
in the proximal segment of the LAD that was not intervened upon.
As for pressures, RA: 4 mmHg, PA mean 37 mmHg and PCWP 22mmHg
with minimal gradient across the aortic valve. Etiology of new
reduced EF is not clear but thought to be multifactorial
secondary to chemotherapy and tachycardia mediated (AF with
rates in the 100s) vs. CAD. ___ was given boluses of IV
lasix 20 with good response. ___ was transitioned to to oral
lasix 20mg daily, and spironolactone 25mg daily. Simvastatin was
changed to atorvastatin, and he was started on aspirin for CAD.
We decreased home lisinopril 10mg twice daily to 10mg daily. He
was instructed to monitor daily weight, and call PCP or
cardiologist if it increases by more than ___ pounds.
# Atrial fibrillation - CHADS2VASC 6 (age, CHF, DVT, HTN):
___ underwent successful TEE cardioversion on ___ with
conversion to NSR. ___ was started on amiodarone load of
400mg BID (___). After this week, he should take 400mg
once daily for 1 week (___), and then he should take 200mg
once daily. ___ was discharged on home rivaroxaban 20mg
nightly per his home regimen, and instructed not to miss any
doses given his recent cardioversion and risk of stroke.
CHRONIC/STABLE ISSUES:
======================
# Hyperlipidemia:
- simvastatin was switched to atorvastatin 40mg
# HTN: meds as above
# h/o DLBCL: Transformed from low grade lymphoma. Received 6
cycles R-EPOCH (completed on ___. EOT PET demonstrated a CR.
No signs or symptoms of disease recurrence currently in clinical
remission.
CORE MEASURES:
==============
CODE STATUS: FULL
HEALTH CARE PROXY:
Name of health care proxy: ___: wife
Phone number: ___
TRANSITIONAL ISSUES:
====================
DISCHARGE WEIGHT: 91.76 kg(202.29 lb)
DISCHARGE Cr: 1.0
DISCHARGE H/H: 12.4/39.6
DISCHARGE K: 4.8 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
s/p fall with subsequent RUE weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 5 minutes
Time (and date) the patient was last known well: 10:45 AM was
time of fall, unclear when deficits started (24h clock)
___ Stroke Scale Score: 2
t-PA given: No Reason t-PA was not given or considered: Unclear
symptom onset
endovascular intervention: []Yes [x]No
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
___ Stroke Scale score was 0:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 2
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
HPI:
___ man with a past medical history significant for
non-small cell lung cancer with brain metastases removed in ___
who presented after a fall with head strike. He states that he
was at home in the bathroom when he felt as if his legs gave out
underneath him. He uses a walker or wheelchair at baseline.
When he fell, he hit the right side of his face on the bathtub.
He denies any loss of consciousness. He activated his lifeline
and EMS arrived within 10 minutes. He states that he has old
right sided arm weakness but that his arm is more weak than it
has been in the past. He also describes new numbness in the
arm. A code stroke was called for his new right arm
paresthesias.
On neuro ROS, chronic difficulty with gait generally requiring a
walker or wheelchair. He currently denies headache despite the
head strike. Chronic right arm weakness, he thinks this is
worse after the fall. He denies changes in vision, dysarthria,
difficulties producing or comprehending speech. On general
review of systems, denies recent illnesses, shortness of breath,
chest pain.
Past Medical History:
- a craniotomy on ___ ___ for the
removal of a poorly differentiated non-small cell lung
metastasis
from the left parietal brain,
- whole brain cranial irradiation from ___ to ___ to
4000 cGyd
- pancoast tumor resection ___
hypertension
depression
paranoia
Social History:
___
Family History:
Mother died of lung cancer at ___
Paternal uncle died of lung cancer
Father died at ___ due to complications of peptic ulcer diseease
Brother died of MI at ___
Physical Exam:
Admission Exam:
- Vitals: Temperature 97.8 67 138/66 16 98% on room air blood
glucose 84
- General: Awake, cooperative, very hard of hearing
- HEENT: In c-collar, no obvious ecchymosis or hematoma
- Pulmonary: no increased WOB
- Abdomen: soft
- Extremities: no edema
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history with some difficulty with details. mixes up dates.
Unable to describe his baseline right arm and hand weakness in a
coherent manner. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name all the objects on the stroke card. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
- Cranial Nerves:
Anisocoria more prominent in the dark. Right ___, left ___,
right ptosis, he says that he has been told in the past his
right eye is smaller than his left. He says that this is not
the pupil, just the eye. VFF to confrontation. EOMI. Facial
sensation equal to pinprick. No facial droop. Hearing intact to
loud voice only. Palate elevates symmetrically. Tongue protrudes
in midline and to either side with no evidence of atrophy or
weakness.
- Motor: Decreased bulk throughout. Marked weakness in the
right arm, unable to extend this. no adventitious movements
such as tremor or asterixis noted.
Markedly decreased range of motion at the right shoulder
Delt Bic Tri WrE WrF FE FF IP Quad Ham TA ___
L 4 ___ ___ 4 5 5 5 5 4
R 4- 4 0 3 3 0 5 4 5 5 5 5 4
- Sensory: Reports sensory loss to pinprick in the right upper
extremity. This is very hard to delineate as the exam is
inconsistent. But the sensory deficits appear most prominent,
25% sensation compared to the left, in the C8 through T2
dermatomes. No extinction to DSS.
No dysmetria on FNF
- Gait: Deferred as the patient is in a c-collar and normally
ambulates with a walker only
Discharge exam:
General exam unremarkable.
Mental status normal, oriented x3, speech fluent without
paraphasic errors.
CN: R pupil 3->2, L pupil 5->3. subtle L facial droop. No
dysarthria.
Motor: Spasticity RUE, RLE.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ ___ 5 4+ 5 5 5 5 5
R 5 4+ 4- ___ 4 4 4 4+ 5
DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2
R 2+ 2+ 2+ 2
Pertinent Results:
___ 03:08PM URINE HOURS-RANDOM
___ 03:08PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:08PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:16PM ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-90 TOT
BILI-0.3
___ 02:16PM ALBUMIN-3.8
___ 02:16PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:21PM CREAT-0.9
___ 12:21PM estGFR-Using this
___ 12:16PM ___ PH-7.40 COMMENTS-GREEN TOP
___ 12:16PM GLUCOSE-91 LACTATE-1.4 NA+-139 K+-4.7 CL--100
TCO2-28
___ 12:16PM freeCa-1.11*
___ 12:00PM UREA N-23*
___ 12:00PM ALT(SGPT)-12 AST(SGOT)-38 ALK PHOS-82 TOT
BILI-0.3
___ 12:00PM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-3.2
MAGNESIUM-2.0
___ 12:00PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 12:00PM WBC-6.6 RBC-4.07* HGB-12.1* HCT-37.1* MCV-91
MCH-29.7 MCHC-32.6 RDW-14.1 RDWSD-47.1*
___ 12:00PM NEUTS-71.1* LYMPHS-16.8* MONOS-10.0 EOS-0.8*
BASOS-0.8 IM ___ AbsNeut-4.69 AbsLymp-1.11* AbsMono-0.66
AbsEos-0.05 AbsBaso-0.05
___ 12:00PM PLT COUNT-195
___ 12:00PM ___ PTT-22.5* ___
CTA head and neck
IMPRESSION:
1. No evidence of acute infarction, hemorrhage, or edema.
Status post left
frontal craniotomy with stable left frontoparietal and right
precentral
encephalomalacia.
2. Right posterior communicating artery aneurysm measuring 4 x 3
mm.
3. Otherwise, patency of the intracranial vasculature without
stenosis or
occlusion.
4. Mild atherosclerotic disease at the right carotid bifurcation
without
internal carotid artery stenosis per NASCET criteria.
5. Severe centrilobular emphysema.
CT c spine
IMPRESSION:
1. No acute fracture or dislocation. Multilevel degenerative
changes
including left greater than right neural foraminal narrowing and
mild central canal narrowing, at least at C5/C6.
MRI head with con
IMPRESSION:
1. There is no evidence of new or recurrent mass.
2. There are no acute intracranial changes.
3. Stable posttreatment changes.
MRI c spine
IMPRESSION:
1. Multilevel advanced degenerative changes in the cervical
spine.
2. Multilevel central canal narrowing, most prominent and
moderate to severe
at C5-C6 level.
3. There is multilevel significant foraminal narrowing.
4. No evidence of metastases.
CXR
IMPRESSION:
No acute cardiopulmonary abnormality
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
cervical myelopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ patient with non-small cell lung cancer, right-sided
weakness. Evaluate for stroke and vascular patency.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
3) Spiral Acquisition 5.0 s, 39.4 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,220.8 mGy-cm.
Total DLP (Head) = 2,051 mGy-cm.
COMPARISON: CT head without contrast of ___, CT cervical spine
without contrast of ___. MRI head with without contrast of ___.
FINDINGS:
NONCONTRAST HEAD CT:
Status post left frontal craniotomy with stable left frontoparietal
encephalomalacia. Subcortical encephalomalacia within the right precentral
gyrus is unchanged since at least ___ (2:21).
There is no evidence of acute large vascular territory infarction, hemorrhage,
edema or mass. Confluent periventricular, subcortical and deep white matter
hypodensities are nonspecific, likely sequelae of chronic small vessel
ischemic disease. Prominent ventricles and sulci suggest age-related
involutional changes.
Chronic bilateral nasal bone fractures are re-demonstrated. No acute fractures
identified. Large right maxillary sinus mucous retention cyst. Remaining
visualized paranasal sinuses, mastoid air cells and middle ear cavities are
clear. Patient is status post bilateral lens surgery.
CTA HEAD: There is a 4 x 3 mm right PCOM aneurysm (3:250). The left PCOM is
unremarkable. Otherwise, the remaining branches of the circle of ___ and
principal intracranial branches are grossly patent without additional
aneurysm, stenosis, dissection or occlusion. Dural venous sinuses are grossly
patent.
CTA NECK: Dominant left vertebral system. The V3 and V4 segments of the right
vertebral artery are diminutive, though do not demonstrate focal abrupt
caliber change. Overall, there is no evidence of stenosis, dissection, or
occlusion within the bilateral carotid or vertebral arteries. There is
moderate calcification of the V4 segment of the left vertebral artery. There
is atherosclerotic disease at the right carotid bifurcation without
significant internal carotid artery stenosis per NASCET criteria.
Other: Severe centrilobular emphysema. Postoperative changes within the right
posterior chest wall, with likely surgical mesh in place. Thyroid gland is
unremarkable without discrete nodule. No cervical lymphadenopathy by CT size
criteria. A 9 mm left level 6 lymph node is unchanged since examination of
___. There is moderate cervical spondylosis, worse at C4-C5 level.
IMPRESSION:
1. No evidence of acute infarction, hemorrhage, or edema. Status post left
frontal craniotomy with stable left frontoparietal and right precentral
encephalomalacia.
2. Right posterior communicating artery aneurysm measuring 4 x 3 mm.
3. Otherwise, patency of the intracranial vasculature without stenosis or
occlusion.
4. Mild atherosclerotic disease at the right carotid bifurcation without
internal carotid artery stenosis per NASCET criteria.
5. Severe centrilobular emphysema.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with fall, head strike// ? traumatic injuries
? traumatic injuries
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 19.5 cm; CTDIvol = 32.1 mGy (Body) DLP = 627.2
mGy-cm.
Total DLP (Body) = 627 mGy-cm.
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen. Multi level degenerative changes
are re-demonstrated with disc space narrowing worst C3 through C7 where there
is also endplate sclerosis and anterior posterior osteophytes. No
prevertebral soft tissue swelling is seen. Multilevel bilateral neural
foramina narrowing is seen, left greater than right, particularly in the mid
to lower cervical spine. There is also mild central canal narrowing at C5/C6.
Partially imaged old-appearing fracture of the right clavicle.
IMPRESSION:
1. No acute fracture or dislocation. Multilevel degenerative changes
including left greater than right neural foraminal narrowing and mild central
canal narrowing, at least at C5/C6.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with ___ who had fall now with new anisocoria//
eval stroke, eval dissection, h/o metastatic cancer
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 6 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CT head ___. MR head ___. MRI brain
___
FINDINGS:
Patient is status post left frontoparietal craniotomy with stable postsurgical
changes. Posttreatment changes within the adjacent left frontal lobe surgical
bed is again demonstrated. There is no evidence of recurrent tumor. The
regions of T2 FLAIR hyperintensity in the periventricular and deep subcortical
white matter, left greater than right, is stable. Area of subcortical FLAIR
hyperintensity in the posterior frontal lobe, probably involving lateral
precentral gyrus is stable since ___, there is no associated enhancement.
There are no new masses or mass effect. There is no evidence of hemorrhage,
territory infarction, or midline shift. There is no abnormal enhancement after
contrast administration.
The ventricles and sulci are prominent in caliber and configuration,
suggestive of age related atrophy and involutional changes. The major
intracranial vascular flow voids are preserved. The dural venous sinuses
appear patent.
Again demonstrated is a right maxillary mucous retention cyst. There is mild
anterior nasal septum deviation to the left. Otherwise, the paranasal
sinuses, bilateral mastoid air cells and middle ear cavities are clear..
IMPRESSION:
1. There is no evidence of new or recurrent mass.
2. There are no acute intracranial changes.
3. Stable posttreatment changes.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old man with hx of small cell lung cancer with met to
brain s/p removal now with worsening right upper extremity weakness// please
assess if lesion or any abnormality to explain worsening RUE weakness
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed. After administration
of 6 mL of Gadavist intravenous contrast, sagittal and axial T1 weighted
imaging was performed.
COMPARISON: CT ___ ___..
FINDINGS:
There has been no change since comparison exam. Alignment is anatomic with
loss of cervical lordosis. There is minimal loss height superior T2 vertebral
body, likely from Schmorl's node, there is no associated vertebral body or
paravertebral edema. Vertebral body heights are preserved. Vertebral body
signal intensity appear normal. There are multilevel degenerative changes
with loss of disc height, loss of intervertebral disc signal intensity,
intervertebral osteophyte formation, hypertrophy of ligamentum flavum, and
facet hypertrophy. There is no evidence of abnormal enhancement post contrast
administration. There are postoperative changes at the right lung apex there
is no cord T2 signal abnormality.
At C2-C3 level, central canal, right foramen are patent. There is mild left
foraminal narrowing.
At C3-C4 level, there is fusion of vertebral bodies across disc space. There
is moderate central canal narrowing, with minimal flattening of the ventral
cord secondary to prominent disc osteophyte complex. A there is moderate
severe left, and moderate right foraminal narrowing.
At C4-C5 level there is mild-to-moderate central canal narrowing. There is
severe left, and mild-to-moderate right foraminal narrowing.
At C5-C6 level there prominent endplate hypertrophic changes, diffuse disc
bulge causing moderate to severe central canal narrowing, mild flattening of
the cord, and nearly complete effacement of CSF. There is severe right, and
moderate left foraminal narrowing.
At C6-C7 level there is mild central canal narrowing. There is moderate
bilateral foraminal narrowing.
At C7-T1 level, central canal is patent. There is mild bilateral foraminal
narrowing.
IMPRESSION:
1. Multilevel advanced degenerative changes in the cervical spine.
2. Multilevel central canal narrowing, most prominent and moderate to severe
at C5-C6 level.
3. There is multilevel significant foraminal narrowing.
4. No evidence of metastases.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hx of small cell lung cancer and brain met
s/p resection with worsening RUE weakness// new pan coast mass?
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Cardiac size is normal. Cardiomediastinal structures are deviated to the
right as before. The aorta is tortuous. Postoperative changes in the right
lung and right chest wall are again noted. Allowing the deformity, no obvious
lesions are identified in the right apex. The lungs are clear. There is no
pneumothorax or pleural effusion.
IMPRESSION:
No acute cardiopulmonary abnormality
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Presyncope, R Arm numbness
Diagnosed with Weakness, Anesthesia of skin
temperature: 97.8
heartrate: 67.0
resprate: 16.0
o2sat: 98.0
sbp: 138.0
dbp: 66.0
level of pain: 0
level of acuity: 1.0 | SUMMARY: ___ right-handed man with past medical history
significant for non-small cell lung cancer with brain metastases
resected in ___ who presented after a fall with head strike
without loss of consciousness, and concern for acute on chronic
right arm weakness.
#Weakness following fall: Patient was admitted due to concern
for worsened weakenss of his baseline weak RUE. Timeline was
unclear, but there was concern for stroke given possible acute
onset (details unclear in ED). Given fall, he underwent CT
C-spine which was negative for acute process, and prominent and
moderate to severe narrowing at C5-C6 level. CT head and CTA was
negative for acute process, including no evidence of vessel
occlusion. MRI brain w/ and without contrast was stable from
prior with no stroke; he did have evidence of left
frontoparietal craniotomy with stable postsurgical changes. MRI
c-spine w/wo showed moderate canal stenosis most prominent at
C5/C6, but no acute findings to explain new weakness. Stroke
risk factors included LDL 57, A1c 5.6 which did not require
intervention.
Overall, and with later clarification of patient history, he
consistently endorsed that his RUE weakness was actually at
baseline. Most likely this was felt to be due to a combination
of prior left hemispheric brain met and cervical spondylosis
with mild myelopathy. ___ recommended rehab. Patient was
arranged for follow up with Neurology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Thorazine / Haldol / trazodone / Iodinated Contrast Media - IV
Dye / barium iodide / fish derived / nadolol /
Gadolinium-Containing Contrast Media / Gadavist
Attending: ___
Chief Complaint:
Fevers, abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMHx of HCV cirrhosis (Child class B, MELD-Na 18, c/b
portal hypertension, esophageal varices, GAVE, recurrent HE,
ascites), opioid use disorder (on Suboxone), complex psych
history with depression, anxiety, schizoaffective disorder and
PTSD, who p/w a few days of nausea, vomiting, abd pain x4-5d.
Pt states that he has been feeling generally unwell for the ___
days with n/v, fatigue, and poor appetite. He believes that it
may have started after eating burger ___ that was left in his
refrigerator and he is unsure of how old it was. He then
developed a fever this morning to 101.3 at home which prompted
him to seek medical attention. He also endorses RUQ abdominal
pain and intermittent confusion. He denies having had any
melena,
hematochezia, hematemesis, bilious vomit, diarrhea, chest pain,
cough, dysuria. He has been compliant on all his medications. He
states he has not taken suboxone recently because he could not
get it refilled and has not been taking anything for pain. He
denies any recent alcohol or drug use, though does state that he
is intermittently confused and not "completely sure" that he did
not take cocaine.
In the ED initial vitals: T 98.5 98 132/55 16 100% RA
- Exam notable for: AAOx3. +RUQ tenderness
- Labs notable for:
CBC: WBC 7.4, Hgb 11.4, platelet 58
Chem7: Na 126, Cr 0.9
LFTs: ALT 30, AST 48, AP 63, TB 2.8
Coags: INR 1.5, ___ WNL
Lipase: WNL
Lactate 2.1
UA: WNL
___ Na <20, Osmol 179
UTox: Pos for cocaine
Bld cx: pending x2
- Imaging notable for:
CXR: No acute cardiopulmonary process.
Abd US: Patent hepatic vasculature. No ascites. Again seen mild
splenomegaly. Re-demonstrated mild gallbladder wall thickening
which may relate to underlying liver disease.
- Consults:
Liver:
- Admit to ET for hyponatremia and abdominal pain of
undetermined
etiology s/p 1 L IVF,
- Recheck BMP before giving more. Increase sodium no more than
8meq in 24 hours
- Follow up cultures, no indications for antibiotics at present
as not bleeding and no ascites
- Continue home medications, no diuretics in setting of
hypovolemia at present
- check urine drug screen as he has a history of opioid
dependence
- Continue lactulose titrate to 3 loose BMs per day
- Patient was given:
___ 18:55 IVF NS ( 1000 mL ordered) ___
Started
___ 19:04 PO OxyCODONE (Immediate Release) 5 mg
___
- ED Course: No fevers in the ED.
On arrival to the floor, the pt endorses the hx above. He states
that he feels better. He is not sure what changed. He continues
to have mild abdominal pain.
Past Medical History:
1. Hepatitis C Cirrhosis c/b medically managed hepatic
encephalopathy and ascites, grade II varices s/p banding
2. Polysubstance abuse.
3. GERD.
4. Depression and anxiety- suicide attempt ___utting left wrist
5. Schizoaffective disorder
6. PTSD.
Social History:
___
Family History:
Father with hepatitis C cirrhosis, status post liver transplant
in ___. Mother with melanoma and uterine Ca.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 98.2 128 / 79 94 16 97 RA
GENERAL: thin appearing, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, ND, mildly tender in RUQ
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, DOWB WNL, no asterixis, moving all 4 extremities
with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 900)
Temp: 98.3 (Tm 98.3), BP: 126/72 (114-128/66-79), HR: 89
(89-94), RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: RA,
Wt: 137.6 lb/62.42 kg
GENERAL: thin, sleepy, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry mucous membranes
CARDIAC: Regular rate and rhythm, systolic murmur
LUNG: clear to auscultation bilaterally, no crackles, wheezes,
or
rhonchi, normal work of breathing
ABD: diffusely tender to palpation, flinching to light touch
EXT: Warm, well perfused, no lower extremity edema
NEURO: oriented x 3, able to recite days of week backwards with
some effort; CNII-XII grossly intact, moving all extremities;
+mild asterixis, milk maid sign
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS
==============
___ 02:50PM BLOOD WBC-7.4 RBC-3.90* Hgb-11.4* Hct-31.7*
MCV-81* MCH-29.2 MCHC-36.0 RDW-15.3 RDWSD-44.9 Plt Ct-58*
___ 02:50PM BLOOD Neuts-69.6 Lymphs-16.3* Monos-10.0
Eos-2.8 Baso-0.8 Im ___ AbsNeut-5.12 AbsLymp-1.20
AbsMono-0.74 AbsEos-0.21 AbsBaso-0.06
___ 02:50PM BLOOD ___ PTT-29.4 ___
___ 02:50PM BLOOD Glucose-85 UreaN-9 Creat-0.9 Na-126*
K-3.9 Cl-91* HCO3-22 AnGap-13
___ 02:50PM BLOOD ALT-30 AST-48* AlkPhos-63 TotBili-2.8*
___ 02:50PM BLOOD Lipase-27
___ 02:50PM BLOOD cTropnT-<0.01
___ 02:50PM BLOOD Albumin-3.6
___ 02:50PM BLOOD Osmolal-258*
___ 02:50PM BLOOD Ethanol-NEG
___ 03:00PM BLOOD Lactate-2.1*
DISCHARGE LABS
==============
___ 12:45PM BLOOD WBC-6.3 RBC-3.61* Hgb-10.4* Hct-29.3*
MCV-81* MCH-28.8 MCHC-35.5 RDW-15.6* RDWSD-46.0 Plt Ct-46*
___ 04:35AM BLOOD Glucose-101* UreaN-10 Creat-0.8 Na-128*
K-4.5 Cl-98 HCO3-24 AnGap-6*
___ 04:35AM BLOOD ALT-24 AST-37 LD(LDH)-207 AlkPhos-77
TotBili-1.5
___ 04:35AM BLOOD Albumin-3.1* Calcium-8.6 Phos-2.5* Mg-2.5
MICROBIOLOGY
============
Blood cultures ___ - pending
Urine culture ___ - pending
IMAGING
=======
RUQUS with Doppler ___
Patent hepatic vasculature. No ascites.
Again seen mild splenomegaly.
Re-demonstrated mild gallbladder wall thickening which may
relate to
underlying liver disease.
CXR ___
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benztropine Mesylate 1 mg PO Q8H
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Lactulose 30 mL PO QID
4. Pantoprazole 40 mg PO Q12H
5. Ranitidine 150 mg PO QHS
6. Rifaximin 550 mg PO BID
7. ZIPRASidone Hydrochloride 60 mg PO QHS
8. Magnesium Oxide 400 mg PO DAILY .
9. Narcan (naloxone) 4 mg/actuation nasal ONCE MR1
10. Nystatin Oral Suspension 10 mL PO TID:PRN swish and swallow
11. Senna 17.2 mg PO QHS
12. Tamsulosin 0.4 mg PO QHS
13. testosterone 10 mg/0.5 gram /actuation transdermal DAILY
14. Spironolactone 100 mg PO 5X/WEEK (___)
15. Furosemide 60 mg PO 2X/WEEK (MO,FR)
16. Furosemide 40 mg PO 5X/WEEK (___)
17. Spironolactone 150 mg PO 2X/WEEK (MO,FR)
Discharge Medications:
1. Benztropine Mesylate 1 mg PO Q8H
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Furosemide 60 mg PO 2X/WEEK (MO,FR)
4. Furosemide 40 mg PO 5X/WEEK (___)
5. Lactulose 30 mL PO QID
6. Magnesium Oxide 400 mg PO DAILY .
7. Narcan (naloxone) 4 mg/actuation nasal ONCE MR1
8. Nystatin Oral Suspension 10 mL PO TID:PRN swish and swallow
9. Pantoprazole 40 mg PO Q12H
10. Ranitidine 150 mg PO QHS
11. Rifaximin 550 mg PO BID
12. Senna 17.2 mg PO QHS
13. Spironolactone 100 mg PO 5X/WEEK (___)
14. Spironolactone 150 mg PO 2X/WEEK (MO,FR)
15. Tamsulosin 0.4 mg PO QHS
16. testosterone 10 mg/0.5 gram /actuation transdermal DAILY
17. ZIPRASidone Hydrochloride 60 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: AMS
Secondary diagnosis: HCV cirrhosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: abdominal pain, eval for PVT, ascites
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Doppler ultrasound ___
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular.. No focal liver
lesions are identified. There is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 5 mm.
Gallbladder: There is mild gallbladder wall thickening, similar to prior,
which is likely due to chronic liver disease. The gallbladder is not
abnormally distended and there are no stones or pericholecystic fluid.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen is again mildly enlarged, measuring 14.1 cm.
Limited view of the kidneys demonstrates no gross hydronephrosis.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 48.5 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
IMPRESSION:
Patent hepatic vasculature. No ascites.
Again seen mild splenomegaly.
Re-demonstrated mild gallbladder wall thickening which may relate to
underlying liver disease.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with fever, PNA?// fever, PNA?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
The cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Fever
Diagnosed with Fever, unspecified
temperature: 98.5
heartrate: 98.0
resprate: 16.0
o2sat: 100.0
sbp: 132.0
dbp: 55.0
level of pain: 7.5
level of acuity: 2.0 | ___ w/ PMHx of HCV cirrhosis (Child class B, MELD-Na 18, c/b
portal hypertension, esophageal varices, GAVE, recurrent HE,
ascites), opioid use disorder (on Suboxone), complex psych
history with depression, anxiety, schizoaffective disorder and
PTSD, who p/w a nausea, vomiting, abd pain x4-5d and
self-reported fever.
# Nausea, vomiting, abd pain
# Subjective fever
Unclear etiology. Ddx included gastroenteritis, food poisoning,
gastritis/PUD. Abdominal exam remained benign (voluntary
guarding without rebound) and improved throughout the day. Labs
and US reassuring against new RUQ pathology, or major intestinal
ischemia. He initially had symptomatic improvement with IV
rehydration. Unfortunately, Mr. ___ chose to leave AMA the
day after admission in order to care for his cat. He was
informed of the risks of leaving before his work up could be
completed and chose to accept those risks. Blood cultures were
pending at the time of discharge, and will be followed up if
positive.
#AMS
Patient reported confusion initially on admission and was
initially nonlinear on interview. He responds inconsistently
when asked if he has been taking his home lactulose. Subtle
asterixis and milk maid sign noted on exam most suggestive of
hepatic encephalopathy in this scenario. Drug induced etiologies
also on differential
given positive utox. Hyponatremia may also have contributed,
which resolved with IVF. His home lactulose and rifaximin were
continued. His mental status improved by the time of discharge
AMA.
# Moderate Hyponatremia
Pt presnted with Na 126. Etiology likely hypovolemic given hx of
n/v, Urine osm 180, ___ Na <20 (which appears to be after 1L
IVF). Patient received 2L IV NS with resolution of his
hyponatremia.
# HCV Cirrhosis:
Hx of HCV cirrhosis, ___ B, MELD-Na 18, c/b portal
hypertension with past hx esophageal varices, GAVE, PHG
recurrent HE, ascites. Admission MELD-Na 24. Transplant status:
currently undergoing evaluation. Home medications were
continued.
# Hx of polysubstance use: pt endorses abstinence from all
illicit drugs ___ years. U tox positive for cocaine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril / losartan / latex
Attending: ___
Chief Complaint:
Exertional Chest pain
Major Surgical or Invasive Procedure:
CABG x 3(lima-lad, svg-diag, svg-pda) on ___
History of Present Illness:
___ year old male with a history of
hypertension, CKD (baseline creatinine ___, diabetes mellitus
type 2, and CVA who was initially admitted to ___ with chest
pain
___. He had a positive stress test and cardiac cath was
recommended but he refused at that time. He represented to ___
___ for ongoing chest pain and underwent cardiac
catheterization ___ which showed coronary artery disease w/
failed PCI. He was transferred to ___ for CABG evaluation
___
and was planned for CABG with Dr. ___ Brilinta washout.
He
ultimately refused surgery and dialysis and was discharged home
without revascularization against medical advice. He presented
to
___ ED with chest pain on exertion. Cardiac surgery consulted
for coronary artery bypass graft evaluation.
Past Medical History:
- Diabetes mellitus type 2
- CKD V (baseline Cr ___, Followed by nephrologist Dr. ___
in ___. Had denied HD in the past, has AV fistula in L arm.
- hypertriglyceridemia
- Hypertension
- Dyslipidemia
- Cerebellar stroke
- Depression
- GERD
Social History:
___
Family History:
Denies any cardiac history
Physical Exam:
Preoperative Assessment:
___ 1600 BP: 139/71 HR: 82 RR: 18 O2 sat: 97% O2 delivery:
ra
Height: 61 in Weight: 91.5
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [c]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses: all palp
Femoral Right: Left:
DP Right: Left:
___ Right: Left:
Radial Right: Left:
Carotid Bruit: Right: absent Left: absent
PHYSICAL EXAM AT DISCHARGE:
___ 1600 BP: 139/71 HR: 82 RR: 18 O2 sat: 97% O2 delivery:
ra
Height: 61 in Weight: 74.8kg (164.9lbs)
General: Sitting at bedside, NAD.
Skin: Dry [x] intact [x]Sternal incision glued without erythema
or drainage.
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally, diminished [x]
Heart: S1S2 RRR [x]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
[x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses: all palpable
Pertinent Results:
Cardiac Catheterization: Date: ___ Place: ___
(Full report in paper chart)
LM: no disease
LAD: 90% mid LAD at the bifurcation of D1, which also has 90%
ostial w/ retroflexed take off. After D1 take off there is 40%
mid LAD. D1 60%.
LCx: 30% proximal
RCA: mid RCA 50% diffuse disease which is IFR negative (0.94),
proximal RCA 50%. TIMI grade 3.
- Failed PCI
TTE ___ at ___ (Full report in paper chart):
- EF 50%
- mild to mod distal anteroseptal, ateroapical , and apical
hypokinesis
- Trace MR
- Trace TR, estimate PASP 18 mmHg
- trivial pericardial effusion
LAST STRESS TEST ___ at ___:
+ Stress Spect on ___ for anteroapical ischemia
Portable CXR ___:
IMPRESSION:
Heart size is enlarged. Sternotomy wires are unchanged. Right
internal
jugular line tip is at the cavoatrial junction. Lungs overall
clear. There is small amount of bilateral pleural effusion.
There is no pneumothorax.
___ 06:38AM BLOOD WBC-10.0 RBC-2.58* Hgb-7.5* Hct-23.1*
MCV-90 MCH-29.1 MCHC-32.5 RDW-14.5 RDWSD-46.9* Plt ___
___ 07:10AM BLOOD WBC-7.0 RBC-3.33* Hgb-9.6* Hct-29.5*
MCV-89 MCH-28.8 MCHC-32.5 RDW-14.2 RDWSD-46.2 Plt ___
___ 06:38AM BLOOD Glucose-95 UreaN-104* Creat-6.3* Na-135
K-4.9 Cl-101 HCO3-17* AnGap-17
___ 05:41AM BLOOD Glucose-121* UreaN-108* Creat-6.9*
Na-134* K-4.6 Cl-100 HCO3-17* AnGap-17
___ 07:10AM BLOOD Glucose-101* UreaN-105* Creat-5.2* Na-141
K-5.0 Cl-112* HCO3-13* AnGap-16
___ 06:38AM BLOOD Mg-3.0*
___ 06:23AM BLOOD %HbA1c-6.4* eAG-137*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
2. Metoprolol Succinate XL 25 mg PO BID
3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
4. Rosuvastatin Calcium 20 mg PO QPM
5. Valsartan 40 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO Q24H
RX *famotidine [Acid Controller] 20 mg 1 tablet(s) by mouth once
a day Disp #*30 Tablet Refills:*0
4. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every six
(6) hours Disp #*30 Tablet Refills:*0
5. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*1
6. Polyethylene Glycol 17 g PO DAILY
7. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Aspirin 81 mg PO DAILY
9. Rosuvastatin Calcium 20 mg PO QPM
10. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
11. HELD- Valsartan 40 mg PO DAILY This medication was held. Do
not restart Valsartan until you are cleared by your kidney
doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Multivessel CAD
Unstable angina
Acute on chronic Kidney injury, improving.
Acute on chronic blood loss anemia, post-operative
CKD Stage V
HTN
DM
Discharge Condition:
DISCHARGE CONDITION:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with s/p CABG // cardiac surgery fast track.
eval for ptx, effusions. call ___ house officer at ___ if there is any
concern with findings Contact name: ___ house officer, ___: ___
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There are postsurgical changes from CABG. The endotracheal tube terminates 3.9
cm above the carina. The right internal jugular central venous catheter
terminates in the upper right atrium. Retraction by 3 cm is recommended. A
left chest tube and mediastinal drains are in place. The enteric tube is
partially looped within the upper esophagus but the tip terminates in the
proximal body of the stomach. Repositioning is recommended.
Low lung volumes are noted. There is no focal consolidation, pleural
effusion or pneumothorax. The cardiomediastinal silhouette is within normal
limits. There is minimal pulmonary edema. No acute osseous abnormalities are
identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p CABG, CTs d/c'd // eval for ptx
TECHNIQUE: Portable chest AP
COMPARISON: Chest radiograph dated ___
FINDINGS:
In comparison to the radiograph from ___, there has been interval
removal of the left chest tube, mediastinal drains, and endotracheal tube. No
pneumothorax. There is increase in the degree of opacification at the left
lower lung base, which likely represents interval increase in a left pleural
effusion and left basilar atelectasis; however, in the appropriate clinical
setting, cannot rule out aspiration. Mild right basilar atelectasis. Mild
pulmonary edema. The cardiomediastinal silhouette is enlarged, which is an
expected post surgical finding.
IMPRESSION:
1. No pneumothorax.
2. Increase in degree of opacification at the left lower lung base, which
likely represents interval increase in a left pleural effusion and left
basilar atelectasis; however, in the appropriate clinical setting, cannot rule
out aspiration.
3. Unchanged mild pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with chest tube d/c'd post cabg // r/o ptx
r/o ptx
IMPRESSION:
Compared to chest radiographs ___ through ___.
Normal postoperative caliber to the upper mediastinum. Moderate enlargement
of the cardiac silhouette has increased slightly, could be due to cardiomegaly
and/or deposition of pericardial effusion. Clinical correlation advised. No
pulmonary edema or pneumothorax. Moderate bibasilar atelectasis. Small
pleural effusions if any.
Right jugular line ends in the low right atrium.
RECOMMENDATION(S): Assess the explanation for increasing cardiac silhouette,
either cardiomegaly or pericardial effusion.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p CABG // eval for effusion eval for
effusion
IMPRESSION:
Heart size is enlarged. Sternotomy wires are unchanged. Right internal
jugular line tip is at the cavoatrial junction. Lungs overall clear. There is
small amount of bilateral pleural effusion. There is no pneumothorax.
Radiology Report
INDICATION: ___ with chest pain // Chest pain
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
Linear opacity in the right midlung with likely due to atelectasis. Lungs are
otherwise clear without consolidation, effusion, or edema. Cardiomediastinal
silhouette is within normal limits. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ year old man with CAD, CKD V, HTN, CVA, DM who presented with
unstable angina s/p cath with significant CAD awaiting CABG. Pre-op CXR per
C-surg // Pre-op CXR per C-surg Surg: ___ (CABG)
COMPARISON: ___
IMPRESSION:
Cardiac monitoring leads overlie the chest wall. Cardiomediastinal silhouette
is stable. There are no focal consolidations, pleural effusion, or pulmonary
edema. There are no pneumothoraces.
Radiology Report
EXAMINATION: Carotid Artery ultrasound
INDICATION: ___ year old man with CAD, CKD V, HTN, CVA, DM who presented with
unstable angina s/p cath with significant CAD on ___, now awaiting CABG.
Pre-op carotid US per C-surg // Pre-op carotid US per C-surg
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
There is mild heterogenous atherosclerotic plaque in the right carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
----------------------------------------------
CCA ___: 94.9 cm/s / 11 cm/s
CCA Distal: 89.4 cm/s / 16 cm/s
ICA ___: 84.8 cm/s / 22.4 cm/s
ICA Mid: 71.7 cm/s / 21.5 cm/s
ICA Distal: 66 cm/s / 17.3 cm/s
ECA: 169 cm/s
Vertebral: Likely occluded
ICA/CCA Ratio: 0.95
The right vertebral artery flow is not well visualized, likely occluded.
LEFT:
There is mild heterogenous atherosclerotic plaque in the left carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
----------------------------------------------
CCA ___: 111 cm/s / 17.2 cm/s
CCA Distal: 99.6 cm/s / 19.6 cm/s
ICA ___: 92.5 cm/s / 22 cm/s
ICA Mid: 93.2 cm/s / 27.3 cm/s
ICA Distal: 93.2 cm/s / 17.5 cm/s
ECA: 143 cm/s
Vertebral: 86.2 cm/s
ICA/CCA Ratio: 0.94
The left vertebral artery flow is antegrade with a normal spectral waveform.
IMPRESSION:
Right ICA <40% stenosis. Right vertebral artery occlusion.
Left ICA <40% stenosis.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Chest pain
Diagnosed with Unstable angina
temperature: 97.1
heartrate: 82.0
resprate: 16.0
o2sat: 99.0
sbp: 151.0
dbp: 76.0
level of pain: 4
level of acuity: 2.0 | The patient was brought to the Operating Room on ___ where
the patient underwent CABG x 3(lima-lad, svg-diag, svg-pda).
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication.
He was followed by renal for his chronic kidney injury and did
develop acute on chronic injury with peak creatinine 6.9, BUN
108 on ___. Of note, he has an AV Fistula, left Upper
Extremity with an excellent thrill and bruit done about one year
ago, per patient. Pt was non-oliguric and there was no
indication for dialysis as his K stayed below 5.0. He was off
diuretics on ___ and his weight remained stable prior to
discharge. Sodium bicarbonate 650mg BID was added on day of
discharge per renal recommendations.
The patient was evaluated by the Physical Therapy service for
assistance with strength and mobility. He was cleared for home.
By the time of discharge on POD 5, the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged ___ in good
condition with appropriate follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vancomycin
Attending: ___.
Chief Complaint:
Fever, Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with AML s/p alloSCT in
___ complicated by chronic GVHD of skin and lungs,
hypogammaglobulinemia, chronic respiratory failure requiring
BiPAP, HFpEF (LVEF 50-55%), ESRD on HD MWF, PE on apixaban, and
recurrent MRSA bacteremia on suppressive minocycline who
presents
with fever and shortness of breath.
Patient recently admitted ___ to ___ for planned IVIG with HD
and course complicated by fever and dyspnea for which he
completed a 10-day course of vancomycin and cefepime after
sputum
culture grew MRSA.
Patient reports that he felt well the morning of admission but
then around 9AM had fever to 100.7 with chills. He also notes
associated shortness of breath. He denies sick contacts. He
denies viral symptoms. Also notes left rib/chest discomfort for
the past ___ days. The pain is worse with movement especially
when raising his left arm above his head. He thinks the pain is
from a pulled muscle which occurred when he was pushing himself
up from his wheelchair. Denies pleuritic pain.
Past Medical History:
- AML s/p alloSCT c/b GVHD
- Cardiomyopathy with EF 30%
- ESRD
- Chronic Sinus Tachycardia
- Pericarditis in ___ as a complication of his allo-BMT
- Hypothyroidism
- GERD
- Depression/Anxiety
- History of RSV in ___
- C. Diff Colitis
- Parainfluenza in ___
- PE
- Streptococcal pneumoniae bacteremia in ___
- MSSA pneumonia and bacteremia presumably from his leg wounds
in ___
- Recurrent skin infections related to his skin changes and
breakdown with necrosis and bacterial overgrowth on the skin and
has been on intermittent courses of oral antibiotics, including
Keflex and Doxycycline with courses in ___ and ___. Improved over ___ with more recent
admissions for skin ulcerations. Followed by Dermatology here at
___ and the Wound care team.
Social History:
___
Family History:
Father with a history of myocardial infarction/coronary artery
disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.2, BP 144/103, HR 105, RR 20, O2 sat 100% BiPAP.
GENERAL: Pleasant chronically ill-appearing man, in no distress,
lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Appears in no respiratory distress, decreased breath
sounds
throughout.
ABD: Non-tender, non-distended, positive bowel sounds, abdominal
wall with firm sclerotic skin.
NEURO: A&Ox3, good attention and linear thought, ___ strength
and sensation intact.
SKIN: Extensive lichenification of skin with scattered
erosions/excoriations, most prominent over upper arms and lower
legs. Lower legs wrapped with kerlix.
ACCESS: Right chest wall port. Left chest wall HD line.
DISCHARGE PHYSICAL EXAM:
VS: 24 HR Data (last updated ___ @ 409)
Temp: 97.3 (Tm 98.0), BP: 134/86 (131-146/82-104), HR: 78
(78-94), RR: 20 (___), O2 sat: 100% (93-100), O2 delivery:
CPAP
GENERAL: Pleasant chronically ill-appearing man, in no distress,
lying in bed comfortably on BiPAP.
HEENT: Anicteric, PERLL, OP clear. CPAP mask on.
CARDIAC: RRR, normal S1/S2, no m/r/g
LUNG: CTAB, decreased breath sounds, not in respiratory
distress,
no crackles/wheezes/rhonchi
ABD: Non-tender, non-distended, positive bowel sounds, abdominal
wall with firm sclerotic skin
NEURO: A&Ox3, good attention and linear thought, ___ strength
and sensation intact.
SKIN: Extensive lichenification of skin with scattered
erosions/excoriations, most prominent over upper arms and lower
legs. Lower legs wrapped with kerlix.
ACCESS: Right chest wall port. Left chest wall HD line. Both w/o
signs of infection.
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC: 13.3* RBC: 3.04* Hgb: 10.0* Hct:
29.8* MCV: 98 MCH: 32.9* MCHC: 33.6 RDW: 16.1* RDWSD: 57.1* Plt
Ct: 292
___ 01:00PM BLOOD Neuts: 87.4* Lymphs: 2.5* Monos: 8.6 Eos:
0.3* Baso: 0.3 Im ___: 0.9* AbsNeut: 11.65* AbsLymp: 0.33*
AbsMono: 1.14* AbsEos: 0.04 AbsBaso: 0.04
___ 01:00PM BLOOD Glucose: 96 UreaN: 29* Creat: 1.5* Na:
138
K: 4.8 Cl: 101 HCO3: 24 AnGap: 13
___ 01:00PM BLOOD cTropnT: <0.01
___ 01:00PM BLOOD proBNP: 401*
___ 01:00PM BLOOD Calcium: 9.1 Phos: 2.6* Mg: 2.0
DISCHARGE LABS:
___ 12:00AM BLOOD WBC-7.2 RBC-2.51* Hgb-8.2* Hct-25.6*
MCV-102* MCH-32.7* MCHC-32.0 RDW-16.4* RDWSD-60.4* Plt ___
___ 12:00AM BLOOD Glucose-115* UreaN-18 Creat-1.6* Na-145
K-3.9 Cl-106 HCO3-29 AnGap-10
___ 12:00AM BLOOD CK(CPK)-17*
___ 12:00AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1
IMAGING:
CHEST (PORTABLE AP) IMPRESSION:
Low lung volumes without definite superimposed acute
cardiopulmonary process.
CTA CHEST IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval improvement in previously seen right lower lobe
consolidation and
multifocal ground-glass opacities.
3. Persistent small pericardial effusion.
MICRO:
___ 1:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS.
Identification and susceptibility testing performed on
culture #
___-___ ___.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0405.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 1:55 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
Daptomycin MIC = 1.0 MCG/ML test result performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ =>32 R
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0405.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 3:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 4:11 am BLOOD CULTURE Source: Line-poc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:00 am BLOOD CULTURE Source: Line-poc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:00 am BLOOD CULTURE Source: Line-POC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Artificial Tears ___ DROP BOTH EYES PRN dry eye
4. Atovaquone Suspension 1500 mg PO DAILY
5. Azithromycin 250 mg PO 3X/WEEK (___)
6. CARVedilol 3.125 mg PO BID
7. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID
8. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES BID
9. FoLIC Acid 2 mg PO DAILY
10. Gabapentin 100 mg PO DAILY
11. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
12. LORazepam 0.5-1 mg PO Q8H:PRN anxiety
13. Minocycline 100 mg PO Q12H
14. Montelukast 10 mg PO DAILY
15. Nephrocaps 1 CAP PO DAILY
16. pilocarpine HCl 5 mg oral TID
17. PredniSONE 10 mg PO DAILY
18. Ranitidine 150 mg PO DAILY
19. ruxolitinib 20 mg oral 3X/WEEK (___)
20. Venlafaxine XR 37.5 mg PO QHS
21. Venlafaxine XR 75 mg PO QAM
22. Vitamin D ___ UNIT PO 1X/WEEK (WE)
23. Dronabinol 2.5-5 mg PO BID:PRN nausea/appetite
24. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
25. petrolatum (mineral oil-hydrophil petrolat) 1 APP topical
BID:PRN dressing care
26. Pulmicort (budesonide) 4 puffs inhalation BID
27. Vitamin E 100 UNIT PO 3X/WEEK (___)
Discharge Medications:
1. Daptomycin-Heparin Lock ___X/WEEK (WE)
Daptomycin 2mg/mL
+ Heparin 100 Units/mL
2. Daptomycin 650 mg IV QFRI
RX *daptomycin 500 mg 650 mg intravenous Every ___ Disp #*3
Vial Refills:*0
3. Daptomycin 450 mg IV HD PROTOCOL M, W
RX *daptomycin 500 mg 450 mg intravenous every ___
Disp #*3 Vial Refills:*0
4. Gentamicin 2.5 mg/mL in Sodium Citrate 4% 12.___X/WEEK (___)
RX *gentamicin-sodium citrate 320 mcg/mL-4 % Use as lock for HD
catheter port Following HD session Disp #*4 Vial Refills:*0
5. Gentamicin 2.5 mg/mL in Sodium Citrate 4% 12.___X/WEEK (___)
Gentamicin 2.5 mg/mL\
in Sodium Citrate 4%
RX *gentamicin-sodium citrate 320 mcg/mL-4 % Use to lock HD
catheter port After each HD session Disp #*4 Vial Refills:*0
6. Acyclovir 400 mg PO DAILY
7. Apixaban 2.5 mg PO BID
8. Artificial Tears ___ DROP BOTH EYES PRN dry eye
9. Atovaquone Suspension 1500 mg PO DAILY
10. Azithromycin 250 mg PO 3X/WEEK (___)
11. CARVedilol 3.125 mg PO BID
12. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye)
BID
13. Dronabinol 2.5-5 mg PO BID:PRN nausea/appetite
14. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES BID
15. FoLIC Acid 2 mg PO DAILY
16. Gabapentin 100 mg PO DAILY
17. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
18. LORazepam 0.5-1 mg PO Q8H:PRN anxiety
19. Minocycline 100 mg PO Q12H
20. Montelukast 10 mg PO DAILY
21. Nephrocaps 1 CAP PO DAILY
22. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
23. petrolatum (mineral oil-hydrophil petrolat) 1 APP topical
BID:PRN dressing care
24. pilocarpine HCl 5 mg oral TID
25. PredniSONE 10 mg PO DAILY
26. Pulmicort (budesonide) 4 puffs inhalation BID
27. Ranitidine 150 mg PO DAILY
28. ruxolitinib 20 mg oral 3X/WEEK (___)
29. Venlafaxine XR 37.5 mg PO QHS
30. Venlafaxine XR 75 mg PO QAM
31. Vitamin D ___ UNIT PO 1X/WEEK (WE)
32. Vitamin E 100 UNIT PO 3X/WEEK (___)
33.Outpatient Lab Work
Please draw weekly (next ___ CBC/diff, BUN/Cr, CPK
ICD-10: B95.2 Enterococcus as the cause of diseases classified
elsewhere
Please fax results to ___ ATTN: ___ D., MD.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: vancomycin resistance enterococcal bacteremia
Secondary diagnosis: acute myeloid leukemia, chronic host versus
graft disease, end stage renal disease, hypogammaglobulinemia,
depression/anxiety, hypertension, hypothyroidism,
gastroesophageal reflux 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
INDICATION: ___ with bilateral lung transplants, p/w fevers/chills and left
chest pain// PNA?
TECHNIQUE: Single portable view of the chest
COMPARISON: Chest x-ray from ___.
FINDINGS:
Left-sided central venous catheter and right chest wall port are again noted.
Lung volumes are extremely low with elevation of the right hemidiaphragm, a
configuration similar to prior. There is probable right basilar atelectasis
and prominence of the extrapleural fat. Cardiac silhouette is unchanged.
Chronic deformities of the bilateral ribs noted in addition to radiopaque
densities within the subcutaneous tissues bilaterally.
IMPRESSION:
Low lung volumes without definite superimposed acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with sarcoidosis, GVHD, p/w dyspnea// PE?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 1.0 s, 0.5 cm; CTDIvol = 6.1 mGy (Body) DLP = 3.0
mGy-cm.
2) Spiral Acquisition 3.2 s, 24.8 cm; CTDIvol = 16.3 mGy (Body) DLP = 404.2
mGy-cm.
Total DLP (Body) = 407 mGy-cm.
COMPARISON: CT chest from ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable.
There is no supraclavicular or axillary lymphadenopathy. The esophagus is
unremarkable. Extensive dermal calcifications are again noted, likely related
to graft-versus-host disease.
UPPER ABDOMEN: Three hyperenhancing hepatic lesions measuring up to 1.7 cm at
the dome (3: 89) appear similar, likely representing hemangiomas. Soft tissue
nodule along the undersurface of the left hemidiaphragm (3:156) is unchanged,
potentially a splenule.
MEDIASTINUM: There is no mediastinal mass or lymphadenopathy.
HILA: There is no hilar mass or lymphadenopathy.
HEART and PERICARDIUM: Heart size is normal. There are no significant coronary
artery calcifications. The thoracic aorta is normal in caliber. A small
pericardial effusion persists.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: Previously seen multifocal ground-glass opacities and severe
consolidation in the right lower lobe have substantially improved, with mild
residual ground-glass opacities persisting predominantly in the bilateral
upper lobes. Mild atelectasis persists in the bilateral lung bases.
2. AIRWAYS: The airways are patent to the level of the segmental bronchi
bilaterally.
3. VESSELS: Main pulmonary artery diameter is within normal limits. There is
no evidence of pulmonary embolism to the subsegmental level
CHEST CAGE: Compression deformities in the T4-T6 and T8-T9 vertebral bodies
appear similar. Multiple old bilateral rib fractures are again seen.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval improvement in previously seen right lower lobe consolidation and
multifocal ground-glass opacities.
3. Persistent small pericardial effusion.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Fever
Diagnosed with Dyspnea, unspecified
temperature: 100.1
heartrate: 130.0
resprate: 20.0
o2sat: 98.0
sbp: 141.0
dbp: 91.0
level of pain: 6
level of acuity: 2.0 | Transitional issues
===================
[] Patient was found to have VRE bacteremia during this
hospitalization. Planning approximately two week course of
daptomycin ___ through ___. Patient will obtain weekly
CBC/diff, BUN/Cr, CPK labs while outpatient on dapto to be
followed up by ___ clinic. Getting gentamycin locks @ HD, has
an HD catheter. He will have daptomycin locks for his port,
which he will get intermittently at the ___ his
chemotherapy.
Mr. ___ is a ___ male with AML s/p alloSCT in
___ complicated by chronic GVHD of skin and lungs,
hypogammaglobulinemia, chronic respiratory failure requiring
BiPAP, HFpEF (LVEF 50-55%), ESRD on HD MWF, PE on apixaban, and
recurrent MRSA bacteremia on suppressive minocycline who
presents with fever and shortness of breath i.s.o vancomycin
resistant enterococcal bacteremia.
Acute issues
============
# Fever:
# Acute on Chronic Dyspnea: his symptoms were concerning for
pulmonary
infection, pneumonia vs. viral URI. Imaging was negative for
consolidation. He had baseline dyspnea secondary to sclerotic
changes from skin GVHD. He currently has a port-o-cath and a
chest wall HD line, both of which are sources of infection.
Blood
cultures were positive for enterococcal bacteremia, vancomycin
resistant, and susceptible to ampicillin, daptomycin, and
linezolid. ID recommended daptomycin.
Chronic issues
==============
# AML s/p allo SCT
# Chronic GVHD: He is s/p alloSCT in ___ complicated by
extensive chronic GVHD of skin, lungs, and eyes. He received
INV-Ruxolitinib 20mg PO post HD, and continued to receive home
pulmicort, montelukast, prednisone, acyclovir, atovaquone,
azithromycin, dronabinol, gabapentin, pilocarpine, cyclosporine,
fluorometholone, and artificial tear eye drops. He continued
with his BiPAP during the night.
# ESRD on HD
He continued to receive dialysis on MWF, and continued his folic
acid, vitamin D, vitamin E, and nephrocaps. Renal was consulted
to manage his ESRD.
# Recurrent MRSA Bacteremia
His suppressive minocycline was held while on IV antibiotics.
# Pulmonary Embolism
His home home apixaban was continued.
# Hypogammaglobulinemia: Recently received IVIG on ___.
# Depression/Anxiety: his home venlafaxine and Ativan were
continued.
# Hypertension
# Chronic Diastolic Heart Failure: LVEF 50-55%. Stable. BNP
lower
than prior. His home carvedilol was continued.
# Hypothyroidism
Continued home levothyroxine.
# GERD
Continued home ranitidine
CODE: Full Code (presumed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___ (girlfriend) ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ left thoracentesis
History of Present Illness:
Mr ___ is a ___ male with hx of HCV cirrhosis
(genotype 2), decompensated with acites, lower extremity edema,
esophageal varices and pleural effusions requiring thoracentesis
(last on ___, with recent admission on ___ for
decompensated cirrhosis, now transferred to ___ from ___
___ for worsening dyspnea on exertion and cough, and
abdominal fullness, over the past several days. His cough has
been non-productive of mucus or blood. He has felt some chest
heaviness with deep breathing, but denies rank chest pain,
palpitations, or lightheadedness. Denies fevers, chills, or
sweats. Has some worsening of his chronic leg swelling. His
abdomen feels more full than usual, but he denies abdominal
pain, nausea, vomiting, diarrhea, constipation, dysuria, or
hematuria. OSH labs notable for TBili/DBili 2.5/0.9, albumin
2.5, Hct 34. CXR showed large L pleural effusion. He was
transferred to ___ as this is where he receives his usual
hepatology care.
.
In the ED, initial vitals were 98.9, 100, 126/68, 16, 95% RA.
Exam notable for soft abdomen. Labs revealed hct 32, INR 1.6,
normal chem panel, Bili 2.6, albumin 2.5. CXR showed large L
pleural effusion. His case was discussed with hepatology, who
recommended admission for diuretic therapy. VS prior to transfer
were: 97, 109/74, 23, 100%2L.
.
ROS: per HPI. Also denies headache, vision changes, congestion,
sore throat, BRBPR, melena, or hematochezia.
Past Medical History:
-- Hepatitis C Genotype 2, cirrhosis, decompensated ascites,
varices, and edema
-- BPH
-- Hypertension
-- Status post cholecystectomy
-- Ataxia of unknown origin currently uses a wheelchair and a
walker
-- Right inguinal hernia s/p repair and now recurrent and
inoperable per pt
Social History:
___
Family History:
uncle with cirrhosis (likely etoh)
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9, 118/53, 94, 18, 98% 3L
GENERAL: Cachectic adult male in NAD, speaking in abbreviated
sentences due to dyspnea. Otherwise appears comfortable and
appropriate
HEENT: Sclera anicteric. PERRL, EOMI. MMM
NECK: Thin, supple, no JVD or LAD
CARDIAC: Tachycardic, regular, non-displaced PMI, S1 S2 without
murmurs, rubs or gallops. No S3 or S4 appreciated
LUNGS: Minimal breath sounds halfway up left lung. + expiratory
wheeze throughout. No chest wall deformities but ribs clearly
visualized. Resp mildly labored but no accessory muscle use,
moving
ABDOMEN: Soft, full, non-distended, non-tender to palpation.
Dullness to percussion over dependent areas but tympanic
anteriorly
EXTREMITIES: Symmetric 3+ edema of ___ to thighs bilaterally.
Warm, with palpable DP/radial pulses bilaterally. No asterixis
.
DISCHARGE PHYSICAL EXAM:
VS: 99.6, 92/56, 82, 18, 97% 3L
GENERAL: Cachectic NAD, Appears comfortable and appropriate
HEENT: Sclera anicteric. PERRL, EOMI. MMM
NECK: Thin, supple, no JVD or LAD
CARDIAC: RRR, S1 S2 without murmurs, rubs or gallops.
LUNGS: Comfortable on supplemental O2. Breath sounds decreased
in lower left lung field. Faint wheezing throughout.
ABDOMEN: Soft, mildly distended, non-tender to palpation.
Dullness to percussion over dependent areas but tympanic
anteriorly.
EXTREMITIES: Symmetric 2+ edema of ___ to thighs bilaterally.
NEURO: Strength preserved in all limbs. No gross sensory loss.
CNIII-XII grossly intact. Dysmmetric finger to nose. No
asterixis.
Pertinent Results:
ADMISSION LABS:
___ 10:04PM BLOOD WBC-3.1* RBC-3.03* Hgb-11.3* Hct-32.1*
MCV-106* MCH-37.5* MCHC-35.3* RDW-15.6* Plt Ct-72*
___ 10:04PM BLOOD Neuts-63.8 Lymphs-15.6* Monos-16.1*
Eos-4.0 Baso-0.5
___ 10:04PM BLOOD ___ PTT-32.5 ___
___ 10:04PM BLOOD UreaN-19 Creat-1.0 Na-135 K-4.0 Cl-100
HCO3-31 AnGap-8
___ 10:04PM BLOOD ALT-32 AST-37 LD(LDH)-204 AlkPhos-79
TotBili-2.6* DirBili-1.0* IndBili-1.6
___ 10:04PM BLOOD Albumin-2.5*
.
PLEURAL FLUID:
___ 02:19PM PLEURAL WBC-150* RBC-1638* Polys-5* Lymphs-47*
Monos-5* Atyps-5* Meso-17* Macro-21*
___ 02:19PM PLEURAL TotProt-1.2 Glucose-123 LD(LDH)-63
Albumin-LESS THAN Cholest-PND Triglyc-PND
.
MICRO:
___ PLEURAL FLUID CULTURE NO GROWTH TO DATE
.
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-3.3* RBC-2.94* Hgb-10.7* Hct-31.5*
MCV-107* MCH-36.4* MCHC-34.1 RDW-15.4 Plt Ct-62*
___ 06:30AM BLOOD ___ PTT-34.3 ___
___ 06:30AM BLOOD Glucose-83 UreaN-19 Creat-1.0 Na-136
K-3.8 Cl-98 HCO3-33* AnGap-9
___ 06:30AM BLOOD ALT-30 AST-35 LD(LDH)-194 AlkPhos-69
TotBili-2.1*
___ 06:30AM BLOOD Albumin-2.1* Calcium-8.5 Phos-3.0 Mg-2.0
.
IMAGING:
___ CXR: COMPARISON: Radiograph available from ___.
FRONTAL AND LATERAL CHEST RADIOGRAPHS:
There is a large left pleural effusion, new since ___
examination, obscuring the left hemidiaphragm and left cardiac
border. The
upper mediastinal border is within normal limits. The right lung
volume is
low. There is no right pleural effusion or right consolidation.
There is no
pneumothorax. The hepatic flexure is gas-filled, also seen on
prior chest
radiograph from ___.
IMPRESSION: New large left pleural effusion.
.
___ CT CHEST
INDICATION: ___ man with hepatitis C cirrhosis and
recurrent pleural effusion status post thoracentesis, now with
cough. Please evaluate for source of cough.
COMPARISON: Multiple prior chest radiographs, most recent
performed
approximately two hours prior.
TECHNIQUE: MDCT-acquired images were obtained through the chest
without
contrast. Coronal and sagittal reformatted images were also
displayed.
FINDINGS: A large, nonhemorrhagic, layering, left pleural
effusion has
substantially reaccumulated when compared to the chest
radiograph two hours earlier, responsible for adjacent
compressive atelectasis. Septal thickening and ground-glass
opacities in the left lower lobe and along the fissure in the
left upper lobe are most likely re-expansion pulmonary edema.
The lungs are otherwise clear.
The airways are patent. There is no mediastinal, hilar, or
axillary
lymphadenopathy. The heart size is normal.
This examination is not tailored for subdiaphragmatic
evaluation. The liver is shrunken and nodular in contour,
consistent with patient's known cirrhosis. The patient is status
post cholecystectomy. The spleen is enlarged. Large volume
ascites, nearly isodense with the left pleural effusion elevates
the right hemidiaphragm as seen on prior chest radiographs.
Stranding throughout the subcutaneous fat is consistent with
anasarca.
BONE WINDOWS: Nondisplaced rib fractures are noted of the right
lateral
seventh through ninth ribs and anterior right sixth rib and the
anterolateral aspects of the left eighth through tenth ribs.
There are no osseous lesions concerning for metastatic disease.
Loose bodies are present posterior to the right humeral head.
IMPRESSION:
1. No evidence of pneumonia. Left lung abnormality is best
explained by
re-expansion pulmonary edema.
2. Substantial reaccumulation of large left pleural effusion.
3. Cirrhotic liver, splenomegaly, and a large amount of ascites.
4. Multiple nondisplaced bilateral rib fractures as detailed
above.
Medications on Admission:
-spironolactone 100 mg daily
-camphor-menthol 0.5-0.5 % Lotion QID PRN pruritis
-lactulose 10 gram/15 mL ___ MLs PO TID
-torsemide 40 mg daily
-phytonadione 5 mg daily
-vit D 1000u daily
Discharge Medications:
1. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea, wheeze.
6. torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please use if patient is bed
bound/non ambulatory. Otherwise, can hold if
exercising/walking.
8. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
9. Outpatient Lab Work
Please get a complete metabolic panel drawn on ___ and fax
results to PCP and hepatologist.
Dr. ___
PCP phone number: ___
Hepatologist
___ MD/ ___ PA
phone number: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Recurrent pleural effusion
Cirrhosis due to hepatitis C infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: History of liver failure with shortness of breath.
COMPARISON: Radiograph available from ___.
FRONTAL AND LATERAL CHEST RADIOGRAPHS:
There is a large left pleural effusion, new since ___
examination, obscuring the left hemidiaphragm and left cardiac border. The
upper mediastinal border is within normal limits. The right lung volume is
low. There is no right pleural effusion or right consolidation. There is no
pneumothorax. The hepatic flexure is gas-filled, also seen on prior chest
radiograph from ___.
IMPRESSION: New large left pleural effusion.
Radiology Report
CHEST RADIOGRAPH
TECHNIQUE: Single upright chest view was read in comparison with prior chest
radiographs through ___ with the most recent from ___.
IMPRESSION;
Following thoracocentesis, moderate-to-large left pleural effusion has
substantially resolved with minimal residual effusion. Bilateral lung volumes
are low. Given the temporal development, new airspace opacities in the left
lung and focal opacity in the right upper lobe are attributed to re-expansion
edema (Reference- Reexpansion pulmonary edema CT findings in 22 patients.
___ et al, J Thorac Imaging ___. No evidence of pneumothorax.
There is no pleural effusion on the right side. Heart size, mediastinal and
hilar contours are normal and stable.
Radiology Report
INDICATION: ___ man with hepatitis C cirrhosis and recurrent pleural
effusion status post thoracentesis, now with cough. Please evaluate for
source of cough.
COMPARISON: Multiple prior chest radiographs, most recent performed
approximately two hours prior.
TECHNIQUE: MDCT-acquired images were obtained through the chest without
contrast. Coronal and sagittal reformatted images were also displayed.
FINDINGS: A large, nonhemorrhagic, layering, left pleural effusion has
substantially reaccumulated when compared to the chest radiograph two hours
earlier, responsible for adjacent compressive atelectasis. Septal thickening
and ground-glass opacities in the left lower lobe and along the fissure in the
left upper lobe are most likely re-expansion pulmonary edema. The lungs are
otherwise clear.
The airways are patent. There is no mediastinal, hilar, or axillary
lymphadenopathy. The heart size is normal.
This examination is not tailored for subdiaphragmatic evaluation. The liver
is shrunken and nodular in contour, consistent with patient's known cirrhosis.
The patient is status post cholecystectomy. The spleen is enlarged. Large
volume ascites, nearly isodense with the left pleural effusion elevates the
right hemidiaphragm as seen on prior chest radiographs.
Stranding throughout the subcutaneous fat is consistent with anasarca.
BONE WINDOWS: Nondisplaced rib fractures are noted of the right lateral
seventh through ninth ribs and anterior right sixth rib and the anterolateral
aspects of the left eighth through tenth ribs. There are no osseous lesions
concerning for metastatic disease. Loose bodies are present posterior to the
right humeral head.
IMPRESSION:
1. No evidence of pneumonia. Left lung abnormality is best explained by
re-expansion pulmonary edema.
2. Substantial reaccumulation of large left pleural effusion.
3. Cirrhotic liver, splenomegaly, and a large amount of ascites.
4. Multiple nondisplaced bilateral rib fractures as detailed above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DOE
Diagnosed with PLEURAL EFFUSION NOS, CIRRHOSIS OF LIVER NOS, CHRONIC HEP C W/OUT COMA, HYPERTENSION NOS
temperature: 98.9
heartrate: 100.0
resprate: 16.0
o2sat: 95.0
sbp: 126.0
dbp: 68.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old male with hepatitis c (HCV)
cirrhosis, decompensated with ascites, lower extremity edema,
pleural effusions, admitted with worsening dyspnea in setting of
new large left pleural effusion. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Haldol / Zyprexa
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
___ - L1-L5 lumbar fusion
History of Present Illness:
Mr ___ is a ___ yo M with h/o cognitive impairment, ___
syndrome, living in independent living with aides but not 24
care, apparently presented to Day Program poorly dressed and
with evidence of vomiting dark brown material on himself.
Pt is poor historian. The manager at his facility ___
___ has been looking to increase services for him recently.
Had admission in ___ (I took care of him then), for a
similar presentation - falls with SDH, persistent ___, and
iron deficiency anemia, which was worked up at the time with the
discovery of esophagitis. With his falls there was concern for
his saftey at home, but after looking into his resources at
home, it was felt that, at the time, home discharge was
appropriate.
Vitals in the ED: 90 120/82 16 99% RA Patient given: 2L NS and
IV pantoprazole. Rectal exam revealed dark stool, guiac
positive. Labs revealed clean UA, lactate of 2.2, H/H of
11.7/36.3, Cr 1.3. Patient pan-scanned, revealing resolution of
prior SDH, subacute right rib fractures, multiple chronic
fractures, small pericardial effusion, thickening of esophagus,
dialated small bowel w/o transition point, and L3 burst fracture
involving the anterior and middle columns, with 5 mm of
retropulsion, appears subacute, new since ___. Vitals prior
to transfer: 98.2 72 132/73 18 100% RA.
On the floor, patient very pleasant, denies any issues and
answers mostly "yes" to all questions (his baseline - I've taken
care of him on prior admissions).
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:
PMH: Bipolar disorder, h/o SBO ___, HTN, h/o postphlebitic
syndrome
PSH: colostomy s/p reversal ___, IVC filter placement ___
Social History:
___
Family History:
Unknown
Physical Exam:
Admissions Physical:
====================
Vitals - 98.6 140/71 78 18 100% RA
GENERAL: NAD
HEENT: PERRL, anicteric sclera, pink conjunctiva, MMM, dried
vomit on his face
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: grossly distended, but soft, NT, hypoactive bowel
sounds
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical:
===================
Pertinent Results:
Admissions Labs:
================
___ 12:30PM BLOOD WBC-8.4# RBC-4.51* Hgb-11.7* Hct-36.3*
MCV-81* MCH-26.0* MCHC-32.3 RDW-15.9* Plt ___
___ 12:30PM BLOOD Neuts-80.1* Lymphs-13.1* Monos-6.6
Eos-0.1 Baso-0.1
___ 12:30PM BLOOD Glucose-141* UreaN-45* Creat-1.3* Na-138
K-4.3 Cl-97 HCO3-27 AnGap-18
___ 12:30PM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.2 Mg-2.3
___ 12:39PM BLOOD Glucose-135* Lactate-2.2*
___ 12:39PM BLOOD Hgb-12.0* calcHCT-36
Pertinent Imaging:
==================
CXR IMPRESSION:
1. No acute intrathoracic process.
2. Cardiomegaly.
3. Gas-filled dilated bowel loops in the upper abdomen, as seen
previously, may reflect ___ syndrome. Please correlate
with subsequent CT.
CT head IMPRESSION:
1. Interval resolution of right cerebral subdural hematoma.
2. Ventricular size increased in the interval. Please correlate
clinically.
CT ABD IMPRESSION:
1. Dilated small and large bowel without transition point
secondary to ___ syndrome.
2. L3 burst fracture involving the anterior and middle columns,
with 5 mm of retropulsion, appears subacute, new since ___.
Subacute 10, 11 and ___ posterior right rib fractures
3. The distal esophagus is thickened, may represent esophagitis,
clinical correlation.
4. Small pericardial effusion.
5. Left common iliac aneurysm measuring 2.1 cm.
MRI Lumbar Spine:
1. L3 burst fracture with associated mild retropulsion which
contacts the traversing right L3 nerve root at the level of the
fracture.
2. Diffusely decreased T1 marrow signal within the L3 vertebral
body is
atypical in appearance and continued followup is recommended to
exclude
underlying pathologic fracture.
3. No evidence of gross ligamentous disruption.
4. Additional multilevel spondylosis including severe neural
foraminal
stenosis at the L4-L5 level, as described above.
CXR ___:
Heart size is enlarged, unchanged. Mediastinum is stable. Old
right rib
fractures are noted. There is no pleural effusion or
pneumothorax.
___ lumbar x ray
Redemonstration of patient's known burst fractured at L3 without
significant retropulsion.
Interval posterior discectomy and fusion spanning L1-L5 without
evidence of hardware complication.
Moderate multilevel background degenerative disc disease most
pronounced at L4-L5 and L5-S1.
ABD SUPINE & LAT DECUB ___
1. Massively dilated gas-filled bowel loops throughout the
abdomen appears overall similar compared to exams dated back to
at least ___ and may reflect ___ syndrome. A moderate
amount of stool is seen in the rectal vault. No evidence of
pneumatosis or free air.
2. Interval lumbar fusion surgery, without evidence of hardware
failure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. QUEtiapine Fumarate 200 mg PO QHS
3. Tamsulosin 0.4 mg PO QHS
4. ZIPRASidone Hydrochloride 40 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Midodrine 5 mg PO TID
7. Pantoprazole 20 mg PO Q12H
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Fleet Enema ___AILY:PRN dulcolax suppository
ineffective
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. Fleet Enema ___AILY:PRN dulcolax suppository
ineffective
4. Midodrine 5 mg PO TID
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
8. ZIPRASidone Hydrochloride 40 mg PO DAILY
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. QUEtiapine Fumarate 200 mg PO QHS
11. Heparin 5000 UNIT SC TID
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Bisacodyl ___AILY
14. Aspirin 81 mg PO DAILY
15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
16. Pantoprazole 20 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L3 burst fracture
urinary tract infection
___ syndrome
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive but lethargic at
times.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST AND ABDOMINAL RADIOGRAPHS
INDICATION: ___ with h/o recurrent SBOs // eval for SBO
COMPARISON: ___.
FINDINGS:
AP upright and lateral views of the chest provided. Lung volumes are low. The
lungs appear clear. The heart is stably enlarged with a left ventricular
configuration. No large effusion or pneumothorax. Mediastinal contour is
normal. Old right rib cage deformities are seen.
Supine and upright views of the abdomen pelvis were provided. An IVC filter
projects over the mid abdomen. There is suture material in the lower mid
abdomen. There is again noted to be diffuse gaseous distention and dilation of
small and large bowel in this patient with known history of ___
syndrome. No evidence of free air below the right hemidiaphragm.
IMPRESSION:
1. No acute intrathoracic process.
2. Cardiomegaly.
3. Gas-filled dilated bowel loops in the upper abdomen, as seen previously,
may reflect ___ syndrome. Please correlate with subsequent CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with vomiting, cognitive delay, recent SDH //
eval for Interval change
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 1338 mGy-cm
CTDI: 53 mGy
COMPARISON: CT head on ___.
FINDINGS:
The previously seen right subdural hematoma overlying the right frontal and
temporal convexity has nearly entirely resolved. There is no new hemorrhage.
There is no acute infarction, mass or midline shift. The size of the
ventricles has slightly increased in size compared to ___, measuring 53
mm compared to 44 mm at the level of the thalamus. No signs of transependymal
CSF resorption. Basilar cisterns are patent. Visualized paranasal sinuses and
mastoid air cells are clear. There is no fracture.
IMPRESSION:
1. Interval resolution of right cerebral subdural hematoma.
2. Ventricular size increased in the interval. Please correlate clinically.
Radiology Report
EXAMINATION: CT OF THE ABDOMEN AND PELVIS
INDICATION: ___ with h/o Ogillvie's now wth abdominal pan and vomiting //
eval f SBO vs. ___
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS. No
oral contrast was administered.
DOSE: DLP: 578 mGy-cm (abdomen and pelvis.
IV Contrast: 130 mL Omnipaque
COMPARISON: CT abdomen pelvis on ___.
FINDINGS:
LOWER CHEST: There is a small pericardial effusion. No pleural effusion. The
lower lungs appear grossly clear. There is mild thickening of the distal
esophagus.
ABDOMEN: The liver appears small and is displaced posteriorly due to multiple
anteriorly positioned dilated bowel loops.The gallbladder is not clearly
visualized. No intrahepatic biliary ductal dilation is seen. The main portal
vein is patent. The spleen appears normal. Both adrenal glands are normal in
size and configuration. Tiny cortical renal hypodensities likely represent
cysts though too small to characterize. The kidneys otherwise appear normal
with symmetric enhancement and prompt excretion of contrast. The pancreas is
atrophic. There is an IVC filter in place. The abdominal aorta is normal in
caliber with mild calcification. There is a a small aneurysm of the left
common iliac artery measuring up to 1.9 x 1.8 cm unchanged, series 2, image
62. No retroperitoneal hematoma or lymphadenopathy is seen.
The stomach and duodenum appear unremarkable. There is small bowel dilation
without transition point. There is large bowel gaseous distention and dilation
which can be traced to the level of the rectum where fecal material fills the
rectal vault. This overall appearance is compatible with ___
pseudo-obstruction with small bowel dilation likely secondary to an
incompetent ileocecal valve.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis. A 2.1 x 1.5 cm ovoid mass with internal calcifications is again seen
to the left bladder, unchanged likely representing infarcted epiploic
appendage.
BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. There are
subacute 10, 11 and ___ posterior right rib fractures, new since ___.
There is a subacute appearing 2 column burst fracture of L3 with 5 mm of
retropulsion, new since ___.
IMPRESSION:
1. Dilated small and large bowel compatible with ___ pseudo obstruction.
2. L3 2 column burst fracture with 5 mm of retropulsion, subacute in
appearance though new since ___.
3. Subacute 10, 11 and ___ posterior right rib fractures
4. Thickening of the distal esophagus, question esophagitis. Correlate
clinically.
5. Small pericardial effusion.
6. Stable left common iliac aneurysm measuring 2.1 cm.
Radiology Report
INDICATION: History: ___ with new fractures, poor historian, recurrent falls,
eval for cspine fx // eval for fx
TECHNIQUE: Axial helical MDCT images were obtained from the skullbase through
the lung apices. Reformatted images in sagittal and coronal axes were
obtained.
DOSE: DLP: 778 mGy-cm
CTDIvol: 37 mGy
COMPARISON: CT of the cervical spine on ___.
FINDINGS:
There is no evidence of acute fracture or traumatic malalignment. There are
moderate degenerative changes of the cervical spine, most prominent at C5-6
and C6-7 with disc space narrowing and osteophytosis. Degenerative changes are
also seen from C3 through C7. CT is not able to provide intrathecal detail
compared to MRI, but the visualized outline of the thecal sac appears
unremarkable. No lymphadenopathy is present by CT size criteria. The lung
apices are clear.
IMPRESSION:
No evidence of acute fracture or dislocation. Multilevel degenerative changes.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: Apparently new fractures, poor historian, evaluate for traumatic
injury.
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images.
DOSE: DLP: 806 mGy-cm.
COMPARISON: None available.
FINDINGS:
The study is limited due to patient motion. The thyroid is normal.
Supraclavicular, axillary, mediastinal and hilar lymph nodes are not enlarged.
Coronary artery calcification is seen. Aortic calcifications are seen. A small
to moderate pericardial effusion is seen. . There is thickening of the mid to
distal esophagus.
There is no focal consolidation, pleural effusion or pneumothorax. Bibasilar
atelectasis. Evaluation of the pulmonary parenchyma is less than optimal due
to respiratory motion.
There are subacute appearing fractures of the posterior right tenth eleventh
and twelfth ribs. There are chronic fractures of the chronic fractures of the
right posterior fourth fifth sixth and seventh ribs. There is a chronic
fracture of the left lateral fourth rib. There are chronic fractures of the
posterior fourth, fifth, and sixth ribs. No acute fractures.
See concurrent CT abdomen and pelvis for abdominal findings.
IMPRESSION:
Limited study due to patient motion. Given this, subacute appearing fractures
of the posterior right tenth, eleventh, and twelfth ribs. Multiple other
chronic fractures bilaterally.
Small to moderate pericardial effusion.
Thickening of the mid to distal esophagus, recommend clinical correlation.
Please see CT abdomen pelvis report for abdominal findings.
Radiology Report
EXAMINATION: mr ___ spine w/o contrast
INDICATION: ___ year old man s/p fall with L3 burst fracture involving the
anterior and middle columns, with 5 mm ofretropulsion new on CT // eval
fracture futher eval fracture futher
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed.
COMPARISON: CT cervical spine, chest, and abdomen pelvis ___.
FINDINGS:
Transitional anatomy is noted the lumbosacral junction. When taking into
account prior CTs of the cervical spine, chest and abdomen pelvis, with 7
cervical vertebral bodies, 12 rib-bearing thoracic vertebral bodies, there is
partial lumbarization of L5-S1. Therefore, the level demonstrating burst
fracture is more accurately L4.
There is a burst fracture of the L4 vertebral body with loss of vertebral body
height and associated spinal canal narrowing secondary to posterior displaced
osseous fragments which contacts the descending right L3 nerve root.
Additionally, there is T2/STIR signal hyperintensity within the L5 vertebral
body with linear T1 hypointense signal, as well as within the superior
endplate of the S1 vertebral body which, when compared to prior CT, likely
represents degenerative endplate sclerosis. There is also increased signal
within the L5-S1 intervertebral disc which is likely on a degenerative basis.
There is edema within the posterior elements including the spinous process at
the level of the fracture. Diffusely decreased T1 marrow signal within the L4
vertebral body which extends to the anterior margin of the pedicles, atypical
in appearance and a pathologic fracture is not entirely excluded. Additional
followup is recommended.
The remaining vertebral body height and alignment within the lumbar spine are
maintained. There are L2 and L3 vertebral body hemangiomas.
The conus medullaris is normal in signal and morphology in terminates at the
L1 level.
There is no evidence of gross ligamentous disruption. There is edema within
the paraspinal soft tissues and paraspinal musculature predominately at the
level of the fracture.
At the L3-L4 level, there is bilateral facet arthropathy, ligamentum flavum
thickening, and a diffuse disc bulge in combination with retropulsed
fragments, there is mild spinal canal narrowing and mild bilateral neural
foraminal narrowing. Additionally, posterior to the L4 level at the right side
of the fracture, the associated posterior displaced osseous fragments contact
the traversing right L4 nerve root.
At the L4-5 level, there is bilateral facet arthropathy, ligamentum flavum
thickening, and a diffuse disc bulge which causes minimal spinal canal
narrowing and moderate bilateral neural foraminal narrowing with contact of
the exiting bilateral L4 nerve roots.
At the L5-S1 level, there is severe loss of disc height and signal, bilateral
facet arthropathy, and ligamentum flavum thickening, as well as intervertebral
osteophytes which cause mild spinal canal narrowing and severe bilateral
neural foraminal narrowing, left greater than right, with compression of the
exiting bilateral L5 nerve roots.
At the S1-S2 level, there is a rudimentary disc. There is bilateral facet
arthropathy as well as intervertebral osteophyte. There is moderate bilateral
neural foraminal narrowing.
Gross distention of the bowel is better characterized by earlier CT scan.
IMPRESSION:
1. Transitional anatomy at the lumbosacral junction. When counted from the
skullbase, the fracture is at the L4 level. L4 burst fracture with associated
mild retropulsion which contacts the traversing right L4 nerve root at the
level of the fracture.
2. Diffusely decreased T1 marrow signal within the L4 vertebral body
potentially due to recent fracture however it is slightly more extensive than
expected. Followup by MRI recommended in approximately 6 weeks to exclude
underlying pathologic fracture to evaluate for return of the normal T1 signal
on subsequent followup.
3. No evidence of gross ligamentous disruption.
4. Additional multilevel spondylosis including severe neural foraminal
stenosis at the L5-S1 level, as described above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with lumbar fracture // eval for pre-op Surg:
___ (lumbar fusion)
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Heart size is enlarged, unchanged. Mediastinum is stable. Old right rib
fractures are noted. There is no pleural effusion or pneumothorax.
Radiology Report
EXAMINATION: L-SPINE (AP AND LAT) IN O.R.
INDICATION: POST. L1-5 FUSION
IMPRESSION:
Images from the operative suite show steps in a L1-5 fusion. Further
information can be gathered from the operative report.
Radiology Report
EXAMINATION: L-SPINE (AP AND LAT)
INDICATION: ___ year old man with recetn surgery. Please do while in brace //
s/p L1-L5 fusion s/p L1-L5 fusion
TECHNIQUE: Frontal and lateral projections of the lumbar spine for a total of
two images.
COMPARISON: MRI of the lumbar spine ___.
FINDINGS:
4 lumbar type non rib-bearing vertebra are visualized with a transitional L5
vertebra. There has been interval posterior fusion and discectomy spanning
L1-L5 with bilateral rods and pedicle screws. There is no evidence of hardware
complication. An IVC filter projects over the L1 vertebral body. The bones are
normally mineralized. There is redemonstration of loss of vertebral body
height at L3 without significant retropulsion consistent with the patient's
known burst fracture. Vertebral body heights are otherwise maintained without
evidence for a compression fracture. There is no vertebral body subluxation.
There is mild to moderate multilevel intervertebral disk space narrowing with
associated endplate osteophyte formation most pronounced at L4-L5 and L5-S1.
The the sacroiliac joint spaces appear well maintained. Chain suture material
is noted over the left lower quadrant the abdomen. There diffusely dilated
colon throughout the abdomen consistent with a postoperative ileus.
IMPRESSION:
Redemonstration of patient's known burst fractured at L3 without significant
retropulsion.
Interval posterior discectomy and fusion spanning L1-L5 without evidence of
hardware complication.
Moderate multilevel background degenerative disc disease most pronounced at
L4-L5 and L5-S1.
Radiology Report
INDICATION: ___ year old man with PMH ___ syndrome, no BM, increasing
abdominal distention, POD 2 from L1-L5 lumbar fusion. // Please evaluate for
ileus, bowel obstruction, air-fluid level.
TECHNIQUE: Supine and upright radiographs of the abdomen.
COMPARISON: Radiographs dated back to ___.
FINDINGS:
Massively dilated gas-filled bowel loops throughout the abdomen appear overall
similar compared to exams dated back to at least ___, and may reflect
___ syndrome. A moderate amount of stool is seen in the rectal vault.
There is no evidence of intra-abdominal free air or pneumatosis. Recent lumbar
fusion hardware is seen, without evidence of hardware complication. An IVC
filter is unchanged in position. The visualized osseous structures are
unremarkable.
IMPRESSION:
1. Massively dilated gas-filled bowel loops throughout the abdomen appears
overall similar compared to exams dated back to at least ___ and may reflect
___ syndrome. A moderate amount of stool is seen in the rectal vault. No
evidence of pneumatosis or free air.
2. Interval lumbar fusion surgery, without evidence of hardware failure.
NOTIFICATION: Discussed with on-call GI fellow on the day of the exam in
person by Dr. ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with VOMITING
temperature: nan
heartrate: 90.0
resprate: 16.0
o2sat: 99.0
sbp: 120.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | Medicine floor course:
Mr ___ is a ___ yo M with h/o cognitive impairment, ___
syndrome, living in independent living with aides but not 24
care, presents with vomiting, found to have multiple sub-acute
fractures, including an L3 fracture.
# L3 Burst fracture: The patient presented and was found to have
a L3 burst fracture on CT. He was seen by neurosurgery in the ED
who recommended MRI and LSO brace. The MRI showed an unstable
fracture and neurosurgery decided he needed a spinal fusion.
# Anemia/dark emesis/Heme + stool: Patient has h/o iron
deficiency anemia in the past. On last admission in ___
patient had ___ for this chronic issue (due to patient's
failure to get outpatient w/u) which revealed mod-severe
esophagitis, normal ___. Patient was started on Pantoprazole
BID. Is on iron. Current anemia is acutally above prior baseline
(Hgb ___. No significant work up was pursued during this
admission given that H/H was stable and he did not have signs of
active bleeding.
# Multiple Fractures s/p falls: indicates recurrent falls (has
had prior admission for this). Known to be orhtostatic, started
on midodrine on last admission. Had been living independently
with good supports for some time, had tried to maintain him at
home during previous admissions despite falls. The patient was
placed on tele to assess for any arrhythmias that could suggest
a cardiogenic cause to his falls. He had no events. His EKG on
presentation was wnl.
# ___: Suspect vomiting ___ ___ (this seems to
happen to him intermittently), and reassuringly, no sign of
obstruction on CT. Abdomen is distended, but this is his
baseline. No rebound tenderness or guarding. His diet was
advanced.
# ___: Cr 1.3 on admission, 1.0 at baseline. S/p 2L in ED. At
this point will assume pre-renal in setting of vomiting.
# L common iliac aneurism: <3cm, so no urgent need for repair,
but should probably be followed with U/S as outpatient
#Bipolar disorder: Per care provider and psychiatrist, has long
history of recurrent manic episodes with medication tapering,
most recently this past ___. Per his psychiatrist Dr. ___,
___ first saw Mr. ___ in ___ for tardive dyskinesia
due to his prior psych regimen. His medications were actually
being tapered over the past ___ months with improvement in the
tardive dyskinesia, but quetiapine recently increased (2 months
prior) from 150mg qhs to 200mg qhs for manic symptoms.
#HTN: amlodipine held on last admission due to orthostasis. Will
continue to hold
#LUTS:
- Continue tamsulosin
Mr. ___ was transferred to the Neurosurgery service on ___
while awaiting spinal fusion for his L4 burst fracture. The
patient was kept on bedrest with HOB no greater than 45 degrees.
A custom LSO brace was at the bedside in preparation for
post-operative ambulation. The patient was stable otherwise
during this time. Aspirin 81 mg was added for a history of
clotting.
___, the patient remained neurologically stable and waiting for
surgery.
___, Mr. ___ was started on antibiotics for a urinary tract
infection. He was pre-op'd for planned surgery on ___.
on ___ he was neurologically stable and was consented for
surgery. He was pre-op'd and made NPO.
On ___, the patient went to the OR for a lumbar fusion L1-L5.
He tolerated the procedure well, was extubated, and transferred
to the PACU for further recovery.
On ___, patient was difficult to examine due to inattention. He
was moving all extremities with good strength and incision was
c/d/i. His brace was at his bedside and he was OOB to chair. His
foley was removed and ___ was consulted. His urine culture showed
group B strep and cipro was discontinued and patient was started
on augmentin x 10 days.
On ___, patient remained stable neurologically stable. His
abdomen was firm and distended on exam, KUB was performed and GI
was consulted for further management of his history of ___
syndrome. ___ also evaluated the patient who recommended rehab.
On ___, the patent remained stable and had a large bowel
movement over night. There was question about aspiration from
the nurses part, and the patient was made NPO and ordered for
speech and swollow study. The patient developed urinary
retention >900cc and a foley was placed.
On ___, the patient remained stable. Speech pathologist screened
the patient for swollowing difficulty and aspiration but the
patient was very sleepy and will attempt to screen him again
tomrrow.
On ___, the patient remained stable. The patient was re-screened
for speech and swallowing and found the patient safe for a
regular diet with thin liquids with 1:1 supervision. The is
being screened for rehab.
On ___, patient remained stable. He was transferred to rehab in
stable conditions. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Abdominal pain, fevers
Major Surgical or Invasive Procedure:
ERCP attempted (___)
PICC (right arm) placed ___
History of Present Illness:
Mr. ___ is a pleasant ___ w/ HTN, HBV, BPH, gout, and
cholangiocarcinoma, s/p chemoRT with infusional ___, course c/b
biliary strictures s/p 2 biliary stents and recurrent MDR E.
coli
BSI and hepatic abscesses (resolved on most recent CT) who
presents with acute onset RUQ abd pain and fevers/chills which
started on the day of admission. Of note, he is receiving his
oncological care at ___, on the liver transplant list,
and is due to see Dr ___ on ___ for an initial visit to
establish local care.
He was in his usual health until yesterday afternoon, when he
developed right-sided lower rib and upper abdominal discomfort.
He was able to sleep through this, but today had persistent
right
upper quadrant abdominal pain with fever to greater than 101. No
chest pain. No diarrhea. No nausea or vomiting.
In the ED, multiple temps were 100.5-100.9 with otherwise
unremarkable vitals and labs. Was started on Zosyn and admitted.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- ___: developed obstructive jaundice, ERCP performed with
stent placecment, brushings showed atypical cells
- ___: developed liver abscess and E coli bacteremia, on
ertepenem through ___
- ___: Imaging showed no disease outside the hilar region,
MRI showed a 2.7 x 2 cm mass with encasement of the left portal
vein and involvement of the right and main portal vein, possibly
the right hepatic artery. CA ___ was 3700.
- ___: ERCP showed localized biliary strictures, two stents
replaced. Brushings negative for malignancy.
- ___: placed on liver transplant list
- ___: MRI Head showed a 13 x 12 mm vestibular schwannoma
- ___: chemoRT with infusional ___. 45 Gy given as
1.5 Gy BID, 225 mg/m2/day CI (490 mg daily)
- ___: ERCP for placement of brachytherapy seeds, c/b fever
and
E coli bacteremia.
- ___: EBRT boost of 6 Gy given as 1.5 Gy BID given difficulty
with brachytherapy
PAST MEDICAL HISTORY (per OMR):
HBV
HTN
depression
gout
hypothyroid
R schwannoma s/p proton beam treatment ___, annual MRI
surveillance
s/p partial thyroidectomy (benign lesions)
s/p bilateral hip replacements
s/p R rotator cuff surgery
Social History:
___
Family History:
No family history of malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: 100.1 PO 128 / 84 87 18 93 Ra
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: CN III-XII intact, strength b/l ___ intact
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1457)
Temp: 97.7 (Tm 98.4), BP: 122/71 (119-122/68-75), HR: 79
(49-79), RR: 18, O2 sat: 93% (93-96), O2 delivery: RA
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: CN III-XII intact, strength b/l ___ intact
Pertinent Results:
===============
ADMISSION LABS:
___
___ 09:24PM BLOOD WBC-7.7 RBC-4.27* Hgb-12.4* Hct-38.8*
MCV-91 MCH-29.0 MCHC-32.0 RDW-15.2 RDWSD-50.4* Plt ___
___ 09:24PM BLOOD ___ PTT-27.2 ___
___ 09:24PM BLOOD Neuts-71.8* Lymphs-13.4* Monos-13.4*
Eos-0.7* Baso-0.3 Im ___ AbsNeut-5.51 AbsLymp-1.03*
AbsMono-1.03* AbsEos-0.05 AbsBaso-0.02
___ 09:24PM BLOOD Glucose-86 UreaN-12 Creat-1.0 Na-136
K-4.3 Cl-98 HCO3-24 AnGap-14
___ 09:24PM BLOOD ALT-35 AST-41* AlkPhos-154* TotBili-0.5
___ 09:24PM BLOOD Albumin-4.0
___ 09:32PM BLOOD Lactate-1.3
___ 01:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
===============
DISCHARGE LABS:
===============
___ 07:05AM BLOOD WBC-5.0 RBC-4.00* Hgb-11.7* Hct-36.8*
MCV-92 MCH-29.3 MCHC-31.8* RDW-15.1 RDWSD-51.0* Plt ___
___ 07:05AM BLOOD Glucose-109* UreaN-8 Creat-0.9 Na-143
K-4.1 Cl-104 HCO3-25 AnGap-14
___ 07:05AM BLOOD ALT-31 AST-36 LD(LDH)-146 AlkPhos-112
TotBili-0.4
___ 07:05AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
================
IMAGING STUDIES:
================
RUQ Ultrasound (___):
No sonographic evidence of hepatic abscess. No intrahepatic
bile duct
dilation. Biliary stent partially visualized.
CXR (___): No acute cardiopulmonary process.
MRCP (___):
1. In comparison to the prior MRI of ___, the
overall degree of biliary dilatation has improved, status post
stent placement. However, note is made of patchy edema and
hyperemia of the anterior segments of the right hepatic lobe
with associated thickening and enhancement of the right anterior
bile ducts which are moderately dilated, consistent with
cholangitis.
2. Persistent irregularity and stricturing of the central
intrahepatic bile ducts. Central geographic areas of mildly
increased T2 and mildly decreased T1 signal in the liver, likely
sequelae of prior radiation therapy.
3. Peripheral wedge-shaped areas of T1 hyperintense signal in
the anterior
right lobe of the liver, consistent with lipofuscin deposition
related to
chronic biliary obstruction.
4. Moderate gallbladder wall thickening with nodularity, as
described,
relatively unchanged compared to more recent CT examinations,
but new since ___, likely sequelae of prior
cholecystitis.
CXR (___):
The tip of a new right PICC line projects over the mid to distal
SVC. No
pneumothorax.
=============
MICROBIOLOGY:
=============
__________________________________________________________
___ 9:20 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ @ ___ ON
___ - ___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
__________________________________________________________
___ 1:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
__________________________________________________________
___ 1:00 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:24 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with cholangioca, h/o hepatic abscess, p/w RUQ
pain and fevers, benign RUQ us// evaluate for infectious process
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 10 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: ___ abdominal CT and ___ MRCP
FINDINGS:
Lower Thorax: There is no pleural effusion.
Liver/biliary: A few scattered punctate nonenhancing foci scattered throughout
the liver are overall unchanged in consistent with cystic biliary hamartomas.
In comparison to the prior study of ___, the liver parenchyma
appears heterogeneous with geographic areas of increased T2 signal
particularly in the right anterior lobe. This area demonstrates heterogeneous
hyper enhancement on the arterial phase with mild persistent hyperenhancement
on subsequent phases of contrast. On the right anterior duct is mildly
dilated and demonstrates wall thickening enhancement. The anterior branch of
the right portal vein appears patent, but mildly attenuated. The signal
changes are most consistent with an infectious/inflammatory process
(cholangitis). Additionally, note is made of wedge-shaped areas of
hyperintense T1 signal in the anterior right lobe, consistent with late
profuscin deposition related to chronic biliary obstruction. Central areas of
mildly decreased T1 and mildly increased T2 signal extending to the hilum
probably reflect radiation related changes.
Biliary stents are better appreciated on the preceding CT. The common bile is
normal in caliber. Previously seen high-grade stenosis at the proximal CBD
has improved. Intrahepatic biliary dilatation is overall improved since the
prior examination of ___, but likely unchanged compared to the
most recent prior CT from ___ abdominal CT. The central intrahepatic
bile ducts remain narrowed with areas of stricturing. There is nodular
gallbladder wall thickening. The appearance is similar to the CT scans dating
back to ___, but new since ___ when only wall edema was
present. The overall appearance and time course favors a chronic inflammatory
process.
Pancreas: The pancreas enhances homogeneously. The main pancreatic duct is
normal in caliber. Pancreas divisum variant noted.
Spleen: The spleen is not enlarged. An accessory spleen is again noted.
Adrenal Glands: The adrenal glands are within normal limits.
Kidneys: Redemonstrated are multiple simple cysts in bilateral kidneys. There
are no concerning renal lesions. No hydronephrosis.
Gastrointestinal Tract: The stomach is decompressed. There is no bowel
obstruction.
Lymph Nodes: A mildly prominent periportal lymph node is similar to the prior
examination. No pathologically enlarged lymph nodes identified.
Vasculature: The abdominal aorta is normal in caliber. The celiac axis, SMA,
and bilateral renal arteries are within normal limits. The portal vein is
patent however the anterior branch of the right portal vein is mildly
attenuated, new compared to prior examination (series 1501, image 74).
Osseous and Soft Tissue Structures: There are no concerning osseous lesions.
IMPRESSION:
1. In comparison to the prior MRI of ___, the overall degree of
biliary dilatation has improved, status post stent placement. However, note
is made of patchy edema and hyperemia of the anterior segments of the right
hepatic lobe with associated thickening and enhancement of the right anterior
bile ducts which are moderately dilated, consistent with cholangitis.
2. Persistent irregularity and stricturing of the central intrahepatic bile
ducts. Central geographic areas of mildly increased T2 and mildly decreased
T1 signal in the liver, likely sequelae of prior radiation therapy.
3. Peripheral wedge-shaped areas of T1 hyperintense signal in the anterior
right lobe of the liver, consistent with lipofuscin deposition related to
chronic biliary obstruction.
4. Moderate gallbladder wall thickening with nodularity, as described,
relatively unchanged compared to more recent CT examinations, but new since
___, likely sequelae of prior cholecystitis.
Radiology Report
INDICATION: ___ year old man with right PICC// Right 46cm PICC ___ ___
Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right PICC line projects over the mid to distal SVC. There is no
focal consolidation, pleural effusion or pneumothorax identified. Unchanged
calcification in the left costophrenic angle. Size the cardiomediastinal
silhouette is within normal limits.
IMPRESSION:
The tip of a new right PICC line projects over the mid to distal SVC. No
pneumothorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, RLQ abdominal pain
Diagnosed with Cholangitis, Essential (primary) hypertension
temperature: 100.9
heartrate: 76.0
resprate: 18.0
o2sat: 98.0
sbp: 154.0
dbp: 82.0
level of pain: 2
level of acuity: 3.0 | ___ w/ HTN, HBV, BPH, gout, and cholangiocarcinoma, s/p chemoRT
with infusional ___, course c/b biliary strictures s/p 2 biliary
stents and recurrent MDR E. coli BSI and hepatic abscesses
(resolved on most recent CT), now p/w acute onset RUQ abdominal
pain and low grade fevers, found to have cholangitis and C.
Diff.
============= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
Reglan / Methotrexate / Dronabinol / chlorhexidine / vancomycin
/ levofloxacin / Betadine / Feraheme / cefepime / adhesives
Attending: ___.
Chief Complaint:
RIJ line infection
Major Surgical or Invasive Procedure:
J tube exchange w/ interventional radiology (___)
G tube exchanged w/ interventional radiology (___)
History of Present Illness:
Patient is a ___ h/o eosinophilic enteropathy, postural
orthostatic tachycardia syndrome with autonomic dysfunction and
gastroparesis, TPN-dependent s/p gastric pacemaker, adrenal
insufficiency, transfusion-dependent chronic anemia, and
recurrent bacteremia due to line infections, who presents with
fevers, purulent discharge from right sided tunneled line, and
pain along right chest wall around her tunneled line.
Upon further review of HPI, patient was feeling well following
her most recent hospitalization (___). Over the weekend she
was able to go to work, but admits feeling exhausted afterwards.
Has had intermittent "low-grade temps" and intermittent
chills/sweats, but this is baseline for her. She was seen ___
in ___ clinic for lab draw from line, without any evidence
of line infection at that time. Later in day, however, on ___
she developed acute discomfort at her tunneled line exit site in
association with fever>101. At that time, she noted purulent
discharge from the site (has image on her iPhone) and came to ED
for further evaluation.
In the ED, she was tachycardic, normotensive, and afebrile. She
was started on IV zosyn and clindamycin for presumed line
infection. A femoral CVL was placed in setting of potential
CLABSI/sepsis syndrome and avoidance of using possibly
contaminated R IJ CVL. However, after review by ___ RN ___
___, plan to continue R IJ CVL use in an attempt for line
preservation pending blood culture results. R femoral CVL has
since been discontinued.
Of note, patient was recently admitted with line infections
___, and ___. Patient has been hospitalized
with recurrent line infections, with a total of 20
hospitalizations at ___ since ___. She has had
polymicrobial bloodstream infections, including Staph aureus,
Klebsiella pneumoniae, Enterococcus faecalis, coag negative
Staph, Pseudomonas ___ albicans and
parapsolosis, and Enterobacter cloaca and asburiae.
Patient's current RIJ was placed by ___ under general anesthesia
on ___, during admission for LIJ infection and RUL
pneumonia. Blood cultures sterile at that time. LIJ subsequently
removed, and she completed course of daptomcyin/zosyn through
___, for SSI at LIJ site and PNA.
In the ED:
Initial vital signs were: T: 98.5, HR: 126, BP: 130/94, RR: 20,
100% RA
Exam notable for:
- Purulence from right sided tunneled line
- Lungs CTA bilaterally
- Abdomen soft, nontender with GJ tube c/d/i
Labs were notable for:
- No leukocytosis, WBC 4.0
- HgB 9.4, Hct: 29.7, Plt 131
- Chemistry panel, LFTs within normal limits
- VBG, lactate also normal
- Blood cultures growing GRAM POSITIVE COCCI IN CLUSTERS
Studies performed include:
CXR (___): No acute cardiopulmonary process.
Patient was given:
- IVF
- IV Zosyn
- IV Clindamycin
- IV Dilaudid PRN
- IV Diphenhydramine PRN pruritis
- IV Daptomycin
- IV Promethazine PRN nausea
Consults: None
Vitals on transfer: T: 99.0F PO, BP: 124/88, HR: 103, RR: 20,
100% Ra
Upon arrival to the floor, the patient is afebrile. She denies
any subjective fevers/chills. She does have tenderness to
palpation over the R lateral edge of her RIJ site, with
associated erythema and purulent drainage. Otherwise, no SOB,
cough, abdominal pain, N/V/D.
Past Medical History:
-Eosinophilic GI disease involving esophagus, stomach and small
intestine
-TPN dependent (cycles over 12 hours at night)
-Previously had been doing: G tube for meds and venting, J tube
for trickle feeds (___) but this is variable.
-POTS with concomitant workup for dysautonomia and Ehlers Danlos
-Adrenal insufficiency
-___: Line-associated Enterobacter absuriae and C.
parapsilosus bacteremia treated with line exchange and 14 days
of cefepime and IV fluconazole
-___: Line infection although blood cultures negative,
treated with IV daptomycin.
-___: Line-associated DVT, started on lovenox
-___: GNR bacteremia and candidal fungemia, ~month-long
hospitalization
-___: enterobacter and klebsiella bacteremia
-Severe gastroparesis
Social History:
___
Family History:
She has an identical twin who has some symptoms of POTS and
question eosinophilic esophagitis and joint pain, but does not
carry a formal diagnosis. She has a maternal cousin with ___
disease. Father has hypertension and a colon tumor. Her maternal
uncle died of pancreatic cancer.
Physical Exam:
Admission Physical Exam:
==============
VITALS: T: 99.0F PO, BP: 124/88, HR: 103, RR: 20, 100% Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition. Oropharynx is clear.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
CHEST: Erythematous, tender RIJ site with purulent drainage
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
ABDOMEN: G tube and J tube site c/d/i. Normal bowels sounds, non
distended, non-tender to deep palpation in all four quadrants.
No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
Discharge Physical Exam
T 99.0 BP 122 / 76 HR 89 RR 16 100% Ra
General: oriented, resting comfortably in bed
Skin: mild erythema around ___, mild tenderness to palpation
Abdominal: mild erythema and irritation around G-tube dressed
with drain sponges without significant drainage. J-tube clean
and dry without erythema.
Pertinent Results:
Admission Labs:
========================
___ 11:15AM BLOOD WBC-4.0 RBC-4.07 Hgb-9.4* Hct-29.7*
MCV-73* MCH-23.1* MCHC-31.6* RDW-17.3* RDWSD-46.1 Plt ___
___ 11:15AM BLOOD Neuts-67.6 ___ Monos-7.5 Eos-0.3*
Baso-0.5 Im ___ AbsNeut-2.70 AbsLymp-0.95* AbsMono-0.30
AbsEos-0.01* AbsBaso-0.02
___ 11:15AM BLOOD Glucose-109* UreaN-10 Creat-0.7 Na-140
K-3.6 Cl-104 HCO3-22 AnGap-14
___ 11:15AM BLOOD ALT-11 AST-12 AlkPhos-84 TotBili-0.4
___ 11:15AM BLOOD TotProt-6.5 Albumin-4.0 Globuln-2.5
Calcium-8.7 Phos-3.4 Mg-1.8
___ 12:32AM BLOOD ___ pO2-35* pCO2-39 pH-7.43
calTCO2-27 Base XS-1
Other Labs:
========================
___ 04:16AM BLOOD WBC-3.8* RBC-2.98* Hgb-6.8* Hct-22.6*
MCV-76* MCH-22.8* MCHC-30.1* RDW-17.6* RDWSD-47.3* Plt ___
___ 06:06AM BLOOD WBC-2.7* RBC-2.85* Hgb-6.7* Hct-21.9*
MCV-77* MCH-23.5* MCHC-30.6* RDW-17.0* RDWSD-47.5* Plt ___
___ 06:30AM BLOOD Lipase-31
___ 05:09AM BLOOD calTIBC-393 ___ Ferritn-6.6* TRF-302
___ 05:09AM BLOOD Triglyc-213*
___ 06:30AM BLOOD Triglyc-460*
___ 11:36PM BLOOD Lactate-1.2
Imaging:
========================
CXR (___): FINDINGS:
Right subclavian line terminates at the cavoatrial junction
without evidence of pneumothorax. No focal consolidation seen.
There is no pleural effusion or pneumothorax. The cardiac
mediastinal silhouettes are stable and unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
CXR (___):
IMPRESSION:
In comparison with the study of ___, there is no
evidence of acute
pneumonia, vascular congestion, or pleural effusion. Central
catheter again extends to the lower SVC. Another tubular
structure projected over the chest is external to the patient.
Upper Extremity Doppler US (___):
IMPRESSION:
Patency of the bilateral internal jugular veins.
TTE (___):
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. The central line
apepars to traverse the tricuspid annulus. Normal left
ventricular wall thickness, cavity size, and regional/global
systolic function (biplane LVEF = 58 %). The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. There is a small pericardial effusion.
IMPRESSION: No valvular pathology or pathologic flow identified.
Normal biventricular cavity sizes with preserved regional and
global biventricular systolic function.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Discharge Labs:
=======================
___ 04:58AM BLOOD WBC-2.7* RBC-2.88* Hgb-7.3* Hct-23.4*
MCV-81* MCH-25.3* MCHC-31.2* RDW-16.8* RDWSD-50.4* Plt ___
___ 04:58AM BLOOD UreaN-9 Creat-0.7 Na-134* K-4.4 Cl-101
HCO3-24 AnGap-9*
___ 04:58AM BLOOD ALT-17 AST-17 AlkPhos-78 TotBili-0.2
___ 04:58AM BLOOD Calcium-8.6 Phos-4.8* Mg-2.3
___ 05:09AM BLOOD calTIBC-393 ___ Ferritn-6.6* TRF-302
___ 04:58AM BLOOD Triglyc-197*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
2. Fentanyl Patch 12 mcg/h TD Q48H
3. Fexofenadine 180 mg PO BID
4. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
5. Hydrocortisone 2.5 mg PO QPM
6. Hydrocortisone 5 mg PO QAM
7. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
8. Lidocaine 5% Patch 2 PTCH TD QAM
9. Promethazine 25 mg IV Q6H:PRN nausea
10. Pyridostigmine Bromide 60 mg PO Q8H
11. Sarna Lotion 1 Appl TP QID:PRN itching
12. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
13. Vitamin D 1000 UNIT PO DAILY
14. Bystolic (nebivolol) 15 mg oral DAILY
15. Nucala (mepolizumab) 1 infusion IV EVERY 8 WEEKS
16. DiphenhydrAMINE 50 mg IV Q4H:PRN pruritis, please
pre-medicate prior to antibiotics to prevent rxn
17. HYDROmorphone (Dilaudid) ___ mg PO/NG Q4H:PRN Pain -
Moderate
Discharge Medications:
1. Bacitracin Ointment 1 Appl TP PRN With Dressing Changes
RX *bacitracin zinc 500 unit/gram apply to ___ site for
dressing changes as needed Refills:*0
2. Calcium Carbonate Suspension 1250 mg PO TID:PRN give with
methadone for intestinal burning
RX *calcium carbonate 500 mg/5 mL calcium (1,250 mg/5 mL) 1250
mg by mouth three times a day Refills:*0
3. Daptomycin-Heparin Lock ___AILY RIJ Infection
Daptomycin 2mg/mL
+ Heparin 100 Units/mL
4. Daptomycin-Heparin Lock 10 mg LOCK Q2H:PRN Lock IV when not
using
Daptomycin 2mg/mL
+ Heparin 100 Units/mL
5. Daptomycin 350 mg IV Q24H MRSA bacteremia
Administer through ___
RX *daptomycin 500 mg 350 mg IV daily Disp #*31 Vial Refills:*0
6. Gabapentin 600 mg PO TID
RX *gabapentin 300 mg/6 mL (6 mL) 12 mL by mouth three times a
day Disp #*1 Bottle Refills:*0
7. Hydromorphone (Oral Solution) 1 mg/1 mL ___ mg PO Q4H Pain
RX *hydromorphone 1 mg/mL ___ mL by mouth every four (4) hours
Refills:*0
8. Lidocaine 5% Ointment 1 Appl TP TID:PRN G-tube stoma pain
RX *lidocaine 5 % apply small amount of ointment three times a
day Refills:*0
9. Methadone (Oral Solution) 2 mg/1 mL 10 mg PO BID
RX *methadone 10 mg/5 mL 10 mg by mouth twice a day Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17g powder(s) by mouth
once a day Refills:*0
11. Senna 17.2 mg PO DAILY
RX *sennosides [senna] 8.8 mg/5 mL 10 mL by mouth once a day
Refills:*0
12. Bystolic (nebivolol) 15 mg oral DAILY
13. DiphenhydrAMINE 50 mg IV Q4H:PRN pruritis, please
pre-medicate prior to antibiotics to prevent rxn
14. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL
DWELL DAILY
15. Fexofenadine 180 mg PO BID
16. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
17. Hydrocortisone 2.5 mg PO QPM
18. Hydrocortisone 5 mg PO QAM
19. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
20. Lidocaine 5% Patch 2 PTCH TD QAM
21. Nucala (mepolizumab) 1 infusion IV EVERY 8 WEEKS
22. Promethazine 25 mg IV Q6H:PRN nausea
23. Pyridostigmine Bromide 60 mg PO Q8H
24. Sarna Lotion 1 Appl TP QID:PRN itching
25. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
26. Vitamin D 1000 UNIT PO DAILY
27.TPN
Resumption of home TPN
28.IV medication use
Resumption of IV medications prior to admission
29.Daptomycin-heparin lock
Daptomycin-Heparin Lock 5mg LOCK DAILY IN EACH LUMEN
Daptomycin 1mg/mL + Heparin 100 Units/ml
2 LOCKS daily until ___ (total 62 doses)
30.Hydration
Resumption of hydration prior to admission
31.Outpatient Lab Work
Patient needs weekly outpatient CBC, BUN, Cr, CPK, and CRP LFTs,
riglycerides, CBC, BUN, Cr, CPK, and CRP
ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC-FAX:
___
Also send all labs to ___. fax: ___ phone:
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
eosinophilic enteropathy on IL-5 inhibitor w/ subsequent GI
bleeding w/ transfusion dependence
postural orthostatic tachycardia syndrome with autonomic
dysfunction
gastroparesis (TPN-dependent, gastric pacemaker, G tube, J tube)
adrenal insufficiency on hydrocortisone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT UP EXT VEINS US
INDICATION: ___ year old woman with recurrent CVL infections.// Please look at
RIJ and LIJ to assess for clots.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: ___.
FINDINGS:
Tailored study to the bilateral internal jugular veins as requested.
There is patency of the bilateral internal jugular veins, as well as the left
subclavian vein.
IMPRESSION:
Patency of the bilateral internal jugular veins.
Radiology Report
INDICATION: ___ year old woman presenting for routine J tube exchange
COMPARISON: J-tube exchange ___
TECHNIQUE:
OPERATORS: Dr. ___ and Dr. ___,
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: General anesthesia was administered by the anesthesiology
department. Please refer to anesthesiology notes for details.
MEDICATIONS: None
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2.6 min, 4 mGy
PROCEDURE: 1. Exchange of a jejunostomy tube.
2. Application of silver nitrate to G-tube site granulation tissue
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper abdomen and tube site was prepped and draped in the usual
sterile fashion.
The existing low-profile jejunostomy tube was injected with contrast and
showed opacification of the valvulae conniventes. An exchange length stiff
Glidewire was advanced through the tube into the jejunum. The existing tube
was then removed using gentle traction. A low profile, 18 ___, 2.5 cm
stomal length jejunostomy tube was advanced over the wire into the jejunum and
the balloon was inflated using contrast diluted in sterile water. Contrast
injection confirmed appropriate position.
Lastly, at the request of the patient, a small amount of silver nitrate was
applied to the granulation tissue at the G-tube site.
Patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Low profile, 18 ___, 2.5 cm jejunostomy tube in the jejunum.
IMPRESSION:
1. Successful exchange of a jejunostomy tube for a new low profile, 18
___, 2.5 cm jejunostomy tube. The tube is ready to use.
2. Administration of silver nitrate to granulation tissue of the G-tube site.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ yo F h/o eosinophilic enteropathy on IL-5 inhibitor w/
subsequent GI bleeding w/ transfusion dependence and chronic line infections
with recent fever// Please r/o PNA
IMPRESSION:
In comparison with the study of ___, there is no evidence of acute
pneumonia, vascular congestion, or pleural effusion. Central catheter again
extends to the lower SVC. Another tubular structure projected over the chest
is external to the patient.
Radiology Report
INDICATION: ___ year old woman with eosinophilic enteropathy c/b TPN
dependence, G-tube, and J-tube (recently replaced this admission). Last button
G-tube exchange ___// Button G-tube replacement
COMPARISON: Prior enteric tube change dated ___.
TECHNIQUE: OPERATORS: Dr. ___, attending radiologist, performed
the procedure.
ANESTHESIA: General anesthesia was administered and monitored by the
department of anesthesiology.
MEDICATIONS: See anesthesia notes
CONTRAST: 5 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.1 min, 1 mGy
PROCEDURE: 1. Exchange of a gastrostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. Anesthesia was induced. The upper abdomen and tube site was
prepped and draped in the usual sterile fashion.
The existing tube was injected with contrast and showed opacification of the
gastric rugae. The balloon was deflated. A ___ wire was advanced through
the tube into the stomach. The existing tube was then removed using gentle
traction. A 18 ___, 3 cm stoma length, low-profile G-tube tube was advanced
over the wire into the stomach and the balloon was inflated using contrast
diluted in sterile water. Contrast injection confirmed appropriate position.
Sterile dressing was applied. Patient tolerated the procedure well and there
were no immediate post-procedure complications.
FINDINGS:
1. 18 ___, 3 cm stoma length, low profile tube in the stomach.
IMPRESSION:
Successful exchange of a gastrostomy tube for a new 18 ___, 3 cm stomal
length, low profile gastrostomy tube. The tube is ready to use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Sepsis, unspecified organism, Infect/inflm react d/t oth cardi/vasc dev/implnt/grft, init, Other medical devices associated with adverse incidents
temperature: 99.1
heartrate: nan
resprate: 18.0
o2sat: nan
sbp: 132.0
dbp: 95.0
level of pain: 6
level of acuity: 3.0 | ___ h/o eosinophilic enteropathy on IL-5 inhibitor w/ subsequent
transfusion dependent GI bleeding, postural orthostatic
tachycardia syndrome with autonomic dysfunction and
gastroparesis (TPN-dependent, gastric pacemaker, G tube, J
tube), adrenal insufficiency on hydrocortisone, and recurrent
bacteremia ___ line infections, who presented with MRSA RIJ line
infection and was started on a 6 week course of daptomycin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Comtrex / Aspirin / Benadryl / Neurontin / Demerol / Latex / IV
Dye, Iodine Containing / Zyprexa
Attending: ___.
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year-old right-handed woman with history of
primary generalized epilepsy as well as non epileptic seizures,
history of psychosis with paranoia, depression, poorly
controlled
T2DM now on insulin, coronary artery disease, non-ischemic
cardiomyopathy, and remote history of non-Hodgkins lymphoma who
presents after having a witnessed generalized convulsion.
Mrs. ___ acknowledges me, but will not give a history. Mrs.
___ is accompanied by ___ (___), her
daughter, who witnessed the event and provides the history.
Ms. ___ reports that his morning at about 10:30 that she
witnessed Mrs. ___ have a generalized convulsion that lasted
one to two minutes. Ms. ___ cannot tell me if her movement
was rhythmic or arrhythmic. Ms. ___ notes that ___
did not respond to her when she tried to speak to her. Mrs.
___ eyes were reported to be closed. Ms. ___ was not
incontinent of urine. Mrs. ___ was laying in bed when the
generalized convulsion occurred. Mrs. ___ was confused for
about one hour after she had her convulsion.
Ms. ___ has lived with her mother for at least ___ years
and
has never seen her mother have a seizure. Ms. ___ knows
that
her mother has been taking her levetiracetam and has not missed
a
dose. There has been a concern in the past that she does not
take medication. Mrs. ___ also takes clonazepam 1 mg which
she takes three times daily. There is no concern that Mrs.
___ has a urinary tract infection or any other infection.
Mrs. ___ has been sleeping well. Ms. ___ does not
believe that Mrs. ___ is under any new stress.
Pertinently, while I was speaking to Ms. ___ Mrs. ___
had
a generalized convulsion. Her arms first went into a flexed
tonic position and then she had irregular, non rhythmic shaking
of both arms and legs. Mrs. ___ resisted eye opening, but
when her eyes were opened they were both deviated upward. There
was foaming at the mouth. The event lasted less than one
minute.
There was no tongue laceration and no urinary incontinence.
Mrs.
___ was able to speak to me within a minute of the event and
nodded that she could hear me speaking to her during her event.
Ms. ___ reported that the event that I witnessed was the same
event that occurred earlier this morning.
Past Medical History:
Mrs. ___ had an EMU admission under Dr. ___ in ___
which revealed the presence of frequent spike and polyspike wave
discharges. She also had captured epileptic seizures. She has
been followed by multiple epileptologists in our department, but
was last seen by Dr. ___ in ___. Ms. ___ tells me
that
Mrs. ___ primary care physician prescribes her
levetiracetam.
She was seen as an inpatient on the consult service in ___
because of concern for increased seizure frequency. Dr. ___ that ___ increased seizure frequency was
because
of hyperglycemia. She had EEG studies while inpatient which did
not reveal abnormal epileptiform discharges, just diffuse
slowing. She last had an MRI brain in ___ which was
unrevealing.
Neurology has been consulted recently ___ and ___
because of whole body myoclonic jerks. Dr. ___
have posited several reasons for the jerks, including medication
side effect, metabolic derangement, and conversion disorder.
Ms.
___ reports that ___ has the abnormal myoclonic
jerks at all times.
Mrs. ___ has an ill defined psychiatric history. I reviewed
her OMR briefly and it looks like she has a history of psychosis
that required admission once to Deac4. She otherwise carries a
diagnosis of depression and unspecified mood disorder. She does
not look to see a mental health expert regularly at least in our
system.
Social History:
___
Family History:
No family history of seizures.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Pulse: 96
Blood pressure: 138/92
Respiratory rate: 16
General examination:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic examination:
Mental status:
Patient is awake and answers simple questions, including name,
date, and location, but will not answer more complex questions.
She will not attempt to answer question and will remain quiet.
She does follow simple commands, but not two step commands.
Cranial nerves:
Blinks to threat. PERRL. No gaze preference. No nystagmus.
Face symmetric. Palate elevates symmetrically. Shoulders sit
symmetrically. Tongue protrudes to midline.
Motor:
There is no pronator drift and there is no drift downward of the
legs when held at 45 angle.
Reflexes:
Diffusely hyporeflexic. Plantar reflexes flexor.
=====
DISCHARGE PHYSICAL EXAM:
Temp: 98.3 PO BP: 128/78 HR: 83 RR: 18 O2 sat: 98%
O2 delivery: RA
General examination:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic examination:
Mental status: awake, alert, answers simple questions,
including
name, date, and location, follows two step commands
Cranial nerves: PERRL, EOMI, VFF, no facial droop, tongue
midline
Motor: strength full
Reflexes: Plantar reflexes flexor.
Pertinent Results:
___ 06:30AM BLOOD WBC-5.8 RBC-3.49* Hgb-10.8* Hct-32.6*
MCV-93 MCH-30.9 MCHC-33.1 RDW-14.1 RDWSD-48.1* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-339* UreaN-15 Creat-0.9 Na-138
K-4.0 Cl-101 HCO3-22 AnGap-15
___ 03:01PM BLOOD Lipase-59
___ 06:30AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.6
___ 03:01PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
cvEEG:
Summary of EEG abnormalities:
1) Frequent brief bursts of generalized spike-wave and
polyspike-wave
discharges occurring in ___ Hz runs. This finding indicates
diffuse cortical
hyperexcitability with potential for seizure, and is compatible
with a primary
generalized epilepsy syndrome.
2) Mild diffuse slowing and disorganization present in the
background,
indicating mild superimposed diffuse cerebral dysfunction that
is nonspecific
in etiology.
Seizures/events captured during recording (by date): none
CHEST XRAY:
IMPRESSION:
Mild to moderate enlargement of the cardiac silhouette.
Possible mild
pulmonary vascular congestion, likely accentuated by AP
technique. No focal
consolidation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID
2. LevETIRAcetam 1000 mg PO BID
3. Pregabalin 150 mg PO TID
4. Sertraline 200 mg PO DAILY
5. RisperiDONE 1 mg PO BID
6. Atorvastatin 40 mg PO QPM
7. GlipiZIDE XL 10 mg PO DAILY
8. HydrOXYzine 25 mg PO Q6H:PRN nausea
9. Glargine Unknown Dose
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. linaGLIPtin 5 mg oral DAILY
12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
13. Metoprolol Succinate XL 200 mg PO DAILY
14. Nortriptyline 10 mg PO QHS
15. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Glargine 10 Units Breakfast
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 1 mg PO TID
4. GlipiZIDE XL 10 mg PO DAILY
5. HydrOXYzine 25 mg PO Q6H:PRN nausea
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. LevETIRAcetam 1000 mg PO BID
8. linaGLIPtin 5 mg oral DAILY
9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
10. Metoprolol Succinate XL 200 mg PO DAILY
11. Nortriptyline 10 mg PO QHS
12. Pantoprazole 40 mg PO Q24H
13. Pregabalin 150 mg PO TID
14. RisperiDONE 1 mg PO BID
15. Sertraline 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with seizure // Infectious work-up
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or evidence of
pneumothorax. There may be mild pulmonary vascular congestion. Cardiac
silhouette size is mild to moderately enlarged. Mediastinal contours are
unremarkable given AP technique.
IMPRESSION:
Mild to moderate enlargement of the cardiac silhouette. Possible mild
pulmonary vascular congestion, likely accentuated by AP technique. No focal
consolidation.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 97.2
heartrate: 94.0
resprate: 20.0
o2sat: 97.0
sbp: 127.0
dbp: 86.0
level of pain: 0
level of acuity: 3.0 | ___ year-old right-handed woman with history of primary
generalized epilepsy as well as non epileptic seizures, poorly
controlled T2DM now on insulin, coronary artery disease,
non-ischemic cardiomyopathy, and remote history of non-Hodgkins
lymphoma admitted after a witnessed generalized convulsion.
#SEIZURE: there was a concern for breakthrough seizures. The
patient was hooked up to the EEG, which did not capture any
epileptiform discharges. Infectious and metabolic workups
negative. Therefore, the patient's presentation and history were
thought to be due to nonepileptic events. Patient was started on
her home AEDs.
#COMORBIDITIES: the patient was started on her home medications
without any changes.
== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
headache; left facial droop
Major Surgical or Invasive Procedure:
fluoro-guided lumbar puncture
History of Present Illness:
Ms. ___ is a ___ F w PMhx of HLD, tobacco use, OSA,
and
anxiety who is transferred to ___ ED from ___ after MRA
there noted a 4-5mm aneurysm of the AComm. Neurosurgery was
consulted at ___ ED and recommended neurology consultation for
newly reported left facial droop (present since at least 10AM on
___.
Ms. ___ states that her symptoms began on ___. At
around 3PM in the afternoon, she started to feel a "migraine."
She notes, however, that his migraine did not feel like migraine
headaches she has gotten in the past. She had no N/V and the
pain
was centered around her L temple. She thought that perhaps she
was dehydrated. The pain continued to build over the next
several
hours. At around 12AM, she took some tylenol and the eased up
and
she went to bed after finishing a late shift at work.
The next morning (___) she awoke at 5AM, with a feeling of
intense nausea. When she opened her eyes, the room was
"spinning"
to the right. Her left sided HA was still present and worse than
the evening prior. She tried to sit up, but felt as though she
was being pushed to her left. She scooted herself to the edge of
her bed, grabbed a garbage can and began vomiting profusely.
After several minutes of this, she felt mildly better - though
her dizziness, nausea, and HA were still present. In fact, her
HA
continued to worsen over the course of the morning - and she
does
describe it as "the worst headache of my life."
After vomiting, Ms. ___ tried to find the most comfortable
position. She found that lying very flat and very still was best
for symptom control. Even when she closed her eyes, she still
felt as though the room was spinning. After several hours, she
was able to get up and get dressed. At around 9AM, she went to
the bathroom to brush her teeth and did not notice any drooping
of her face. She was able to walk, but was very cautious and
kept
feeling as though she was falling to the left. She drank some
seltzer water to try to feel a bit better, but noted some pain
with swallowing which she assumed was due to all the vomiting.
At this point (?10AM), she called a cab to take her to the
hospital. From ___, she called her daughter who
told Ms. ___ that she "sounded drugged" - though Ms. ___
had not recieved any medications at that time. At ___, a
___, MRI + MRA brain were performed. The MRA showed a 4-5mm
AComm aneurysm which prompted the doctors there to ___
transfer to ___ ED for neurosurgery evaluation. Of note,
physicians there did note a left facial droop which Ms. ___
states is new since 9AM on ___.
On my interview, Ms. ___ had just undergone an unsuccessful
lumbar puncture but was otherwise doing well. At rest, she
denies
significant dizziness or nausea. She continues to have a mild L
sided HA. She denies any associated weakness, numbness, language
difficulty / confusion, or bowel / bladder problems. She does
note that the left side of her neck has been hurting, starting
with when she presented to ___.
Past Medical History:
migraines, has not had migraine in "years"
-- reports that they are triggered by "eating hot dogs"
-- she will feel a holocephalic HA, and intense N/V
-- after vomiting, she feels much better
anxiety / depression
HLD
obesity and OSA (not using home CPAP)
rheumatoid arthritis
-- previously treated with Enbril in ___ > ___ years ago
-- when she moved to ___, her doctor stopped the medication
and told her that they would simply monitor her. She has had no
further flares off medication.
Social History:
___
Family History:
Mother - recently deceased from COPD/CHF; mother had migraines
Daughter - diabetes ___, migraines
Uncle - deceased from ___ at age ___
Cousin - deceased from ___ at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
VS T 98.1 HR 60 BP 147/77 RR 18 O2SAT 98% RA
GEN - elderly F, pleasant and cooperative, NAD
HEENT - NC/AT, MMM, enlarged tonsils b/l
NECK - full ROM, no menigismus
CV - RRR
RESP - normal WOB
ABD - obese, soft, NT, ND
EXTR - atraumatic, WWP
NEUROLOGICAL EXAM:
MS - awake, alert, oriented x 3. attention to examiner easily
attained and maintained. concentration maintained when recalling
months backwards. recalls a coherent recent and remote medical
histoyr. speech is fluent with normal prosody and no paraphasic
errors. naming, reading, repetition, and comprehension are all
intact. no apraxia. no e/o hemineglect. no left-right agnosia.
CN II L pupils is 4 --> 2 R is 3 --> 2 [III, IV, VI] EOMI, no
nystagmus. she denies double vision in all directions of gaze
but does report symptomatic N when looking up. ? slight
restriction in upgaze of the R eye vs the L eye. [V] V1 - V3
without deficits to light touch bilaterally. she does report
decreased sensation to PP (50% of normal) over R V2 and V3.
[VII] at rest, left side of the mouth hangs open. she gives poor
effort with volitional smile. b/l eye closure and forehead
wrinkling is symmetric. [VIII] hearing intact to voice. [IV, X]
palate elevation symmetric. [XI] SCM/trapezius strength ___ b/l
[XII] tongue midline, ? decreased strength to the L
MOTOR: normal bulk and tone. no pronation, no drift. no orbiting
with arm roll. no tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ 5 4+ 4+ ___ 5
R ___ 5 5
?some elemtn of give-way on the L side
Sensory - in tact to LT throughout. reports decriment to PP,
~50% of normal, to entire RUE and RLE. joint position sense
intact at the great toes bilaterally.
REFLEXES
Bi Tri ___ Pat Ach
L ___ 2 2
R ___ 2 2 = ___ beats of clonus
plantar response upgoing bilaterally.
COORD - no dysmetria with finger to nose testing. good speed and
itnact cadence with rapid alternating movements. sways to the
left and steps out with Romberg.
GAIT - only able to test few steps given, IV attached to pump
attached to bed. normal initation. narrow base. normal stride
length and arm swing. grossly stable.
DISCHARGE PHYSICAL EXAM
R face/arm/leg decriment to PP; ?LUE weakness; L facial droop
Pertinent Results:
ADMISSION LABS
------------------
___ 08:55PM WBC-8.3 RBC-4.20 HGB-12.8 HCT-37.8 MCV-90
MCH-30.5 MCHC-33.9 RDW-12.4 RDWSD-40.7
___ 08:55PM NEUTS-64.1 ___ MONOS-4.2* EOS-1.6
BASOS-0.6 IM ___ AbsNeut-5.31 AbsLymp-2.41 AbsMono-0.35
AbsEos-0.13 AbsBaso-0.05
___ 08:55PM PLT COUNT-248
___ 08:55PM ___ PTT-30.7 ___
___ 08:55PM GLUCOSE-86 UREA N-13 CREAT-0.8 SODIUM-139
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
DISCHARGE LABS
------------------
___ 03:23AM %HbA1c-5.7 eAG-117
___ 06:44AM GLUCOSE-133* UREA N-13 CREAT-0.9 SODIUM-139
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-16
___ 06:44AM WBC-7.1 RBC-4.04 HGB-12.2 HCT-37.3 MCV-92
MCH-30.2 MCHC-32.7 RDW-12.5 RDWSD-42.6
___ 06:44AM ALT(SGPT)-11 AST(SGOT)-17 LD(LDH)-138
CK(CPK)-34 ALK PHOS-76 TOT BILI-0.5
___ 06:44AM CK-MB-1 cTropnT-<0.01
___ 06:44AM PLT COUNT-251
___ 06:44AM ___ PTT-30.2 ___
PERTINENT LABS
------------------
___ 10:30AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 POLYS-0
___ ___ 10:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-36
GLUCOSE-59
IMAGING
------------------
CXR ___
IMPRESSION:
The lung volumes are normal. Normal size of the cardiac
silhouette. Normal
hilar and mediastinal structures. No pneumonia, no pulmonary
edema, no
pleural effusion. No pneumothorax.
MRI&MRV BRAIN ___
IMPRESSION:
1. In comparison with the most recent CTA examination of the
head and neck,
there is an unchanged anterior communicating artery aneurysm,
with no evidence
of underlying subarachnoid hemorrhage. There is no evidence of
acute or
subacute intracranial process, no diffusion abnormalities are
detected, there
is no evidence of abnormal enhancement.
2. Essentially normal MRV of the head, with no evidence of
dural venous sinus
thrombosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. BuPROPion 450 mg PO QAM
3. Citalopram 60 mg PO DAILY
4. Prazosin 1 mg PO QHS
5. Simvastatin 10 mg PO QPM
Discharge Medications:
SAME AS ADMISSION MEDS
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ female with history of ACOMM aneurysm presenting
with headache evaluate for aneurysm at the ACOMM site and other sites.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
5) Spiral Acquisition 4.8 s, 37.6 cm; CTDIvol = 31.7 mGy (Head) DLP =
1,193.1 mGy-cm.
Total DLP (Head) = 2,120 mGy-cm.
COMPARISON: ___ noncontrast head CT
___ head and neck noncontrast MRI/MRA
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
There is prominence of the ventricles and sulci suggestive involutional
changes. The visualized portion of the mastoid air cells, and middle ear
cavities are clear. There is a left maxillary sinus mucous retention cyst.
The visualized portion of the orbits are unremarkable. Dental artifact
moderately limits examination of the oropharynx. Incidental note is made of a
metopic suture.
CTA HEAD: There is minimal atherosclerosis of the bilateral cavernous carotid
arteries. The vessels of the circle of ___ and their principal
intracranial branches appear patent without stenosis or occlusion. A 5 mm
aneurysm arising from the anterior communicating artery is present (5:247,
___. No additional aneurysms are identified. There is a diminutive
left A1 segment. The dural venous sinuses are patent.
CTA NECK:
Mild atherosclerotic calcification at the origin of the left vertebral artery
is noted. Otherwise, the carotid and vertebral arteries and their major
branches appear normal with no evidence of stenosis or occlusion. There is no
evidence of internal carotid stenosis by NASCET criteria.
OTHER:
There is paraseptal and centrilobular emphysema in the bilateral lung apices.
The visualized portion of the thyroid gland is within normal limits. There is
no lymphadenopathy by CT size criteria. There are multilevel degenerative
changes throughout the cervical spine.
IMPRESSION:
1. Head CT with no acute intracranial process. No acute intracranial
hemorrhage.
2. 5 mm anterior communicating artery aneurysm.
3. No additional aneurysms, dissection, or stenosis on CTA.
Radiology Report
EXAMINATION: MRI and MRA Head, MRA of the neck.
INDICATION: ___ year old woman with dizziness, ?multiple cranial nerves, long
tract signs // brainstem stroke? please perform with thin cuts through the
brainstem
TECHNIQUE: Precontrast axial and sagittal T1 weighted images were obtained,
axial FLAIR, axial T2, axial magnetic susceptibility and axial
diffusion-weighted images. The T1 weighted sequences were repeated after the
administration of gadolinium contrast in axial projection. Sagittal MPRAGE
and multiplanar reformations were also obtained, high-resolution images
through the posterior fossa were also obtained with FLAIR technique
MRV of the head. 3D phase contrast MRV of the head was obtained, maximal
intensity projection images were reviewed.
COMPARISON: CTA of the head and neck dated ___.
FINDINGS:
MRI of the head: There is an unchanged aneurysm in the anterior communicating
artery, projecting anteriorly, measuring approximately 3.8 x 5.2 mm in
transverse dimension (image 15, series 15). There is no evidence of acute
intracranial hemorrhage mass, mass effect or shifting of the normally midline
structures. The ventricles are slightly prominent, suggesting mild
ventriculomegaly, however, there is no evidence of transependymal migration of
CSF. The sulci are normal in size and configuration for the patient's age.
No diffusion abnormalities are detected. There is no evidence of abnormal
enhancement. The orbits are normal, the paranasal sinuses and the mastoid air
cells are clear.
MRV of the head. The major dural venous sinuses are patent, there is no
evidence of venous sinus thrombosis.
IMPRESSION:
1. In comparison with the most recent CTA examination of the head and neck,
there is an unchanged anterior communicating artery aneurysm, with no evidence
of underlying subarachnoid hemorrhage. There is no evidence of acute or
subacute intracranial process, no diffusion abnormalities are detected, there
is no evidence of abnormal enhancement.
2. Essentially normal MRV of the head, with no evidence of dural venous sinus
thrombosis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dizziness // r/o infection
COMPARISON: No comparison
IMPRESSION:
The lung volumes are normal. Normal size of the cardiac silhouette. Normal
hilar and mediastinal structures. No pneumonia, no pulmonary edema, no
pleural effusion. No pneumothorax.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ year old woman with dizziness and headache. Question sentinel
bleed.
TECHNIQUE: After informed consent was obtained from the patient explaining
the risks, benefits, and alternatives to the procedure, the patient was laid
in prone position on the fluoroscopic table. A preprocedure time-out was
performed confirming the patient's identity, relevant history, procedure to be
performed and labs.
Puncture was performed at L2-3.
Approximately 10 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 20 gauge spinal needle was inserted into the
thecal sac. There was good return of clear CSF. 20 mls of CSF were collected
in 4 tubes and sent for requested analysis.
COMPARISON: None.
FINDINGS:
20 mls of CSF were collected in 4 tubes.
IMPRESSION:
1. Lumbar puncture at L2 3 without complication.
I, Dr. ___ supervised the trainee during the key components of
the above procedure and I reviewed and agree with the trainee's findings and
dictation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Headache, L Facial droop
Diagnosed with NONRUPT CEREBRAL ANEURYM, FACIAL WEAKNESS, HEADACHE, VERTIGO/DIZZINESS
temperature: 98.1
heartrate: 60.0
resprate: 18.0
o2sat: 98.0
sbp: 147.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with migraines, HLD, tobacco use,
OSA, and anxiety who was admitted as a transfered to ___ ED
from ___ for neurosurgery evaluation of a 4-5mm
AComm aneurysm on MRA. On presentation, she had a new L facial
droop. Chief complaint was headache that does not feel like a
migraine she had in the past. Headache was "the worst headache
of my life," also had some spinning sensation and vomiting. On
admission exam, pt had a new onset L facial droop that activates
symmetrically with R, confirmed with patient when pt was given a
mirror. Sensory exam was non-focal and inconsistent but V2/V3
distribution was decreased to pinprick as was RUE/RLE to
pinprick. Pt had a positive Romberg with sway towards the left
upon walking. Given concerns of possible stroke vs slow-bleeding
SAH, pt was admitted to neuro stroke service.
During her hospitalization, pt noted markedly improved headaches
and nausea; no vomiting. Pt had further labs/imaging: CTA showed
5.5mm aneurysm, NCHCT showed no acute intracranial process.
First LP was unsuccessful, pt had follow-up fluorscopy-guided LP
which was negative for xanthochromia (clear fluid, 0 RBC,
protein/glucose wnl). Risk factors were negative for TSH and
HbA1c, LDL was pending at time of discharge. MRI/MRV showed no
concerns for sinus thrombosis, acute infarction, cortical
changes, or other signs of stroke. Following LP, pt noted back
pain but no worsening of headache. Pt had good motor strength in
upper and lower extremities with good affect at time of
discharge. Furthermore, at time of discharge, pt's exam also
improved with daughter noting no facial droop although sensory
sensing to PP continued to be diffusely patchy and inconsistent
with prior exam. Pt was cleared by neurosurgery with
recommendation for outpatient follow-up regarding aneurysm. Pt
was ambulatory upon discharge, was given a letter to stay home
from work until ___, and will follow-up with
outpatient neurosurgery and outpatient neurology, following
discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Amaurosis fugax
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a ___ w/ h/o CAD s/p cardiac stent and pacemaker,
HTN, HLD who one week ago had an episode of amorosis fugaux w/
transient blackening of L visual field that lasted for about 5
mins. Pt was seen by his PCP where carotid duplex U/S revealed
critical stenosis of L carotid. Pt was set to have caroid
endarterectomy at ___, however, after learning that
the patient had previous radiation to L neck for remote h/o base
of the tongue cancer ___ years ago, he decided to send the
patient
to ___ for further mgmnt. Currently pt is asymptomatic. Denies
any HA/N/V. No vision changes, motor/sensory deficits.
Past Medical History:
CAD s/p cardiac stent and pacemaker, HTN, HLD. Remote h/o base
of the tongue cancer (unresectable) s/p radiation and chemo ___
years ago).
Appendectomy, Pacemaker, Coronary PTCA/Stent
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission:
AF/VSS
Gen: NAD. A&Ox3
Neuro: CN II -XII intact. Motor/sensory grossly intact in all
exctremities. No focal deficits.
CV: RRR
Pulm: EWOB
GI: Abd S/NT/ND
Pulses: All Palpable
Discharge:
Gen: NAD. A/Ox3
Neuro: CN II-XII intact. motor and sensory intact in all four
extremities
CV: RRR
Pulses: palpable femoral, popliteal, dp, pt pulses bilaterally
Pertinent Results:
___ 06:25AM BLOOD WBC-6.0 RBC-5.23 Hgb-16.8 Hct-51.0 MCV-98
MCH-32.2* MCHC-33.0 RDW-13.2 Plt ___
___ 06:25AM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-141
K-3.7 Cl-100 HCO3-32 AnGap-13
___ 06:25AM BLOOD Calcium-9.8 Phos-3.4 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 30 mg PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 30 mg PO DAILY
6. Amlodipine 5 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Enoxaparin Sodium 130 mg SC DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left carotid artery stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ with Left carotid stenosis by U/S at OSH, images unavailable.
TECHNIQUE: Noncontrast CT head was performed. CTA of the head and neck
performed. 3-D renderind and MIP reconstructions were performed on a separate
workstation.
COMPARISON: No prior examinations for comparison at this institution.
FINDINGS:
Noncontrast CT head: Periventricular and patchy bihemispheric deep white
matter hypodensity is nonspecific; in light of the patient's age, this may
represent sequela of chronic microangiopathic change. Ventricular, cisternal,
and sulcal prominence may be a function of age-related parenchymal volume
loss. There is prominence of extra-axial space at the bifrontal convexities.
No edema, mass effect, midline shift, or herniation is identified. No
intra-axial or extra-axial hemorrhage or fluid collection is seen. No
significant bony abnormalities are seen. The paranasal sinuses demonstrate
scattered areas of mucosal thickening. The mastoid air cells are clear
CTA head: There is suboptimal opacification of the arterial vessels.
Atherosclerotic calcifications are noted within the petrous, cavernous, and
supraclinoid portions of the internal carotid arteries. There is asymmetric
mldly diminished caliber of the left A1 and MCA arteries compared to the
contralateral side. The anterior and middle cerebral arteries are otherwise
unremarkable. The anterior communicating artery region is normal. The right
posterior communicating artery is not seen; the left posterior communicating
artery is small in caliber. Bilateral posterior cerebral, basilar, bilateral
superior cerebellar, and bilateral intradural segments to both vertebral
arteries appear unremarkable. The vertebral arteries are codominant. No
saccular aneurysm or AVM is identified.
CTA neck: There is suboptimal opacification of the arterial vessels.
Atherosclerotic calcifications are noted within the aortic arch. Common
origin of the innominate and left common carotid arteries is a normal variant.
The origin of the innominate, left common carotid, and left subclavian
arteries are otherwise unremarkable. There is extensive atherosclerotic
calcification and soft plaque within region of the right carotid bulb and
proximal right internal carotid artery with approximately 60% stenosis by
NASCET criteria. Prominent atherosclerotic calcifications and soft plaque are
noted within the region of the left carotid bulb and proximal left internal
carotid artery, with near-complete occlusion of the proximal left internal
carotid artery; there is reconstitution of flow beyond the area of high grade
stenosis. Atherosclerotic calcifications are also noted within the bilateral
external carotid arteries. The atherosclerotic calcifications are also noted
at the origins of the vertebral arteries; otherwise normal enhancement of the
vertebral arteries. No dissection, aneurysm, or pseudoaneurysm is identified.
The thyroid gland is normal in size and contour without evidence of mass or
cyst. The salivary glands as visualized are unremarkable. No significant
lymphadenopathy is appreciated. Scattered mildly prominent subcentimeter
cervical lymph nodes are non specific. The aerodigestive tract is patent.
The nasopharynx, oropharynx, hypopharynx, supraglottic and epiglottic larynx,
and proximal trachea are normal without mass, fluid collection, or asymmetry.
The vocal cords appear unremarkable without gross asymmetry. The valleculae
and piriform sinuses demonstrate no gross abnormalities. There is an 8 mm
subcutaneous nodule with within the right anteromedial mid neck. No abnormal
area of contrast enhancement is seen. The included bones demonstrate
scattered multilevel degenerative changes.
The included lungs demonstrate dependent hypoventilatory changes. A 4.4 mm
right upper lobe nodule, and a 3 mm right upper lobe subpleural nodule, are
noted. Two calcified probable granulomas noted within the left upper lobe.
IMPRESSION:
Age-related involutional chronic microangiopathic changes without acute
intracranial process identified.
Near-complete occlusion of the left internal carotid artery.
Approximately 60% stenosis of the right internal carotid artery.
Pulmonary nodules measuring up to 4 mm in the right upper lobe can be further
characterized with CT chest as clinically warranted.
Radiology Report
HISTORY: ___ male with left internal carotid artery occlusion and 70%
right internal carotid artery stenosis via report from outside hospital.
COMPARISON: CTA of the neck ___
TECHNIQUE: Evaluation of bilateral extracranial internal carotid arteries was
performed with grayscale, color and spectral Doppler ultrasound.
FINDINGS:
RIGHT
There is long segment severe calcified plaque within the proximal right
internal carotid artery.
On the right side, the peak systolic/diastolic velocities were 119/37 cm/sec
in the proximal ICA, 213/76 cm/sec in the mid ICA, and 189/63 cm/sec in the
distal right ICA. Additionally, peak systolic velocity in the right common
carotid artery was 57 cm/sec and peak systolic velocity in the right external
carotid artery was 157 cm/s. The right vertebral artery demonstrates
antegrade flow with a peak systolic velocity of 76 cm/sec.
The right ICA/CCA ratio was 3.7 with a predicted 60-69% stenosis
LEFT
Severe calcified plaque with near complete occlusion within the proximal left
internal carotid artery.
On the left side, the peak systolic/diastolic velocities were ___ cm/sec in
the proximal ICA, 99/39 cm/sec in the mid ICA, and 384/137 cm/sec in the
distal left ICA. Additionally, peak systolic velocity in the left common
carotid artery was low at 24 cm/sec and peak systolic velocity in the left
external carotid artery was also low at 23 cm/s. The left vertebral artery
demonstrates antegrade flow with a peak systolic velocity of 28 cm/sec.
The left ICA/CCA ratio was 16 with a predicted ___ % stenosis.
IMPRESSION:
1. Calcified plaque bilaterally.
2. ___ % stenosis of the left internal carotid artery with slow flow more
proximally in the left common carotid artery.
2. 60-69% stenosis of the right internal carotid artery.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CAROTID OCCLUSION
Diagnosed with OCCLUS CAROTID ART NO INFARCT, STATUS POST ADMINISTRATION OF TPA (RTPA) IN A DIFFERENT FACILITY WITHIN THE LAST 24 HOURS PRIOR TO ADMISSION TO CURRENT FACILITY
temperature: 98.1
heartrate: 96.0
resprate: 16.0
o2sat: 96.0
sbp: 156.0
dbp: 66.0
level of pain: nan
level of acuity: 2.0 | Mr. ___ was transferred to ___ from an outside hospital
on ___ for evaluation and management of his carotid artery
stenosis. He had a CTA of his head and neck, which showed
Age-related involutional chronic microangiopathic changes
without acute intracranial process identified. Near-complete
occlusion of the left internal carotid artery. Approximately
60% stenosis of the right internal carotid artery. Pulmonary
nodules measuring up to 4 mm in the right upper lobe can be
further characterized with CT chest as clinically warranted. He
also had repeat ultrasound imaging of his carotid arteries,
which showed . Calcified plaque bilaterally, ___ % stenosis of
the left internal carotid artery with slow flow more proximally
in the left common carotid artery and 60-69% stenosis of the
right internal carotid artery. This was all consistent with
outside hospital reports. He remained symptom-free aside from
the single episode of temporary left eye vision change that
prompted his initial workup. He was placed on a heparin drip,
aspirin and plavix as well as his home blood pressure
medications and statin. Given that his symptoms had not recurred
and his situation, while very concerning, does not call for
emergency surgery, he was discharged on aspirin, plavix, lovenox
and home medications and plans were made for scheduled left
carotid stent placement next week. He was given prescriptions
for his new medications as well as teaching for his Lovenox
injections. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___
Chief Complaint:
Atrial fibrillation with rapid ventricular response
Presyncope
Major Surgical or Invasive Procedure:
Cardioversions on ___ (unsuccessful) and ___
(successful)
History of Present Illness:
___ gentleman with hypertension, CKD III, PMR on steroids since
___ and recently diagnosed atrial fibrillation presenting with
presyncope and low grade fever. He was diagnosed with both Afib
and PMR in ___ and was started on prednisone and xarelto
shortly thereafter. He saw Dr. ___ ___ and his
metoprolol was increased and plan was made for cardioversion,
scheduled for later this week.
His initial diagnosis was made after a presyncopal episode in a
___ parking lot, and he has since had 2 more episodes,
on of them at his PCP's office on ___. At that visit he was
found to have BP 94/70 and pulse irregular, 121. Metoprolol was
stopped, he was started diltiazem 30mg BID. Prednisone for PMR
was also decreased to 5mg daily at that time. He saw his PCP
again on the day of admission and was found to have a
temperature of 99.6 (while on steroids) and was still have
presyncopal episodes especially with walking so was referred to
the ED. He says that he knows when he is going to have a
presyncopal episode because he starts to feel very weak, but no
dizziness, chest pain, nausea, diaphoresis, tunnel vision.
In the ED, initial vitals were: 99.3 100 159/66 20 98%
- Labs were significant for leukocytosis to 14k, Hgb 15
(baseline ___ creatinine 1.3 (basleine),
- ECG showed afib with RVR with a rate of about 130, no ST
changes, very similar in appearance to tracing from PCP office
on ___.
- Imaging revealed a normal 2-view CXR on prelim read.
- The patient was given 10mg IV diltiazem and 30mg PO and
admitted to medicine.
Upon arrival to the floor, patient is feeling well, he is
accompanied by his wife ___.
REVIEW OF SYSTEMS:
(+) Per HPI, also notes that he had 3 episodes of large volume
brown watery diarrhea this morning which is unusual for him.
Denies travel, suspicious foods, or sick contacts, denies recent
antibiotics. Left shoulder pain ongoing, worse today
(-) Denies feeling subjective fever, chills, night sweats,
recent weight loss or gain. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.
Past Medical History:
-Atrial fibrillation dx ___, on xarelto
-Hypertension
-Polymyalgia rheumatica dx ___ on long steroid taper
-Chronic kidney disease III ___ 1.3, followed by ___
-Benign positional vertigo
-Cough variant asthma
-Glaucoma
-h/o perirectal abscess
Social History:
___
Family History:
Mother with unknown "heart problems"
Father had "heart bypass surgery twice"
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3F, BP 104/74, HR 110, RR 14, 97% RA
supine 126/84, HR 110
sitting 104/74 HR 120
statnding 104/64 HR 126
General: Alert, oriented, no acute distress, laying flat
comfortably in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, pupils are
at least 6mm in darkened room but equal and reactive
Neck: Supple, JVP not elevated, no LAD; has blanchable erythema
and small papules over the skin of his neck
CV:tachycardic, irregularly irregular, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly distended but non-tender, normal bowel
sounds, tympanitic to percussion. Firm area in RLQ difficult to
characterize due to mild distension
GU: No foley
Ext: Warm, well perfused, 2+ DP and ___ pulses, no clubbing,
cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
DISCHARGE EXAM:
Vitals: 98.4F, BP 108/77, HR 65, RR 16, 98% RA
General: Alert, oriented, no acute distress, laying flat
comfortably in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP not elevated, no LAD
CV: regular, normal S1/S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly distended but non-tender, normal bowel
sounds, tympanitic to percussion. Firm area in RLQ difficult to
characterize due to mild distension
Ext: Warm, well perfused, 2+ DP and ___ pulses, no clubbing,
cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
Pertinent Results:
ADMISSION LABS
===============
___ 06:06PM BLOOD WBC-14.5* RBC-4.69 Hgb-15.0 Hct-43.8
MCV-93 MCH-31.9 MCHC-34.2 RDW-16.2* Plt ___
___ 06:06PM BLOOD Neuts-78.7* Lymphs-13.2* Monos-6.8
Eos-0.8 Baso-0.4
___ 06:06PM BLOOD Glucose-113* UreaN-20 Creat-1.3* Na-135
K-4.7 Cl-98 HCO3-28 AnGap-14
PERTINENT LABS
==============
___ 04:55AM BLOOD Cortsol-7.5
DISCHARGE LABS
===============
___ 11:25AM BLOOD WBC-11.7* RBC-4.28* Hgb-13.6* Hct-40.6
MCV-95 MCH-31.6 MCHC-33.4 RDW-15.8* Plt ___
___ 11:25AM BLOOD ___ PTT-34.4 ___
___ 11:25AM BLOOD Glucose-106* UreaN-19 Creat-1.1 Na-138
K-4.6 Cl-103 HCO3-25 AnGap-15
___ 11:25AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
MICROBIOLOGY
=============
- URINE CULTURE (Final ___: <10,000 organisms/ml.
- BLOOD CULTURE ___ 4:55 am): NGTD (PENDING)
- URINE CULTURE (Final ___: <10,000 organisms/ml.
RELEVANT STUDIES
=================
- EKG (___): Rate 132. Atrial fibrillation with a rapid
ventricular response and baseline artifact precluding adequate
interpretation. No previous tracing available for comparison.
- CXR (___): Lung volumes are low. The heart is borderline
in size. Within the limitations of technique, the mediastinal
and hilar contours are unremarkable. There is no pleural
effusion or pneumothorax. The lungs appear clear. No acute
cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem 30 mg PO BID
2. Rivaroxaban 20 mg PO DAILY
3. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
4. Lorazepam 0.5 mg PO BID
5. QUEtiapine Fumarate 50 mg PO QHS
6. Venlafaxine XR 150 mg PO DAILY
7. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Lorazepam 0.5 mg PO BID
2. QUEtiapine Fumarate 50 mg PO QHS
3. Rivaroxaban 20 mg PO DAILY
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Venlafaxine XR 150 mg PO DAILY
6. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
7. PredniSONE 5 mg PO DAILY
8. Sotalol 120 mg PO BID
RX *sotalol 120 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Cough.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: None.
FINDINGS:
Lung volumes are low. The heart is borderline in size. Within the
limitations of technique, the mediastinal and hilar contours are unremarkable.
There is no pleural effusion or pneumothorax. The lungs appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Syncope
Diagnosed with SYNCOPE AND COLLAPSE, TACHYCARDIA NOS, ATRIAL FIBRILLATION, UNSPECIFIED FALL
temperature: 99.3
heartrate: 100.0
resprate: 20.0
o2sat: 98.0
sbp: 159.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | ___ gentleman with hypertension, CKD III, PMR on steroids since
___, and recently diagnosed atrial fibrillation presenting
with presyncope, in Afib with RVR, and with orthostasis. Started
on diltiazem for rate control, and given slow bolus of 500cc for
orthostasis, after which symptoms improved. Then switched to
sotalol for rhythm control. Cardioversion attempted ___ with
two shocks (300J) but pt had early recurrence of afib. Sotalol
was increased, and pt was cardioverted again on ___ which was
successful. He was continued on home rivaroxaban throughout.
Discharged ___ with ___ of Hearts monitor on new sotalol
regimen of 120mg twice daily, with EP follow-up appt w/ Dr.
___ in 1 month.
# Atrial fibrillation with RVR: ChADS2-VASc 2, making
anticoagulation reasonable to decrease stroke risk. RVR may be
fueled by occult infection and/or mild volume depletion as
discussed below. TSH has been checked and was normal, echo did
not show significant valvular disease. Started on diltiazem in
ED for rate control, which was switched to sotalol for rhythm
control on the floor. Cardioversion attempted ___ with two
shocks (300J) but pt had early recurrence of afib. Sotalol was
increased, and pt was cardioverted again on ___ which was
successful. He was continued on home rivaroxaban throughout.
Discharged ___ with ___ of Hearts monitor on new sotalol
regimen of 120mg twice daily, with EP follow-up appt w/ Dr.
___ in 1 month.
# Presyncopal episodes: Orthostatics positive on arrival, likely
volume depleted due to diarrhea in addition to having Afib with
runs of RVR. Sx improved after rate control and slow 500cc fluid
bolus. AM cortisol was normal. Remained asymptomatic throughout
hospitalization, while being monitored on telelmetry. ___
consulted but deferred as pt was ambulating well on his own.
# Leukocytosis: 14 WBC count on arrival to ED, resolved after
fluid bolus. Could have been due to steroids. No other signs of
sepsis, temperature not exceeding ___ but he is on chronic
prednisone, which may be acting as an antipyretic. He is at risk
for PCP after being on high dose steroids (>20mg/day for >20
days earlier this year), but his CXR was not consistent with
this. Diarrhea is most likely related to diet but could be a
viral gastroenteritis. No RFs for c. diff. UA bland, blood and
urine cultures NGTD.
CHRONIC ISSUES
# Chronic kidney disease: During admission, was at baseline of
Cr 1.3.
# Polymyalgia rhematica: Given prednisone 20 as outpt, tapered
to 10 on ___ then to 5 on ___. Continued on 5mg daily while
admitted.
TRANSITIONAL ISSUES
==================
- Results pending: None
- Medications changed: Stopped diltiazem, started sotalol
- Follow-up needed: has appointment with cardiology NP on
___ (works with Dr. ___
- ___ cardioversion x3, which resulted in normal sinus
rhythm at the time of discharge
- Full Code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Polytrauma s/p fall from balcony
Major Surgical or Invasive Procedure:
___ : closed reduction left distal radius fracture
History of Present Illness:
___ y/o F who is brought in by EMS after a fall. She was on a ___
story porch when her child accidentally locked her out. She
tried to climb down when she fell. +LOC with amnesia to the
event. Ambulatory after and called EMS. Backboard and collar
placed by EMS. Reports severe back to her R shoulder, also pain
to the L wrist. Had some mild epistaxis which resolved. Has not
tried anything for pain. Mild numbness to the left index finger.
Not tried anything for the pain. Denies SOB, abd pain, n/v.
Previously well, denies urinary sx. Denies drugs or EtOH.
Past Medical History:
none
Social History:
___
Family History:
noncontributory
Physical Exam:
Gen: NAD, comfortable but slightly anxious, pain well controlled
Temp: 98.6 HR: 98 BP: 118/88 Resp: 16 O(2)Sat: 99
HEENT: significant ecchymosis around the R eye, improved from
admission. PERRL.
Normal visual field.
Resp: CTAB, still painful with deep inspiration
Cards: RRR
Abd: Soft, Nontender to palpation, active bowel sounds.
Ext: No deficits, no edema
Neuro: A&Ox3, speech fluent
Psych: normal mood, appropriate
Pertinent Results:
___ 06:40AM BLOOD WBC-9.1 RBC-4.20 Hgb-12.2 Hct-37.8 MCV-90
MCH-29.0 MCHC-32.3 RDW-13.4 Plt ___
___ 01:20PM BLOOD WBC-15.0* RBC-4.22 Hgb-12.5 Hct-38.0
MCV-90 MCH-29.6 MCHC-32.9 RDW-13.3 Plt ___
___ 01:20PM BLOOD Glucose-177* UreaN-10 Creat-0.6 Na-139
K-3.9 Cl-108 HCO3-22 AnGap-13
IMAGING:
CXR ___: In comparison with the study of ___, there
is little change. Persistent opacification at the right base,
which may be slightly better than on the previous study.
CT SINUS/MANDIBLE/MAXILLOFACIAL
1. Unchanged right frontal bone fracture, extending into the
lateral right orbital wall superiorly, there is no evidence of
retrobulbar hematoma, unchanged soft tissue swelling is noted in
the right periorbital region.
2. Unchanged mucosal thickening identified in the ethmoidal air
cells, and sphenoid sinus as described above.
GLENO-HUMERAL SHOULDER
Right distal clavicle fracture, superiorly displaced.
CT HEAD W/O CONTRAST
Right-sided frontal bone fracture extending into the lateral
right orbital wall with right ___ STS. No
intracranial hemorrhage.
CT CHEST W/O CONTRAST
1. Large area of contusion with areas of laceration in the
right lung posteriorly. Small right hemothorax and pneumothorax.
2. Right-sided rib (costovertebral junction) fractures and
transverse process fractures, as described above.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
Please do not take more than 3000 mg in a 24 hour period
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth three times a day Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID constipation
Please do not take if you have loose stools.
RX *docusate sodium 100 mg 1 capsule(s) by mouth once a day Disp
#*15 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not operate vehicle while taking
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
stop if you have loose stools
RX *sennosides [Senexon] 8.6 mg 1 tablet by mouth once a day
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Polytrauma:
1. Large right posterior lung contusion and laceration
2. Right distal clavicle fracture
3. Left distal radius fracture
4. Right frontal bone fracture extending to right orbital wall
5. Right 3, 6 and 8 costovertebral rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest x-ray PA and lateral
INDICATION: ___ year old woman with fall from height with significant
pulmonary contusion (right) and hemopneumothorax // interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Lung volumes are low. Again seen is asymmetrical opacification of the right
lung base, which appears slightly worse than the ___ radiograph.
However, it is difficult to assess if this has changed since the last CT
chest. There is a small right apical pneumothorax. The heart and mediastinum
are within normal limits.The right distal clavicular fracture is unchanged in
appearance.
IMPRESSION:
1. Small right apical pneumothorax.
2. Right lung base opacity that appears slightly worse compared to the ___ CXR. This is likely pulmonary hemorrhage versus known hemothorax.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ year old woman with R orbital fracture in addition to mult
other traumatic injuries post fall from ___ story balcony. // assessment of
additional facial injuries.
TECHNIQUE: Helical axial images were acquired through the paranasal sinuses.
Coronal reformatted images were also obtained, the images were reviewed using
soft tissue and bone window algorithms.
DOSE: DLP: ___ MGy-cm; CTDI: ___ MGy
COMPARISON: Prior head CT dated ___.
FINDINGS:
There is an unchanged right frontal bone fracture, extending into the lateral
right orbital wall superiorly, with no evidence of underlying subcutaneous
emphysema or pneumocephalus. There is right periorbital soft tissue swelling,
the right eye globe appears intact, there is no evidence of retrobulbar
hematoma, the intra and extraconal structures on the right are unremarkable.
Unchanged mucosal thickening is identified in the sphenoid sinus, ethmoidal
air cells, with minimal nasal septum deviation towards the right, the left
orbit appears unremarkable. The visualized intracranial contents are grossly
normal.
IMPRESSION:
1. Unchanged right frontal bone fracture, extending into the lateral right
orbital wall superiorly, there is no evidence of retrobulbar hematoma,
unchanged soft tissue swelling is noted in the right periorbital region.
2. Unchanged mucosal thickening identified in the ethmoidal air cells, and
sphenoid sinus as described above.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with traumatic hemopneumothorax post fall from
second floor. // follow up on pneumothorax follow up on pneumothorax
IMPRESSION:
In comparison with the study of ___, there is little change.
Persistent opacification at the right base, which may be slightly better than
on the previous study.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ with fall, head strike, left wrist deformity, right rib pain
and scapular pain. Please obtain scapular views. // Eval for injury
COMPARISON: None
FINDINGS:
AP portable supine view of the chest. Lung volumes are somewhat low. Subtle
diffuse peribronchial vascular opacities throughout the lungs may represent
scattered atelectasis versus subtle contusion. No large effusion or
pneumothorax on this supine radiograph is seen. The cardiomediastinal
silhouette is normal. A calcified left hilar node is present. There may be an
acute fracture involving the right sixth lateral rib arch. The distal right
clavicle is fractured and better assessed on the dedicated right clavicle
radiographs.
IMPRESSION:
Possible minimally displaced fracture of the right sixth lateral rib.
Fractured right distal clavicle. Possible mild atelectasis versus contusion in
the lungs.
Radiology Report
INDICATION: ___ with fall, head strike, left wrist deformity, right rib pain
and scapular pain. Please obtain scapular views. // Eval for injury
COMPARISON: None.
FINDINGS:
Three views of the left wrist were provided. There is an acute intraarticular
fracture through the left distal radius with dorsal displacement of the distal
fracture fragment. There is a small ulnar styloid fracture is well. Carpal
alignment appears grossly preserved. Soft tissue swelling at the left wrist
is noted.
IMPRESSION:
Acute comminuted intra-articular fracture through the left distal radius with
dorsal displacement. Tiny ulnar styloid fracture.
Radiology Report
INDICATION: ___ with fall, head strike, left wrist deformity, right rib pain
and scapular pain. Please obtain scapular views. // Eval for injury
COMPARISON: None.
FINDINGS:
A total of five views of the right shoulder and right clavicle were provided.
There is acute fracture through the distal shaft of the right clavicle. The
distal clavicle fracture fragment is superior displaced by approximately 1
bone width. No additional fractures are identified. The right glenohumeral
joint aligns normally. The imaged right upper ribs appear intact.
IMPRESSION:
Right distal clavicle fracture, superiorly displaced.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall, head strike, left wrist deformity, right rib pain
and scapular pain. Please obtain scapular views. // Eval for injury
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 891.93 mGy-cm
CTDI: 50.10 mGy
COMPARISON: None.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Ventricles and sulci are normal in overall size and configuration.
A frontal bone fracture is seen extending from the lateral right orbital wall
superiorly. Overlying soft tissue swelling/hematoma noted. There is no
pneumocephalus or evidence of epidural hematoma. Small amount of fluid within
the sphenoid sinus is noted. The mastoid air cells and middle ear cavities are
well-aerated. Significant right preseptal and right periorbital soft tissue
swelling is noted. The right globe appears intact without evidence of
retrobulbar hematoma.
IMPRESSION:
Right-sided frontal bone fracture extending into the lateral right orbital
wall with right ___ STS. No intracranial hemorrhage.
Radiology Report
INDICATION: ___ with left radius fx s/p reduction.
COMPARISON: Prior exam from earlier today.
FINDINGS:
Three views of the left wrist were provided status post reduction. There is
improved alignment of the distal radial fracture which is now near anatomic
with neutral angulation at the radiocarpal joint. Ulnar styloid fracture
poorly visualized.
IMPRESSION:
Near anatomic alignment of distal radius fracture post reduction.
Radiology Report
EXAMINATION: Chest CT
INDICATION: ___ with possible right 6th rib fx // Eval for rib fx
TECHNIQUE: Multidetector CT through the chest was performed without oral or
IV contrast with multiplanar reformations provided.
DOSE: ___.23 mGy-cm DLP
COMPARISON: Same day chest radiograph.
FINDINGS:
The mediastinal great vessels appear normal in overall course and caliber.
There is no convincing evidence for mediastinal hematoma. Residual thymic
tissue resides in the anterior mediastinal space. No pneumomediastinum is
seen. The heart appears normal in overall size and shape. There is no
pericardial effusion.
There is a small right pleural effusion, likely represents hemothorax. There
is contusion within the posterior segment of the right upper lobe, as well as
within the superior and posterior basal segments of the right lower lobe.
Pneumatoceles containing air-fluid levels seen within the contused lung
reflects the presence of pulmonary laceration. There is a small right
pneumothorax. The left lung is clear. A punctate nodule is seen in the left
mid lung on series 2, image 22, of doubtful clinical significance in a patient
of this age.
In the imaged portion of the upper abdomen, no abnormalities are detected.
Bones: Right rib fractures are seen at the ___, and ___ costovertebral
junction. There is also a nondisplaced fracture through the lateral arch of
the right sixth rib. Also noted are mildly displaced fractures of right
transverse processes of T1-5. Thoracic spine aligns normally. The sternum
appears intact.
IMPRESSION:
1. Large area of contusion with areas of laceration in the right lung
posteriorly. Small right hemothorax and pneumothorax.
2. Right-sided rib (costovertebral junction) fractures and transverse process
fractures, as described above.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FX DISTAL RADIUS NEC-CL, FX CLAVICLE NOS-CLOSED, FRACTURE THREE RIBS-CLOS, FX DORSAL VERTEBRA-CLOSE, CL SKULL VLT FX-COMA NOS, LUNG CONTUSION-CLOSED, TRAUM PNEUMOHEMOTHOR-CL, FALL FROM BUILDING
temperature: 98.8
heartrate: 106.0
resprate: 16.0
o2sat: 98.0
sbp: 128.0
dbp: 90.0
level of pain: 8
level of acuity: 1.0 | General:
The patient presented to Emergency Department on ___
following a fall off a second floor balcony. She sustained
multiple injuries and was evaluated by ACS, Plastic and
Orthopedic services. She did not have any urgent operative
needs. Orthopedic surgery placed a splint for her left distal
radius fracture.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral medication and
tolerated a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient was allowed to resume regular diet once she
was deemed nonoperative and tolerated diet well. No issues
during the hospitalization.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Spironolactone / Ranexa / Augmentin / Imdur
Attending: ___.
Chief Complaint:
CHF exacerbation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old M w/ PMHx of CAD (s/p (radial to
OM1/2, SVG to PDA, LIMA to LAD, ___, systolic CHF (LVEF
___, AFib, Aortic Stenosis, CKD stg IV, who
presented with worsening dyspnea, 6lb weight gain over past
week, and rising Cr despite increase in diuretic on outpatient
basis.
Patient received biventricular pacer on ___ he was
subsequently admitted for ___ (peak Cr 3.7, down to 3.02 on
follow-up as outpatient) and uremia secondary to cardiorenal
syndrome. During this hospitalization, he was hypotensive
prompting discontinuation of carvedilol. He had been discharged
on torsemide 40mg and 60mg on alternating days. Furthermore,
metoprolol 25mg was added on ___. The patient's wife called Dr.
___ (outpatient cardiologist) regarding his recent
weight gain, with recommendation to increase torsemide dose to
60mg BID. His weight continued to rise, resulting in his
presentation to the ED this morning.
In the emergency department, BNP was 41049 (23536 on last
admission), BUN/Cr 116/4.4 (up from 134/3.6). Troponins were
elevated to 0.63 (baseline 0.3). SBPs were in the ___, and he
was given 20mg IV lasix in the ED out of concern of dropping his
BP. Repeat EKG showed peaked T waves, and he received an
additional dose of Lasix and calcium gluconate out of concern
for hyperkalemia of 5.7. The patient was admitted to ___ for
further management of acute CHF exacerbation.
On the floor, the patient reported worsening fatigue and gradual
increase in weight and abdominal distention. He has had
intermittent bilious emesis and nausea, causing him to have poor
appetite, with a blood glucose of 39 the day prior to admission
which improved with PO glucose. His O2 sat at his most recent
___ visit was reportedly 83%.
The patient had poor urine output to multiple doses of IV lasix
on the ___ service, with a K of 6.2. He was given insulin and
glucose with improvement to 5.1. The decision was made to
transfer the patient to the CCU for closer monitoring and
management.
Upon arrival to the CCU, the patient reports decreased urine
output over the past week approximately, and worsening fatigue
over the same time period. Of note, he denies any cough,
dyspnea, paroxysmal noctunal dyspnea, pillow orthopnea.
Past Medical History:
Coronary artery disease s/p CABG ___ (radial to OM1/2, SVG to
PDA, LIMA to LAD)
Congestive heart failure- Last TTE (___) with LVEF 40%.
Atrial fibrillation- on coumadin
Aortic stenosis
Hypercholesterolemia
Hypertension
Diabetes mellitus
Chronic kidney disease (Stage IV, Baseline Cr 1.8-2.3)
Peripheral vascular disease
Hypothyroidism
Gout
GERD
Anemia
Hyperuricemia
Social History:
___
Family History:
Father died of MI at ___. Mother died of cervical cancer at
___.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
97.5, 86, 97/72, 22, 100%
General: NAD, cachectic male, appears older than stated age,
nontoxic appearing
HEENT: NCAT, MMM, PERRL, EOM grossly intact
Neck: supple, JVD noted to mandible sitting at 90 degrees on
left side (known hx of tricuspid regurg), +Kussmaul sign
CV: irregular rhythm, III/VI systolic murmur, no rubs or gallops
Lungs: no increased work of breathing, no crackles auscultated
Abdomen: Distended, +fluid wave, nontended, no guarding/rebound
tenderness. +Hepatosplenomegaly (liver border 4cm below costal
margin). No stigmata of liver disease evident
Ext: Cool extremities (feet > hands; R > L hand), ___ with 1+
pitting edema, faint pulses peripherally
Neuro: A&Ox3, moving all extremities grossly
=======================
DISCHARGE PHYSICAL EXAM
=======================
98.4, 99, 86/69, 13, 98% on RA
General: sleepy, NAD, cachectic male, appears older than stated
age, nontoxic appearing
The patient was impaired orientation to place, oriented to year.
Impaired attention to the weeks of the day.
HEENT: NCAT, MMM, PERRL, EOM grossly intact
Neck: supple, JVD noted to tragus known hx of tricuspid regurg),
+Kussmaul sign
CV: regular rate and rhythm, grade III/VI mid-peaking systolic
murmur, no rubs or gallops
Lungs: no increased work of breathing, scant bibasilar crackles.
Poor air movement
Abdomen: Distended, +fluid wave, distended, no guarding/rebound
tenderness. +Hepatosplenomegaly (liver border 4cm below costal
margin). No stigmata of liver disease evident
Ext: Cool, ___ with 1+ pitting edema, faint pulses peripherally
Neuro: A&Ox3, moving all extremities grossly
Pertinent Results:
==============
ADMISSION LABS
==============
___ 05:06AM ___ PO2-45* PCO2-34* PH-7.49* TOTAL
CO2-27 BASE XS-2 COMMENTS-GREEN TOP
___ 05:06AM LACTATE-2.4* K+-5.5*
___ 05:06AM O2 SAT-78
___ 05:00AM GLUCOSE-139* UREA N-115* CREAT-4.3*
SODIUM-127* POTASSIUM-5.7* CHLORIDE-86* TOTAL CO2-26 ANION
GAP-21*
___ 05:00AM estGFR-Using this
___ 05:00AM ALT(SGPT)-64* AST(SGOT)-115* CK(CPK)-351* ALK
PHOS-146* TOT BILI-1.4
___ 05:00AM LIPASE-36
___ 05:00AM CK-MB-9 cTropnT-0.63* ___
___ 05:00AM ALBUMIN-3.2*
___ 05:00AM WBC-7.9 RBC-3.23* HGB-10.4* HCT-31.2* MCV-97
MCH-32.2* MCHC-33.3 RDW-16.6* RDWSD-57.8*
___ 05:00AM NEUTS-85.5* LYMPHS-6.2* MONOS-6.6 EOS-0.8*
BASOS-0.1 NUC RBCS-0.4* IM ___ AbsNeut-6.75* AbsLymp-0.49*
AbsMono-0.52 AbsEos-0.06 AbsBaso-0.01
___ 05:00AM PLT COUNT-144*
___ 05:00AM RET AUT-3.0* ABS RET-0.10
=======
IMAGING
=======
___ RUQ US
IMPRESSION:
Large amount of ascites is increased since ___.
___ CXR
IMPRESSION:
Moderate cardiomegaly is chronic. Lungs are clear. There is no
pleural
abnormality. Biventricular pacer leads are unchanged in their
respective
positions since at least ___, continuous from the left
pectoral
generator.
___ TTE
The left atrial volume index is moderately increased. Left
ventricular wall thicknesses and cavity size are normal. There
is severe global left ventricular hypokinesia. Quantitative
(biplane) LVEF = 19%. The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size is normal; there
si moderate global free wall systolic dysfunction. There is
abnormal diastolic septal motion/position consistent with right
ventricular volume overload. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets are moderately thickened. The aortic valve VTI = 55 cm.
There is moderate aortic valve stenosis (valve area 1.2cm2).
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Moderate (2+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Severe global left ventricular systolic dysfunction.
Moderate right ventricular systolic dysfunction. Moderate aortic
stenosis. Moderate mitral and tricuspid regurgitation. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of ___, the
findings are similar.
==============
DISCHARGE LABS
==============
___ 03:33AM BLOOD WBC-11.0* RBC-3.29* Hgb-10.4* Hct-32.1*
MCV-98 MCH-31.6 MCHC-32.4 RDW-16.5* RDWSD-57.9* Plt ___
___ 03:33AM BLOOD Plt ___
___ 03:33AM BLOOD ___ PTT-37.4* ___
___ 03:33AM BLOOD Glucose-170* UreaN-120* Creat-4.7*
Na-125* K-3.9 Cl-78* HCO3-27 AnGap-24*
___ 03:33AM BLOOD Calcium-8.3* Phos-5.3* Mg-2.3
___ 03:42AM BLOOD ___ Temp-36.1 Comment-___
___ 03:42AM BLOOD Lactate-2.6*
============
MICROBIOLOGY
============
- none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO BID
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO 2X/WEEK (___)
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Omeprazole 20 mg PO BID
8. Rosuvastatin Calcium 10 mg PO QPM
9. Warfarin 2 mg PO DAILY16
10. Torsemide 60 mg PO BID
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Potassium Chloride 20 mEq PO DAILY
13. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
14. Nepro Carb Steady (nut.tx.impaired renal fxn,soy) 0.08-1.80
gram-kcal/mL oral DAILY
15. 70/30 12 Units Breakfast
70/30 6 Units Lunch
70/30 6 Units Dinner
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
2. Acetaminophen 650 mg PO Q8H:PRN pain
RX *acetaminophen 650 mg/20.3 mL 650 solution(s) by mouth Q8H
PRN Disp #*406 Milliliter Milliliter Refills:*0
3. Lorazepam 0.5 mg PO Q4H:PRN nausea/anxiety
RX *lorazepam 0.5 mg 1 tab by mouth Q4H PRN Disp #*60 Tablet
Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg q tablet(s) by mouth Q8H PRN Disp #*30
Tablet Refills:*0
5. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 5 mg by mouth Q4H PRN Refills:*0
Discharge Disposition:
Extended Care
Discharge Diagnosis:
==================
PRIMARY DIAGNOSES
==================
- Heart failure exacerbation
- End-stage renal disease
- Cardiorenal syndrome
===================
SECONDARY DIAGNOSES
===================
- Altered mental status
- Coronary artery disease
- Atrial fibrillation
- Aortic stenosis
- Hypertension
- Diabetes mellitus
- Chronic kidney disease (Stage IV)
- Peripheral vascular disease
- Hypothyroidism
- Gout
- Gastroesophageal reflux disease
- Anemia
- Hyperuricemia
- Status post biventricular pacer implantation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with coronary artery disease with dyspnea and abdominal
distension
TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained.
COMPARISON: Liver ultrasound from ___.
FINDINGS:
There is a large amount of ascites. The largest pocket appears to be in the
left upper quadrant. Cirrhotic liver is incompletely assessed.
IMPRESSION:
Large amount of ascites is increased since ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with systolic CHF, here with volume overload,
difficulty diuresing // Pulm edema vs infiltrative process Pulm edema vs
infiltrative process
COMPARISON: Prior chest radiographs ___ through ___ at 01:03.
IMPRESSION:
Moderate cardiomegaly is chronic. Lungs are clear. There is no pleural
abnormality. Biventricular pacer leads are unchanged in their respective
positions since at least ___ one, continuous from the left pectoral
generator.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 97.0
heartrate: 100.0
resprate: 18.0
o2sat: nan
sbp: 102.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with h/o CAD s/p CABG ___,
ischemic HFrEF (EF ___ with severe RV dysfunction, afib,
moderate AS, moderate MR, and severe TR, CKD-4 who presented
with acute decompensated heart failure complicated by
cardiogenic shock.
============= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abd Pain, ___
___ Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ yoF with h/o h/o IDDM c/b recurrent DKA,
chronic low back pain s/p lumbar disk surgery, marijuana use
(quit 1 wk ago), depression, anxiety, complex trauma hx,
episodic hypertension, gastroparesis with multiple ED
visits/hospitalizations for abdominal pain presenting to the ED
for back and LUQ abd pain. Pain is similar to her prior
episodes. Patient reports that back pain began at 7 AM today
without a clear trigger, states back pain is much more severe
than abd pain and back pain triggers abd pain. She reports
associated nausea and non-bloody emesis (although some "redness
in vomit" which she attributes to food she ate), denies any
fevers, diarrhea, blood in stools. She reports being compliant
with her insulin however has not taken gabapentin in 2 days as
she has not been able to pick up Rx. She denies any chest pain,
dysuria, she does endorse SOB however only when in pain or
anxious, does endorse numbness/weakness in legs x1 m and
difficulty walking due to pain. No bb incontinence, no BM in 4
days, no dysuria. Gained 20 lbs in last 3 month. Last PO
intake was last night and she states that she took 25 ___ this AM (usual dose is 35 U). States "my body is
breaking down, I can't deal with stress;" stressors include son
not with her and unable to work due to illness, and mother
leaving. Endorses depression, states she would never hurt
herself because of her son. States disease took everything from
her.
In the ED, initial vitals were: 10 98.1 89 161/108 16 99% RA.
BP increased to 170/92 while in the ED. Labs were notable for
WBC of 13.9. UA was nl however urine culture was sent. EKG
showed NSR with PACs, QTc 427. She was given lorazepam dilaudid
0.5 x3, Zofran x2, insulin, morphine 5 mg IV x1 and 3 L NS.
Given her sxs were unable to be controlled in the ED she was
admitted for further management.
On arrival to the floor, pt appears very anxious however calms
down during the interview.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough. Denies chest
pain or tightness, palpitations. Denies diarrhea. No dysuria.
10 pt ros otherwise negative.
Past Medical History:
(per chart, confirmed with pt):
IDDM with recurrent DKA and reported gastroparesis
Chronic low back pain s/p L4/5 discectomy
Marijuana use
Depression
Anxiety
Prior domestic abuse
Social History:
___
Family History:
(per chart, confirmed with pt):
Her father died of diabetes mellitus and a paternal aunt has
gastroparesis. Her son also has type 1 DM and gastroparesis.
Also CHF in family.
Physical Exam:
Vitals: 99.2 PO 179 / ___
Constitutional: Alert, oriented, anxious and uncomfortable
appearing however calms down with interview
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
Neck: Supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, mild TTP in LUQ, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, no CCE
NEURO: aaox3, CNII-XII grossly intact, ___ strength in ___, nl
sensation except for mild numbness in bilateral lateral thighs
SKIN: no rashes or lesions
MSK: paraspinal tenderness in lumbar region, no midline ttp
Pertinent Results:
___ 01:38PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 01:38PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-5
___ 01:38PM URINE MUCOUS-RARE*
___ 11:05AM URINE HOURS-RANDOM
___ 11:05AM URINE HOURS-RANDOM
___ 11:05AM URINE HOURS-RANDOM
___ 11:05AM URINE UCG-NEGATIVE
___ 11:05AM URINE UHOLD-HOLD
___ 11:05AM URINE GR HOLD-HOLD
___ 10:01AM GLUCOSE-111* UREA N-8 CREAT-0.6 SODIUM-138
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
___ 10:01AM ALT(SGPT)-14 AST(SGOT)-25 ALK PHOS-83 TOT
BILI-0.9
___ 10:01AM LIPASE-26
___ 10:01AM ALBUMIN-4.3
___ 10:01AM WBC-13.9* RBC-4.45 HGB-12.0 HCT-38.0 MCV-85
MCH-27.0 MCHC-31.6* RDW-14.8 RDWSD-46.4*
___ 10:01AM NEUTS-70.5 ___ MONOS-6.8 EOS-1.7
BASOS-0.4 IM ___ AbsNeut-9.82* AbsLymp-2.84 AbsMono-0.95*
AbsEos-0.23 AbsBaso-0.06
___ 10:01AM PLT COUNT-388
CT ABD:
IMPRESSION:
No evidence of malignancy within the abdomen. Please note that
the pelvis was
not imaged, and extra-adrenal lesions in the pelvis cannot be
excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO TID
2. Lidocaine 5% Patch 2 PTCH TD QAM
3. Metoclopramide 10 mg PO QIDACHS
4. Senna 17.2 mg PO BID
5. Sertraline 200 mg PO DAILY
6. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
7. ClonazePAM 0.5 mg PO TID:PRN anxiety
8. Amitriptyline 25 mg PO QHS
9. Tizanidine 4 mg PO BID
10. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain -
Moderate
11. Glargine 35 Units Breakfast
Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
limit 3 grams per day
RX *acetaminophen 500 mg 2 capsule(s) by mouth three times a day
Disp #*180 Capsule Refills:*0
2. LevoCARNitine 990 mg PO TID
RX *levocarnitine 330 mg 3 tablet(s) by mouth three times a day
Disp #*270 Tablet Refills:*0
3. Glargine 35 Units Breakfast
Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Amitriptyline 25 mg PO QHS
5. ClonazePAM 0.5 mg PO TID:PRN anxiety
6. Gabapentin 800 mg PO TID
RX *gabapentin 400 mg 2 capsule(s) by mouth three times a day
Disp #*180 Capsule Refills:*0
7. Lidocaine 5% Patch 2 PTCH TD QAM
8. Metoclopramide 10 mg PO QIDACHS
9. Senna 17.2 mg PO BID
10. Sertraline 200 mg PO DAILY
11. Tizanidine 4 mg PO BID
12. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
home supply
Discharge Disposition:
Home
Discharge Diagnosis:
Acute lumbar muscle strain
Type 1 diabetes
Diabetic gastroparesis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD WANDW/O C
INDICATION: ___ year old woman with IDDM, gastroparesis, severe intermittent
htn, abd pain, elevated plasma normetanephrines// Please eval for pheo
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen following intravenous contrast administration with split
bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.7 s, 30.4 cm; CTDIvol = 7.0 mGy (Body) DLP = 207.9
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 8.8 s, 0.2 cm; CTDIvol = 117.7 mGy (Body) DLP =
23.5 mGy-cm.
4) Spiral Acquisition 4.6 s, 29.9 cm; CTDIvol = 7.0 mGy (Body) DLP = 204.1
mGy-cm.
5) Spiral Acquisition 4.6 s, 29.9 cm; CTDIvol = 7.0 mGy (Body) DLP = 204.1
mGy-cm.
Total DLP (Body) = 641 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: Imaged small and large bowel loops demonstrate normal
caliber, wall thickness, enhancement throughout.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal wall is within normal limits.
IMPRESSION:
No evidence of malignancy within the abdomen. Please note that the pelvis was
not imaged, and extra-adrenal lesions in the pelvis cannot be excluded.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Nausea with vomiting, unspecified, Unspecified abdominal pain, Type 1 diabetes w diabetic autonomic (poly)neuropathy, Gastroparesis
temperature: 98.1
heartrate: 89.0
resprate: 16.0
o2sat: 99.0
sbp: 161.0
dbp: 108.0
level of pain: 10
level of acuity: 3.0 | ___ yo F with h/o h/o IDDM c/b recurrent DKA, chronic low back
pain s/p lumbar disk surgery,depression,
anxiety, complex trauma hx, episodic hypertension, gastroparesis
with multiple ED visits/hospitalizations for abdominal pain
presenting to the ED for back and LUQ abd pain, also with severe
HTN. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
azithromycin / Reglan / erythromycin base
Attending: ___.
Chief Complaint:
back and abdominal pain
Major Surgical or Invasive Procedure:
gj tube replacement
History of Present Illness:
Ms. ___ is a ___ year old female with a PMHx of recurrent
pancreatitis and possible gastroparesis who presents with back
and abdominal pain.
She recalls that one year ago everything started at ___ with
pancreatitis. She was there for 2 weeks. She spent all three
months last summer in various hospitals (___, ___, ___. She was unable to take solids, then when to
___ where a gastric emptying study showed gastroparesis
(though she was apparently receiving opioids while this was
done). She was transferred here for the rest of the summer
(___) and had a feeding tube placed. Since then, she
thinks this is her fifth flare of pancreatitis.
Two days ago she started to feel back pain. This morning she had
an appointment for her GJ tube replacement but when she woke up
she had epigastric pain and bloating. The pain was worsening
hour
by hour. When she went for her ___ procedure, she was referred to
the ED given her abdominal pain. Typically she has a lipase of
500-800 during flares. She says her current symptoms are
consistent with prior episodes of pancreatitis, though on
further
exploration she has RUQ pain that has been going on for ___
weeks
and is somewhat atypical.
She has nausea but has not had anything to vomit. She does not
eat any food by mouth. She stopped the TFs at 10:00pm last
night.
She has not had fevers or chills. She has chronic diarrhea which
has not changed recently. She takes her TFs over 20 hours per
day.
In the ED here, her vital signs were stable and normal. Labs
were
notable for a AP of 132 and a lipase of 107 (LFTs were otherwise
normal). She had a CT abdomen/pelvis with contrast which showed
"Mild stranding around the pancreatic head and uncinate process
compatible with interstitial edematous pancreatitis." She was
given IVF, IV morphine, and IV ondansetron and admitted to
medicine for further care.
ROS: Pertinent positives and negatives as noted in the HPI.
Otherwise a 10-point ROS was reviewed and is negative.
Past Medical History:
-Recurrent pancreatitis
-Question of gastroparesis
-Depression
-Hypothyroidism
C-section ___
Lipoma resection ___
Social History:
___
Family History:
Grandfather had prostate cancer.
No family h/o IBD or colon cancer on mother's side. Father's
history unknown.
Physical Exam:
VITALS: ___ 2210 Temp: 98.0 PO BP: 145/92 R Lying HR: 74
RR:
18 O2 sat: 96% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score:
___
GENERAL: Alert and in mild distress
EYES: Anicteric, no conjunctival injection, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesions, erythema or exudate.
CV: Heart regular, no murmur, no S3, no S4.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, tender in the RUQ and epigastrium to gentle
palpation, non-tender in the lower quadrants, non-distended. No
rebound or guarding.
GU: No suprapubic fullness or tenderness to palpation.
MSK: Moves all extremities, warm and well perfused, no ___ edema.
SKIN: No rashes or ulcerations noted.
NEURO: Alert, oriented, face symmetric, gaze conjugate with EOM,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate mood and affect
Pertinent Results:
___ 11:40AM BLOOD WBC-10.1* RBC-3.83* Hgb-11.8 Hct-34.7
MCV-91 MCH-30.8 MCHC-34.0 RDW-16.0* RDWSD-52.0* Plt ___
___ 11:40AM BLOOD Neuts-72.6* ___ Monos-5.4 Eos-1.1
Baso-0.4 Im ___ AbsNeut-7.31* AbsLymp-2.03 AbsMono-0.54
AbsEos-0.11 AbsBaso-0.04
___ 11:40AM BLOOD ___ PTT-24.1* ___
___ 11:40AM BLOOD Glucose-102* UreaN-7 Creat-0.6 Na-143
K-3.5 Cl-103 HCO3-23 AnGap-17
___ 11:40AM BLOOD ALT-13 AST-14 AlkPhos-132* TotBili-0.3
___ 08:28AM BLOOD Lipase-712*
___ 08:28AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.4*
___ 12:17PM BLOOD Lactate-1.2
CT ABD:
IMPRESSION:
Mild stranding around the pancreatic head and uncinate process
compatible with
interstitial edematous pancreatitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 100 mg PO BID
2. Diazepam 10 mg PO Q8H
3. Gabapentin 300 mg PO TID:PRN pain
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Omeprazole 40 mg PO BID
6. potassium chloride 20 mEq/15 mL oral ASDIR
7. Vitamin D 1000 UNIT PO DAILY
8. loperamide 1 mg/5 mL oral TID:PRN
9. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 daily Disp #*30 Patch Refills:*0
2. OxycoDONE Liquid 5 mg PO Q6H:PRN Pain - Moderate Duration: 5
Days
RX *oxycodone 5 mg/5 mL 5 ml by mouth every six (6) hours
Refills:*0
3. BuPROPion (Sustained Release) 100 mg PO BID
4. Diazepam 10 mg PO Q8H
5. Gabapentin 300 mg PO TID:PRN pain
6. Levothyroxine Sodium 88 mcg PO DAILY
7. loperamide 1 mg/5 mL oral TID:PRN
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Omeprazole 40 mg PO BID
10. potassium chloride 20 mEq/15 mL oral ASDIR
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Acute on chronic idiopathic pancreatitis
Gastroparesis
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with hx of pancreatitis, gastroparesis,
presenting with recurrent abdominal pain// ?evidence of acute process
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.0 s, 53.2 cm; CTDIvol = 15.7 mGy (Body) DLP = 835.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 9.0 s, 0.5 cm; CTDIvol = 50.3 mGy (Body) DLP =
25.2 mGy-cm.
Total DLP (Body) = 863 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: The lung bases are clear besides dependent atelectasis. There is
no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: There is mild peripancreatic stranding around the head and uncinate
process. There is homogeneous enhancement of the pancreatic parenchyma.
Pancreatic divisum is incidentally noted. There is no pancreatic ductal
dilatation. No peripancreatic fluid collections. Portal vein and splenic
vein are patent.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal suspicious renal lesions or hydronephrosis.
Subcentimeter hypodensity at the upper pole the right kidney is too small to
characterize but likely a cyst. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is notable for percutaneous gastrojejunostomy
tube.. Small bowel loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal limits.
Surgical clips at the base of the cecum suggest prior appendectomy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus and adnexae are within normal limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Mild stranding around the pancreatic head and uncinate process compatible with
interstitial edematous pancreatitis.
Radiology Report
INDICATION: ___ year old woman with gastroparesis// current tube is clogged,
needs to be replaced.
COMPARISON: Tube change dated ___
TECHNIQUE: OPERATORS: Dr. ___, attending radiologist,
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 5 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse.
MEDICATIONS: Fentanyl, Versed, 1% lidocaine
CONTRAST: 10 ml of Optiray
FLUOROSCOPY TIME AND DOSE: 34 seconds, 9 mGy
PROCEDURE: MIC, low profile gastrojejunostomy exchange.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
A 0.035 stiff Glidewire was passed through the existing low-profile MIC
gastrojejunostomy tube. The balloon was taken down and the tube was removed
over the wire. A new, 16 ___, low profile MIC, 3.5 cm stoma length
gastrojejunostomy tube was advanced over the wire into position under
fluoroscopy. The balloon was inflated. Contrast was administered through the
jejunostomy and gastrostomy lumens to confirm appropriate positioning. Both
lumens were flushed and capped. The site was dressed. The patient tolerated
the procedure well without immediate complications.
FINDINGS:
1. Appropriately positioned new 16 ___ low profile, 3.5 cm stoma length,
MIC gastrojejunostomy tube.
IMPRESSION:
Successful exchange of a gastrojejunostomy tube for a new 16 ___ low
profile MIC gastrojejunostomy tube. The tube is ready to use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Epigastric pain, Acute pancreatitis without necrosis or infection, unsp
temperature: 98.3
heartrate: 95.0
resprate: 17.0
o2sat: 95.0
sbp: 138.0
dbp: 68.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ woman with recurrent idiopathic pancreatitis,
depression, hypothyroidism, presenting with back and abdominal
pain consistent with acute pancreatititis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
unable to give
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Asked to evaluate this ___ year old white male with unknown
past medical history for bi-frontal sdh. Per ED, the pt was
intoxicated and being asked to leave a party when he was punched
in the face and fell backwards striking his head with witnessed
LOC. He was brought to the hospital for evaluation.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
O: T: 97.6 BP:135 /67 HR:72 R 15 O2Sats___
Gen: WD/WN, comfortable, NAD at rest / on stretcher in hard
collar
HEENT: Pupils: ___ EOMi grossly
Neck: in collar
Extrem: Warm and well-perfused./ bruising to bilateral tricep
regions
Neuro:
Mental status: Lethargic/ difficult to arouse / non cooperative
with exam.
Orientation: non participating / states "stop it" or " alright"
to most questions.
Recall: unable
Language: Speech fluent / one - two word statements .
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to2
mm bilaterally. Visual fields uanblet to test.
III, IV, VI: Extraocular movements grossly intact bilaterally
without nystagmus.
V, VII: Facial strength and sensation unable to assess. no
obvious facial
VIII: Hearing intact to voice.
IX, X: Palatal elevation unable to assess
XI: Sternocleidomastoid and trapezius uanble to assess .
XII: Tongue appears midline
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
CT:Bi frontal sdh / L>R, sulcal effacement on the left out of
proportion to sdh
On Discharge:
A&OX3
PERRL
EOMS intact
face symmetrical
L periorbital ecchymosis
full motor
No pronator drift
Pertinent Results:
CT HEAD W/O CONTRAST ___
1. Interval increased conspicuity of a 2.4 x 1.3 cm left frontal
hemorrhagic contusion.
2. Stable-appearing thin left frontoparietal and right frontal
subdural
hematomas with subfalcine extension.
3. Stable effacement of the left lateral ventricle and focal
markings,
without significant interval increase in mass effect.
4. Surgical staples over a known right occipital subgaleal
hematoma and
laceration.
___ Ct maxillary/sinus - 1. Comminuted and depressed
anterolateral fracture of the left maxillary
sinus with associated hemorrhage within the sinus.
2. Nondisplaced anterior nasal spine fracture.
3. Mildly comminuted minimally displaced left nasal bone
fracture.
4. Trace paranasal sinus disease.
___ CT head -
1. No significant interval change in appearance of left frontal
intraparenchymal hematoma, left frontoparietal subdural
hematoma, or right
frontal subdural hematoma with subfalcine extension.
2. Stable effacement of the left lateral ventricle without shift
of normally
midline structures or central herniation.
3. No new intracranial hemorrhage or acute large vascular
territorial
infarction.
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
3. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral SDH
L frontal contusion
Cerebral edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with intoxication status post fall with loss of
consciousness. Question intracranial hemorrhage.
COMPARISON: None available.
TECHNIQUE: Contiguous non-contrast axial images were acquired through the
brain, with multiplanar reformations.
FINDINGS: There is significant nasal and facial edema with an underlying
mildly comminuted and depressed anterolateral left maxillary wall fracture
with layering blood within the left maxillary sinus. No other fracture is
definitely detected on current exam. There is minimal mucosal thickening in
the ethmoidal air cells and right maxillary sinus. The mastoid air cells are
well aerated.
Within the brain, there is a 3-mm subdural hematoma along the left
frontoparietal convexity, also layering along the falx and right frontal
region. It is difficult to exclude subtle distribution to the tentorial
leaflets. There is sulcal effacement on the left with effacement of the left
lateral ventricle as compared to the right. Suprasellar and basilar cisterns
remain patent.
IMPRESSION:
1. Status post trauma with small left frontoparietal and right frontal
subdural hematoma with parafalcine extension and sulcal and lateral
ventricular effacement. No definite intra-axial hemorrhage.
2. Left maxillary fracture with overlying soft tissue edema. Recommend
further assessment by sinus CT.
Findings reported to Dr. ___ at 3:30 a.m. via phone on ___.
Radiology Report
INDICATION: ___ male with intoxication status post fall and loss of
consciousness. Question fracture.
COMPARISON: Same day head CT.
TECHNIQUE: MDCT of the cervical spine was performed without contrast
administration, with multiplanar reformations.
FINDINGS: There is no evidence of fracture or malalignment. Prevertebral and
paravertebral soft tissues appear unremarkable. There is no significant canal
or neural foraminal narrowing. Allowing for motion, oropharyngeal and
nasopharyngeal soft tissues are symmetric. There is no focal thyroid lesion.
Deep cervical soft tissues are otherwise within normal limits. Trace mucosal
disease is seen in the right maxillary sinus. Layering blood within the left
maxillary sinus is not well encompassed on current exam. Lung apices are
clear.
IMPRESSION: No cervical spine fracture.
Radiology Report
INDICATION: ___ male with left maxillary sinus fracture and subdural
hematoma.
COMPARISON: Same day CT head and CT C-spine.
TECHNIQUE: MDCT of the maxillofacial bones was performed without contrast
administration, with multiplanar reformations.
FINDINGS: There is depressed and comminuted fracture of the anterolateral
left maxillary wall with approximately 1 cm inward depression on coronal view.
This is associated with hemorrhage within the left maxillary sinus. Note is
also made of an oblique nondisplaced fracture of the anterior nasal spine.
There is in addition, a minimally displaced left nasal bone fracture at the
base (2, 54). The lamina papyracea, zygomatic arches, pterygoid plates, and
anterior clinoid processes appear intact. The mandible is intact. The TMJs
are well articulated. There is mucosal thickening within the right maxillary
sinus. The frontal sinus is well aerated. Trace anterior air cell
opacification is seen in the ethmoidal air cells. Sphenoid sinus is clear.
Bilateral OMUs appear to be obstructed. Upper cervical spine is intact.
There is marked left facial and nasal soft tissue edema. Oral and
nasopharyngeal soft tissues are symmetric. Deep cervical soft tissues are
otherwise unremarkable.
IMPRESSION:
1. Comminuted and depressed anterolateral fracture of the left maxillary
sinus with associated hemorrhage within the sinus.
2. Nondisplaced anterior nasal spine fracture.
3. Mildly comminuted minimally displaced left nasal bone fracture.
4. Trace paranasal sinus disease.
Radiology Report
HISTORY: SDH intoxicated, question acute process.
TRAUMA SERIES INCLUDING AP CHEST AND AP PELVIS:
CHEST: The cardiac silhouette is prominent, but likely accentuated by supine
technique. There is upper zone redistribution, also likely accentuated by
technique. The mediastinal silhouette is within normal limits. There is
scattered subsegmental atelectasis. No CHF, frank consolidation or effusion
is identified. No supine film evidence of pneumothorax is detected. Limited
assessment of osseous structures is grossly unremarkable. Of note, detail in
the thoracic spine is obscured due to overlying soft tissues.
PELVIS, SINGLE AP VIEW: Pelvic girdle is congruent, without SI joint or pubic
symphysis diastasis. Streaky lucencies in the pelvis are seen, but likely
represent fat. There are mild degenerative changes of both hips, with slight
joint space narrowing and accentuation of subchondral acetabular sclerosis and
a small right acetabular spur. There is incomplete coverage of the femoral
head by the acetabulum on both sides, representing a subtle form of acetabular
insufficiency. In addition, there is bony buttressing along the lateral
femoral head-neck junction on both sides -- in the appropriate clinical
setting, this can contribute to femoracetabular impingement.
IMPRESSION:
1. Allowing for supine technique, no acute process identified in the chest.
2. No displaced fracture identified about the pelvic girdle.
Radiology Report
INDICATION: ___ male status post trauma with subdural hematoma, check
interval change.
___ at 1:54.
TECHNIQUE: Contiguous non-contrast axial images were acquired through the
brain, with multiplanar reformations.
FINDINGS: Since preceding exam, there has been interval blossoming of a left
frontal hemorrhagic contusion measuring 2.4 x 1.3 cm, now hyperdense. The
3-mm left frontoparietal and right frontal subdural hematoma with subfalcine
extension appear unchanged. There is persistent, but stable left sulcal
effacement and lateral ventricular effacement. No definite increase in mass
effect. Suprasellar and basilar cisterns are patent. Again seen is blood
products in the left maxillary sinus, associated with known depressed left
anterolateral maxillary wall fracture, better correlated with preceding sinus
CT. There is also mucosal thickening in the right maxillary sinus. Globes
and orbits are intact.
IMPRESSION:
1. Interval increased conspicuity of a 2.4 x 1.3 cm left frontal hemorrhagic
contusion.
2. Stable-appearing thin left frontoparietal and right frontal subdural
hematomas with subfalcine extension.
3. Stable effacement of the left lateral ventricle and focal markings,
without significant interval increase in mass effect.
4. Surgical staples over a known right occipital subgaleal hematoma and
laceration.
Radiology Report
INDICATION: Left frontal contusion with worsening headache. Evaluate for
interval change.
TECHNIQUE: Sequential axial images were acquired through the head without the
administration of intravenous contrast material.
COMPARISON: CT head from ___.
FINDINGS: Intraparenchymal hemorrhage within the left frontal lobe is not
significantly changed in size, measuring up to 2.1 x 1.2 cm in its greatest
axial ___. Similarly, left frontoparietal and right frontal subdural
hematomas are not significantly changed. The extent of parafalcine subdural
hematoma along the right frontal lobe is also unchanged. There is no new
intracranial hemorrhage. Marked compression of the left lateral ventricle
persists. There is no shift of the normally midline structures or central
herniation. There is no evidence of hydrocephalus or acute large vascular
territorial infarction. The orbits are grossly unremarkable. An air-fluid
level is again seen within the left maxillary sinus, unchanged. A tiny
quantity of fluid is also seen within the right maxillary sinus. The
remainder of the visualized portions of the paranasal sinuses and mastoid air
cells are well aerated.
IMPRESSION:
1. No significant interval change in appearance of left frontal
intraparenchymal hematoma, left frontoparietal subdural hematoma, or right
frontal subdural hematoma with subfalcine extension.
2. Stable effacement of the left lateral ventricle without shift of normally
midline structures or central herniation.
3. No new intracranial hemorrhage or acute large vascular territorial
infarction.
Radiology Report
INDICATION: ___ male with traumatic brain injury, contusion.
Followup edema, contusion.
COMPARISON: CT head on ___.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered.
FINDINGS: The previously seen intraparenchymal hemorrhage within the left
frontal lobe is unchanged in size. The left frontoparietal and right frontal
subdural hematoma is unchanged. Some subdural blood is now along the
posterior falx, likely due to redistribution of blood and not new subdural
hematoma. No new intraparenchymal hemorrhage. Marked compression of the left
lateral ventricle again persists. There is no shift of normally midline
structures or central herniation. There is no hydrocephalus. There is no
infarction. A linear right occipital bone fracture extending into the foramen
magnum is unchanged. The facial bone fractures are not well seen on the
study. Mastoid air cells are well aerated.
IMPRESSION:
1. Unchanged left frontal intraparenchymal hemorrhage. Repositioning of
subdural hematoma with some blood now layering in the posterior falx. No new
hemorrhage. 2. Unchanged compression of the left lateral ventricle. No
hydrocephalus.
3. A linear right occipital bone fracture extending into the foramen magnum
is unchanged. Previously seen facial bone fractures are not well visualized
on this study.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P ALTERCATION
Diagnosed with CL SKUL BASE FX/BRF COMA, ASSAULT NEC, ALCOHOL ABUSE-UNSPEC
temperature: 97.6
heartrate: 72.0
resprate: 15.0
o2sat: 97.0
sbp: 135.0
dbp: 67.0
level of pain: nan
level of acuity: 2.0 | ___ y/o M +EOTH presents s/p assault. Patient was seen to have
b/l SDH as well as left maxillary sinus, anterior nasal spine
and left nasal bone fractures. He was admitted to the
neurosurgery service for further evaluation and monitoring. On
repeat head CT, patient was seen to have blossoming of L frontal
contusion. He remained neuro intact on examination. Plastics
evaluated patient for facial fractures and determined no surgery
was necessary, he is to follow up as an outpatient. In the
afternoon, patient complained of worsening headache that was
unrelieved with pain medication, repeat head CT was done and
showed increase in size of L frontal contusion with surrounding
edema. He continues to be neuro intact.
Now DOD, he is afebrile, VSS, and neurologically stable. He was
evaluated by ___ and they recommended home without ___. His pain
was controlled on dilaudid. He was discharged home on ___ and
will follow up with Neurosurgery in 4 weeks with a repeat Head
CT. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Naprosyn
Attending: ___.
Chief Complaint:
R wrist pain, swelling
Major Surgical or Invasive Procedure:
Right wrist joint tap
History of Present Illness:
___ year old male with history of severe gout ___ flares per
year), c/b septic arthritis required surgical debridement and
washout in ___, with recurrence in left shoulder and recent
hospitalization at ___. He was discharged on ___, on IV
Nafcillin with a PICC line in place for a 2 week course.
He was feeling improved until ___ night, when he started
developing right hand and wrist pain. He saw his Rheumatologist
on ___ who performed joint aspirations on the wrist and
shoulder. Per patient report, it showed 68K WBC. He also
followed up with his ID specialist who recommended TTE, but
patient unable to schedule it until ___. HE also recalls some
mention of a blood stream infection. He had bloodwork drawn and
went home. Results of bloodwork showed hypokalemia so the
patient was instructed to go to a local ED for repletion. He
presented to ___ where was given 60mg po K. During his
evaluation at ___, his right hand and wrist suddenly got
more swollen and red and painful. Given the rapidity of
progression, tt was concerning for joint infection he was given
a dose of vancomycin, so the patient was transferred to ___
for higher level of care. He was also noted to have BNP 900.
On presentation to ___ ED, his right hand and wrist were warm
erythematous and exquisitely tender to palpation with limited
ROM. He also endorses current discomfort in bilateral ankles and
L great toe which he attributes to refractory gout. His
shoulders are currently pain-free
He reports one episode of dyspnea yesterday which has resolved.
He denies chest pain, orthopnea or increased peripheral edema
except at the affected joints.
In the ED intial vitals were: 99.4 98 149/90 14 100% ra
- Labs were significant for K 3.7
- Patient was given Nafcillin, NS and dilaudid
- he was seen by plastic surgery who splinted his wrist. They
will consider OR for washout based on results of joint tap.
Vitals prior to transfer were: 99.3 90 127/79 18 96% RA
On the floor, he reports significant pain in the right hand with
some tingling.
Past Medical History:
- Gout - exacerbations 4 to 5 times a year.
- Status post left knee arthroscopic meniscal repair.
- Hypertension.
- Hyperlipidemia.
- Anxiety.
- History of DVT ___ years ago after arthroscopy
Social History:
___
Family History:
Mother died at age of ___ because of ___ disease and
Alzheimer's dementia. Sister has breast cancer. Does not know
his father well.
Physical Exam:
Admission Physical
===================
Vitals- 99.5 148/87 72 28 96% RA
General- WD, overweight, uncomfortable
HEENT- PERRL, EOMI, no scleral icterus
Neck- supple, no JVP elevation
Lungs- CTAB
CV- RRR II/VI murmur at apex
Abdomen- soft, number
Ext- right hand/wrist casted midway down forearm, cap refill
sluggish but patient able to move fingers. Left hand and
bilateral shoulders WNL. Right ___ toe erythematous and warm,
lateral aspect of right foot with 2 nodules that are painful and
warm but not red. Left ___ with large tophus. Right ankle also
mild effusion, TTP
Neuro- senstion to light touch intact in exposed right fingers
Discharge Physical
==================
Vitals: 97.8, 135/89, 63, 16, 100% on RA
I/O: MN 50/400
General- lying in bed, NAD
HEENT: MMM
Neck- supple, no JVP elevation
Lungs- CTAB/L no w/r/r
CV- RRR no murmurs
Abdomen- soft, no TTP, normoactive BS, nondistended
Ext- R wrist very improved, not splinted, no erythema or warmth
to touch, digits improved, patient with more range of motion of
entire R arm, large improving nontender effusion on R elbow.
left hand and shoulders with no pain. Right ___ toe improved
swelling. Left ___ toe with large tophus. Right ankle with
effusion, mild TTP, left ankle with effusion, mild TTP both
improved. R knee with TTP and warm and erythemaotous along
medial meniscus.
Pertinent Results:
Admission Labs
===============
___ 07:50AM BLOOD WBC-9.6 RBC-2.92* Hgb-10.5* Hct-31.3*
MCV-107* MCH-35.9* MCHC-33.4 RDW-14.0 Plt ___
___ 07:50AM BLOOD ___ PTT-31.1 ___
___ 07:50AM BLOOD ESR-131*
___ 02:05AM BLOOD Glucose-88 UreaN-8 Creat-0.6 Na-139 K-3.7
Cl-104 HCO3-22 AnGap-17
___ 07:50AM BLOOD Calcium-9.0 Phos-2.1* Mg-1.6 UricAcd-5.4
___ 06:03AM BLOOD VitB12-402 Folate-2.9
___ 01:00PM BLOOD TSH-1.4
___ 01:00PM BLOOD PTH-30
___ 07:50AM BLOOD CRP-267.3*
Discharge Labs
===============
___ 04:57AM BLOOD WBC-10.1 RBC-2.91* Hgb-9.6* Hct-30.2*
MCV-104* MCH-32.9* MCHC-31.8 RDW-15.2 Plt ___
___ 04:37AM BLOOD Na-137 K-4.7 Cl-97
___ 04:57AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.0
Microbiology
===========
___ 06:30PM JOINT FLUID WBC-56 ___ Polys-50*
___ Macro-11
___ 06:30PM JOINT FLUID Crystal-FEW Shape-ROD Locatio-I/E
Birefri-NEG Comment-c/w monoso
___ 7:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:23 am BLOOD CULTURE Source: Line-Rt PICC 2 OF
2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:51 pm JOINT FLUID Source: R wrist.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 1:57 pm BLOOD CULTURE Source: Line-picc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:28 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Imaging
========
TTE ___
IMPRESSION: Normal biventricular size and function. No valvular
massess are seen, and no clinically significant regurgitation is
present. The absence of vegetation seen on TTE is insufficient
to exclude endocarditis in the presence of high clinical
suspicion. Consider TEE for further evaluation if clinically
indicated.
R Hand/Wrist Xray ___
IMPRESSION: Findings most consistent with gout involving the
fifth middle
phalanx and possibly the radial styloid.
R Wrist Ultrasound ___
IMPRESSION: No discrete fluid collections seen. Fluid
surrounding the
extensor tendons consistent with tenosynovitis appears to be the
extensor
carpi radialis tendon, although this is not clearly demarcated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO BID
2. Colchicine 0.6 mg PO BID:PRN gout flare
3. Atenolol 50 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Ibuprofen 600 mg PO Q8H:PRN pain
6. Klor-Con (potassium chloride) 8 mEq oral daily
Discharge Medications:
1. Allopurinol ___ mg PO BID
2. Atenolol 50 mg PO DAILY
3. Colchicine 0.6 mg PO BID
4. Simvastatin 20 mg PO DAILY
5. Acetaminophen 650 mg PO Q4H:PRN fever
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth every 8 hours Disp #*30 Tablet
Refills:*0
6. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
7. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 8.6 mg by mouth twice a day Disp
#*30 Capsule Refills:*0
8. PredniSONE 20 mg PO BID
RX *prednisone 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
9. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth daily Disp #*30 Capsule Refills:*0
10. CefazoLIN 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 gm IV every 8
hours Disp #*36 Bag Refills:*0
11. Morphine SR (MS ___ 60 mg PO Q12H
RX *morphine [MS ___ 15 mg 4 tablet extended release(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
12. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine-menthol [LidoPatch] 4 %-1 % to wrist daily Disp
#*15 Unit Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Gout flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
RADIOGRAPHS OF THE RIGHT WRIST AND HAND
HISTORY: Right wrist pain. History of gout and septic arthritis.
COMPARISONS: None.
TECHNIQUE: Right wrist and hand, three views of each side.
FINDINGS: There are very small vague lucencies along the radial styloid which
could be considered potential small erosions. The joint spaces appear
preserved. A nonaggressive lucency within the scaphoid has sclerotic margins.
Mild angulation of the distal shaft of the fifth metacarpal is noted in
appearance that could be seen with prior injury. A large erosion with
corticated with an overhanging edge involving the fifth middle phalanx with
overlying soft tissue prominence is suspicious for tophaceous gout. The first
interphalangeal joint is mildly narrowed. There is a small subchondral
lucency with corticated margins in the third metatarsal head, but deep to the
bony surface, possibly a subchondral cyst.
IMPRESSION: Findings most consistent with gout involving the fifth middle
phalanx and possibly the radial styloid.
Radiology Report
INDICATION: Right hand swelling, septic joint versus gout flare, please
evaluate for fluid collection to be tapped if present.
TECHNIQUE: Real-time grayscale ultrasound images were obtained in the region
of the dorsum of the wrist.
COMPARISON: Right hand and wrist radiograph ___.
FINDINGS:
Limited images were performed in the region of the patient's swelling.
Although the images are labeled as anterior, they were obtained from the
dorsal aspect of the wrist. There is diffuse subcutaneous edema tracking
along fascial planes, but no discrete fluid collection seen. The hypoechoic
structures visualized on several images are veins. There is a small amount of
fluid surrounding the extensor tendons on either side of Lister's tubercle,
likely the extensor carpi radialis tendons, although the precise delineation
is not clear. This most likely reflects reactive tenosynovitis.
IMPRESSION: No discrete fluid collections seen. Fluid surrounding the
extensor tendons consistent with tenosynovitis appears to be the extensor
carpi radialis tendon, although this is not clearly demarcated.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RIGHT HAND PAIN
Diagnosed with JOINT PAIN-FOREARM, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 99.4
heartrate: 98.0
resprate: 14.0
o2sat: 100.0
sbp: 149.0
dbp: 90.0
level of pain: 8
level of acuity: 3.0 | # Polyarticular Gout - The patient endorsed a severe prior
history of gout. Initially, there was concern that his R wrist
swelling could be a infected. Hand surgery was consulted who
recommended xray and ultrasound which were consistent with gout.
He had the joint tapped which showed only 56 WBCs, and no
organisms. He had crystals consistent with gout. He was
initially maintained on colchicine, nsaids, and continued on his
allopurinol. However, he got worse with erythema and swelling of
his bilateral ankles. He was then started on prednisone 30mg. He
continued to get worse, with more swelling in his right elbow
and right knee. Rheumatology was consulted and his steroids were
increased to prednisone 20mg BID. His pain medications were
increased as well. He was on a low fat diet and received
extensive information fro the nutritionist. Hand surgery
eventually signed off after his symptoms improved with
medications. He was sent home on 20mg BID of prednisone with
plan for outpatient taper with Dr. ___ outpatient
rheumatologist. It was thought his severe disease was due to
noncompliance with diet as through his prolonged hospital course
he became more upfront about the foods that he would eat.
Throughout he maintained he did not drink alcohol.
# Bacteremia - Has history of MSSA bacteremia from soft tissue
bursitis near shoulder joint on the left. He had been on three
weeks of nafcillin prior to admission. It was decided that
despite negative cultures he would receive six weeks of therapy.
He was switched to cefazolin due to repeated hypokalemia. Blood
cultures were negative throughout his stay.
# Macrocytosis - He had an elevated macrocytosis, with no liver
abnormalities. He denied recent alcohol use. His B12 and folate
were checked and normal. He was asked to follow up as an
outpatient.
# HTN - He remained normotensive on his atenolol.
# HLD - His home dose of simvastatin was continued.
# Heart murmur - The patient was noted to have a heart murmur.
He had a history of MSSA in the past. An ECHO was ordered to
evaluate for vegetations but none were appreciated. Patient
remained stable with no further decompensation and no more
evidence of endocarditis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Hydrocodone
Attending: ___.
Chief Complaint:
Fever, productive cough.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with PMH rheumatoid arthritis returns to the
ED with compaints of cough and fever.
She was seen ___ in the ED for worsening SOB, cough, and
persistent fever to 102. At that time, CXR was unrevealing
however clinical suspicion for pneumoina was high and she was
given azithromycin and discharged home. Despite being treated
with azithromycin, she continued to report ongoing fevers to 102
and productive, painful cough and returned to the ED. Notably,
one of her grandson's who she takes care of has had a case of
"walking pneumonia."
In the ED, initial 102.4 87 120/80 20 97% WBC 4.7 HGB: 11.3,
Lactate:1.2, U/A negative. She was given Levaquin 750mg IV
and admitted to medicine for further management. Vitals on
transfer: 99.5 87 20 104/67 100%RA
On arrival to the medical floor, vitals were T:100.5 P:77
BP:105/69 RR:77 SaO2: 97% on Room air. She reported sorethroat
from coughing, and ongoing dyspnea with productive cough. She
also reports chronic headache and neckpain secondary to multiple
neck surgeries and removal of infected hardware most previously
in ___.
REVIEW OF SYSTEMS:
Denies: vision changes, rhinorrhea, congestion, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Anterior cervical diskectomy and reconstruction (___)
Cervical spine wound infection
Depression c/b SI
Hypothyroid
Cocaine abuse
Obstructive sleep apnea
Rheumatoid arthritis
s/p exp lap
s/p CCY
I&D of deep cervical abscess (___)
Bilateral Knee and Hip replacement
R rotator cuff repair x2
Social History:
___
Family History:
2 Children with RA. 1 child with fibromyalgia
Physical Exam:
Admission PHYSICAL EXAM:
VS - T:100.5 P:77 BP:105/69 RR:77 SaO2: 97% on Room air.
GENERAL - Middle aged female appearing fatigued, alert,
interactive, in NAD
HEENT - Tender cervical lymphadenopathy, no tonsillar exudate
NECK - Supple, JVP non-elevated
HEART - RRR, nl S1-S2, no MRG
LUNGS - Right sided inspiratory wheezes, no rales/ronchi, good
air movement, resp unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, No edema
NEURO - awake, A&Ox3, CNs II-XII intact
Discharge Physical Exam
VS - T:98.2 P:69 BP:115/74 RR:17 SaO2: 98% RA.
GENERAL - Female appearing stated age, NAD, slightly odd affect.
AAOx3.
HEENT - MMM, OP clear, no tonsillar exudate
NECK - Supple, JVP non-elevated
HEART - RRR, nl S1-S2, no MRG
LUNGS - Clear to ausculation bilaterally, no tactile fremitus
without adventitious breath sounds. resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, No edema. 2+ pulses
NEURO - awake, A&Ox3, CNs II-XII intact
Pertinent Results:
___ 04:53AM BLOOD WBC-3.4* RBC-4.20 Hgb-10.8* Hct-36.1
MCV-86 MCH-25.8* MCHC-30.0* RDW-13.7 Plt ___
___ 04:38AM BLOOD WBC-3.3* RBC-4.24 Hgb-11.0* Hct-36.8
MCV-87 MCH-25.9* MCHC-29.8* RDW-14.0 Plt ___
___ 03:40PM BLOOD WBC-4.7 RBC-4.39 Hgb-11.3* Hct-37.8
MCV-86 MCH-25.8* MCHC-30.0* RDW-14.1 Plt ___
___ 04:53AM BLOOD Glucose-107* UreaN-7 Creat-0.9 Na-141
K-3.3 Cl-105 HCO3-28 AnGap-11
___ 04:38AM BLOOD Glucose-133* UreaN-9 Creat-1.0 Na-140
K-3.5 Cl-103 HCO3-23 AnGap-18
___ 03:40PM BLOOD Glucose-91 UreaN-8 Creat-0.8 Na-140 K-3.5
Cl-104 HCO3-26 AnGap-14
___ 04:53AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.4
___ 04:01PM BLOOD Lactate-1.2
___ 04:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Micro:
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
Imaging:
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of cough
and dyspnea
and fever.
COMPARISONS: ___.
FINDINGS: Frontal and lateral views of the chest were obtained.
There is
minimal bibasilar atelectasis without focal consolidation. No
pleural
effusion or pneumothorax. The cardiac and mediastinal
silhouettes are stable with the cardiac silhouette top normal.
Mild elevation of left hemidiaphragm
is again seen.
IMPRESSION: No acute cardiopulmonary process. No significant
change from one day prior.
Pending at discharge:
Blood cultures
Medications on Admission:
Calcium 600 + D(3) 600 mg (1,500 mg)-400 unit Tab 2 Tablet BID
diazepam 5 mg Tab daily
Simvastatin 10 mg Daily
Omeprazole 20 mg daily
Zolpidem 5 mg Tab ___ QHS PRN
Synthroid ___ mcg Daily
Sertraline 25 mg Daily
Gabapentin 300 mg Cap 1 QHS
Folic acid 1 mg Tab Daily
fluticasone 50 mcg/actuation Nasal Spray,Daily
olyethylene glycol 3350 17 gram/dose PRN
Discharge Medications:
1. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
2. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
3. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: Two (2)
Tablet PO twice a day.
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for Anxiety.
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. zolpidem 5 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as
needed for insomnia.
7. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
spray Nasal once a day.
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Respiratory illness (viral vs community acquired pneumonia)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of cough and dyspnea
and fever.
COMPARISONS: ___.
FINDINGS: Frontal and lateral views of the chest were obtained. There is
minimal bibasilar atelectasis without focal consolidation. No pleural
effusion or pneumothorax. The cardiac and mediastinal silhouettes are stable
with the cardiac silhouette top normal. Mild elevation of left hemidiaphragm
is again seen.
IMPRESSION: No acute cardiopulmonary process. No significant change from one
day prior.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with SHORTNESS OF BREATH, COUGH, DEHYDRATION, HYPERTENSION NOS
temperature: 103.0
heartrate: 94.0
resprate: 20.0
o2sat: 100.0
sbp: 113.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | ___ year old female with a past medical history of RA (not
actively being treated) who presented with fevers and cough
despite two days of treatment with azithromycin who subsequently
was admitted for treatment of community acquired pneumonia.
Active Issues:
# Community acquired pneumonia: This patient presented to the
emergency room 2 days prior with cough and fever. Her chest xray
at the time was clear. She was empirically treated with
azithromycin. She came back to the emergency room two days later
with cough and fever to 102. Her chest xray was clear. Her white
count was initially decreased at 3.8. Cultures were done which
are pending at the time of discharge. She was started
empirically rochephin and azithromycin for community acquired
pneumonia. She subsequently improved as evidenced by
defervescence. She was discharged to home on
cefpodoxime/azithromycin with the differential diagnosis of
community acquired pneumonia versus viral upper respiratory
tract infection.
-Azithromycin x 5 days (7 day course)
-Cefpodoxime x 8 days (10 day course) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cipro /
Neosporin (neo-bac-polym) / amoxicillin / ACE Inhibitors
Attending: ___.
Chief Complaint:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
___ year old female with PMH of hypertension, HL and recent
admission at ___ found to have choledocholithiasis and possible
cholecystitis s/p ERCP with common bile duct stent presenting
with sudden onset of severe RUQ pain the morning of admission.
She reports feeling well after discharge from ___ on ___
without any abdominal pain and was eating well. Woke up this
morning at 2 AM with sudden onset sharp RUQ pain, constant, not
radiating, has nausea but denies vomiting. Denies f/c. Had 1
episode of loose stool yesterday, denies blood in stool or dark
stool. Presented to ED, she was afebrile, blood work was
unremarkable. RUQ-US showed partially visualized biliary stent
with expected pneumobilia and distended gallbladder with stone
in gallbladder neck. ACS and ERCP were consulted, she was given
IV morphine and IV dilaudid.
Currently reports she had ___ RUQ pain, improved after
receiving morphine. Denies f/c, headache, CP, cough, SOB,
dysuria, rash.
ROS: As above, ten point ROS conducted and otherwise negative.
___ course: presented with abdominal pain, vomiting, bloating.
T bili 4, AST 411, ALT 580, AP 149, CT A/P showed gallstones in
gallbladder fundus, CBD 15 mm. MRCP showed 1.1 cm distal CBD
stone, small stone vs. polyp in gallbladder fundus and probably
cholecystitis. ERCP showed large stone at least 1.5 cm, short
distal CBD stenosis. Brushings were taken (pathology negative
for malignant cells) and a plastic biliary stent was placed.
Sphincterotomy was not performed. Her pain resolved, bilirubin
improved to 0.9. Discharged with 1 week of Flagyl and Vantin
with plan for repeat ERCP in ___ and eventual
cholecystectomy.
Past Medical History:
HTN
HL
Distant partial colectomy due to colonic perforation after
polypectomy, had colostomy s/p reversal
Bilateral hip replacements
Social History:
___
Family History:
Brothers had COPD, father died of CAD, mother died of an
abdominal cancer
Physical Exam:
Admission PE:
VS: 97.4 123/54 64 16 94 ra
Gen: NAD, resting comfortably in bed
HEENT: EOMI, MMM, OP clear, anicteric sclera
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, moderate RUQ tenderness, ND +BS
Ext: no c/c/e
Neuro: CN II-XII intact, ___ strength throughout
Skin: warm, dry no rashes
Psych: pleasant, normal affect
GU: no foley
Discharge PE:
VS: 99.4 98.4 89 149/83 18 94RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, MMM, OP clear, anicteric sclera
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, appropriately tender near incisions with port site
dressings c/d/I, non-distended. No rebound or guarding.
Ext: no c/c/e
Neuro: CN II-XII intact, ___ strength throughout
Skin: warm, dry no rashes
Psych: pleasant, normal affect
Pertinent Results:
___ 10:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:38AM LACTATE-1.6 K+-4.1
___ 04:30AM GLUCOSE-110* UREA N-22* CREAT-1.0 SODIUM-130*
POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-25 ANION GAP-15
___ 04:30AM ALT(SGPT)-28 AST(SGOT)-59* ALK PHOS-53 TOT
BILI-0.5
___ 04:30AM LIPASE-98*
___ 04:30AM WBC-9.9 RBC-4.59 HGB-15.2 HCT-45.1* MCV-98
MCH-33.1* MCHC-33.7 RDW-12.0 RDWSD-43.7
RUQ US ___:
IMPRESSION:
1. Partially visualized stent in the common bile duct.
Pneumobilia reflects stent patency.
2. Distended gallbladder with a stone at the gallbladder neck.
No
pericholecystic fluid or gallbladder wall edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Potassium Chloride 10 mEq PO DAILY
7. Pravastatin 20 mg PO QPM
8. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
please hold for loose stool
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
do NOT drink alcohol or drive while taking this medication
4. Senna 8.6 mg PO BID:PRN constipation
5. Ascorbic Acid ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Potassium Chloride 10 mEq PO DAILY
Hold for K >
11. Pravastatin 20 mg PO QPM
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ female with right upper quadrant pain and history of
common bile duct stent. Evaluate stent patency and location. Evaluate for
cholecystitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. A stent is partially
visualized in the common bile duct. Pneumobilia is noted reflecting stent
patency.
GALLBLADDER: The gallbladder is distended with a shadowing stone noted at the
gallbladder neck.
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Partially visualized stent in the common bile duct. Pneumobilia reflects
stent patency.
2. Distended gallbladder with a stone at the gallbladder neck. No
pericholecystic fluid or gallbladder wall edema.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RUQ abdominal pain
Diagnosed with Right upper quadrant pain
temperature: 98.0
heartrate: 66.0
resprate: 15.0
o2sat: 97.0
sbp: 162.0
dbp: 72.0
level of pain: 6
level of acuity: 3.0 | The patient presented with severe right upper quadrant pain with
RUQ ultrasound showing an impacted gallstone in the gallbladder
neck, concerning for cholecystitis though she was afebrile
without lab abnormalities. Of note, she was recently admitted at
___ and was found to have choledocholithiasis and possible
cholecystitis, where she underwent ERCP with common bile duct
stent. While here, the medicine team felt that given her LFTs
have been normal and ultrasound shows no CBD dilation, her
biliary stent is most likely functioning appropriately. Per GI,
she will follow up with Dr. ___ an elective ERCP in the
future to remove the prior stent and attempt to remove the large
stone in the common bile duct.
The patient underwent laparoscopic cholecystectomy with the
acute care surgery team one day after initial presentation. The
procedure was uncomplicated (see Operative Note for more
detail). She did well post-operatively and was stable in the
PACU prior to transfer to the floor. She voided appropriately,
tolerated a regular diet, had pain well controlled with oral
pain medication, and was able to ambulate prior to discharge on
POD2. She will follow up in the acute care surgery clinic in one
to two weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
not feeling well
Major Surgical or Invasive Procedure:
Paracentesis x2, diagnostic and therapeutic.
History of Present Illness:
___ yo M with hep C and alcohol cirrhosis with advanced
hepatocellular carcinoma intolerant to chemo and currently
transitioning to hospice presents with failure to the thrive.
Unfortunately the patient is withdrawn and minimally verbal on
my interview so much of the history is gathered from ___ notes.
His friend called EMS to bring him to the ED because he was not
eating or drinking for the past 2 days and he was worried about
him. Friend reports he has been sleeping more and not talking
much. He has only taken his oxycodone once each day, and he
usually takes it around the clock. The patient just states he
"doesn't feel well" and endorses ongoing chronic abdominal pain
but he will not elaborate on symptoms.
In the ED, initial vitals were 99.1 61 129/72 18 96%. Labs
showed worsening liver function with INR 2.3, tbili 7.3, chronic
macrocytic anemia, Na 130, transaminases elevated but stable,
plts low 101. Head CT with no obvious mets. Diagnostic para with
no evidence of SBP. After speaking with the hepatology fellow,
he was admitted to ___ for further management.
On the floor he is lying in bed with covers up to his mouth and
refusing interview or exam. He will not give any history other
than what's stated above.
Past Medical History:
Hepatitis C cirrhosis, c/b ascites, grade 1 varices, HCC
Hepatocellular carcinoma, advanced stages, intolerance of chemo
and in the process of transitioning to hospice
Tumor thrombus
Primary hemochromatosis by MRI
H/o polysubstance abuse
Hypertension
Social History:
___
Family History:
The patient's father died of cardiovascular disease. His mother
died of lung cancer. A niece was treated for stomach cancer and
an aunt for breast cancer. He had four brothers and two sisters.
One brother had cirrhosis. He has no children.
Physical Exam:
ADMISSION
VS: T 97.8, BP 131/77, HR 65, RR 18, O2 sat 100% RA
General: thin chronically ill appearing man, withdrawn, flat
affect but begins to cry
HEENT: Sclera anicteric, EOMI, otherwise unabe to examine
further due to patient's refusal
Neck: supple, no JVD
CV: RRR, normal s1,s2, soft ___ systolic murmur heard at base
Lungs: CTAB, no wheezes, rales or rhonchi
Abdomen: Somewhat firm, moderately tender to palpation however
unable to fully examine due to patient's refusal
Ext: warm, dry, no edema
Neuro: does say occasional non-sensical phases, no gross defects
noted but unable to do full exam.
Skin: no rashes or lesions seen on cursory exam
DISCHARGE
VITALS: 98.1 120/72 81 18 95% RA
GEN: thin, NAD, interactive and alert
HEENT: Sclera anicteric, EOMI
Neck: supple, no JVD
CV: RRR, normal s1,s2, soft ___ systolic murmur heard at base
Lungs: Diminished right halfway up, othwerwise clear but limited
___ effort
Abdomen: Somewhat firm and distended, mildly TTP
Ext: warm, dry, no edema
Neuro: Oriented to date, hospital, participating in conversation
Skin: no rashes or lesions
Pertinent Results:
ADMISSION LABS
___ 08:35PM WBC-5.5 RBC-2.74* HGB-11.0* HCT-32.9*
MCV-120* MCH-40.3* MCHC-33.6 RDW-13.7
___ 08:35PM NEUTS-81* BANDS-0 LYMPHS-15* MONOS-4 EOS-0
BASOS-0 ___ MYELOS-0
___ 08:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+
TEARDROP-OCCASIONAL
___ 08:35PM PLT SMR-LOW PLT COUNT-101*#
___ 08:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:35PM ALBUMIN-2.0*
___ 08:35PM LIPASE-30
___ 08:35PM ALT(SGPT)-63* AST(SGOT)-170* ALK PHOS-253*
TOT BILI-7.3*
___ 08:35PM GLUCOSE-140* UREA N-27* CREAT-1.1 SODIUM-130*
POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-24 ANION GAP-14
___ 09:20PM ___ PTT-37.6* ___
___ 11:42PM ASCITES WBC-270* RBC-156* POLYS-30* LYMPHS-18*
MONOS-14* MESOTHELI-5* MACROPHAG-33*
___ 11:42PM ASCITES TOT PROT-0.4 GLUCOSE-143
DISCHARGE LABS
___ 05:30AM BLOOD WBC-5.9 RBC-2.35* Hgb-9.7* Hct-28.4*
MCV-121* MCH-41.1* MCHC-34.0 RDW-13.7 Plt Ct-79*
___ 05:30AM BLOOD Plt Ct-79*
___ 05:30AM BLOOD ___
___ 05:30AM BLOOD Glucose-109* UreaN-26* Creat-1.3* Na-129*
K-4.4 Cl-101 HCO3-22 AnGap-10
___ 05:30AM BLOOD ALT-54* AST-148* AlkPhos-198*
TotBili-6.6___ 05:30AM BLOOD Albumin-2.0* Calcium-8.2* Phos-2.8 Mg-1.9
MICROBIOLOGY
___ 5:59 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 11:42 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Blood cultures ___ NGTD
IMAGING
CT HEAD
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect or
major vascular territorial infarction. There is no shift of
midline
structures. Ventricles and sulci are normal in size and
configuration.
Gray-white matter differentiation is preserved. There is no
fracture. Imaged
paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION: No acute intracranial process. Please note for
assessment of
small metastatic lesions, MRI is more sensitive.
CXR
IMPRESSION: Low lung volumes limiting assessment without acute
process.
Basilar opacities are most likely atelectasis given low lung
volumes. Trace
edema cannot be excluded given low lung volumes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Nadolol 20 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
4. Spironolactone 50 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. Lactulose 30 mL PO TID
8. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
Apply to red bumps twice a day Do not use on each spot for more
than 14 days per month
9. Omeprazole 40 mg PO DAILY
10. Ondansetron 4 mg PO BID
11. QUEtiapine Fumarate 25 mg PO HS:PRN insomnia
Discharge Medications:
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Nadolol 20 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Ondansetron 4 mg PO BID
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. QUEtiapine Fumarate 25 mg PO HS:PRN insomnia
10. Spironolactone 50 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 6 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0
13. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hepatic encephelopathy
HCV cirrhosis
Hepatocellular carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Suggest HCC with fatigue decrease in uptake.
COMPARISON: None.
FINDINGS: 2 views were obtained of the chest. Of note the lateral view is
limited significantly with the arms being down over the chest. The lungs are
low in volume with bibasilar opacities, which given lung volumes are likely
atelectasis. The appearance of bronchovascular crowding is most likely due to
lung volumes as well, though trace edema is impossible to exclude. No pleural
effusion or pneumothorax is seen. The heart and mediastinal contours are
otherwise unremarkable.
IMPRESSION: Low lung volumes limiting assessment without acute process.
Basilar opacities are most likely atelectasis given low lung volumes. Trace
edema cannot be excluded given low lung volumes.
Radiology Report
HISTORY: Advanced HCC. Assess for metastasis.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformations were prepared.
COMPARISON: None.
FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or
major vascular territorial infarction. There is no shift of midline
structures. Ventricles and sulci are normal in size and configuration.
Gray-white matter differentiation is preserved. There is no fracture. Imaged
paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION: No acute intracranial process. Please note for assessment of
small metastatic lesions, MRI is more sensitive.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ALTERED MENTAL STATUS
Diagnosed with ALTERED MENTAL STATUS , OTHER MALAISE AND FATIGUE
temperature: 99.1
heartrate: 61.0
resprate: 18.0
o2sat: 96.0
sbp: 129.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with hep C and alcohol cirrhosis with advanced
hepatocellular carcinoma intolerant to chemo and currently
transitioning to hospice presents with encephalopathy.
ACTIVE ISSUES
# Encephalopathy: Most likely reflects hepatic encephalopathy
and improved significantly with lactulose and rifaximin.
Infectious workup revealed urine culture with >100,000 coag
positive staph, which was treated with Bactrim x7 day course.
Otherwise, infectious w/u was negative. CT head did not show
mets or bleed.
# UTI: UA w/___ WBCs and culture w/ >100,000 coag positive staph.
Thought to be clinically significant in this patient
w/encephalopathy. Treated with Bactrim DS BID x7 day course.
# Hepatocellular carcinoma: very advanced with multiple large
lesions replacing much of the liver parenchyma. Was not able to
tolerate chemo. At this admission, confirmed patient's desire
to transition to palliative care and was set up with home
hospice, with plan for patient to move in with his HCP when
feasible. Pain controlled with oxycodone.
# Hep C cirrhosis: Decompensated with ascites and varices. MELD
24 on admission with rising bilirubin and INR, transaminases are
stably elevated. Patient with distension on day of discharge,
prompting therapeutic paracentesis during which 5L fluid
removed. Patient received albumin afterwards. His furosemide,
spironolactone, nadolol were continued. Lactulose was increased
and he was started on rifaximin at this admission.
# Goals of care: Pt transitioned to hospice care during this
admission and was sent home with ___ hospice, with plan to move
in with ___, healthcare proxy, when feasible. Has
changed his code status to DNR/DNI. Overall plan is to continue
to treat active medical conditions and pursue interventions for
pt comfort.
TRANSITIONAL ISSUES
Blood cultures from ___ pending at time of discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female was brought to ___ by EMS after a fall with
occipital bleeding. She was notabley intoxicated on her
admission. A ___ was completed as part of her trauma work up
which demonstrated a large SAH bleed with intraparenchymal and
subdural components.
Past Medical History:
daily ETOH, anxiety and depression
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 96.9 HR: 91 BP: 127/86 Resp: 14 O(2)Sat: 97
Constitutional: Comfortable
HEENT: Posterior scalp avulsion laceration actively bleeding
C. collar
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Moving all extremities
___: No petechiae
Discharge Physical Exam:
VS: T: 98.6, HR: 98, BP: 137/77, RR: 16, O2: 95% RA
HEENT: L scalp laceration with sutures, skin well-approximated.
EOM intact.
GENERAL: A+Ox3, NAD
CV: RRR
PULM: mild wheezing b/l with expiration, no respiratory
distress.
Extremities: no edema b/l
Pertinent Results:
___ 11:07PM ___ PTT-31.9 ___
___ 09:10PM GLUCOSE-165* UREA N-5* CREAT-0.5 SODIUM-136
POTASSIUM-3.0* CHLORIDE-95* TOTAL CO2-24 ANION GAP-20
___ 09:10PM ALT(SGPT)-134* AST(SGOT)-207* ALK PHOS-67 TOT
BILI-0.8
___ 09:10PM LIPASE-152*
___ 09:10PM ALBUMIN-4.2 CALCIUM-9.0 PHOSPHATE-3.3
MAGNESIUM-1.8
___ 09:10PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:10PM WBC-4.6 RBC-3.92 HGB-13.8 HCT-38.8 MCV-99*
MCH-35.2* MCHC-35.6 RDW-12.1 RDWSD-44.1
___ 09:10PM NEUTS-48.6 ___ MONOS-12.2 EOS-2.0
BASOS-1.7* IM ___ AbsNeut-2.23 AbsLymp-1.61 AbsMono-0.56
AbsEos-0.09 AbsBaso-0.08
___ 09:10PM NEUTS-48.6 ___ MONOS-12.2 EOS-2.0
BASOS-1.7* IM ___ AbsNeut-2.23 AbsLymp-1.61 AbsMono-0.56
AbsEos-0.09 AbsBaso-0.08
___ 09:10PM PLT SMR-VERY LOW PLT COUNT-66*
IMAGING:
___: CT Head:
1. Bilateral subarachnoid hemorrhage, as above, right greater
than left.
Acute subdural hematoma tracking along the right tentorium.
Intraventricular hemorrhage without evidence of current
hydrocephalus.
2. Left posterior parietal subgaleal hematoma and scalp
laceration.
___: CT C-spine:
1. Bilateral subarachnoid hemorrhage, as above, right greater
than left.
Acute subdural hematoma tracking along the right tentorium.
Intraventricular hemorrhage without evidence of current
hydrocephalus.
2. Left posterior parietal subgaleal hematoma and scalp
laceration.
___: CXR:
No acute intrathoracic process.
___: CTA Head:
1. 2 mm focal areas of outpouching seen at the bilateral supra
clinoid ICAs near the MCA origin likely secondary to tiny
aneurysms versus infundibuli. Otherwise, no dissection,
stenosis or occlusion is seen involving the circle of ___.
2. Extensive subarachnoid hemorrhage right greater than left.
3. Left parietal scalp hematoma/laceration, similar to the prior
exam.
4. Congenital attenuation of the right V4 segment of the
vertebral artery.
___: CXR:
ET tube terminates 4.2 cm above the carina.
___: CT Head:
1. Increased hemorrhage at the left posterior scalp laceration.
2. Multi focal intracranial hemorrhage is overall similar in
amount and
distribution compared to prior.
___: CXR:
Comparison to ___. The endotracheal tube and the
feeding tube were removed. There is no evidence of
pneumothorax. Normal lung volumes. Normal size of the cardiac
silhouette. Mild fluid overload but no overt pulmonary edema.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
NO strenuous exercise while taking this medication
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*10 Tablet Refills:*0
3. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*5 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
-Bilateral subarachnoid hemorrhage
-Acute subdural hematoma
-Intraventricular hemorrhage
-Left posterior parietal subgaleal hematoma
-Left scalp laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall // r/o trauma
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
Acute subarachnoid hemorrhage is seen in the bilateral frontal regions, right
parietal and temporal regions including tracking along the sylvian fissure and
along the suprasellar cistern. Subarachnoid hemorrhage is seen in the right
cerebellar hemisphere. Intra-articular hemorrhage is seen layering
dependently in the posterior horns bilaterally as well as present in the right
frontal horn. Subdural hemorrhage is noted along the right tentorium. There
is no evidence of hydrocephalus currently.
There is no evidence of acute fracture. There maybe chronic deformity at the
left lamina papyracea. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable. There is a large left posterior parietal
subgaleal hematoma and scalp laceration.
IMPRESSION:
1. Bilateral subarachnoid hemorrhage, as above, right greater than left.
Acute subdural hematoma tracking along the right tentorium. Intraventricular
hemorrhage without evidence of current hydrocephalus.
2. Left posterior parietal subgaleal hematoma and scalp laceration.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 10:40 ___, 2 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with fall // r/o trauma r/o trauma
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.1 s, 24.4 cm; CTDIvol = 37.0 mGy (Body) DLP = 901.1
mGy-cm.
Total DLP (Body) = 901 mGy-cm.
COMPARISON: None.
FINDINGS:
No traumatic malalignment is identified. No fractures are identified.There is
no prevertebral soft tissue swelling.Degenerative changes are noted at
multiple levels. At C5-6, there is severe right neural foraminal narrowing
and mild central canal narrowing. Intracranial subarachnoid hemorrhage was
better seen on concurrent CT head.
IMPRESSION:
1. No fracture is identified. At C5-6, there is severe right neural foraminal
narrowing and mild mild canal narrowing.
Radiology Report
INDICATION: History: ___ with s/p fall, intoxicated, large L posterior
occipital hematoma w/ active bleeding // eval traumatic injury
TECHNIQUE: Single supine AP portable view of the chest
COMPARISON: None.
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
The cardiac and mediastinal silhouettes are unremarkable. No displaced
fracture is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD.
INDICATION: History: ___ with s/p fall, large traumatic SAH // eval ?
ruptured aneurysm.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of Omnipaqueintravenous contrast
material. Three-dimensional angiographic volume rendered and segmented images
were then generated on a dedicated workstation. This report is based on
interpretation of all of these images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 38.1 mGy (Head) DLP =
19.1 mGy-cm.
2) Spiral Acquisition 2.9 s, 22.8 cm; CTDIvol = 31.2 mGy (Head) DLP = 711.4
mGy-cm.
Total DLP (Head) = 730 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal with no evidence of stenosis, occlusion, or aneurysm. The dural
venous sinuses are patent. 2 mm areas of focal outpouching is seen at the
bilateral supra clinoid ICAs near the MCA origins, likely secondary to tiny
aneurysms (image 25, series 603b, and image 33, series series 103b, image 11,
series 601b).
Extensive subarachnoid hemorrhage is re- demonstrated bilaterally, right
greater than left. A small amount of subdural hematoma along the right
tentorium is also seen, similar to the prior exam.
No acute fracture is identified. There is mild right maxillary sinus mucosal
thickening. Aside from mild mucosal thickening involving the ethmoid air
cells. The visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. Left posterior scalp hematoma/laceration appear similar
to the prior exam. No underlying fractures identified.
IMPRESSION:
1. 2 mm focal areas of outpouching seen at the bilateral supra clinoid ICAs
near the MCA origin likely secondary to tiny aneurysms versus infundibuli.
Otherwise, no dissection, stenosis or occlusion is seen involving the circle
of ___.
2. Extensive subarachnoid hemorrhage right greater than left.
3. Left parietal scalp hematoma/laceration, similar to the prior exam.
4. Congenital attenuation of the right V4 segment of the vertebral artery.
RECOMMENDATION(S): Consultation with interventional neuroradiology is advised
to consider to obtain a cerebral angiogram.
NOTIFICATION: The above findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:46 AM, 5 minutes after discovery of
the findings.
Radiology Report
INDICATION: History: ___ with declining mental status w/ SAH now s/p
intubation // eval ETT, OGT placement
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ 22:35
FINDINGS:
ET tube terminates 4.2 cm above the carina. Transesophageal tube terminates
in the stomach. Lung volume is low. There is no consolidation, pneumothorax,
or large pleural effusion.
IMPRESSION:
ET tube terminates 4.2 cm above the carina.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall down stairs intoxicated, ?LOC, +HS p/w b/l SAH, R
SDH, IVH and L posterior scalp lac with subgaleal hematoma // assess position
of ETT and OGT; assess interval change
TECHNIQUE: Portable chest
___ at 10 01:00
FINDINGS:
The ET tube and NG tube are unchanged. There is some increased volume loss at
the right base.
IMPRESSION:
Increased volume loss at the right base otherwise no significant interval
change
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ s/p fall down stairs intoxicated, ?LOC, +HS p/w b/l SAH, R
SDH, IVH and L posterior scalp lac with subgaleal hematoma // assess interval
change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 840 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
Again subarachnoid hemorrhage is seen in the bilateral frontal, right parietal
and temporal regions, including subarachnoid blood tracking along the sylvian
fissure and along the suprasellar cistern. Subarachnoid hemorrhage is seen in
the right cerebellar hemisphere. Intraventricular hemorrhage is seen layering
dependently in the posterior horns bilaterally. Subdural hemorrhage is noted
along the right tentorium. There is no evidence of acute territorial
infarction or large mass. The ventricles and sulci are similar in size and
configuration compared to prior.
There is a large left posterior parietal subgaleal hematoma and scalp
laceration with increased hemorrhage since prior. There is no evidence of
fracture. The visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Increased hemorrhage at the left posterior scalp laceration.
2. Multi focal intracranial hemorrhage is overall similar in amount and
distribution compared to prior.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p trauma with subgaleal hematoma. //
Respiratory source of infection. Respiratory source of infection.
IMPRESSION:
Comparison to ___. The endotracheal tube and the feeding tube were
removed. There is no evidence of pneumothorax. Normal lung volumes. Normal
size of the cardiac silhouette. Mild fluid overload but no overt pulmonary
edema.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: s/p Fall, Head injury
Diagnosed with Traum subrac hem w/o loss of consciousness, init, Fall (on) (from) other stairs and steps, initial encounter
temperature: 96.9
heartrate: 91.0
resprate: 14.0
o2sat: 97.0
sbp: 127.0
dbp: 86.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is a ___ year-old female who was brought to ___ by
EMS after a fall with
occipital bleeding. She was notabley intoxicated on her
admission. A NCHCT was completed as part of her trauma work up
which demonstrated a large SAH bleed with intraparenchymal and
subdural components. She was admitted to the Acute Care Surgery
service for further medical care. The Neurosurgery service was
consulted to evaluate the patient's intracranial injuries. The
patient was started on a course of keppra. The patient was
transferred to the Trauma ICU for neurovascular checks and to be
placed on phenobarbital protocol for EtOH withdrawal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left index finger edema and pain s/p cat bite
Major Surgical or Invasive Procedure:
I&D of left index finger for flexor tenosynovitis, ___
History of Present Illness:
Ms. ___ is a ___ woman presenting to the ___ ED with
left index finger edema and erythema after a cat bite to her
hand
2 days ago. On the evening of ___, she grabbed her
grandson's
cat, who bit her multiple times. The following morning, she
developed pain, edema, and erythema near the cat bites and along
the index finger. She had no fevers or chills. The cat is up to
date on vaccines.
She was initially seen at ___ this morning, where
she
was given IV unasyn for concern for tenosynovitis, as well as
pain control with oxycodone, Toradol, and tylenol. She received
a
tetanus booster. Per patient, swelling decreased noticeably at
the OSH. She was transferred to ___ for further management.
Past Medical History:
-CAD: s/p CABG and multiple PCI
-PAD
-HTN
-HL
-OA
-depression
Social History:
Social History:
Retired. Lives ___ ___ with husband and grandson.
Nonsmoker, denies EtOH, illicitis, or herbals.
Physical Exam:
On admission:
VS: T 99.1, HR 64, BP 122/59, RR 18, O2Sat 92% ra
Gen: NAD
Left hand: Multiple puncture wounds on volar and dorsal aspect
of
left index MCP with minimal surrounding erythema, moderate edema
of MCP.
- Left index finger held ___ flexion
- Fusiform swelling of index finger extending just distal to DIP
- Pain with passive extension of index finger
- Tenderness to palpation along index finger flexor tendon
sheath
from PIP to distal palmar crease; also has milder tenderness to
palpation ___ dorsum of hand overlying index MCP
- SILT, FDS, FDP, extensor tendons intact, cap refill < 1s on
left index
Pertinent Results:
___
WBC 7.2 Neut 69.8%
___ 5:00 pm SWAB Site: FINGER
LEFT INDEX FINGER FLEXOR TENOSYNOVITIS.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). RARE GROWTH.
SUSGGESTING PASTEURELLA SPECIES.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ 9:17 am SWAB
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO DAILY
2. Labetalol 200 mg PO BID
3. DiCYCLOmine 10 mg PO QID
4. Aspirin 81 mg PO DAILY
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Furosemide 40 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Robinul (glycopyrrolate) 1 tab oral bid
10. Nitroglycerin SR 0.4 mg PO Q5M
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Furosemide 40 mg PO BID
4. Labetalol 200 mg PO BID
5. Losartan Potassium 100 mg PO DAILY
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Sertraline 50 mg PO DAILY
8. DiCYCLOmine 10 mg PO QID
9. Nitroglycerin SR 0.4 mg PO Q5M
10. Robinul (glycopyrrolate) 1 tab oral bid
11. Acetaminophen 650 mg PO Q6H:PRN pain
12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
Every 12 hours Disp #*10 Tablet Refills:*0
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours Disp #*40
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left index flexor tenosynovitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with left hand cellulitis after CAT bite.
COMPARISON: None available.
FINDINGS:
PA, lateral, and PA oblique views of the left hand were obtained. These
demonstrate no fracture or dislocation. Significant degenerative changes are
identified within the distal interphalangeal joints most prominent at the
second third and fourth digits with joint space narrowing and osteophytosis.
Degenerative changes about the first CMC and triscaphe joint are additionally
noted. The carpals appear in normal alignment. An irregular distal radius
likely reflects prior trauma. No radiopaque foreign body or soft tissue
calcification is identified.
IMPRESSION:
No fracture or dislocation. No evidence of radiopaque foreign bodies or soft
tissue calcification. Significant degenerative changes identified compatible
with osteoarthritis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Cat bite, L HAND INFECTION
Diagnosed with CELLULITIS, FINGER NOS, OPEN WOUND FINGER-COMPL, ANIMAL BITE NEC
temperature: 99.1
heartrate: 64.0
resprate: 18.0
o2sat: 92.0
sbp: 122.0
dbp: 59.0
level of pain: 5
level of acuity: 3.0 | The patient was admitted to the plastic surgery service on on
___ and had a I&D of left index finger for flexor
tenosynovitis. The patient tolerated the procedure well.
.
ID: The patient had been started on IV unasyn at the outside
hospital on ___ prior to arrival at ___ for concern for
left index flexor tenosynovitis. She was re-started with empiric
antibiotic therapy with IV unasyn upon arrival to the ___ ED.
She was placed ___ a volar resting splint and kept her hand
elevated, and she was observed ___ the ED overnight. The
following morning on HD#2, there was noted to be minimal
improvement of the left hand edema. A bedside I&D was performed
___ the ED with drainage of purulent fluid from the dorsum of the
left hand, which was sent for culture. Gram stain showed GPCs ___
pairs and clusters, and final culture was pending at time of
discharge. Serial exams throughout HD#2 showed worsening exam,
and patient was sent to the OR for irrigation and debridement of
left index finger. Purulent fluid was seen ___ both the dorsum of
the hand and flexor sheath, which was sent for culture. Patient
was replaced ___ a splint, kept the hand elevated, and started on
TID betadine soaks on POD#1. Patient remained afebrile.
.
Neuro: Post-operatively, the patient received Morphine PCA with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced when appropriate,
which was tolerated well. Intake and output were closely
monitored.
.
Prophylaxis: The patient was encouraged to get up and ambulate
as early as possible.
.
At the time of discharge on POD#3, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. Exam of the hand at discharge showed improving
erythema and swelling, improved range of motion. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
cefazolin
Attending: ___.
Chief Complaint:
Abdominal pain
Postoperative ileus
Major Surgical or Invasive Procedure:
___ Laparotomy and resection of ileocolic anastomosis
___ Drainage of intra-abdominal collection
History of Present Illness:
___ with recent history of laparoscopic colectomy for colon CA
discharged from ___ under colorectal surgery service ___
now presents with abdominal pain. Since discharge he has had
moderate difficulty with PO intake, reporting frequent burping
and emesis after taking liquids. He called with concerns on
___ and was suggested to come in but elected to try to manage
with liquids at home. Now he presents with about 24 hours of
decreased bowel function as measured by no stool output and
decreased flatus.
Past Medical History:
hypothyroid
depression
htn
prostate CA- s/p RRP
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on presentation:
98.5 98 114/70 18 97% RA
AOx3 NAD, pleasant
RRR S1S2
Normal WOB
Abd softly distended, incisions healing well, mild ttp, nonfocal
examination
Ext well perfused
Exam at discharge:
General: cooperative, abulating with assistance
VSS
GEN: NAD, AOx3
ABD: midline incision open and packed with gauze dressing, ___
drain in place
Pertinent Results:
___ 04:15AM BLOOD WBC-10.6 RBC-3.59* Hgb-9.7* Hct-30.1*
MCV-84 MCH-27.1 MCHC-32.3 RDW-14.6 Plt ___
___ 06:40AM BLOOD WBC-12.1* RBC-3.32* Hgb-9.0* Hct-28.1*
MCV-85 MCH-27.0 MCHC-31.9 RDW-14.3 Plt ___
___ 06:20AM BLOOD WBC-14.7* RBC-3.65* Hgb-9.7* Hct-30.9*
MCV-85 MCH-26.7* MCHC-31.6 RDW-14.5 Plt ___
___ 04:40AM BLOOD WBC-15.6* RBC-4.30* Hgb-11.7* Hct-35.9*
MCV-83 MCH-27.2 MCHC-32.6 RDW-14.7 Plt ___
___ 08:10AM BLOOD WBC-11.2* RBC-4.09* Hgb-11.2* Hct-34.4*
MCV-84 MCH-27.4 MCHC-32.5 RDW-14.8 Plt ___
___ 07:10AM BLOOD WBC-12.2* RBC-3.95* Hgb-10.9* Hct-33.3*
MCV-84 MCH-27.6 MCHC-32.7 RDW-14.6 Plt ___
___ 06:50AM BLOOD WBC-12.5* RBC-3.81* Hgb-10.3* Hct-31.9*
MCV-84 MCH-27.1 MCHC-32.4 RDW-14.1 Plt ___ 04:15AM
BLOOD Glucose-149* UreaN-20 Creat-0.7 Na-137 K-3.7 Cl-103
HCO3-27 ___ 05:09AM BLOOD Glucose-127* UreaN-20
Creat-0.7 Na-139 K-4.0 Cl-104 HCO3-30 ___ 10:13AM
BLOOD Glucose-493* UreaN-17 Creat-0.7 Na-134 K-4.0 Cl-102
HCO3-30 AnGap-6
___ 06:20AM BLOOD Glucose-129* UreaN-13 Creat-1.0 Na-137
K-4.8 Cl-102 HCO3-28 AnGap-12
___ 04:40AM BLOOD Glucose-135* UreaN-12 Creat-0.9 Na-138
K-4.8 Cl-103 HCO3-29 AnGap-11
___ 08:10AM BLOOD Glucose-118* UreaN-7 Creat-0.9 Na-138
K-4.5 Cl-103 HCO3-30 AnGap-10
___ 07:10AM BLOOD Glucose-135* UreaN-7 Creat-0.9 Na-139
K-4.5 Cl-101 HCO3-31 AnGap-12
___ 06:50AM BLOOD Glucose-133* UreaN-8 Creat-1.0 Na-142
K-3.9 Cl-103 HCO3-33* AnGap-10
___ 10:13AM BLOOD Albumin-2.6* Calcium-8.7 Phos-3.1 Mg-2.1
Iron-17*
___ 06:40AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
___ 06:20AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
___ 04:40AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.9
___ 08:10AM BLOOD Albumin-3.1*
___ 10:13AM BLOOD calTIBC-198* Ferritn-209 TRF-152*
___ 10:13AM BLOOD Triglyc-117
___ 05:00AM BLOOD HoldBLu-HOLD
___ 05:00AM BLOOD LtGrnHD-HOLD
CHEST PORT. LINE PLACEMENT Study Date of ___ 9:26 AM
IMPRESSION:
Right PICC terminates in the mid SVC. No pneumothorax.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 10:31 AM
IMPRESSION:
1. Multiple new organized fluid collections within the abdomen
as described above, raising concern for abscess/infection.
2. Two foci of air are seen adjacent to the duodenum, could
reflect a
potential leak versus residual post-operative air.
3. Right and left colonic anastomoses appear grossly intact.
4. Multiple fluid-filled dilated loops of small bowel with no
definite
transition point identified and fluid seen in distal colon.
Findings could
relate to postsurgical ileus.
5. Moderate intra-abdominal ascites.
6. 6.8 cm fat attenuating lesion in the right upper quadrant,
for which
differential diagnoses include lipoma versus low grade
liposarcoma.
7. Moderate amount of air seen within the urinary bladder,
likely relates to
recent instrumentation. Correlation with history recommended.
PERC IMAGE GUID FLUID COLLECT DRAIN W
CATH(ABSC,HEMA/SEROMA;LYMPHOCELE,CYST);PERIT/RETROPERITONEAL
Study Date of ___ 3:36 ___
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into
the right mid abdominal collection. Sample sent for
microbiology evaluation.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
11:42 AM
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism. No
pneumonia.
2. Small foci of extraluminal air at the right colonic
anastomotic site, deep to the umbilical port site, are new from
___. If there has been interval manipulation of the
port site, the air may be related to manipulation. If there is
not been manipulation, this raises the possibility of an
anastomotic leak and close clinical followup is suggested.
3. Ileus. No drainable fluid collection in the abdomen or
pelvis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 12.5 mcg IV DAILY
2. Amlodipine 10 mg PO DAILY
3. Epinephrine 1:1000 0.3 mg IM ASDIR
4. Hydrochlorothiazide 25 mg PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. Sertraline 50 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice day
Disp #*14 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
3. Epinephrine 1:1000 0.3 mg IM ASDIR
uses only for bee stings
4. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*14 Tablet Refills:*0
5. Sertraline 50 mg PO DAILY
RX *sertraline [Zoloft] 50 mg 1 tablet(s) by mouth once a day
Disp #*14 Tablet Refills:*0
6. Levothyroxine Sodium 25 mcg PO DAILY
RX *levothyroxine 25 mcg 1 tablet(s) by mouth once a day Disp
#*14 Tablet Refills:*0
7. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
8. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 2 Weeks
Continue until ___
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*42 Tablet Refills:*0
9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Weeks
Coninue until ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Twice a
day Disp #*28 Tablet Refills:*0
10. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*40 Tablet Refills:*0
12. sodium chloride 0.9 % 5 cc ___ drain site Daily
Please flush ___ placed drain with 5cc of sterile normal saline
once saily to maintain patency of drain
RX *sodium chloride 0.9 % 0.9 % 5 cc ___ Drain Daily Disp #*14
Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Postoperative ileus
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)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with recent extended right colectomy now with
ileus // rule out any reason for him to desat on RA, large atelectases,
pneumonia, PE
COMPARISON: Chest radiograph ___.
IMPRESSION:
Mild bibasilar atelectasis unchanged. Upper lungs clear. No appreciable
pleural abnormality. Heart size top-normal.
Radiology Report
EXAMINATION: CTA TORSO
INDICATION: ___ year old man with tachycardia, desat, r/p PE // r/o PE.
Patient is postoperative day 8 from left and right colectomy for colon cancer.
Ileus on outside hospital CT scan with nausea and loose stools.
TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed
with intravenous contrast. Images are presented for displayed in the axial
plane at 2 mm and 1 mm collimation. A series multiplanar reformations images
are submitted for review. Subsequently, MDCT axial images from the lung bases
to the pubic symphysis were obtained with oral Gastrografin and intravenous
contrast. Coronal and sagittal reformations were provided for review.
DLP: 979.60 mGy-cm
COMPARISON: CT ___ from ___ ; CT ___ and ___ from ___ ; MRI ___
FINDINGS:
CTA CHEST: The thoracic aorta is normal in caliber without evidence of
dissection with mild atherosclerotic calcifications along its course.
Pulmonary arterial vasculature is well visualized to the subsegmental level
without filling defect to suggest pulmonary embolism. No pathologically
enlarged supraclavicular, axillary, mediastinal or hilar lymph nodes are
identified. Moderate atherosclerotic calcifications in the LAD coronary artery
are of unknown hemodynamic significance. There is no pleural or pericardial
effusion. Linear atelectasis or scarring in the left upper lobe is new from
___. There is mild dependent bibasilar atelectasis with right middle and left
lower lobe atelectasis. Mosaic attenuation suggests small airways disease. No
worrisome nodule, mass, or consolidation. Airways are patent to the
subsegmental levels bilaterally. Minimal gynecomastia is noted bilaterally.
CT ABDOMEN: The liver has homogeneous attenuation throughout. No focal liver
lesion is identified. There is no intra or extrahepatic bile duct dilation.
The gallbladder is surgically absent. The spleen, pancreas and bilateral
adrenal glands are unremarkable. The kidneys enhance symmetrically and excrete
contrast promptly without hydronephrosis. A 6 mm exophytic lesion at the
posterior left renal interpolar region (10:47) is better evaluated on the
prior MRI, suspicious for renal cell carcinoma. A 2.6 cm simple cyst at the
left renal lower pole is unchanged (10:50).
Oral contrast remains within small bowel without reaching the colonic
anastomotic sites. Fluid is seen in mildly dilated small bowel loops with
some more decompressed small bowel loops distally. However, there is fluid in
the colon, which is not collapsed, suggesting ileus rather than bowel
obstruction.
Small foci of extraluminal air at the right colonic anastomotic site (10:59)
are new from ___. This is deep to the umbilical port site, which
contains small air and more fluid than on ___. If there has been
interval manipulation of the port site, this air may be related to
manipulation. If there has not been manipulation, this raises the possibility
of an anastomotic leak, although no adjacent fluid is seen. The left colonic
anastomotic site appears intact. Small free air and free fluid in the left
upper quadrant are similar to the prior study without an organized fluid
collection, likely post operative or due to fat necrosis. Elsewhere, there is
small free intraperitoneal fluid without an organized fluid collection.
The abdominal aorta is normal caliber throughout with moderate atherosclerotic
calcifications along its course. The main portal vein, splenic vein and SMV
are patent. No pathologically enlarged mesenteric or retroperitoneal lymph
nodes are identified.
CT PELVIS: The rectum and sigmoid colon are unremarkable. Free fluid in the
pelvis is likely tracking from the abdomen. A right bladder diverticulum is
noted (10:85). The patient is status post prostatectomy. Penile implants are
in place. No pelvic or inguinal lymphadenopathy.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism. No pneumonia.
2. Small foci of extraluminal air at the right colonic anastomotic site, deep
to the umbilical port site, are new from ___. If there has been
interval manipulation of the port site, the air may be related to
manipulation. If there is not been manipulation, this raises the possibility
of an anastomotic leak and close clinical followup is suggested.
3. Ileus. No drainable fluid collection in the abdomen or pelvis.
NOTIFICATION: The findings were discussed by Dr. ___ with ___
___ on the telephone on ___ at 12:30 ___ and at 3:55PM.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE ONLY)
INDICATION: ___ year old man with SBO // eval NGT position
COMPARISON: No comparison
IMPRESSION:
The nasogastric tube shows a normal course. In the fundus of the stomach, the
tube is coiled but the tip points downwards towards the middle parts of the
stomach. No complications, notably no pneumothorax.
Radiology Report
EXAMINATION: CONTRAST ENHANCED CT ABDOMEN AND PELVIS
INDICATION: Status post recent extending right colectomy now with ileus, now
status post ex lap revision of anastomosis. Evaluate for leak or abscess.
TECHNIQUE: Axial MDCT images were obtained through the abdomen and pelvis
after the uneventful administration of IV and oral contrast. Sagittal and
coronal reformats were generated.
TOTAL EXAM DLP: 819 mGy-cm.
COMPARISON: Torso CTA from ___, abdominal/ pelvic CT from ___ and abdominal MR from ___.
FINDINGS:
Visualized portions of the left lower lung demonstrate atelectasis. Visualized
portions of the heart and pericardium are within normal limits.
CT of the abdomen: The liver enhances homogeneously with no focal hepatic
lesions identified. There is no intrahepatic biliary ductal dilatation. The
gallbladder has been surgically removed. Surgical clips are seen in the right
upper quadrant. The pancreas is normal. There is no pancreatic duct dilatation
or peripancreatic fluid collections. The adrenal glands are normal. The
spleen is homogeneous and normal in size. In the lower pole of the left
kidney, there is redemonstration of a 3.4 x 2.4 cm hypodensity which measures
up to 5 Hounsfield units, characterized as a complex cystic lesion on prior MR
from ___ (series 5, image 41). Additionally, there is
redemonstration of a 10 mm left peripelvic cyst. A small 6 mm exophytic
lesion in the interpolar region of the left kidney is again seen, better
assessed on prior MR, and suspicious for renal cell carcinoma (series 5, image
36). The kidneys otherwise enhance symmetrically and excrete contrast without
evidence of hydronephrosis. There is mild to moderate amount of perihepatic
ascites.
The stomach is normal. Patient is status post bilateral colectomy. Both right
and left colonic anastomoses appear grossly intact. However, note is made of
multiple mildly dilated fluid filled loops of small bowel, measuring up to 3.7
cm. No transition point is identified and fluid is seen in portions of the
distal colon. These findings could relate to ileus. Two foci of air are seen
adjacent to the duodenum and could reflect a potential leak versus residual
post-operative air (series 5, image 29). There is redemonstration of a 6.8 x
4.7 cm fat attenuating lesion in the right upper quadrant (series 5, image
29).
Surrounding the duodenum, there is a well organized fluid collection with a
mild hyperdense rim measuring 3.7 (TV) x 2.9 (AP) x 3.9 (CC) cm (series 5,
image 22; series 8, image 29). In the right paracolic gutter, there is an
additional new well organized and hypodense fluid collection with a hyperdense
rim which abuts multiple loops of bowel and measures approximately 4.3 (TV) x
3.2 (AP) x 9.3 (in coronal view) cm (series 5, image 37; series 7, image 28).
Lastly, there is a smaller hypodense fluid collection with a hyperdense rim in
the right lower quadrant, just inferior to the rectus sheath on the right
which measures 5.2 x 1.0 cm (series 5, image 58). In the left upper quadrant,
just inferior to the spleen, there is redemonstration of presumed surgical
material, possibly Surgicel, surrounded by a small amount of free fluid,
measuring up to 3.9 x 3.2 cm (series 5, image 23).
The abdominal aorta is tortuous with moderate amount of atherosclerotic
calcifications. The celiac axis, SMA, bilateral renal arteries and ___ are
patent. Along the anterior abdominal wall at midline, there is an open wound,
with surrounding fat stranding, likely related to recent surgery.
CT of the pelvis: A moderate amount of air is seen in the urinary bladder,
which could relate to recent instrumentation. There is redemonstration of a
right bladder diverticulum which now contains a small amount of air (series 5,
image 80). Multiple surgical clips are seen in the pelvis, patient is status
post prostatectomy. There is a moderate amount of low density attenuating
fluid in the pelvis. The rectum is grossly intact. There are bilateral fat
containing inguinal hernias. The one on the left contains a small
unobstructed loop of bowel. Penile imlpants are in place.
Osseous structures: No blastic or lytic lesion concerning for malignancy.
Multilevel moderate degenerative changes are noted along the lumbar spine with
anterior osteophytosis, multilevel vacuum disc phenomenon and endplate
sclerosis.
IMPRESSION:
1. Multiple new organized fluid collections within the abdomen as described
above, raising concern for abscess/infection.
2. Two foci of air are seen adjacent to the duodenum, could reflect a
potential leak versus residual post-operative air.
3. Right and left colonic anastomoses appear grossly intact.
4. Multiple fluid-filled dilated loops of small bowel with no definite
transition point identified and fluid seen in distal colon. Findings could
relate to postsurgical ileus.
5. Moderate intra-abdominal ascites.
6. 6.8 cm fat attenuating lesion in the right upper quadrant, for which
differential diagnoses include lipoma versus low grade liposarcoma.
7. Moderate amount of air seen within the urinary bladder, likely relates to
recent instrumentation. Correlation with history recommended.
NOTIFICATION: Findings #1 and #3 were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 2:05 ___, 15 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with intra-abdominal abscess // please evaluate
for drainage
TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained.
COMPARISON: Abdominal CT of ___ at 10:36.
FINDINGS:
Targeted sonographic imaging was performed of the right mid abdomen to
determine whether the collection seen in this region on the preceding CT, was
amenable for ultrasound guided drainage. An air and fluid containing
collection was identified in the location corresponding to that seen on prior
CT. Immediately superior to the collection is a homogeneous, hyperechoic
structure measuring 3.7 x 5.3 cm, a sonographic appearance suggestive of a fat
containing lesion. The collection to be drained was identified immediately
inferior to this and measures 3.0 x 4.2 cm. The loops of bowel adjacent to the
collection were identified. The collection was deemed amenable for ultrasound
guided percutaneous drainage.
Please note that is images of the drainage procedure which was performed
immediately following this ultrasound, are included in this same clip (images
10 through 14) but refer to the ultrasound guided drainage reported separately
under clip ___.
IMPRESSION:
1. 3.0 x 4.2 cm air and fluid containing collection in the right mid abdomen
consistent with abscess, amenable to ultrasound-guided drainage. Please refer
to separately dictated report of drainage procedure which was performed
immediately following the study..
2. 3.7 x 5.3 cm echogenic structure is seen just superior to the collection to
be drained, suggestive of a fat containing lesion. Diagnostic considerations
would include lipoma or low-grade liposarcoma.
Radiology Report
INDICATION: ___ year old man with intra-abdominal abscess, s/p right and left
colectomy // please evaluate for drainage of right sided intra-abdominal
abscess
COMPARISON: Abdominal ultrasound of same date; abdominal CT of same date
PROCEDURE: Ultrasound-guided drainage of right mid abdominal collection.
OPERATORS: Dr. ___ trainee and Dr. ___ radiologist,
who was present and supervising throughout the total procedure time.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. In
addition, an adjacent structures were identified including the loops of bowel
surrounding the collection. Based on the ultrasound findings an appropriate
skin entry site for the drain placement was chosen. The site was marked.
Local anesthesia was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the collection. The tip of the trocar was
observed at all times during entry into the collection, and upon entry into
the fluid, the sharp trocar was promptly withdrawn allowing deployment of the
flexible plastic catheter. A sample of fluid was aspirated, confirming
catheter position within the collection. The pigtail was deployed. The
position of the pigtail was confirmed within the collection via ultrasound.
Approximately 15 cc of turbid brown, purulent and succus appearing fluid was
drained with a sample sent for microbiology evaluation. The catheter was
secured by a StatLock. The catheter was attached to JP bulb. Sterile dressing
was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 20
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Air and fluid containing collection in the right mid abdomen. Please note that
images are included in CLIP number ___.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the right mid
abdominal collection. Sample sent for microbiology evaluation.
Radiology Report
INDICATION:
___ year old man with new R PICC // 43cm R brachial DL PICC - ___ ___
Contact name: ___: ___ .
COMPARISON: Chest radiograph ___.
TECHNIQUE
Portable view of the chest.
FINDINGS:
A new right PICC terminates in the mid SVC. There is no pneumothorax. Lung
volumes are low reflected in increased subsegmental atelectasis in the right
lower lung. Cardiomediastinal silhouette is normal. Top normal heart size.
IMPRESSION:
Right PICC terminates in the mid SVC. No pneumothorax.
NOTIFICATION: Findings discussed with the IV nurse by Dr. ___ on ___ at 10:00, at the time of discovery.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.5
heartrate: 98.0
resprate: 18.0
o2sat: 97.0
sbp: 114.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ presented to the ED at ___ on ___ for
abdominal pain and symptoms of postoperative ileus as well as
rash, which was non-operatively managed without the need for NGT
placement. After a brief and uneventful stay in the ED, the
patient was transferred to the floor for further management.
Neuro: His pain was well-controlled on IV transitioned to PO
pain meds.
CV: He remained stable throughout the hospitalization from a
cardiac standpoint.
Pulm: He remained stable throughout his hospitalization from a
pulmonary standpoint. Incentive Spirometry and frequent
ambulation were encoraged.
GI: CT scan at the time of admission showed no specific focal
findings, other than a small amount of air under the midline
incision near the ileocolic anastomosis. On ___ the midline
incision began to drain moderate amounts of bilious fluid
through the wound and this was likely a fistula. Given that the
patient was not to far from his initial procedure he was taken
to the operating room for Laparotomy and resection of ileocolic
anastomosis ___. THe remainer of the admission was
complicated by awaiting return of bowel function, intraabdominal
fluid collection, and wound infection. An NGT was left in place
post-opreatively and was draining bilious fluid. On ___ the
foley catheter was removed and the patient was due to void. We
awaited retun of bowel function. On ___ The NGT was
removed. On ___ The pervena vac was removed and the
incision looked intact. On ___ antibiotics were
discontinued however the wound appeared red and this was opened
at the bedside. On ___ The patient had signs of ileus and a
CT scan of the abdomen was preformed to rule out leak and a
fluid collections were seen within the abdomen above, raising
concern for infection. The collection was drained. On ___
the patient was started on PPN and he remained NPO with
intravenous fluids. On ___ a PICC line was placed and TPN
initiated. ___ the patient had episodes of desat's to mid
80's however this improved with oxygen. Over the next few days
he continued to improve. The drain was drianing. The abscess
appeared to be connected to the bowel and the ___ placed drain
was draining green bile. The patient remained on bowel rest with
the hopes that this connection would close on it's own. He was
started on PO antibiotics for discharge home to cover the
multiple bacteria which grew from the abscess culture. He would
remain on TPN for discharge home with close followup with Dr.
___ to decide if the diet would be advanced or if any further
intervention whould be needed to repair this area. The Midine
wound was left open with a gauze packing to be cared for at home
by the ___. It was not redened or drianing puss.
GU: After the foley catheter was removed, the patient voided
without issue.
SKIN: On admission, patient had a raised rash whith what
appeared to be wheels over the skin of his anterior abdomen
extending to his groin, chest, and back. He was not taking any
new medications that would signify the rash to be allergic.
However, after drainage of the intraabdominal fluid collection
and improvement in his overall clinical picutre, the rash
resolved. The exact cause of this rash was not determined
however, it seemed to be likely related to a reaction to his
overall clinical situation at the time of his admission.
Discharge Planning: There was a large effort from case managment
and the nursing staff to organize a safe discharge plan for this
patient. The patient was taught to care for the drain site and
basic PICC line care. There were multiple levels of discharge
planning coordinating with the family and IV services for the
TPN. The family decided to pay for the TPN on their own given
lack of insurance coverage. The IV team met with the family
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ACE Inhibitors / rosuvastatin / fluticasone
Attending: ___.
Chief Complaint:
ANEMIA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female w COPD, PE on anticoag, GI bleed, p/w worsening
anemia requiring transfusion. This patient was recently admitted
with a PE c/b GI bleed, after risk/benefits discussion, decision
was made to cont anticoagulation for this pt. Recently pt states
feels more fatigued, dyspnea, especially on exertion. She had
labs at rehab which showed worsening anemia. Per pt and her
nephew, her breathing has been better since her previous
discharge. She was mainly transferred to the ___ due to anemia
found on outpatient labs. She has specific goals of care
outlined as below. Of note, she was recently admitted for 16
days in ___ with concern for cholangitis
initially managed medically in setting of hypoxic respiratory
failure secondary to pleural effusions and acute pulmonary
embolism, s/p R thoracentesis and initiation of anticoagulation.
She reports better breathing since her last hospitalization.
In the ED, initial vital signs were: T98 P58 BP126/62 R16 O2
sat 100% RA
- Exam was remarkable for AAOx3, slight confusion to day of
week.
- Labs were notable for brown guiac +, H/H of 7.1/___.4, WBC
3.5. Benign UA.
- Studies performed include CXR: Increasing pleural effusions
and lower lobe consolidations concerning for atelectasis versus
pneumonia. Mild edema appears new. Persistently large hiatal
hernia
- Patient was typed and crossed and received 2 units of pRBC
- Vitals on transfer: T 97.2 P 66 BP 145/66 R 20 O2sat 97% on
2.5 NC
Past Medical History:
COPD
cholelithiasis presentation a month ago
HTN
hypothyroid
angina
vertigo
Social History:
___
Family History:
non contributory to current presentation
Physical Exam:
ADMISSION
Vitals- T 97.2 P 66 BP 145/66 R 20 O2sat 97% on 2.5 NC
General: Fatigued but non-toxic appearing ___ year old female.
HEENT: PERRL. EOMI. Clear oropharynx.
Neck: No LAD.
CV: Slightly loud S2. No m/r/g.
Lungs: Decreased breath sounds at the bilateral bases. No
crackles, rhonchi or wheezing noted.
Abdomen: Soft. NT. ND.
Ext: Skin is thin and loose. No edema bilaterally.
Skin: Questionable spoon nails exhibited on the thumbs.
Neuro: AAOx2. Unable to state location or year. Able to
remember 3 objects and name the current president. Did not
understand why she was in the hospital.
DISCHARGE
Vitals: T 98 BP 146/60 HR 70 R 18 O2sat 99% on 3L NC
General: Well-appearing, in NAD
PERRL. EOMI. Clear oropharynx. Facial pallor improved.
Neck: No LAD.
CV: Slightly loud S2. No m/r/g.
Lungs: Decreased breath sounds at the bilateral bases. No
crackles, rhonchi or wheezing noted.
Abdomen: Soft. NT. ND.
Ext: Skin is thin and loose. No edema bilaterally.
Skin: Questionable spoon nails exhibited on the thumbs.
Neuro: AAOx2. Unable to state location or year. Able to
remember 3 objects and name the current president. Did not
understand why she was in the hospital.
Pertinent Results:
ADMISSION LABS
___ 01:40PM BLOOD WBC-3.5* RBC-2.33* Hgb-7.1* Hct-23.4*
MCV-100* MCH-30.5 MCHC-30.3* RDW-17.6* RDWSD-64.7* Plt ___
___ 01:40PM BLOOD Neuts-46.6 ___ Monos-12.6 Eos-3.7
Baso-0.9 Im ___ AbsNeut-1.62# AbsLymp-1.25 AbsMono-0.44
AbsEos-0.13 AbsBaso-0.03
___ 01:40PM BLOOD Glucose-88 UreaN-11 Creat-0.7 Na-140
K-4.7 Cl-102 HCO3-32 AnGap-11
DISCHARGE LABS
___ 07:00AM BLOOD WBC-3.8* RBC-3.10*# Hgb-9.4*# Hct-29.7*#
MCV-96 MCH-30.3 MCHC-31.6* RDW-17.2* RDWSD-58.6* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-34.1 ___
___ 07:00AM BLOOD Glucose-77 UreaN-9 Creat-0.7 Na-139 K-4.2
Cl-99 HCO3-33* AnGap-11
___ 07:00AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.7
IMAGING
CXR PA/LAT ___
Increasing pleural effusions and lower lobe consolidations
concerning for
atelectasis versus pneumonia. Mild edema appears new. Large
hiatal hernia again seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Guaifenesin ___ mL PO Q6H:PRN cough
2. Ipratropium-Albuterol Neb 1 NEB NEB Q8H:PRN wheeze
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Sertraline 25 mg PO DAILY
7. Simvastatin 10 mg PO QPM
8. Tiotropium Bromide 1 CAP IH DAILY
9. Warfarin 3.5 mg PO DAILY16
10. Ferrous Sulfate 325 mg PO HS
11. Pantoprazole 40 mg PO Q12H
12. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation Q12H
13. Fleet Enema ___AILY:PRN constipation
14. Meclizine 12.5 mg PO Q8H:PRN verigo
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Ferrous Sulfate 325 mg PO HS
2. Fleet Enema ___AILY:PRN constipation
3. Guaifenesin ___ mL PO Q6H:PRN cough
4. Ipratropium-Albuterol Neb 1 NEB NEB Q8H:PRN wheeze
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Meclizine 12.5 mg PO Q8H:PRN verigo
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Sertraline 25 mg PO DAILY
12. Simvastatin 10 mg PO QPM
13. Tiotropium Bromide 1 CAP IH DAILY
14. Warfarin 3.5 mg PO DAILY16
15. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation Q12H
16. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Anemia, dyspnea
Secondary: hypertension, pulmonary embolism
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with recent PNA< pleural effusion // PNA?
COMPARISON: ___ and chest CTA from ___.
FINDINGS:
AP upright and lateral views of the chest provided. This patient is known to
have a large hiatal hernia which can be seen on this radiograph with
gas-filled loops of colon in the retrocardiac space. Bilateral pleural
effusions and lower lobe atelectasis versus pneumonia appear slightly
progressed from prior. Upper lungs remain well aerated. There is likely a
component of mild pulmonary edema. Heart size is difficult to assess. Bony
structures appear intact. A catheter projects over the upper abdomen.
IMPRESSION:
Increasing pleural effusions and lower lobe consolidations concerning for
atelectasis versus pneumonia. Mild edema appears new. Large hiatal hernia
again seen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Anemia, Lethargy
Diagnosed with Anemia, unspecified, Long term (current) use of anticoagulants
temperature: 98.0
heartrate: 58.0
resprate: 16.0
o2sat: 100.0
sbp: 126.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | This is an ___ year old female with past medical history of COPD,
recent PE on anticoagulation and s/p recent R thoracentesis w/
MOLST indicating no invasive interventions/hospitalizations who
presented with worsening anemia from labs at acute rehab.
ACTIVE ISSUES
# Anemia: During the last admission, the patient was placed on
anticoagulation for her PE despite GI bleeding. Likely, the
patient is chronically bleeding from her GI tract causing her
decreased RBC count. Patient received 2 units of pRBC in the ED.
Per specific goals of care outlined after last hospitalization,
the patient does not want any invasive procedures such as EGD to
assess location of the bleeding and was only admitted for a RBC
transfusion.
#Reported Dyspnea: Per rehab facility, patient has been
dyspneic. However, according to both patient and nephew,
patient has shown much improvement since last hospitalization.
She may also have some dyspnea ___ to her anemia. CXR in the ED
also revealed worsening bilateral effusions, however pneumonia
was thought unlikely as the patient has no cough, fever, or
constitutional symptoms. Patient was continued on duonebs,
supplemental O2, but no invasive measures were taken.
# Goals of Care - Last hospitalization, a conversation with her
nephew/HCP was had and patient declined any additional
"operations" and "procedures". While she may have a slow GI
bleed while on anticoagulation for her PE, anticoagulation was
continued with the knowledge she may need transfusions in the
future. Anticoagulation continued during this hospitalization.
Per MOSLT form, she does not want to be re-hospitalized and
outpatient blood transfusions should be done in the future if
necessary.
#Hypertension
- patient continued on metoprolol. Since last discharge, HCTZ
and valsartan wee discontinued
#CAD
- patient was continued on home metoprolol, statin. Since last
discharge, Plavix discontinued.
CHRONIC ISSUES
# Hypothryoidism - continue home levothyroxine
# Depression - continue home sertraline
# Vertigo - continue home meclizine
===================================================
Transitional Issues
- MOLST w/ indication to not hospitalize, DNR/DNI. Last
discharge summary said it was okay to continue transfusions as
needed, which should be done in the future as an outpatient.
Per patient's PCP office, it is possible to arrange outpatient
transfusions at ___ in ___ via the ___
___ (___).
- please titrate O2 as required. Patient was admitted from rehab
on 2L of O2.
- please draw labs for INR on ___. INR on discharge 1.8
# Code Status: DNR/DNI
# Emergency Contact/HCP: ___, ___ (nephew) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Intermittent Chest/Back Pressure
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with PMH of DVT/PE (DVT in early ___, PE in ___,
identified via CT chest, placed on chronic A/C, coumadin), who
p/w chronic intermittent back pressure which began ___ yrs ago,
but increased in frequency over the past 4 weeks. He reported
that the pressure occurs episodically ___ at a time) then
goes away, is not felt to be painful, but makes him
uncomfortable/nervous and provokes his anxiety. He stated that
the pressure is non-exertional, non-anginal, and is not a/w
cardiac sx (SOB, diaphoresis, nausea, vomiting, syncope). He
recently found that his INR was 1.7 at clinic (___,
q3-4wks), so there was concern that he could have had another
PE. He went to PCP who saw ___ changes in his EKG, and was
concerned for ACS/PE so he referred him to ED. He stated that
his BP is normally 130s at home.
On arrival to ED, pts vitals were T 98.1, HR 58, BP 164/91, RR
18, O2 sat 100% on RA. Pt was given 325 ASA. Labs were notable
for neg trop and INR 2.4. EKG looked similar to prior, but
T-waves in V2 were deeper than in last EKG in ___. CTA was
negative for PE. Bedside u/s showed no evidence of right heart
strain or obvious focal wall deficit (especially no septal wall
abnormalities w/ the v2 changes). Pt was admitted to cardiology
floor for cardiac workup.
On arrival to floor, pt's vitals were T=97.8 BP=183/91 HR=58
RR=16 O2 sat=100%RA. Pt was comfortable, CP free, without HA,
vision changes, or nausea/vomiting. He was given 6.25 captopril,
and BP decreased to 150/90.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia (+), Hypertension (+)
2. CARDIAC HISTORY:
-CABG: Never
-PERCUTANEOUS CORONARY INTERVENTIONS: Never
-PACING/ICD: Never
3. OTHER PAST MEDICAL HISTORY:
HTN (per Atrius records, "high normal", pt denies h/o HTN)
HLD
Migraine
DVT/PE (DVT in early ___, PE in ___, identified via CT
chest, placed on chronic A/C, coumadin)
Social History:
___
Family History:
No h/o coagulopathies in family. Otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL:
VS: T= 97.8 BP=183/91 HR=58 RR=16 O2 sat=100%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
PULSES: 2+ DP and radial pulses
DISCHARGE PHYSICAL:
TM 97.9 BP129-150/70-90, P58-62, R16, ___-100RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
PULSES: 2+ DP and radial pulses
Pertinent Results:
PERTINENT LABS:
___ 06:30PM BLOOD WBC-4.8 RBC-4.75 Hgb-15.1 Hct-43.1 MCV-91
MCH-31.7 MCHC-35.0 RDW-13.0 Plt ___
___ 06:15AM BLOOD WBC-4.2 RBC-4.67 Hgb-15.0 Hct-41.7 MCV-89
MCH-32.1* MCHC-35.9* RDW-13.0 Plt ___
___ 06:30PM BLOOD ___ PTT-43.9* ___
___ 06:15AM BLOOD ___ PTT-39.0* ___
___ 06:30PM BLOOD Glucose-103* UreaN-24* Creat-0.9 Na-137
K-3.9 Cl-99 HCO3-30 AnGap-12
___ 06:15AM BLOOD Glucose-90 UreaN-17 Creat-0.9 Na-137
K-3.7 Cl-100 HCO3-30 AnGap-11
___ 06:30PM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:30PM BLOOD Calcium-9.5 Phos-3.0 Mg-2.2
CXR: No acute cardiopulmonary process.
CT CHEST W&W/OUT CONTRAST: No acute aortic pathology or
pulmonary embolus.
CARDIAC PERFUSION:
1. Normal myocardial perfusion.
2. Normal wall motion with Ejection Fraction of 63%.
EXERCISE STRESS:
Good exercise tolerance. No anginal symptoms with
uninterpretable ST-T wave changes (see above). Baseline systolic
hypertension with an appropriate blood pressure and heart rate
response to exercise. Nuclear report sent separately.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO 5X/WEEK (___)
2. Warfarin 6.25 mg PO 2X/WEEK (WE,SA)
3. Lorazepam 0.5 mg PO HS:PRN insomnia
Discharge Medications:
1. Lorazepam 0.5 mg PO HS:PRN insomnia
2. Warfarin 5 mg PO 5X/WEEK (___)
3. Warfarin 6.25 mg PO 2X/WEEK (WE,SA)
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain, non-cardiac etiology
Back pain, non-cardiac etiology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with back and chest pain.
COMPARISON: None.
FINDINGS:
PA and lateral views of the chest. The lungs are clear of focal
consolidation. Cardiomediastinal silhouette is within normal limits. No
acute osseous abnormalities detected.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: Prior history of pulmonary embolus with current EKG findings
concerning for repeat PE.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained of the chest after the
administration of IV contrast in the arterial phase. Multiplanar reformatted
images were generated in the coronal and sagittal planes as well as bilateral
maximum intensity projection oblique images.
DLP: 306.53 mGy-cm.
FINDINGS:
CT CHEST: The imaged portion of the thyroid is unremarkable in appearance.
Heart size is top normal without pericardial effusion. The thoracic aortic
arch is normal in caliber without aneurysm or dissection although tortuous.
Incidental note of bovine aortic arch anatomy and the left vertebral artery
arising directly from the aorta. The main pulmonary artery is normal in
caliber, and there is no pulmonary embolus to the segmental level. There is
no supraclavicular, axillary, hilar or mediastinal lymphadenopathy by CT size
criteria.
This study is not tailored for subdiaphragmatic diagnosis; however, the
visualized upper abdomen is grossly unremarkable.
The airways are patent to the subsegmental level. Bibasilar atelectasis is
small. Lungs are clear without nodule or focal consolidation. Pleural
surfaces are clear without effusion or pneumothorax.
OSSEOUS STRUCTURES: There are no focal blastic or lytic lesions in the
visualized osseous structures concerning for malignancy.
IMPRESSION: No acute aortic pathology or pulmonary embolus.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: UPPER BACK, CHEST PAIN
Diagnosed with BACKACHE NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, HX VENOUS THROMBOSIS/EMBOLISM, PERSONAL HISTORY OF PULMONARY EMBOLISM, LONG TERM USE ANTIGOAGULANT
temperature: 98.1
heartrate: 58.0
resprate: 18.0
o2sat: 100.0
sbp: 164.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | ___ year old gentleman with history of DVT/PE on coumadin
presenting with 4 weeks of atypical chest/back discomfort,
referred by PCP for DVT/cardiac work-up.
================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Dapsone
Attending: ___.
Chief Complaint:
cc: leg pain with ulceration, associated with fall
Note: History from patient limited by expressive aphasia,
patient able to only answer yes/no questions.
Major Surgical or Invasive Procedure:
Wound care
History of Present Illness:
PCP: ___, subsequently ___ at
___
HPI: The patient is a ___ year old man with known HIV/AIDS with
known PML with expressive aphasia. He has a reported baseline of
'yes/no' answers, Yes/no only at baseline. The following history
was obtained through a combination of the patient's limited
answers, the patient's HCP ___ at the bedside, and the ICU team
and documentation. The patient's covering PCP at ___ (Dr ___
___ Dr ___ also contributed helpful background.
The patient was reportedly found down at home, after he reports
falling out of his wheelchair. He reportedly pressed his
lifeline at that time, but the exact timing of the fall in
relation to the lifeline call is unknown. On EMS arrival, the
patient was found on the floor, and EMS reportedly documented
that the apartment was covered in stool and was in dissaray. A
report of unclean food was also made.
In the ___ ED, the patient was noted to be hypotensive to
79/41 and his creatinine was 2.2 from a baseline of 0.9 and CK
of 459. CXR and UA negative, and his tox screen was positive for
benzodiazepines in his urine but this is a medication he is
typically prescribed. He received 3Liters NS with persistent
hypotension, so transferred to ___. He also reportedly received
vancomycin and ceftriaxone for possibly skin/soft tissue
infection of his right leg ulcer, and for gram negative coverage
given the ulcer was reportedly covered in stool.
In the FICU, the patient had a blood pressure of 94/61 and was
found to be at his neuro baseline with yes/no questions. He
reports taking his meds daily and previous records suggest that
he has a weekly visiting PCA (___) whom the patient
responds remains part of his care team. His HCP ___ was at the
bedside on transfer to the medical floor and confirmed this
information. He also noted that the patient is otherwise
remarkably self-sufficient in his daily routine, but does have
weekly help in cleaning his apartment.
On exam in the FICU the patient reportedly had shallow ___
ulcerations consistent with pressure injuries, as well as a
large (4-5cm) circular necrotic ulcer on lateral aspect of his
right ___. No puss was noted on presentation with some
surrounding erythema. Ulcer itself looked painful, and patient
reaches in pain due to leg ulcer and may have led to presenting
fall, and responded 'yes' when asked if the ulcer has hurt him
recently. Per ___, the patient was noted to have this ulcer in
the past, but has not sought care for it recently. There was
suggestion by ___ that the patient had deferred care for his
ulcer until this fall. ___ reported, and the patient agreed,
that the patient may have had a fall the week prior to admission
as well, with potentially similar circumstances to the
presentation leading to this admission.
ROS: Per ICU team, notable for recent leg pain with ulceration.
Per yes/no answers, the patient denies nausea or vomiting and
denies diarrhea currently, but ___ reports that the patient has
had significant diarrhea on several occasions in the last few
weeks, and in one case the week PTA may have had a similar
episode to the day of admission where he became soiled by the
stool. Per confirmation with ___, concern that the ulcer may be
a subacute issue which has been worsening. Patient unable to
provide a fully detailed ROS due to expressive aphasia.
Past Medical History:
Per OMR, attempted review with patient given aphasia:
-HIV per report undetectable viral load, CD4 379 in ___, repeat
CD4 count pending
-PML ___ - not currently undergoing therapy
-Expressive aphasia
-R hemiparesis, wheelchair bound at baseline
-report of prior EtOH abuse
-Chronic R foot ___ digit infection s/p course of
TMP-SMX/cephalexin on ___ but allergy developed to
bactrim so last treated ___ with doxy/cephalexin
-DVT/PE s/p IVC filter ___
-humeral shaft fracture 2/p repair ___
-h/o C diff infection, per report of HCP
Social History:
___
Family History:
(per ___ records)
Father - HTN, Mother - HTN, sister -DM.
Physical Exam:
Examination on Transfer from the Medical ICU to the Medical
Floor:
Temp 98.2F BP 122/77 HR 93 RR 18 95% on RA
GEN: [X] NAD [ ] Uncomfortable [ ] Pale [ ] Increased work of
breathing
EYE: [ ] EOMI [X] Anicteric
ENT: [ ] Mucous membranes moist [ ] No Erythema [X] Dry mucous
membranes
CV: [X] RRR [X] no M/R/G [X] JVP not elevated
RESP: [X] No Rales [ ] Rales on __Left/__Right [ ] No Wheeze
[X] No Rhonchi [ ] Rhonchi on __Left/__Right
GI: [X] Soft [X] Non-tender [X] Normal Bowel Sounds [X] obese
EXT: [ ] Warm [ ] No Edema [ ] Right ___ skin wound
SKIN: [ ] Dry [X] Pressure Ulcers:
NEURO: [X] Alert [ ] Non-Focal [ ] Fluent Speech [X] Normal
concentration
PSYCH: [X] Calm [X] Appropriate
ACCESS [ ] PICC [X] Peripheral IV
CATHETER [X] Foley __1__days, if not chronic
Discharge exam:
AVSS
No apparent disress
Anicteric, EOMI
RR, nl rate, no r/g/m
CTAB
soft, nontender, nondisteded, pos BS
right club foot, ___ with ulcer, c/d/i
right sided paralysis
answers yes / no questions, knows 14 words
Pertinent Results:
___ 11:00PM BLOOD WBC-10.8# RBC-4.79 Hgb-12.9* Hct-37.2*
MCV-78*# MCH-26.8* MCHC-34.5 RDW-13.8 Plt ___
___ 07:05AM BLOOD WBC-17.1*# RBC-4.82 Hgb-12.7* Hct-37.9*
MCV-79* MCH-26.3* MCHC-33.4 RDW-15.5 Plt ___
___ 07:25AM BLOOD WBC-4.6 RBC-4.64 Hgb-12.4* Hct-38.8*
MCV-84 MCH-26.6* MCHC-31.9 RDW-16.0* Plt ___
___ 07:55AM BLOOD ___ PTT-25.9 ___
___ 06:00AM BLOOD WBC-7.2 Lymph-18 Abs ___ CD3%-75
Abs CD3-975 CD4%-48 Abs CD4-617 CD8%-26 Abs CD8-335 CD4/CD8-1.9
___ 11:00PM BLOOD Glucose-96 UreaN-46* Creat-2.2*# Na-133
K-4.1 Cl-98 HCO3-17* AnGap-22*
___ 06:50AM BLOOD Glucose-89 UreaN-12 Creat-0.7 Na-138
K-4.0 Cl-105 HCO3-24 AnGap-13
___ 11:00PM BLOOD CK(CPK)-459*
___ 07:20AM BLOOD ALT-233* AST-72* LD(LDH)-288* AlkPhos-67
TotBili-0.7
___ 06:25AM BLOOD ALT-75* AST-28 AlkPhos-54 TotBili-0.2
___ 06:50AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
___ 06:00AM BLOOD calTIBC-261 Ferritn-176 TRF-201
___ 07:20AM BLOOD TSH-4.0
___ 06:35AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE IgM
HAV-NEGATIVE
___ 11:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:35AM BLOOD HCV Ab-NEGATIVE
___ 04:00AM BLOOD Lactate-1.1
CXR: There is a stable 4 mm right upper lobe granuloma.
Otherwise, the lungs are clear with no evidence of a
consolidation, effusion, or pneumothorax. Heart appears at the
upper limits of normal in size but stable. No acute fractures
are identified. IMPRESSION: No acute cardiopulmonary process.
U/S: IMPRESSION: Limited exam demonstrating echogenic liver
likely due to fatty infiltration but other more forms of liver
disease including cirrhosis and fibrosis cannot be excluded.
Patent portal vein, no intra- or extra-hepatic biliary
dilatation. Gall stones but no definite evidence of
cholecystitis. Recommend either a followup full complete liver
and gallbladder ultrasound or further evaluation or possibly
MRCP if clinically indicated.
CT head: IMPRESSION: No acute intracranial process. No
significant interval change in marked left hemispheric
encephalomalacia, ex vacuo dilatation of the left lateral
ventricle, and mild dilatation of the right lateral and third
ventricles.
CTA lungs and abdomen: IMPRESSION: 1. Limited study due to
extensive respiratory motion. No large or central pulmonary
emboli. One segmental and two subsegmental arterial filling
defects are equivocal findings given the degree of respiratory
motion, but given their size, even if they are emboli, their
contribution to significant hypoxia is questionable. 2. Mild
residual apical pulmonary edema. 3. Unchanged pulmonary nodules,
stable since ___ requiring no further specific follow up, with
calcified hilar and hilar lymph nodes and granulomas
consistent with prior granulomatous disease. 4. Unchanged
biapical mild bronchiectasis is likely related to prior
infectious process.
___: CONCLUSION: No evidence of above-knee DVT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. Nevirapine 200 mg PO BID
3. Gabapentin 900 mg PO TID
4. Quetiapine Fumarate 50 mg PO BID
5. Famotidine 20 mg PO BID
6. Sertraline 100 mg PO DAILY
7. Clonazepam 2 mg PO TID
8. Multivitamins 1 TAB PO DAILY
9. Thiamine 100 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. traZODONE 50 mg PO HS:PRN insomnia
12. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
13. Acamprosate 666 mg PO BID
14. Lisinopril 10 mg PO DAILY
15. Hydrochlorothiazide 25 mg PO DAILY
16. Fish Oil (Omega 3) 1000 mg PO BID w meals
Medications on hold on transfer from FICU:
Lisionpril 10
HCTZ 25
Potassium 10meq
trazodone
Clonazepam 2mg po tid
quetiapine 50mg bid
As of ___, medications being held:
Lisionpril 10
HCTZ 25
Discharge Medications:
1. Acamprosate 666 mg PO BID
2. Clonazepam 1.5 mg PO TID:PRN anxiety
3. Famotidine 20 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 900 mg PO TID
6. Lisinopril 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nevirapine 200 mg PO BID
9. Sertraline 100 mg PO DAILY
10. Thiamine 100 mg PO DAILY
11. traZODONE 50 mg PO HS:PRN insomnia
12. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO BID w meals
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right leg ulceration with cellulitis
HIV/AIDS
PML with right hemiplegia with aphasia and wheelchair bound
status
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: HIV with difficulty breathing, to assess for pneumonia.
FINDINGS: In comparison with the study of ___, allowing for the AP
projection, there is little overall change. No evidence of pneumonia,
vascular congestion, or pleural effusion.
Radiology Report
INDICATION: History of HIV/AIDS, PML with hemiparesis, aphasia, wheelchair
bound initially presented after being down, found to have a right lower
extremity wound and cellulitis now much improved with elevated transaminases,
elevation in lipase, asymptomatic.
COMPARISONS: CT abdomen and pelvis from ___. Liver ultrasound from
___.
FINDINGS: Targeted exam of the liver and gallbladder was performed. This is
a limited exam due to patient body habitus and inability to cooperate. The
liver is diffusely echogenic, but there are no definite focal lesions. The
left lobe is not clearly visualized. There is no intrahepatic biliary
dilatation. The portal vein is patent with normal hepatopetal flow. The
common bile duct measures 4 mm. Evaluation of the gallbladder is limited, but
the wall is not thickened and the gallbladder remains nondistended, without
evidence of acute cholecystitis. Gall stones noted as on prior CT scans. The
pancreas is not visualized due to bowel gas.
IMPRESSION:
Limited exam demonstrating echogenic liver likely due to fatty infiltration
but other more forms of liver disease including cirrhosis and fibrosis cannot
be excluded. Patent portal vein, no intra- or extra-hepatic biliary
dilatation. Gall stones but no definite evidence of cholecystitis. Recommend
either a followup full complete liver and gallbladder ultrasound or further
evaluation or possibly MRCP if clinically indicated.
These findings were discussed with ___, M.D. by Dr. ___
telephone at around 6:30 p.m.
Radiology Report
AP CHEST, 5:09 P.M. ___
HISTORY: ___ man with crackles and hypoxia, low-grade fever. Suspect
volume overload or pneumonia.
IMPRESSION:
AP chest compared to ___:
Lungs are low in volume, interstitial abnormality is new and pulmonary and
mediastinal vasculature is more engorged, all pointing to mild pulmonary edema
due to cardiac decompensation. No pneumothorax. Pleural effusion is minimal
if any.
Radiology Report
INDICATION: History of HIV/AIDS as well as progressive multifocal
leukoencephalopathy. Presenting status post fall with worsening agitation,
nystagmus, and SIADH. Evaluate for evidence of progressive multifocal
leukoencephalopathy or other new pathology.
TECHNIQUE: Sequential axial images were acquired through the head both before
and during administration of 90 cc of intravenous Omnipaque contrast material.
COMPARISON: CT head from ___.
FINDINGS: There is no evidence of intracranial hemorrhage, edema, mass, or
acute large vascular territorial infarction. Severe left frontoparietal and
occipital encephalomalacia with associated marked ex vacuo dilatation of the
left lateral ventricle is not significantly changed compared to prior CT from
___. Comparatively mild dilatation of the right lateral
ventricle and third ventricle are also not significantly changed compared to
the prior study. Periventricular white matter hypodensities are stable in
appearance. Mild rightward shift of the normally midline structures is not
significantly changed, related to underlying parenchymal volume loss. There
is no central herniation. The orbits are unremarkable. Note is made of a
mucus retention cyst within the right maxillary sinus. The remainder of the
visualized portions of the paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION: No acute intracranial process. No significant interval change in
marked left hemispheric encephalomalacia, ex vacuo dilatation of the left
lateral ventricle, and mild dilatation of the right lateral and third
ventricles.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Low saturation and tachypnea.
Comparison is made with prior study ___.
Mild cardiomegaly, tortuous aorta, low lung volumes are stable. Mild vascular
congestion has almost resolved. Left lower lobe atelectasis has improved.
There is no pneumothorax or large effusions. There are no new lung
abnormalities.
Radiology Report
HISTORY: Hypoxia, tachycardia please assess for pulmonary embolism.
TECHNIQUE: CT images were obtained through the chest after the uneventful
intravenous administration of 150 mL Omnipaque contrast medium using a
recirculation technique after administration at 2 mL/second due to limited IV
access. Multiplanar reformations were prepared.
COMPARISON: ___ knee.
FINDINGS: The thyroid gland is normal and symmetric in enhancement. The aorta
and major branches are patent and normal in caliber without evidence of acute
aortic pathology. The heart and pericardium unremarkable without pericardial
effusion. Mild coronary atherosclerotic calcification is noted.
The main and central pulmonary arteries are well opacified without evidence of
filling defect. Assessment of subsegmental pulmonary arteries is limited by
patient respiratory motion and use of recirculation technique due to limited
IV access. Accordingly, the reliablility of the finding of apparent filling
defects in one segmental and two subsegmental arteries to the lower lobes is
unclear (3:108, 114, 115).
There is no pathologic mediastinal, axillary or hilar lymph node enlargement
although calcified left hilar lymph nodes are noted along with scattered
calcified pulmonary granulomata, suggesting prior granulomatous disease. The
esophagus is normal aside from small axial hiatal hernia. Although the study
is not tailored for subdiaphragmatic evaluation, the imaged upper abdomen is
unremarkable.
The trachea and central airways are patent to the segmental level. Mild
bibasilar atelectasis is present without pleural effusion. Haziness of the
apices with mild septal thickening is consistent with mild residual pulmonary
edema. Biapical bronchiectasis, more pronounced in the left upper lobe, could
reflect prior infection. There is no focal consolidation in the lungs to
suggest infection. Six mm right apical pulmonary nodule (3:32), 2 mm right
upper lobe nodule (3:49), and 4 mm subpleural right upper lobe nodule (3:77)
are unchanged since ___.
OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion to suggest
osseous malignancy with old left posterior rib fractures noted.
IMPRESSION:
1. Limited study due to extensive respiratory motion. No large or central
pulmonary emboli. One segmental and two subsegmental arterial filling defects
are equivocal findings given the degree of respiratory motion, but given their
size, even if they are emboli, their contribution to significant hypoxia is
questionable. These findings were discussed with Dr. ___ by Dr.
___ at 0945 on ___ by phone, 5 minutes after discovery.
2. Mild residual apical pulmonary edema.
3. Unchanged pulmonary nodules, stable since ___ requiring no further
specific follow up, with calcified hilar and hilar lymph nodes and granulomas
consistent with prior granulomatous disease.
4. Unchanged biapical mild bronchiectasis is likely related to prior
infectious process.
Radiology Report
STUDY: Duplex ultrasound of right lower extremity.
INDICATION: Leg swelling, shortness of breath.
TECHNIQUE: Gray scale, color flow and pulse wave Doppler studies of the deep
veins of the right lower extremity was performed using dynamic compression
maneuvers where appropriate to assess for vessel patency.
COMPARISON: None.
REPORT: There is normal compressibility, augmentation and respiratory
variation in the deep veins of right lower extremity. Note that the
below-knee deep veins could not be adequately assessed due to the presence of
bandage and swelling. There is no above-knee DVT.
CONCLUSION: No evidence of above-knee DVT.
Radiology Report
CT ABDOMEN WITH CONTRAST
INDICATION: ___ man for assessment of biliary tract.
COMPARISON: ___ CT abdomen and pelvis and upper abdominal portions
from the CTPA from ___.
TECHNIQUE: Enhanced CT of the abdomen was obtained after administration of
200 cc of Omnipaque 350. No oral contrast was administered. Multiplanar
reformatted images were obtained and reviewed.
DLP: 717.22 mGy-cm.
FINDINGS:
CT ABDOMEN:
Bilateral gynecomastia is noted.
Bibasilar dependent atelectasis is noted. No significant pleural effusion is
noted. Mild mediastinal lipomatosis is noted. The heart is normal in size
without pericardial effusion. Small hiatal hernia with mild nonspecific distal
esophageal wall thickening.
The liver measures 21.8 cm in craniocaudal dimension. Normal liver contour is
noted. No intrahepatic or extrahepatic biliary ductal dilatation is noted.
No focal lesions are noted.
The pancreas is homogeneous without pancreatic ductal dilatation. The spleen,
bilateral adrenal glands, and both kidneys are normal. However, there are few
small hypodense lesions in both kidneys which are too small to characterize,
but statistically likely represent renal cysts. Gallbladder is distended with
layering gallstones noted.
The visualized large bowel is mildly distended diffusely and contains fluid,
without obvious wall thickening or obstruction.
No retroperitoneal or porta hepatic lymphadenopathy is appreciated. An IVC
filter is noted.
BONES: No significant abnormalities.
IMPRESSION:
1. No evidence of intrahepatic or extrahepatic biliary ductal dilatation.
Cholelithiasis is noted. However, no CT evidence of cholecystitis.
2. Mild large bowel distention with left sided colonic fluid. No wall
thickening or obstruction seen. However, underlying early colitis can have a
similar appearance and should be considered clinically.
3. Small bilateral hypodense renal lesions, too small to characterize, but
statistically likely renal cysts.
3. Small hiatal hernia with mild nonspecific thickening of the distal
esophagus.
Gender: M
Race: OTHER
Arrive by UNKNOWN
Chief complaint: CARE DEFICIT
Diagnosed with RHABDOMYOLYSIS, ASYMPTOMATIC HIV INFECTION
temperature: 99.4
heartrate: 95.0
resprate: 16.0
o2sat: 93.0
sbp: 79.0
dbp: 41.0
level of pain: 0
level of acuity: 1.0 | ___ with HIV/AIDS, c/b PML with rt. sided hemiparesis
(wheelchair bound) and aphasia (answers yes/no only), legally
blind, who was found down covered in stool at home. He
apparently fell out of w/c (information gathered from his HCP
___ and was not 'down' for long. EMS arrived and found
apt in filth, noted rt. lateral ___ ulceration. Pt. brought to
the ED, and admitted for management of rt lat ___ ulceration and
cellulitis. He was given (since admission) 10 days of
Vancomycin/CTX/Flagyl with improvement in cellulitis. He was
doing well until ___ when he developed leukocytosis,
transaminitis without abdominal pain. Ultrasound and CT abdomen
were negative for hepatobiliary process. He developed low grade
fevers and tachycardia. He was empirically restarted on
antibiotics with vanc/cefepime/flagyl. His labs improved
including LFTs. He was discontinued from the antibiotics and
monitored for 72 hours without evidence of ongoing infection. He
denies all symptoms. He worked with ___ and was having difficulty
with independent transfers so he was sent to rehab.
# Leg ulcer, cellulitis: He received 10 days of vanc, ctx and
flagyl with improvement in the cellulitis. Would care was
consulted and recommended aquacel and kerlix to be changed
daily. This resolved with treatment.
# Transaminitis, tachycardia, fever, presumed sepsis: He
decompensated off the antibiotics and these were restarted.
Cultures including blood, urine, and imaging studies were
negative for etiology. His labs and vitals improved on the
antibiotics. These were discontinued on ___ and he was
monitored for 72 hours with continued stability. No clear source
was identified.
# Gluteal ulcers: He was evaluted by wound care who recommended
Mepilex sacrum dressing, change q 3 days. These were stage I-II
and improved.
# HIV/AIDS, h/o PML: He was continued on his home HAART regimen.
His HIV is well controlled with negative VL and CD4 > 600.
# HTN, benign: his HCTZ was discontinued as it was not needed.
# Hyponatremia: resolved with discontinuing HCTZ and IVF.
# Incontinent stool: Soft stool ___ episodes per day. Per
patient he feels it coming on but lacks mobility in the hospital
which causes him to be incontinent. He was negative for C. diff.
This will be an important issue to evaluate prior to discharge
home as it is contributing to skin infection.
# Home situation: Difficult situation. He is incontinent of
stool (not diarrhea, no evidence of infection). He wants to be
at home and often resists services. He then gets skin infection
or falls. He is at very high risk of complication from going
home. His health care proxy understands these risks but feels
that he wants to keep the patients autonomy. Currently he is
having difficulty with transfers (requires assist). Given this,
___ was reconsulted and will likely recommend rehab. He will be
screened by ___. He states if he needs rehab he is willing
to go (HCP agrees with this as well). At discharge, he will need
increased services/supports at home as his current living
situation is unsafe. He may require group home living situation.
At this point he appears to have good capacity. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived / Iodinated Contrast Media - IV Dye / codeine
/ Klonopin
Attending: ___
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time: 222
_
________________________________________________________________
PCP: Dr. ___, ___
.
_
________________________________________________________________
___ 1.5 week ago BM x4 with BRB with dark stool and blood
inside the stool. he was admitted to ___ for 1.5 days, pt had
a CT scan that was negative. +nauseous and dizzy x 2 weeks.
Severe pain in his L stomach which has been unbearable. He is
not able to eat. Pt has continued to have BRBPR since leaving.
No scope at ___. Since leaving pt has had increasing l sided
abd pain and bloody stools. Pt had emesis with blood (food with
dark blood and coffee ground emesis).+ lethargy. + weakness. +
dizziness with standing. pt has been taking 800mg ibuprofen once
per day up until 2 weeks ago s/p knee surgery recently
___. Hx of Crohns as a child from age ___. Pt sees Dr.
___ GI (has apt next week). He used to be admitted for IV
abx.
unable to tolerate po, hematemesis x1, BRBPR with dark stool. +
small amount of weight loss.
+ R sided sharp chest pain intermittently lasting 20 secs x one
week. It is not associated with exertion, emesis or reflux. Pain
resolves without clear ameliorating factor. No associated
nausea/sob/diaphoresis. No sob at all. No fevers or chills. His
last Bm was at 330 pm on the day of presentation.
+ Night sweats x one year
No recent foreign travel
No strange foods
No sick contacts
In ER: (Triage Vitals:
8
99.8
107
141/97
18
97% RA )
Meds and IVF Given:
___ 23:54 IV Morphine Sulfate 4 mg ___
___ 23:54 IV Ondansetron 4 mg ___
___ 00:53 IV Morphine Sulfate 4 mg ___
___ 01:07 IV Pantoprazole 40 mg ___
___ 01:51 IVF 1000 ml ___ ___ Started 75
mL/hr
Radiology Studies:
consults called: GI
.
PAIN ___ L sided pain
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal, no mouth sores
RESPIRATORY: [X] All normal
CARDIAC: [+]per HPI, no h/o trauma, not worse with movement
GI: As per HPI
GU: [X] All normal
SKIN: [+] rash on R posteriior neck
MUSCULOSKELETAL: [+] R leg pain s/p surgery and aches in arms
NEURO: [X] All normal
ENDOCRINE: [+] decreased energy
HEME/LYMPH: [X] No easy bleeding or bruising
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
___ disease as a child in remission for ___ years
Insomnia secondary to night sweats for which he takes trazodone
h/o of childhood seizure disorder and neuropsychiatric issues
following head trauma.
Social History:
___
Family History:
His mother has epilepsy, HTN
His MGM has DM
Paternal cousin with ___ disease. No one with other
autoimmune disorders.
Physical Exam:
Vitals: T 98.0 P 96 BP 139/78 RR 18 SaO2 96% on RA
GEN: NAD, comfortable appearing
HEENT: ncat anicteric MMM
CV: s1s2, borderline tachy and regularno m/r/g
RESP: b/l ae no w/c/r
ABD: +bs, soft, L mid and LLQ tenderness as well as L
supra-pubic tenderness no guarding or rebound
RECTAL: Vault empty of stool, miniscule smear of stool obtained
which was guiac negative
EXTR:no c/c/e 2+ ___ pulses b/l
DERM: mild erythema of the left neck
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
d/c:
EXAM 98.0 122/69 69
Lying in bed, calm, looks comfortable, abdomen is soft NTND, no
HSM, no peripheral edema, no signs of DVT.
Pertinent Results:
___ 09:57PM HGB-15.9 calcHCT-48
___ 09:52PM GLUCOSE-113* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15
___ 09:52PM estGFR-Using this
___ 09:52PM WBC-6.7 RBC-5.26 HGB-15.5 HCT-44.9 MCV-85
MCH-29.5 MCHC-34.5 RDW-12.7 RDWSD-39.1
___ 09:52PM NEUTS-47.2 ___ MONOS-9.7 EOS-3.9
BASOS-0.7 IM ___ AbsNeut-3.16 AbsLymp-2.56 AbsMono-0.65
AbsEos-0.26 AbsBaso-0.05
___ 09:52PM PLT COUNT-207
___ 09:52PM ___ PTT-31.4 ___
=============================
ECG: SR at 77 bpm, no acute changes
CT abdomen report ___ obtained from ___: Severe hepatic
steatosis with reactive periportal adenopathy upto 1.7cm,
Colonic diverticulosis without diverticulitis.
Endoscopy ___:
Impression: Diffuse mild erythema consistent with mild
gastritis. (biopsy)
An area of heaped up mucosa was seen in the antrum. (biopsy)
Mild erythema and friability in the duodenal bulb compatible
with mild duodenitis
(biopsy)
Otherwise normal sigmoidoscopy to third part of the duodenum
___ 08:15AM BLOOD Hct-41.7
___ 01:39PM BLOOD ALT-30 AST-21 AlkPhos-56 TotBili-0.3
___ 01:39PM BLOOD Lipase-52
___ 01:39PM BLOOD CK-MB-1 cTropnT-<0.01
RUQ US:
1. Technically limited ultrasound examination of the abdomen
demonstrating a diffusely echogenic liver and normal appearance
of the gallbladder.
2. The echogenic liver is consistent with steatosis. Other forms
of liver
disease and more advanced liver disease including
steatohepatitis or
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
Medications on Admission:
zoloft 50 mg daily
Trazodone 50 mg qhs prn
Discharge Disposition:
Home
Discharge Diagnosis:
Gastritis
Duodenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with persistant epigastric pain worsened with
food // ? cholecystolithiasis? other
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
The examination is significantly limited secondary to the patient's body
habitus limiting penetration of the sound waves.
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
IMPRESSION:
1. Technically limited ultrasound examination of the abdomen demonstrating a
diffusely echogenic liver and normal appearance of the gallbladder.
2. The echogenic liver is consistent with steatosis. Other forms of liver
disease and more advanced liver disease including steatohepatitis or
significant hepatic fibrosis/cirrhosis cannot be excluded on this study.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR, BRBPR
Diagnosed with Gastrointestinal hemorrhage, unspecified, Epigastric pain
temperature: 99.8
heartrate: 107.0
resprate: 18.0
o2sat: 97.0
sbp: 141.0
dbp: 97.0
level of pain: 8
level of acuity: 3.0 | ___ w/h/o chron's disease in childhood > ___ in remission, past
smoker 15 pack years, past heavy ETOH on trazodone and
sertraline at home for insomnia. More recently s/p knee surgery
___ following which he has been taking 800mg ibuprofen
once. Admitted on ___ for several days of left sided abdominal
pain and reported BRBPR, Melena and hematemesis after previous
admission in OSH with reportedly normal CT abdomen but no
further workup. On admission tachycardic with temp of 99.8 and
otherwise normal vital signs. Labs remarkable for normal and
stable Hb. CRP of 6.8. Underwent EGD on ___ which showed
diffuse mild erythema consistent with mild gastritis, an area of
heaped up mucosa in the antrum, mild erythema and friability in
the duodenal bulb compatible with mild duodenitis. No definitive
source of patient's bleeding was identified and no active
bleeding or stigmata of recent bleed were seen. Subsequently
managed with PPI and antacids. Had ongoing abdominal pain. Hct
remained stable. LFT's, Lipase, cardiac enzymes were normal. RUQ
US was done which showed hepatosteatosis but no cause for pain.
Patient tolerated oral hydration and nutrition and remained
afebrile and hemodynamically stable throughout his admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization with ___ x1
History of Present Illness:
___ with PMH of CAD s/p multiple PCIs, ESRD on HD, HFpEF who
presents with worsening exertional chest pain over the last two
weeks with rest chest pain over last few days. She states she
has ___ intermittent left sided chest pain, different from past
documented episodes, for the past two weeks. It is worsening and
associated with shortness of breath. She expressed she felt that
she should have gone to the ED a few days ago after taking a
long walk. She developed chest pain and had to sit down to rest
for awhile. She took three NTG with relief. Reports that she has
been taking nitro for these episodes with relief. She came in
today after HD from home. She reports that she arrived to the
wrong campus and on walking to the ___ from the East she
developed substernal chest pain partially relieved by nitro. No
dyspnea, leg swelling, weight gain.
Patient complained of previous angina episodes on rest that were
attributed to musculoskeletal complaints in ___ when she
was seen by her cardiologist. She had a pMIBI done in ___ that showed medium defect of moderate intensity in the mid
to basal inferior, mid inferolateral and apical lateral walls
with very mild partial reversible defect. Post-stress LVEF 65%
without RWM abnormalities. Test conclusion that of medium area
of myocardial scar in the distribution of PDA/OM coronary artery
with very mild periinfarct ischemia. No intervention was done at
the time and she kept on being medically managed.
Past Medical History:
- ESRD from DM2, HTN
- sarcoidosis
- DM2
- Hypertension
- uveitis
- hyperlipidemia
- hypothyroidism
- obesity
- retinopathy
- ocular hypertension
- osteoarthritis
- CHF
- gout
- sleep apnea
Social History:
___
Family History:
mother died of a myocardial infarction. Sister with diabetes. No
one with kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7 143/62 67 18 98%RA
Weight: None
Blood sugar: 238
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no elevated JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs. No chest pain on palpation
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. LUE with fistula
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
VS: Tm 100.2 Tc 98.6 110-120s/50-60s 50-70s 18 95 on RA
Weight: None
GENERAL:
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no elevated JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs. No chest pain on palpation
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 bruit at R femoral cath site. Distal
pulses palpable and symmetric. LUE with fistula
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
___ 03:56PM BLOOD WBC-4.9 RBC-4.33# Hgb-13.0# Hct-40.4#
MCV-93 MCH-30.0 MCHC-32.2 RDW-15.9* RDWSD-54.4* Plt ___
___ 03:56PM BLOOD Neuts-57.5 ___ Monos-10.0 Eos-1.4
Baso-0.4 Im ___ AbsNeut-2.82 AbsLymp-1.49 AbsMono-0.49
AbsEos-0.07 AbsBaso-0.02
___ 03:56PM BLOOD ___ PTT-35.0 ___
___ 03:56PM BLOOD Glucose-105* UreaN-20 Creat-2.6* Na-142
K-4.0 Cl-101 HCO3-29 AnGap-16
___ 03:56PM BLOOD CK(CPK)-105
___ 12:26AM BLOOD CK(CPK)-83
___ 06:50AM BLOOD Calcium-9.8 Phos-5.2*# Mg-2.0
___ 03:56PM BLOOD CK-MB-2
___ 03:56PM BLOOD cTropnT-0.53*
___ 12:26AM BLOOD CK-MB-2 cTropnT-0.49*
___ 01:27PM BLOOD CK-MB-2 cTropnT-0.39*
___ 12:11AM BLOOD cTropnT-0.31*
___ 07:10PM BLOOD CK-MB-1 cTropnT-0.20*
___ 06:45AM BLOOD CK-MB-1 cTropnT-0.16*
___ 06:45AM BLOOD WBC-5.3 RBC-3.95 Hgb-11.8 Hct-36.5 MCV-92
MCH-29.9 MCHC-32.3 RDW-15.6* RDWSD-53.2* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-82 UreaN-27* Creat-3.4*# Na-137
K-4.6 Cl-98 HCO3-32 AnGap-12
___ 06:45AM BLOOD Calcium-10.1 Phos-4.4# Mg-1.9
IMAGING
Cath (___) Right Dominant LMCA no significant. LAD (Proximal),
Discrete 60% lesion. FFR 0.89. DIAG1 (Ostial), Discrete 40%
lesion. Cx Artery CX (Distal), Discrete 60% lesion RCA
(Proximal), Complex ___ lesion RCA (Mid), Tubular 70% lesion RCA
(Distal), Discrete 70% lesion Comments:: After discussion with
Dr ___ wire of LAD done which showed FFR 0.89.
Remains on Plavix given diabetic state and small-caliber stent
size.
ECHO ___: There is moderate concentric LVH with septal
predominance and narrow LV outflow tract. Overall LVEF is
estimated 60-65%. There is a mid cavity gradient with a peak
velocity at rest of 1.6 m/s and peak pressure gradient of
10mmHg. This increased to a peak velocity of 3.1 m/s and peak
pressure gradient of 39 mmHg with valsalva.
EKG: Sinus at rate of 62, LAD, RBBB, unchanged from ED, new from
previous
___ CARDIAC SPEC STUDY ___:
CONCLUSION :
The patient's stress test results are abnormal and consistent
with the following: A medium area of myocardial scar in the
distribution of the PDA/OM coronary artery, with very mild
___ ischemia. Normal global LV systolic function. No
prior study for comparison.
___ CXR
Subsegmental bibasilar atelectasis.
___ TTE
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
The estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Doppler parameters are
indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
there is no aortic stenosis or regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mildly dilated thoracic aorta. Mild mitral regurgitation.
___ CARDIAC CATH:
Dominance: Right
Heavily calcified coronary arteries.
* Left Main Coronary Artery
The ___ has a 40-50% ostial stenosis..
* Left Anterior Descending
The LAD has 50% ___ and mid stenoses.
The ___ Diagonal has a 40% ostial stenosis.
* Circumflex
The Circumflex has a 40% ostial stenosis
___
MRN: ___
DOB: ___
Procedure Date: ___
Cath Number: ___
___ 4 Brief Preliminary Cardiac
Catheterization & Endovascular Procedure Note Tel: ___ Page 3 of 3 Reported created: ___ 6:25 ___
Fax: ___
* Right Coronary Artery
The RCA is a large vessel with previously deployed stents in
___, mid, and distal segments. Mid and
distal stents were widely patent. There was a 95% highly
eccentric stenosis at the proximal margin of the
proximal stent, extending back into the native RCA.
Impressions:
2 vessel CAD.
Successful PTCA/stent or proximal RCA using drug-eluting stent.
Recommendations
ASA 81mg QD indefinitely. Plavix 75mg QD for minimum 12 months,
but consider longer use.
Further management as per primary cardiology team.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Allopurinol ___ mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Glargine 18 Units Bedtime
lispro 10 Units Breakfast
lispro 10 Units Lunch
lispro 10 Units Dinner
9. Vitamin D ___ UNIT PO DAILY
10. Carvedilol 25 mg PO BID
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Cinacalcet 30 mg PO DAILY
13. Senna 8.6 mg PO BID:PRN constipation
14. Pyridoxine 50 mg PO DAILY
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
16. Aspirin 81 mg PO DAILY
17. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Carvedilol 25 mg PO BID
6. Cinacalcet 30 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Levothyroxine Sodium 175 mcg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
12. Pyridoxine 50 mg PO DAILY
13. Senna 8.6 mg PO BID:PRN constipation
14. sevelamer CARBONATE 1600 mg PO TID W/MEALS
15. Vitamin D ___ UNIT PO DAILY
16. Fish Oil (Omega 3) 1000 mg PO DAILY
17. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 8 hours Disp
#*40 Tablet Refills:*0
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually every 5min up
to 3 times Disp #*25 Tablet Refills:*0
19. Glargine 18 Units Bedtime
lispro 10 Units Breakfast
lispro 10 Units Lunch
lispro 10 Units Dinner
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Non-ST Elevation Myocardial Infarction
Secondary
End Stage Renal Disease on HD
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 history of CAD, CHF, who presents with chest
pain and new TWI, concern for new cardiac ischemia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Heart size is mildly enlarged with a left ventricular predominance. The aorta
is diffusely calcified and tortuous. No mediastinal widening is otherwise
noted. Pulmonary vasculature is not engorged. Hilar contours are normal.
Linear opacities in both lung bases are compatible with areas of subsegmental
atelectasis. No focal consolidation, pleural effusion or pneumothorax is
present. There are moderate multilevel degenerative changes seen in the
thoracic spine.
IMPRESSION:
Subsegmental bibasilar atelectasis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Cardiomyopathy, unspecified
temperature: 97.3
heartrate: 69.0
resprate: 18.0
o2sat: 99.0
sbp: 131.0
dbp: 60.0
level of pain: 6
level of acuity: 2.0 | ___ with PMH of CAD s/p multiple PCIs, ESRD on HD, HFpEF who
presents with worsening exertional chest pain over the last two
weeks with rest chest pain over last few days prior to
admission. In the ED initial vitals were: 97.3 HR: 69 BP:
131/60 RR: 18 99% RA
ECG: RBBB, TWI in V1-V3
Labs/studies notable for: guaic neg stool. Trop 0.53. CK 105. MB
2. Hgb 13.0. Hct 40.4. Plt 231. BUN 20. Cr 2.6. INR 1.1
CXR ___: IMPRESSION: Subsegmental bibasilar atelectasis.
Patient was given: Full dose Aspirin
On the floor, the patient had occasional resting CP. Troponin
and CK-MB were trended and showed
___ 13:27 0.39*1
___ 00:26 0.49*1
___ 15:56 0.53*2
Patient was given full dose ASA, nitro, started on hep gtt with
goal PTT 60-79. Interventional cardiology was consulted and the
decision was made to undergo cardiac
catheterization for concerns of ischemic disease. Cardiac
catheterization showed:
The RCA is a large vessel with previously deployed stents in
___, mid, and distal segments. Mid and distal stents were
widely patent. There was a 95% highly
eccentric stenosis at the proximal margin of the proximal stent,
extending back into the native RCA. 2 vessel CAD. Successful
PTCA/stent or proximal RCA using drug-eluting stent. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ceftriaxone
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Female transferred from ___ after
presenting with abdominal pain and found with dilated CBD
suspicious for an obstruction, and is transferred for ERCP
evaluation. The patient notes 24 hour of epigastric pain, nausea
and generally feeling unwell. On ultrasound at ___ she was
noted with a 8mm CBD and leukocytosis to 24.9. Her LFTs at
___ were not notable for transaminitis. She was given
ciprofloxacin and metronidazole for presumed infection (although
afebrile objectively, she has had subjective feeling warm. She
does note rhinorrhea, cough and pharyngitis over the several
days prior to admission.
In the ___ ED her initial vitals were 99.3, 100, 120/72, 16,
99%
Past Medical History:
Hypothyroidism
Hypertension
Hyperlipidemia
COPD
Social History:
___
Family History:
Mother:
Father:
Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: %
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
DISCHARGE PHYSICAL EXAM
Vital signs. AF 110s-150s/60s-80s ___ 18 92-96% Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils asymmetric (R pupil irregular - history
of bilateral cataract surgeries), unchanged
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate; MMMs
CV: RRR no m/r/g
RESP: CTAB
GI: Abdomen soft, non-distended, mild TTP in RUQ. No HSM
MSK/EXTR: No joint erythema, wwp, no edema, distal pulses intact
SKIN: Rash has fully resolved
NEURO: alert and oriented to year and month, but thought was in
___ rehab; CNs, sensation, strength, reflexes grossly
symmetric/intact; ___ backwards intact; able to follow basic
directions but some difficulty with more complex instructions
PSYCH: pleasant, appropriate affect
Pertinent Results:
======================
Pertinent results:
WBC: 24 -> 21 -> 18 -> 15 -> 11 -> 12
HGB mostly ~ 10 MCV mid ___
Iron 19 TIBC ___ Ferritin 391 B12 590
TSH 7.1 Free T4 1.2
Intermittent low Ca, Mg, Phos
Albumin 2.8 -> 2.9
Alk phos 145 -> 105 -> 111 ->106
Transaminases/Bili wnl
Cre 2.2 -> 2.1 -> 1.7 -> 1.4 -> 1.1 -> 0.9
Sodium: 128 -> 130 -> 131 (stable at 131 for 3 days)
Urine cx neg
Blood cx NGTD
CXR ___
There are no prior chest radiographs available for review.
Heterogeneous opacification predominantly right lower lobe most
likely broncho pneumonia. Hyperinflation suggests COPD. Heart
size is normal. Pulmonary vasculature is engorged. No
appreciable pleural effusion.
MRCP ___. Normal biliary tree. No evidence of choledocholithiasis.
2. Bibasilar right greater than left airspace opacities,
concerning for
pneumonia.
3. Bilateral renal cysts, including some that are likely
hemorrhagic, given the noncontrast examination, a renal
ultrasound is suggested for confirmation.
4. Multiple liver cysts versus biliary hamartomas.
Renal US ___
Moderate centrilobular emphysema with diffuse bronchial wall
thickening.
Heterogeneous peribronchial interstitial thickening-suggest
multifocal
pneumonia.
Few bilateral pulmonary nodules.
CT Chest ___
IMPRESSION:
Moderate centrilobular emphysema with diffuse bronchial wall
thickening.
Heterogeneous peribronchial interstitial thickening-suggest
multifocal
pneumonia.
Few bilateral pulmonary nodules.
RECOMMENDATION(S): Follow up of the pulmonary nodules and
presumed pneumonia
is recommended after therapy, no sooner than 3 months.
CT head ___
No evidence of large territorial infarction or intracranial
hemorrhage.
======================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. losartan-hydrochlorothiazide 100-25 mg oral DAILY
3. Pravastatin 20 mg PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth up to three times
daily as needed Disp #*90 Capsule Refills:*0
2. Levofloxacin 750 mg PO Q24H
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*5 Tablet Refills:*0
3. Levothyroxine Sodium 88 mcg PO DAILY
4. losartan-hydrochlorothiazide 100-25 mg oral DAILY
5. Pravastatin 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Metabolic encephalopathy (delirium)
Hyponatremia
Acute kidney injury
Anemia
Hypoalbuminemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with leukocytosis, ___, crackles// ?pneumonia
or other pulmonary process ?pneumonia or other pulmonary process
IMPRESSION:
There are no prior chest radiographs available for review.
Heterogeneous opacification predominantly right lower lobe most likely broncho
pneumonia. Hyperinflation suggests COPD. Heart size is normal. Pulmonary
vasculature is engorged. No appreciable pleural effusion.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: ___ year old woman with abdominal pain, leukocytosis, CBD
dilatation, ?choledocholithiasis. FYI cre 2.2, no gadolinium//
?choledocholithiasis. FYI cre 2.2, no gadolinium
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
No intravenous contrast was administered.
COMPARISON: Chest radiograph ___
FINDINGS:
Lower Thorax: There are bibasilar, right greater than left patchy alveolar
airspace opacities. There is a trace pleural effusion on the right.
Liver: There are multiple T2 hyperintense lesions in the liver, consistent
with cysts versus biliary hamartomas. No suspicious lesion is identified.
Liver is normal in morphology and signal intensity. There is no ascites.
Biliary: Gallbladder is unremarkable. There is no intra or extrahepatic
biliary duct dilation. Common bile duct measures 7 mm. No filling defect is
seen.
Pancreas: The pancreas is normal in signal intensity. No focal pancreatic
lesion is seen. There is no pancreatic duct dilation.
Spleen: The spleen is normal in size and signal intensity.
Adrenal Glands: The adrenal glands are unremarkable.
Kidneys: Kidneys are symmetric in size. There are multiple simple renal cysts
measuring up to 1.0 cm in the right lower pole. In addition to simple renal
cysts, there are T2 hypointense lesions in the bilateral kidneys, most with
intrinsic T1 hyperintense signal, suggesting hemorrhagic cysts. A T2
hypointense lesion in the right upper pole measuring 1.0 cm is without
definite T1 hyperintense correlate (series 6, image 24). No hydronephrosis is
seen.
Gastrointestinal Tract: There is no hiatal hernia. Views of the large bowel
are notable for diverticulosis.
Lymph Nodes: There is no mesenteric or retroperitoneal adenopathy.
Vasculature: Flow voids are preserved.
Osseous and Soft Tissue Structures: There are no suspicious bony lesions.
There is no superficial soft tissue abnormality.
IMPRESSION:
1. Normal biliary tree. No evidence of choledocholithiasis.
2. Bibasilar right greater than left airspace opacities, concerning for
pneumonia.
3. Bilateral renal cysts, including some that are likely hemorrhagic, given
the noncontrast examination, a renal ultrasound is suggested for confirmation.
4. Multiple liver cysts versus biliary hamartomas.
RECOMMENDATION(S): Renal ultrasound.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with pneumonia and ?hemorrhagic renal cysts on
MRCP// characterization of renal cysts
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: MRCP ___
FINDINGS:
The right kidney measures 12.4 cm. The left kidney measures 12.4 cm. There is
simple cyst in the mid and lower pole of the right kidney measuring up to 1.4
and 1.2 cm across maximal diameters, respectively. There is a simple cyst in
the lower pole of the left kidney measuring 1.3 by 0.9 x 0.8 cm. There is
another simple cyst in the lower pole left kidney measuring 1.5 x 1.5 x 1.3
cm.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Simple cysts in the bilateral kidneys. No worrisome renal lesion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old woman with confusion// r/o acute intracranial
process.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.8 s, 20.1 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,047.7 mGy-cm.
Total DLP (Head) = 1,048 mGy-cm.
COMPARISON: No prior head CT examinations are available.
FINDINGS:
There is no evidence of left territorial infarction,hemorrhage,edema,or
mass-effect. Ventricles and sulci are appropriate for patient age.
There is no evidence of fracture. There is mucosal thickening with
aerosolized secretions of the left maxillary sinus. There is mild mucosal
thickening in the bilateral anterior ethmoid air cells and the right frontal
sinus. The remaining visualized portion of the paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. Patient is status post bilateral
lens replacements.
IMPRESSION:
No evidence of large territorial infarction or intracranial hemorrhage.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with pneumonia, hyponatremia, hypoalbuminemia,
anemia, encephalopathy.
Please assess for mass or other underlying pulmonary process
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.5 s, 34.4 cm; CTDIvol = 6.6 mGy (Body) DLP = 230.3
mGy-cm.
Total DLP (Body) = 230 mGy-cm.
COMPARISON: There are no previous chest CT studies available for compared
FINDINGS:
No incidental thyroid findings .
Few measurable not pathologically enlarged lymph node in the mediastinum for
example right lower paratracheal 9 mm (5:107).
No lymphadenopathy in the axilla bilaterally.
There is no cardiomegaly or pericardial effusion .
Mild atherosclerotic calcifications of the aortic valve annulus and along the
thoracic aorta .
Respirator motion artifact compromises fine anatomic detail in the lower
lobes.
Moderate centrilobular emphysema prominent in the upper lobes. Diffuse
bronchial wall thickening.
Many regions of peribronchial infiltration and interstitial thickening
opacities in both lungs, most extensive in the right lower lobe, are probably
multifocal pneumonia, but lung cancer in the distorted architecture of severe
emphysema could be present. The largest region interstitial abnormality, a
geographic region markedly thickened bullous walls and interstitium in the
left upper lobe, ___ is probably scarring.
Left upper lobe irregular solid nodule 7 mm (5:75).
Another left upper lobe solid nodule measuring 10 mm (5:143).
In the right lower lobe staple lines from a preview surgery, associated with
fibrotic changes and mild adjacent traction bronchiectasis.
Along the staple lines a nodule grossly measuring 14 x 10 mm (5:242).
Right lower lobe subpleural interstitial line thickening could be fibrotic or
inflammatory in origin, with lung nodule measuring 10 x 11 mm (5:198).
Few scattered calcified granulomas bilaterally.
There is no pleural effusion.
In both lobes of the liver there are multiple hypodense round lesions better
evaluated on the MRI dated ___.
Scattered calcified granuloma in the liver.
The remaining included upper abdominal organs are with no gross findings .
No evidence of bony destructive lesions.
IMPRESSION:
Moderate centrilobular emphysema with diffuse bronchial wall thickening.
Heterogeneous peribronchial interstitial thickening-suggest multifocal
pneumonia.
Few bilateral pulmonary nodules.
RECOMMENDATION(S): Follow up of the pulmonary nodules and presumed pneumonia
is recommended after therapy, no sooner than 3 months.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Calculus of bile duct w/o cholangitis or cholecyst w/o obst
temperature: 99.3
heartrate: 100.0
resprate: 16.0
o2sat: 99.0
sbp: 120.0
dbp: 72.0
level of pain: 0
level of acuity: 3.0 | ___ year old woman with HTN, HL, hypothyroidism, and COPD, who
was admitted with bilateral pneumonia, sepsis, ___, and
hyponatremia. Of note she initially transferred with concern for
cholangitis, but the work-up did not reveal any such findings.
Her course was complicated by metabolic encephalopathy and
possible rash due to ceftriaxone.
#Sepsis due to bilateral pneumonia:
Patient reported nonspecific symptoms for ___ weeks prior to
presentation, suggesting this was likely brewing for a while.
She was initially tachycardic but this subsequently improved.
She had initially been started on flagyl/levaquin for Gi
coverage when cholangitis was suspected but was changed to
ceftriaxone doxy subsequently. On ___ due to concern for
antibiotic reaction to ceftriaxone she was changed to levaquin
monotherapy. She completed 5 days of treatment as inpatient and
will complete 5 additional days for a 10 day course given her
prolonged time with symptoms prior to presentation.
#Metabolic encephalopathy:
Patient with intermittent confusion, worse at night. Overall
improving prior to discharge, although not entirely back to
baseline. Neuro exam nonfocal. Worked up with head CT, labs,
TSH, B12, without clear cause. Mild hyponatremia may be playing
a role, so treating as per below. TSH slightly elevated but T4
wnl. In discussing with her sister it sounds like there may be
some very early cognitive/memory impairment, so recommending
further outpatient work-up. Will be discharged to ___,
where her brother can provide ___ supervision. Will also have
___ for safety check. In discussion with the family it was felt
this plan would be the safest and provide the best chance of
quick recovery vs continued hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
EGD x2
Colonoscopy
___ guided embolization of gastroduodenal artery
IVC filter placement and removal
History of Present Illness:
Mr. ___ is a ___ with 75-100 PY-smoking history (quit in
___, COPD rarely uses 2L home O2, inferior STEMI ___ s/p
streptokinase; RCA CTO with L->R collaterals), ischemic HFrEF
(LVEF ___, VT s/p dcPPM/ICD, who was initially diagnosed in
___ with Stage Ib lung adenocarcinoma which was treated with
a
LUL wedge resection (___) with recurrence to the brain,
chest,
a/p, and bone in ___ on surveillance scans who was recently
diagnosed with R mainstem PE on ___, started on Xarelto as
outpt, now presenting with worsening DOE.
On ___, patient had screening imaging which demonstrated
metastatic disease to brain, bones. Given progression on
previous
chemo regimen, changed to Pembrlozumab monotherapy, first dose
of
which was ___, second dose ___. During his visit for his
second dose of Pembro on ___, he was noted to be severely SOB,
desatting to 81% on RA while getting weighed. In this setting,
had a CTA which demonstrated large pulmonary emboli. He was
started on Rivaroxaban 15mg PO BID, symptoms improved after
starting 2L NC, but was not admitted.
He now presents with progressively worsening SOB and O2
requirement since the events of ___. Was up to 6L yesterday
(unclear if titrated based on pulse ox vs symptoms only) before
neighbor, who is ___, called ambulance. Today, he stood up from a
chair and became acutely short of breath after just three steps.
He has not had any cough, productive sputum, fevers, chills,
wheezing, sore throat, or other respiratory symptoms. No sick
contacts. No swelling, no PND or othopnea. No calf pain.
At baseline he has dyspnea with exertion, on ___ was the first
time he experienced dyspnea while at rest. Has home O2 available
but prior to ___ rarely used it. Sleeps on a flat bed with one
pillow at home. Sometimes gets acutely dyspneic triggered by
exertion (e.g. lifting heavy object), though has never been
hospitalized for COPD exacerbation. Denies wheezing during these
dyspneic episodes at home. Takes tiotropium and one other
inhaler
(doesn't recall name), rarely uses albuterol rescue inhaler.
Last dose of Rivaroxaban was 7pm on ___.
In the ED,
Initial vitals:
-96.9 73 ___ 98% 2L NC
Exam notable for:
-lungs clear bilaterally, JVP 12, abdomen soft
Labs notable for:
-Hgb 7.1 (on ___ was 9.8), WBC 10.6 and plt 357
-___ 30.9 INR 2.8
-Cr 1 BUN 39 rest of lytes wnl
-ALT 49 AST 32 AP 39 Total B <0.2
-troponin <0.01, BNP ___
Imaging notable for:
-LENIS: 1. Nonocclusive thrombus extending from the left common
femoral vein to the popliteal vein. At the level of the distal
femoral vein it is near occlusive. 2. No evidence of DVT in the
right lower extremity.
-CXR: No focal consolidation, pulmonary edema or pleural
effusion. Patient's known pulmonary emboli are not well
evaluated
on the current exam.
Consults:
-MASCOT: work up for possible COPD exacerbation, infectious
workup, anemia work up. Vascular medicine will follow on OMED
service. OK with no anticoagulation until ___ on ___ as
patient last took rivaroxaban on ___ around ___. Would
discuss with oncology before initiating therapy, but would start
lovenox 1mg/kg SC BID beginning 0700 on ___ would also be
helpful to discuss whether degree of fall in Hgb is
disproportionate to what is expected 3 days following
myelosuppressive therapy; No indication for lysis at this point
and patient has absolute as well as relative contraindications;
Please keep NPO for now in case IVC filter is needed
Pt given:
___ 04:39 IH Ipratropium-Albuterol Neb 1 NEB
___ 04:39 IVF 500cc LR
Upon arrival to the floor, the patient reports feeling his
breathing is ok at rest but is worried that he will quickly
decompensate again like he did on ___. Anxious about whether he
is getting enough O2. Breathing feels slightly better sitting up
compared to lying down. Denies fevers, chills, chest pain, leg
pain, abdominal pain.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
COPD, diagnosed about ___ years ago;
- myocardial infarction in ___
- ischemic cardiomyopathy;
- hypertension;
- hyperlipidemia;
- peripheral vascular disease
PAST SURGICAL HISTORY
-iliac aneurysm repair in ___
-right femoral vascular procedure in ___
-repair of an abdominal aortic aneurysm
-appendectomy
PAST ONCOLOGIC HISTORY:
___ Initial diagnosis of lung adenocarcinoma
___ Wedge resection of 3.7 cm adenocarcinoma of the LUL,
stage pT2aN0M0 = Stage Ib
___ MRI brain w/ right parieto-occipital lesion
___ PET w/ 1.3 mass at the previous wedge resection site,
multiple metastasis at the chest, abdomen and pelvis [adrenal
mass, pancreatic head, left iliac bone pathologic fracture]
___ Initial encounter w/ MedOnc ___
___ Bone biopsy (left iliac): Adenocarcinoma c/w lung met
___ Completed ___ fractions of SRT to the right
parieto-occipital brain metastasis w/ Dr ___
___ FoundationOne report from initial tissue ___
revealed no actionable mutations [Microsatellite status
MS-Stable, Tumor Mutational Burden ___ Muts/Mb, CDKN2A loss,
CDKN2B loss, CHEK2, CHEK2(___) duplication intron 2 -
intron 4, FH splice site 1391-1G>T, RAD51C E303fs*11, TP53
splice
site 375+1G>C].
___ C1D1 Carboplatin/Pemetrexed/Pembrolizumab
___ C2D1 Carboplatin(-20%)/Pemetrexed(-20%)/Pembrolizumab
PAST MEDICAL HISTORY:
-COPD rarely uses 2L home O2, ___-100 PY-smoking history (quit in
___
-inferior STEMI ___ s/p streptokinase; RCA CTO with L->R
collaterals) -ischemic HFrEF (LVEF ___
-VT s/p dcPPM/ICD
-Stage Ib lung adenocarcinoma ___ which was treated with a
LUL
wedge resection (___) with recurrence to the brain, chest,
a/p, and bone in ___ on surveillance scans
-Submassive PE ___ on rivaroxaban
-Appendectomy (___)
Social History:
___
Family History:
Siblings: brother died of COPD and heart issues.
Father side: no cancer history.
Mother: breast cancer age ___.
No other known family members with cancer.
- father died at age ___ from complications of ___
disease
- mother died at ___ from dementia
- brother died from COPD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: ___ 1200 Temp: 98.1 PO BP: 149/75 L Lying HR: 63 RR: 18
O2 sat: 98% O2 delivery: 2L NC
GENERAL: NAD, NC in place
HEENT: AT/NC, anicteric sclera, MMM
NECK: JVP 10cm
CV: distant heart sounds, RRR, no MRG
PULM: Fine inspiratory crackles up to midfields bilaterally, no
wheezes or ronchi, mildly increased WOB with some use of
accessory muscles
ABD: soft, NT, ND
EXT: trace ___ edema bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 811)
Temp: 98.2 (Tm 98.7), BP: 128/76 (102-144/50-76), HR: 71
(71-81), RR: 18, O2 sat: 97% (91-98), O2 delivery: 1.5L NC
GENERAL: awake, alert, NAD
HEENT: NCAT, anicteric sclera, MMM
CV: distant heart sounds, RRR, no MRG
PULM: CTAB, no wheezes or rhonchi
ABD: S, NT, ND
EXT: ___ ___ edema bilaterally, diffuse rash on upper
extremities, erythematous, macular rash on left calf and right
lateral thigh as well which continues to improve.
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
ADMISSION LABS:
===============
___ 02:46AM BLOOD WBC-10.6* RBC-2.29* Hgb-7.1* Hct-23.1*
MCV-101* MCH-31.0 MCHC-30.7* RDW-14.0 RDWSD-48.9* Plt ___
___:46AM BLOOD Neuts-83.0* Lymphs-9.7* Monos-6.1
Eos-0.3* Baso-0.1 Im ___ AbsNeut-8.82* AbsLymp-1.03*
AbsMono-0.65 AbsEos-0.03* AbsBaso-0.01
___ 02:46AM BLOOD Poiklo-1+* Macrocy-2+* Ovalocy-1+* RBC
Mor-SLIDE REVI
___ 02:46AM BLOOD ___ PTT-29.2 ___
___ 11:00AM BLOOD ___ 02:46AM BLOOD Ret Aut-1.5 Abs Ret-0.03
___ 02:46AM BLOOD Glucose-85 UreaN-39* Creat-1.0 Na-144
K-5.2 Cl-111* HCO3-24 AnGap-9*
___ 02:46AM BLOOD ALT-49* AST-32 LD(LDH)-277* CK(CPK)-26*
AlkPhos-39* TotBili-<0.2
___ 02:46AM BLOOD CK-MB-1 ___ 02:46AM BLOOD cTropnT-<0.01
___ 02:46AM BLOOD Albumin-2.5*
___ 03:15AM BLOOD Albumin-2.4* Calcium-8.4 Phos-4.1 Mg-1.6
___ 02:46AM BLOOD ___ Folate-16 Hapto-347*
___ 05:28AM BLOOD calTIBC-244* Hapto-287* Ferritn-949*
TRF-188*
___ 06:00AM BLOOD Triglyc-423*
___ 07:34AM BLOOD Type-MIX pH-7.33*
___ 07:34AM BLOOD freeCa-1.13
___ 07:50AM URINE Color-Straw Appear-Clear Sp ___
___ 07:50AM URINE Blood-MOD* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 07:50AM URINE RBC-111* WBC-2 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 07:50AM URINE Mucous-RARE*
___ 01:02PM STOOL HELICOBACTER ANTIGEN DETECTION,
STOOL-Test
PERTINENT INTERMITTENT LABS:
============================
Test Result Reference
Range/Units
ZINC 48 L 60-130 mcg/dL
Test Result Reference
Range/Units
COPPER 84 70-175 mcg/dL
Test Result Reference
Range/Units
VITAMIN A (RETINOL) 26 L 38-98 mcg/dL
___ 05:33AM BLOOD Triglyc-235*
___ 06:00AM BLOOD Triglyc-423*
___ 05:28AM BLOOD calTIBC-244* Hapto-287* Ferritn-949*
TRF-188*
___ 04:48AM BLOOD 25VitD-44
PERTINENT STUDIES:
=================
CT head ___
1. No evidence of acute intracranial hemorrhage or fracture.
2. Redemonstration of a right parieto-occipital lobe mass,
better
characterized on prior MRI dated ___.
Transthoracic Echocardiogram Report Date: ___ 08:49
The visually estimated left ventricular ejection fraction is
25%.
IMPRESSION: Small circumferential pericardial effusion without
echocardiographic evidence for tamponade physiology . Severe
regional left ventricular systolic dysfunction most consistent
with multivessel coronary artery disease.
___ Colonoscopy
Diverticulosis of sigmoid.
Normal mucosa in the whole colon and 10cm into the terminal
ileum without a bleeding lesion or active bleeding.
Wireless capsule located in cecum and removed.
___ EGD (for pill cam placement past pylorus)
Normal mucosa in whole esophagus.
Patchy areas of pale mucosa noted in gastric antrum and body, no
blood seen in stomach.
An ulcer was seen in the duodenal bulb with 2 clips attached to
mucosa that closed the ulcer base completely. No stigmata or
bleeding were noted.
A 5mm linear non-bleeding clean-based ulcer was found the
proximal second portion of the duodenum.
Patchy ares of pale mucosa were noted in the ___ and ___ portion
of the duodenum.
Normal mucosa in the examined jejunum.
Radiology ReportIVC FILTER PLACEMENTStudy Date ___
Successful deployment of Denali infrarenal retrievable IVC
filter.
Radiology ReportCT ABD & PELVIS WITH CONTRAST Date of
___
1. No evidence of active hemorrhage.
2. Segmental pulmonary embolism demonstrated in right lower
lobe, unchanged.
Persistent thrombus in the left common and superficial femoral
veins with more
chronic appearance.
3. No short term change in metastatic disease.
4. Small but increased left pleural effusion. Small but
slightly increased
pericardial effusion.
Radiology Report ___ EMBOLIZATION Study Date of ___ 12:57
___
IMPRESSION:
Successful right common femoral artery approach gastroduodenal
artery
embolization.
___ EGD REPORT
Two ulcers were seen at the level of duodenal sweep. One was 5mm
clean based on the anterior wall. Adjacent to it abutting the
posterior wall was a cratered 10mm ulcer with visible vessel.
Initially there was no active bleeding. Two endoclips were
successfully applied however with this there was active bleeding
noted. Given patient was on systemic anticoagulation and to
avoid prolonged bleeding, hemospray was applied successfully for
hemostasis.
Normal mucosa in the whole esophagus.
Normal mucosa in the whole stomach.
Transthoracic Echocardiogram Report ___ 03:43
visually estimated left ventricular ejection fraction is 30%.
IMPRESSION: Focused TTE. Normal left ventricular size with
regional (in RCA territory) and global systolic dysfunction.
Normal right ventricular size with mild systolic
dysfunction/dyssynchrony. Indeterminate pulmonary arterial
systolic pressure. Small circumferential pericardial effusion
without cardiac tamponade.
Radiology ReportCT ABD & PELVIS W/O CONTRAST Date ___
1. No evidence of retroperitoneal or significant intramuscular
hematoma.
2. Moderately sized pericardial effusion which is slightly
larger in
comparison to prior.
3. Trace new left pleural effusion.
4. Indeterminate left renal lesions, which appear increased in
size compared
to prior outside study on ___. Ultrasound or MRI
renal mass
protocol is recommended for further evaluation.
5. Slight interval increase in the size of the right adrenal
nodular
thickening, which may represent posttreatment changes or
progression of
disease.
6. Sigmoid diverticulosis without evidence of diverticulitis.
7. Chronic fracture deformity of the left ilium with associated
periosteal new
bone formation.
Radiology ReportCHEST (PA & LAT)Study Date of ___
No focal consolidation, pulmonary edema or pleural effusion.
Patient's known pulmonary emboli are not well evaluated on the
current exam.
Radiology ReportBILAT LOWER EXT VEINSStudy Date of ___
1. Non-occlusive thrombus extending from the left common femoral
vein to thepopliteal vein. At the level of the distal femoral
vein it is near occlusive.
2. No evidence of DVT in the right lower extremity.
MICROBIOLOGY:
=============
___ 7:50 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 7:10 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:21 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS:
===============
___ 06:03AM BLOOD WBC-9.5 RBC-2.64* Hgb-8.0* Hct-25.9*
MCV-98 MCH-30.3 MCHC-30.9* RDW-19.9* RDWSD-69.8* Plt ___
___ 06:03AM BLOOD Glucose-99 UreaN-7 Creat-0.8 Na-141 K-4.5
Cl-109* HCO3-23 AnGap-9*
___ 06:03AM BLOOD Calcium-7.2* Phos-2.0* Mg-1.7
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with stage 4 lung adeno and known PEs diagnosed
on CTA ___// Worsening DOE I/s/o known R lobar PEs, on anticoagulation but
want to eval for other cause of hypoxia, PNA, pleural effusion etc.
TECHNIQUE: Chest PA and lateral
COMPARISON: CTA chest ___. Chest radiograph ___.
FINDINGS:
Postsurgical changes are noted in the left upper lobe. The lungs are clear
without focal consolidation, pulmonary edema large pleural effusion or
pneumothorax. There is bibasilar atelectasis. Cardiomediastinal silhouette
is top normal but unchanged. A dual lead pacemaker defibrillator device is
seen with leads terminating in the right atrium and right lateral ventricle.
IMPRESSION:
No focal consolidation, pulmonary edema or pleural effusion. Patient's known
pulmonary emboli are not well evaluated on the current exam.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with stage 4 lung adenocarcinoma presenting with
PEs diagnosed 2.19, persistent SOB// Eval for concomitant DVTs in patient with
known PEs
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
CTA chest ___
FINDINGS:
RIGHT: There is normal compressibility, color flow, and spectral doppler of
the common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
LEFT: There is discontinuous nonocclusive thrombus extending from the left
common femoral vein through the popliteal vein. At the level of the distal
femoral vein, the thrombus is near occlusive. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Non-occlusive thrombus extending from the left common femoral vein to the
popliteal vein. At the level of the distal femoral vein it is near occlusive.
2. No evidence of DVT in the right lower extremity.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION: ___ year old man with stage 4 lung adenocarcinoma, Large PE,
recently started on AC// New Hgb drop, no hemolysis or frank red blood per
rectum, eval for RP bleed or intra-abd bleed
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis without intravenous contrast.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
Please note that nonenhanced examination is have limited sensitivity in the
detection of intra-abdominal infection and or malignancy.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 11.6 mGy (Body) DLP = 593.1
mGy-cm.
Total DLP (Body) = 593 mGy-cm.
COMPARISON: Reference CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Moderately sized pericardial effusion is slightly larger in
comparison to prior. There is a partially visualized AICD lead in the right
ventricle. Hypodensity within the blood pool and visualization of the
interventricular septum compatible with anemia. Trace left pleural effusion
is new. Visualized lung bases are clear.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions within the limitation of a nonenhanced
study. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains gallstones without wall thickening or
surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation within the limitation of a
nonenhanced study. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions on this noncontrast study.
ADRENALS: The left adrenal gland is unremarkable. There is nodular thickening
of the left adrenal gland, which is slightly increased compared to prior study
on ___.
URINARY: Kidneys are symmetric in size . Scattered cystic renal lesions are
noted some of which are indeterminate in density, for example in the
interpolar region of the left kidney measuring up to 2.2 cm (02:25). In the
left upper pole there is a 2.4 cm relatively hyperdense renal lesion,
indeterminate (02:20).
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Surgical suture
material seen in the cecum. There are sigmoid diverticula without evidence of
diverticulitis. The remain colon and rectum are within normal limits. The
appendix is not visualized and may be surgically absent. No evidence of
retroperitoneal hematoma.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted. Patient is status post placement of a infrarenal bi-iliac
aortic stent, not well evaluated on this non-contrast study.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Chronic fracture is seen of the left ilium with associated periosteal new bone
formation. No evidence of intramuscular hematoma.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of retroperitoneal or significant intramuscular hematoma.
2. Moderately sized pericardial effusion which is slightly larger in
comparison to prior.
3. Trace new left pleural effusion.
4. Indeterminate left renal lesions, which appear increased in size compared
to prior outside study on ___. Ultrasound or MRI renal mass
protocol is recommended for further evaluation.
5. Slight interval increase in the size of the right adrenal nodular
thickening, which may represent posttreatment changes or progression of
disease.
6. Sigmoid diverticulosis without evidence of diverticulitis.
7. Chronic fracture deformity of the left ilium with associated periosteal new
bone formation.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new PICC// Rt. ___ FR. 42 cm. DL PICC new ___
___ Contact name: ___: ___ Rt. ___ FR. 42 cm. DL PICC new ___
___
IMPRESSION:
New right PIC line passes into the neck and out of view.
Small left pleural effusion may be slightly larger today or augmented by new
left basal atelectasis. Right lung grossly clear. No right pleural
abnormality. Normal cardiomediastinal silhouette. Transvenous right atrial
pacer and right ventricular pacer defibrillator leads continuous from the left
pectoral generator.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with Rt. PICC malposition now power flushed// Rt.
PICC power flushed ___ ___ Rt. PICC power flushed ___ ___
IMPRESSION:
Compared to chest radiographs of wary fifth through ___.
Right PIC line still ends in the jugular system.
Progressive atelectasis is reflected in increased elevation of the left lung
base. Lungs elsewhere clear. Heart size normal. No pneumothorax or
appreciable pleural effusion.
Radiology Report
INDICATION: ___ year old man with poor access, R PICC placed today but went
into RIJ, position didn't correct with power flush, needs repositioning by
___// Please reposition R PICC, please schedule after his endoscopy today
COMPARISON: Radiograph of the chest dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: None
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 1.4 minutes, 1 mGy
PROCEDURE: 1. Repositioning of right PICC.
PROCEDURE DETAILS: Using aseptic technique, the existing right PICC line was
briskly flushed PICC line was noted to flip down with the tip from the IJ
flipping down to overlying the region of the distal SVC. The patient
tolerated the procedure well. There were no immediate complications.
FINDINGS:
1. Existing right arm approach PICC with tip in the right internal jugular
vein repositioned with the tip in the low SVC.
IMPRESSION:
Successful repositioning of a right arm approach double lumen PowerPICC with
tip in the low SVC. The line is ready to use.
Radiology Report
INDICATION: ___ year old man with bleeding duodenal ulcer// Arteriogram with
possible embolization.
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___, attending Interventional
Radiologist and Dr. ___, Interventional Radiology fellow performed
the procedure. Dr. ___ personally supervised the trainee
during any key components of the procedure where applicable and reviewed and
agrees with the findings as reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 81 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: 100 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 23 minutes and 21 seconds, 280 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Celiac arteriogram.
3. Gastroduodenal arteriogram.
4. Left gastroepiploic arteriogram.
5. Coil and Gel-Foam embolization of the gastroduodenal artery.
6. Post embolization celiac arteriogram.
7. Superior mesenteric arteriogram.
8. Right common femoral arteriogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right and left groin was prepped and draped in the usual sterile
fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A 5 ___ SOS catheter was advanced over ___ wire into the aorta. The
catheter was then used to cannulate the celiac artery. Contrast was injected
to confirm positioning. A celiac arteriogram was performed. A STC
microcatheter and double angled Glidewire were then advanced through the
common hepatic artery and into the gastroduodenal artery. The wire was
removed and contrast was injected to confirm positioning. A gastroduodenal
arteriogram was performed. The microcatheter was then a advanced to the
distal GDA. Contrast was injected to confirm positioning. A left
gastroepiploic arteriogram was performed. The microcatheter was then pulled
back and contrast was injected until the origin of the gastroepiploic artery
was identified.
Subsequently, multiple coils were deposited in the gastroduodenal artery with
intermittent injections of Gel-Foam. Following gastroduodenal artery
embolization, the microcatheter was removed. A repeat celiac arteriogram was
performed showing stasis within the gastroduodenal artery and a patent common
hepatic/proper hepatic artery.
The SOS catheter was then disengaged from the celiac artery and used to engage
the superior mesenteric artery. Contrast was injected to confirm positioning.
A superior mesenteric arteriogram was then performed. No bleeding or supply
to the duodenum was identified.
The SOS catheter was then removed over the ___ wire. A right common
femoral arteriogram was performed through the 5 ___ sheath. The 5 ___
sheath was removed and a Angio-Seal device was used to achieve hemostasis. A
sterile dressing was applied. The patient tolerated the procedure well and
there were no immediate postprocedure complications.
All arteriograms performed were medically necessary for diagnositic, planning
and treatment purposes.
FINDINGS:
1. Conventional celiac artery anatomy with gastroduodenal artery in close
proximity to the duodenal clips placed by endoscopy. No active bleeding
identified.
2. Successful coil and Gel-Foam embolization of the gastroduodenal artery.
3. Post gastroduodenal artery embolization revealed patent common
hepatic/proper hepatic arteries and no evidence of active bleeding.
4. No significant supply to the duodenum was identified from the superior
mesenteric artery.
IMPRESSION:
Successful right common femoral artery approach gastroduodenal artery
embolization.
Radiology Report
EXAMINATION: CT of the abdomen and pelvis.
INDICATION: Mr. ___ is a very pleasant ___ with 75-100 PY-smoking
history (quit in ___, COPD rarely uses 2L home O2, inferior STEMI ___ s/p
streptokinase; RCA CTO with L->R collaterals), ischemic HFrEF (LVEF ___,
VT s/p dcPPM/ICD, who was initially diagnosed in ___ with Stage Ib lung
adenocarcinoma which was treated with a LUL wedge resection (___) with
recurrence to the brain, chest, a/p, and bone in ___ on surveillance scans
who was recently diagnosed with a large PE on ___, started on Xarelto as
outpt, now presenting with worsening DOE. Found to have downtrending Hb iso
melenic/wine colored
TECHNIQUE: Following acquisition of a noncontrast scan of the abdomen and
pelvis, multidetector CT images of the abdomen and pelvis were obtained with
intravenous contrast in the arterial and portal venous phases. Sagittal and
coronal reformations were also performed.
DOSE: DLP is 712.10 mGy-cm.
COMPARISON: Study can be compared to ___ and more recent CT
dated ___. Another helpful comparison is a chest CT dated
___.
FINDINGS:
Small left pleural effusion has, however, increased somewhat. There is minor
associated atelectasis. A small pericardial effusion is also somewhat
increased.
Segmental pulmonary embolism appears unchanged in the right lower lobe (10:
8).
Small dependent calcified stones are found in the gallbladder. No definite
suspicious focal liver lesions are identified. There is no biliary
dilatation. Pancreas appears normal. Spleen is normal in size. Two
metastatic lesions involving the right adrenal gland in addition to a left
interpolar renal metastasis appear unchanged. Few simple cysts are also found
bilaterally, as before. There is no hydronephrosis involving either kidney.
Stomach appears normal. Coils are found along the course of the
gastroduodenal artery. Small hyperdense foci are found in the stomach and
proximal colon prior to contrast administration. Fluid along the colon is
hyperdense more generally. However, there is no evidence for active
extravasation of contrast on this examination. Sigmoid diverticulosis is
moderate in severity. Patient is status post appendectomy.
Prostate is moderately enlarged with central hypertrophy. Seminal vesicles
and bladder appear normal. Atherosclerotic disease is generally of moderate
severity. Aortoiliac stent graft is patent widely patent. Irregular
calcification and multifocal mild narrowing is noted along bilateral common
and external iliac arteries.
There is an eccentric nonocclusive thrombus in the left common and superficial
femoral vein, also involving the proximal left greater saphenous vein,
consistent with the chronic venous thrombosis, of all somewhat since the prior
examinations do a more chronic appearance.
A destructive lesion of the anterior left iliac crest with adjacent
predominantly cystic soft tissue component is consistent with the metastatic
disease including pathological fracture, very similar to the very recent prior
CT.
IMPRESSION:
1. No evidence of active hemorrhage.
2. Segmental pulmonary embolism demonstrated in right lower lobe, unchanged.
Persistent thrombus in the left common and superficial femoral veins with more
chronic appearance.
3. No short term change in metastatic disease.
4. Small but increased left pleural effusion. Small but slightly increased
pericardial effusion.
Radiology Report
INDICATION: ___ year old man with PE, DVT, active GIB, very high risk of
further propogation of proximal DVT, would like to stop heparin gtt. Please
place IVC filter// IVC filter
COMPARISON: CT abdomen and pelvis ___
TECHNIQUE: OPERATORS: Dr. ___, attending Interventional Radiologist
and Dr. ___, Radiology resident performed the procedure. Dr. ___
___ supervised the trainee during any key components of the procedure
where applicable and reviewed and agrees with the findings as reported below.
ANESTHESIA: Sedation was provided by administrating divided doses of 50mcg of
fentanyl throughout the total intra-service time of 12 minutes during which
the patient's hemodynamic parameters were continuously monitored by an
independent trained radiology nurse. 1% lidocaine was injected in the skin and
subcutaneous tissues overlying the access site.
MEDICATIONS: None
CONTRAST: 20 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 1:12 , 1 mGy
PROCEDURE:
1. Right iliac vein and IVC venogram.
2. Infrarenal Denali IVC filter deployment.
3. Post-filter placement venogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. the right groin was prepped and draped in the usual sterile fashion.
Under ultrasound and fluoroscopic guidance, the patent and compressible Right
common femoral vein was punctured using a 19G needle. Ultrasound images of
the access was stored on PACS. A ___ wire was advanced through the
micropuncture sheath into the inferior vena cava.The sheath was then advanced
into the right iliac vein.
A rightcommon iliac and inferior vena cava venogram was performed. Based on
the results of the venogram, detailed below, a decision was made to place a
Denali filter. An Denali vena cava filter was advanced until the cranial tip
was at the level of the inferior margin of the lower renal vein. The sheath
was then withdrawn until the filter was deployed. The wire and loading device
were then removed through the sheath and a repeat contrast injection was
performed, confirming appropriate filter positioning. The final image was
stored on PACS.
The sheath was removed and pressure was held for 10 minutes,at which point
hemostasis was achieved. A sterile dressing was applied.
The patient tolerated the procedure well and there were no immediate post
procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with single left renal vein and one
main and one accessory right renal veins and no evidence of a clot.
2. Successful deployment of an infra-renal Denali IVC filter.
IMPRESSION:
Successful deployment of Denali infrarenal retrievable IVC filter.
Radiology Report
EXAMINATION: Abdominal radiographs, two AP supine porta views.
INDICATION: Lung cancer, gastrointestinal bleeding and capsule endoscopy.
Supine views.
COMPARISON: Prior CT is available from ___.
FINDINGS:
Capsule projects over the right lower quadrant. Precise location is difficult
to assess with radiography although its position would be consistent with the
location of the ileocecal valve. IVC filter and aortoiliac stent graft are
also visible in addition to gastroduodenal artery coils. Bowel gas pattern is
unremarkable. There are no dilated loops of large or small bowel. Air and
stool are seen the colon including the rectum. No definite free air.
IMPRESSION:
Capsule projecting over the right lower quadrant.
Radiology Report
INDICATION: none// capsule location? colon vs small bowel.
TECHNIQUE: Frontal supine abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis ___, IVC placement fluoroscopy ___
FINDINGS:
There is an approximately 1.3 cm rounded hypodense object projecting over the
right ilium, which likely represents endoscopic capsule. Note is made of an
aortoiliac stent graft, IVC filter, embolic material in the right upper
quadrant, as well as cholecystectomy clips. The bowel gas pattern is
unremarkable with gas seen in nondistended loops of large and small bowel.
There is no evidence of ileus or obstruction. Supine positioning limits
evaluation of intraperitoneal free air. The bony structures are unremarkable.
IMPRESSION:
Endoscopic capsule projects over the right lower quadrant.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HFpEF, GIB, lung cancer, volume overload,
new SOB// Assess for volume overload, aspiration
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph ___
FINDINGS:
The right-sided PICC courses superiorly and terminates in the right internal
jugular system. Left pectoral pacer leads terminate in the right atrium and
right ventricle, as expected.
Mild central pulmonary vascular congestion has slightly increased from prior,
without overt pulmonary edema. There is a small left pleural effusion, which
is not significantly changed from the prior radiograph performed on ___. There is likely associated atelectasis. There is no
pneumothorax.
IMPRESSION:
1. The tip of the right PICC line courses superiorly within the right internal
jugular venous system.
2. Mild increase in central pulmonary vascular congestion, without overt
pulmonary edema.
3. Small left pleural effusion with likely associated compressive atelectasis.
NOTIFICATION: Findings were communicated to and acknowledged by Dr. ___
at 20h30 by Dr. ___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with PICC in RIJ// eval s/p picc reposition
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
A left chest wall dual lead ICD is present. Unchanged retrocardiac opacities
which likely reflect a combination of atelectasis and pleural fluid. The tip
of the right internal jugular central line again projects up into the right
neck. The right lung is clear. The size of the cardiac silhouette is
enlarged but unchanged.
IMPRESSION:
The tip of the right PICC line projects up into the right internal jugular
venous system, unchanged.
Radiology Report
INDICATION: ___ year old man with R sided PICC, seen on ___ CXR to be
malpositioned (curved up into RIJ again), power flushes couldn't reposition.//
R PICC is malpositioned (curved up into RIJ again), please reposition
COMPARISON: Chest radiograph ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: None
MEDICATIONS:
CONTRAST: ml of contrast
FLUOROSCOPY TIME AND DOSE: 1 min, 2 mGy
PROCEDURE: 1. Repositioning of right PICC.
PROCEDURE DETAILS: Using aseptic technique and local anesthesia, the existing
right PICC line was aspirated and briskly flushed under fluoroscopy. This
resulted 18 the PICC pointing into the SVC but looped subclavian IJ
confluence. The PICC line was retracted approximately 4 cm. The patient
tolerated the procedure well. There were no immediate complications.
FINDINGS:
1. Existing right arm approach PICC with tip in the right internal jugular
vein repositioned with the tip in the low SVC.
IMPRESSION:
Successful repositioning of a right arm approach single lumen PowerPICC with
tip in the low SVC. The line is ready to use.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with metastatic lung ca s/p fall with headstrike
on heparin.// ?bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP =
940.0 mGy-cm.
2) Stationary Acquisition 1.0 s, 4.0 cm; CTDIvol = 47.0 mGy (Head) DLP =
188.0 mGy-cm.
Total DLP (Head) = 1,128 mGy-cm.
COMPARISON: MRI brain dated ___.
FINDINGS:
There is no evidence of acute large territorial infarction,hemorrhage,edema,or
new mass. There is redemonstration of a right parieto-occipital lobe
hypodense lesion, better characterized on prior MRI dated ___.
There is prominence of the ventricles and sulci suggestive of involutional
changes. Bilateral subcortical and periventricular white matter hypodensities
are nonspecific but likely represent sequelae of chronic small vessel ischemic
disease.
There is no evidence of fracture. There is complete opacification of the left
sphenoid and posterior ethmoid sinuses. Otherwise, the visualized portion of
the paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or fracture.
2. Redemonstration of a right parieto-occipital lobe mass, better
characterized on prior MRI dated ___.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old man with metastatic lung cancer s/p fall with head
strike on heparin.// ?fx ?fx
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.8 s, 22.2 cm; CTDIvol = 26.3 mGy (Body) DLP = 565.5
mGy-cm.
Total DLP (Body) = 566 mGy-cm.
COMPARISON: None.
FINDINGS:
No evidence of acute fracture or traumatic subluxation of the cervical
spine.There is minimal retrolisthesis at C4-C5, likely degenerative.There is
no prevertebral soft tissue swelling. There are extensive multilevel
degenerative changes of the cervical spine, most prominent from C4-C6.
Multiple Schmorl's nodes are seen within the C4 and C5 vertebral bodies.
Additional foci of gas within the C5 vertebral body may represent vertebral
pneumatocysts. There is mild-to-moderate spinal canal stenosis and moderate
neural foraminal stenosis at C4-C5 and C5-C6.There is no evidence of infection
or neoplasm.
The bilateral lung apices are unremarkable. The thyroid gland is
unremarkable. There is no lymphadenopathy based on CT size criteria.
Moderate calcified plaques are seen in the ICA origins bilaterally.
IMPRESSION:
No evidence of acute fracture or traumatic subluxation of the cervical spine.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PE, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale, Anemia, unspecified
temperature: 96.9
heartrate: 73.0
resprate: 20.0
o2sat: 98.0
sbp: 110.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with 75-100 PY-smoking history (quit in
___, COPD rarely uses 2L home O2, inferior STEMI ___ s/p
streptokinase; RCA CTO with L->R collaterals), ischemic HFrEF
(LVEF ___, VT s/p dcPPM/ICD, who was initially diagnosed in
___ with Stage Ib lung adenocarcinoma which was treated with
a LUL wedge resection (___) with recurrence to the brain,
chest, a/p, and bone in ___ on surveillance scans who was
recently diagnosed with R mainstem PE on ___, started on
Xarelto as outpt, presented with worsening DOE. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Monistat 1 (tioconazole)
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
his is a ___ woman with a history of chronic shortness
of breath related to advanced emphysema and COPD who called EMS
earlier today because she felt like she could not breathe. She
describes approximately 1 week of increased shortness of breath
that was much worse today and EMS transported her to the ___ the ED physician noted that she is usually on 3
L
nasal cannula around the clock and when she woke up her nasal
cannula had accidentally fallen off replacing the nasal cannula
improved her shortness of breath. She notes an increased cough
recently with some increased yellow phlegm production she takes
azithromycin chronically to diminish the risk of COPD
exacerbations. She denies any pleuritic chest pain or
palpitations. She does not feel dizzy but is quite fatigued
this
evening. She describes noting some bilateral symmetric lower
extremity edema that was present previously and resolved on its
own over a week ago.
Her ED course was notable for a pulse in the ___ to low 100s
normotension and satting 100% on 2 L nasal cannula she received
IV methylprednisolone 60 mg and a dose of azithromycin ___s one dose of albuterol at 1 ___.
Review of systems notable for pertinent positives in the HPI but
otherwise is negative in 10 point review of systems.
Past Medical History:
1. Severe emphysema/COPD (last FEV1 18% in ___
2. History of prior breast biopsies
3. Tobacco abuse.
4. Depression.
5. Osteoporosis.
6. Cataracts.
7. Treatment for latent TB infection.
8. Previous abdominal surgery.
9. Ectopic pregnancy.
10. Bronchiectasis.
11. GERD
12. Hyperlipidemia
13. CAD with stable angina
14. History of Warthin's tumor (reportedly benign)
Past Surgical History:
Cataract for the left eye
ORIF of the left distal radius fx
tonsillectomy
Ectopic pregnancy w tubal ligation and one ovary removed
Warthin's tumor removal from neck
appendectomy
exploratory laparotomy )
Social History:
___
Family History:
Positive for diabetes mellitus, hypertension, and CVA. Mom died
at the age of ___ with diabetes. She had diabetes mellitus, CVA,
dementia, and seizures, and towards the end of her life, she was
hospitalized. She has a family history of tuberculosis. Her dad
died at the age of ___ with complications of alcoholism
Physical Exam:
Admission exam
___ 1800 Temp: 98.2 PO BP: 174/79 R Sitting HR: 111 RR: 24
O2 sat: 99% O2 delivery: 3L NC Dyspnea: 10 RASS: 0 Pain Score:
___
She does not appear in pain or distress she is speaking fairly
slowly and pauses at times to collect her thoughts but is not
otherwise confused her tongue is dry without any oral thrush
breath sounds are symmetric but very distant and quiet there are
no audible wheezes or expiration phase is somewhat prolonged
her S1 and S2 are distinct and regular
her abdomen is thin soft without any tenderness or palpable
organomegaly
she does not have any peripheral edema at the calves or ankles
nor is there any rash to her torso or extremities she moves all
extremities equally and has facial symmetry
Discharge exam
98.8 149 / 64 98 22 99 1L NC
GENERAL: thin, elderly female, alert, resting in bed, no
distress, intermittently dyspneic with talking though improved
from prior
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Distant breath sounds throughout, moderate air movement,
no
wheezing or crackles
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: nl affect
Pertinent Results:
Admission labs
___ 12:50PM BLOOD WBC-7.2 RBC-3.64* Hgb-10.7* Hct-36.4
MCV-100* MCH-29.4 MCHC-29.4* RDW-11.8 RDWSD-43.2 Plt ___
___ 12:50PM BLOOD Glucose-102* UreaN-14 Creat-0.5 Na-146
K-3.7 Cl-92* HCO3-42* AnGap-12
___ 06:57PM BLOOD Type-ART Temp-37 pO2-158* pCO2-90*
pH-7.35 calTCO2-52* Base XS-19 Intubat-NOT INTUBA
Discharge labs
___ 06:03AM BLOOD WBC-6.4 RBC-3.59* Hgb-10.5* Hct-34.0
MCV-95 MCH-29.2 MCHC-30.9* RDW-11.9 RDWSD-41.3 Plt ___
___ 05:17AM BLOOD Glucose-83 UreaN-11 Creat-0.5 Na-144
K-4.4 Cl-97 HCO3-39* AnGap-8*
___ 05:17AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.8
CXR ___
FINDINGS:
Changes consistent with severe emphysema are again seen
including
hyperexpanded lungs with flattened diaphragms. There is no
pleural effusion,
focal consolidation, or pneumothorax. Chronic blunting of the
costophrenic
angles is again noted, likely secondary to pleural thickening.
Heart size is
normal. Aortic arch calcifications are noted. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process. Severe emphysema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 1 mg PO QHS
2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheeze
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Azithromycin 250 mg PO Q24H
5. Pantoprazole 40 mg PO Q24H heartburn
6. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
7. Aspirin 81 mg PO DAILY
8. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
Tapered dose - DOWN
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
3. Aspirin 81 mg PO DAILY
4. Azithromycin 250 mg PO Q24H
5. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
8. LORazepam 1 mg PO QHS
9. LORazepam 0.5 mg PO BID:PRN anxiety
10. Pantoprazole 40 mg PO Q24H heartburn
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with shortness of breath// shortness of breath
TECHNIQUE: Chest PA and lateral
COMPARISON: Radiograph from ___
FINDINGS:
Changes consistent with severe emphysema are again seen including
hyperexpanded lungs with flattened diaphragms. There is no pleural effusion,
focal consolidation, or pneumothorax. Chronic blunting of the costophrenic
angles is again noted, likely secondary to pleural thickening. Heart size is
normal. Aortic arch calcifications are noted. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process. Severe emphysema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: 95.0
heartrate: 100.0
resprate: 19.0
o2sat: 100.0
sbp: 129.0
dbp: 49.0
level of pain: 0
level of acuity: 3.0 | The patient is a ___ y/o F with hx of COPD on ___ NC at home,
bronchiectasis, anxiety, GERD who presents with acute on chronic
shortness of breath, admitted for COPD exacerbation. She
improved with steroids and continuation of home azithromycin.
She was discharged on pred taper given severity of symptoms and
home ___.
ACUTE/ACTIVE PROBLEMS:
#Acute on chronic shortness of breath
#Bronchiectasis
#COPD exacerbation
#Acute on Chronic hypoxemic and hypercarbic respiratory failure
- patient at baseline has poor functional capacity related to
respiratory status. Per discussion with patient's pulmonologist,
patient has severe disease and has continued to smoke despite
this. Current cause of exacerbation unclear, no sick contacts,
or fluid overload. ___ be part of overall decline. ABG from
admission with PCO2 of 90 however patient mentating well. Pt was
started on pred 60 daily and continued on her home azithromycin.
Duonebs and home advair were also continued. Pt improved
significantly in terms of symptoms (improved dyspnea/tachypnea
at rest) and pCO2 on VBG prior to discharge. She was discharged
on pred taper given prolonged and severe symptoms.
#constipation: has constipation at baseline. continued bowel
regimen |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with PMH CVA, HTN, MGUS who
presents with sleepiness, weakness today.
Per family when they were visiting she was trying to take off
her pants and she had to sit on the ground due to weakness.
There was no fall or head strike. They have noticed that she has
had a worsening cough. She denies any fevers or shortness of
breath. She is also had urinary frequency and foul odor to her
urine. She denies any abdominal pain, nausea, vomiting. Per
family she was febrile for EMS but they were not aware of any
fevers prior. Lives at home by herself.
In the ED, initial vitals were: 100.2 87 144/74 19 94% RA.
- Labs notable for: WBC 4 w/ 89% PMNs, Na 128.
- Imaging was notable for: Heterogeneous opacification of the
right middle lobe concerning for a pneumonia.
- Patient was given: IV Ceftriaxone, Azithromycin.
- Vitals prior to transfer: 99.5 86 133/65 22 95% RA.
Upon arrival to the floor, patient is sleepy, intermittently
cooperating with exam and responding to questions. Knew she was
at ___ and knew the month and year. Her daughter and
granddaughter answered most of the questions that they knew the
answer to, however, they did to know her full medication list
because the patient does her medications on her own.
She went to her regular day program today without any problems.
They think she has been eating and drinking well.
On ___, the granddaughter spoke to the patient and she was
coughing on the phone but it was a dry cough. The patient said
that the reason she was coughing was probably from her
lisinopril and that the doctor had told her that could be a side
effect of the medication. Today her cough seems more productive,
but she is not coughing much. Denies SOB. Has been having fevers
and chills today. Denies chest pain, palpitations, dysuria. She
has baseline urinary incontinence. Her legs have been swollen
for awhile but maybe have worsened over the past couple of
weeks. No acute changes in leg swelling over the past couple of
days. She does not like to wear compression stockings for her
swollen legs. She denies N/V/D/C.
They denied any history of Afib, blood clots, heart failure.
Per the records from Dr. ___ had a TTE which showed
asymmetric septal LVH, normal LV/RV size/fx, 1+ AS/AR/MR. ___
26 mmHg + RA. Event monitor showed 5 auto-triggered recordings
with SR and ___ beats of AT. There was concern that her
multiple strokes were cardioembolic so she was started on
Apixaban, although no evidence of Afib at that time.
She also complains of lower back pain.
Past Medical History:
- Lacunar infarct L external capsule
- R MCA infarct ___ w LLE weakness
- Vertigo
- Emphysema
- MGUS
- Colonic adenoma
- Stress incontinence
- Headaches
- HLD
- TB s/p treatment, bilateral apical scarring on CXR
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vital Signs: 98.9 144 / 70 89 18 91% RA
General: Sleepy, orientedx3, no acute distress. Warm to touch.
Not responding to questions much or cooperating with exam.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, II/VI
crescendo-decrescendo murmur heard best at RUSB.
Lungs: Decreased breath sounds on right side. No crackles or
wheezes appreciated.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
DISCHARGE PHYSICAL EXAM
VS: 97.4 ___ RA
GENERAL: Pleasant, primarily ___ woman in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: Neck veins flat sitting upright
HEART: RRR, loud systolic ejection murmur heard best at RLSB,
slightly TTP across L lower anterior chest wall directly over
rib
LUNGS: CTAB other than slightly diminished breath sounds.
ABDOMEN: Nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: WWP, bilateral 2+ pitting edema to knee
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3, grossly intact
Pertinent Results:
ADMISSION LABS:
___ 06:30PM BLOOD WBC-4.0 RBC-3.47* Hgb-11.6 Hct-35.9
MCV-104* MCH-33.4* MCHC-32.3 RDW-14.5 RDWSD-55.2* Plt ___
___ 06:30PM BLOOD Neuts-89.3* Lymphs-6.0* Monos-4.0*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-3.58# AbsLymp-0.24*
AbsMono-0.16* AbsEos-0.00* AbsBaso-0.01
___ 06:30PM BLOOD Plt ___
___ 06:30PM BLOOD Glucose-110* UreaN-17 Creat-0.7 Na-128*
K-3.9 Cl-92* HCO3-23 AnGap-17
___ 06:30PM BLOOD Calcium-8.3* Phos-2.9 Mg-2.1
___ 06:46PM BLOOD Lactate-1.5
MICRO:
___ 8:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
___ CXR:
FINDINGS:
There is heterogeneous opacification of the right middle lobe
which may
represent a pneumonia, as it is new from the prior study. There
is mild
fullness of the pulmonary vasculature. No interstitial edema.
No pleural
effusion. Heart size is normal. Osseous structures are within
normal limits.
IMPRESSION:
Heterogeneous opacification of the right middle lobe concerning
for a
pneumonia in the appropriate clinical setting.
___ CT CHEST W/O CONSTRAST:
IMPRESSION:
No pneumonia. No evidence of intrathoracic malignancy.
Severe aortic valvular calcification, new since ___, suggests
significant
aortic stenosis. Atherosclerotic coronary calcification has
also worsened.
Multifocal bronchiectasis, mild to moderate severity, in the
lower lobes,
probably not related to apical bronchiectasis and granulomatous
calcifications
suggesting remote tuberculosis. The bibasilar atelectasis could
be due to
non-tuberculous mycobacterial infection or more likely chronic
aspiration.
There are no findings to suggest bronchogenic dissemination of
infection
either tuberculosis from the right apex or from the bibasilar
bronchiectasis.
Possible small pseudoaneurysm descending thoracic aorta. No
evidence of
active bleeding.
Chronic, non restrictive, right pleural calcification probably
due to previous
empyema or hemothorax, not asbestos exposure.
RECOMMENDATION(S): Cardiac evaluation.
Sputum collection for possible purulent bronchiectasis.
___ MRI HEAD W/ CONTRAST:
FINDINGS:
There is an area of encephalomalacia surrounded by gliosis in
the right
occipital lobe and medial aspect of the right temporal lobe in
the territory
of the right PCA consistent with chronic infarct. Chronic
infarct involving
the right insula and right frontal lobe in the territory of the
right MCA is
redemonstrated. Again noted is hyperintensity in FLAIR/T2 in
the
periventricular white matter that is nonspecific, however could
represent
chronic small vessel ischemic disease. There is no evidence of
hemorrhage,
edema, masses, mass effect, midline shift or acute infarction.
Again noted is
mild prominence of the cerebral sulci and lateral ventricles in
keeping with
age related involutional changes. There is no abnormal
enhancement after
contrast administration.
Visualized portion of the paranasal sinuses demonstrates
retention
cysts/polyps in both maxillary sinuses and mucosal thickening in
the bilateral
ethmoid air cells.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Chronic infarcts in the territory of the right PCA and right
MCA.
3. Similar supratentorial white matter signal abnormality that
is nonspecific,
however likely represents chronic small vessel ischemic disease.
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-2.3* RBC-3.27* Hgb-10.8* Hct-31.2*
MCV-95 MCH-33.0* MCHC-34.6 RDW-13.7 RDWSD-48.6* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___ PTT-28.2 ___
___ 02:02PM BLOOD Na-130*
___ 06:10AM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-129*
K-3.6 Cl-95* HCO3-24 AnGap-14
___ 06:10AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.9
___ 06:10AM BLOOD Osmolal-265*
Radiology Report
INDICATION: ___ with cough, fever, confusion// ? infectious process
TECHNIQUE: AP upright and lateral chest radiographs
COMPARISON: ___
FINDINGS:
There is heterogeneous opacification of the right middle lobe which may
represent a pneumonia, as it is new from the prior study. There is mild
fullness of the pulmonary vasculature. No interstitial edema. No pleural
effusion. Heart size is normal. Osseous structures are within normal limits.
IMPRESSION:
Heterogeneous opacification of the right middle lobe concerning for a
pneumonia in the appropriate clinical setting.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ with PMHx CVA, HTN, MGUS who presented with sleepiness and
weakness then found to have fever and pneumonia. Patient now w/ improving
confusion and hyponatremia. Labs c/w SIADH and history of 20 lbs weight loss
over last year.// Eval for mass or signs of malignancy
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.2 s, 34.2 cm; CTDIvol = 6.6 mGy (Body) DLP = 223.9
mGy-cm.
2) Spiral Acquisition 0.7 s, 11.2 cm; CTDIvol = 6.2 mGy (Body) DLP = 69.7
mGy-cm.
Total DLP (Body) = 294 mGy-cm.
COMPARISON: Compared to chest CTA, ___.
FINDINGS:
Supraclavicular and axillary lymph nodes are not enlarged. Specifically
excluding the breasts which requires mammography for evaluation, there are no
soft tissue abnormalities in the chest wall concerning for malignancy.
Thyroid is unremarkable. Atherosclerotic calcification is not apparent in
head and neck vessels but is considerable in at least left main anterior
descending and circumflex coronary arteries. Aortic valvular calcification is
extremely heavy. Nevertheless aorta, pulmonary arteries and cardiac chambers
are normal size. A 9 x 13 mm pseudoaneurysm may have developed since ___
along the posterior 0 medial wall of the descending thoracic aorta, 3028:119.
There is no evidence of associated bleeding.
Small pericardial effusion is new. Continuous pleural calcification in the
right hemithorax is chronic. There is none on the left suggesting prior
unilateral pleural insult, either infection or hemothorax, rather than
asbestos exposure.
Esophagus is unremarkable.
Thoracic lymph nodes:
Lymph nodes with large calcifications are found in the a upper and lower
paratracheal, and subcarinal mediastinal stations and both hila. There is no
bronchial compromise.
Lungs: Small region of moderate bronchiectasis with retained secretions and
calcifications in the right lung apex is slightly more extensive today than in
___, 3028:29. Bronchiectasis and atelectasis in right middle lobe and in the
right lung base are also more severe, but there are no bronchiolar
abnormalities to suggest widespread bronchogenic spread of infection.
Interstitial abnormality at the left lung base consists of thickened septi or
dilated lymphatics. There is no pneumonia anywhere.
There are several nodular opacities in regions of bronchiectasis due to
densely impacted bronchi or granulomatous nodules, but in areas free of
bronchiectasis, there are no lung nodules concerning for malignancy.
Elevation of the left hemidiaphragm is probably due to eventration.
Chest cage:
There are no compression or pathologic fractures or destructive lesions in the
chest cage.
IMPRESSION:
No pneumonia. No evidence of intrathoracic malignancy.
Severe aortic valvular calcification, new since ___, suggests significant
aortic stenosis. Atherosclerotic coronary calcification has also worsened.
Multifocal bronchiectasis, mild to moderate severity, in the lower lobes,
probably not related to apical bronchiectasis and granulomatous calcifications
suggesting remote tuberculosis. The bibasilar atelectasis could be due to
non-tuberculous mycobacterial infection or more likely chronic aspiration.
There are no findings to suggest bronchogenic dissemination of infection
either tuberculosis from the right apex or from the bibasilar bronchiectasis.
Possible small pseudoaneurysm descending thoracic aorta. No evidence of
active bleeding.
Chronic, non restrictive, right pleural calcification probably due to previous
empyema or hemothorax, not asbestos exposure.
RECOMMENDATION(S): Cardiac evaluation.
Sputum collection for possible purulent bronchiectasis.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ with PMHx CVA, HTN, MGUS who presented with sleepiness and
weakness then found to have fever and pneumonia. Patient now with improving
confusion and persistent hyponatremia.// ?mass, bleed or acute intracranial
process
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 7 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: MRI of the brain from ___.
FINDINGS:
There is an area of encephalomalacia surrounded by gliosis in the right
occipital lobe and medial aspect of the right temporal lobe in the territory
of the right PCA consistent with chronic infarct. Chronic infarct involving
the right insula and right frontal lobe in the territory of the right MCA is
redemonstrated. Again noted is hyperintensity in FLAIR/T2 in the
periventricular white matter that is nonspecific, however could represent
chronic small vessel ischemic disease. There is no evidence of hemorrhage,
edema, masses, mass effect, midline shift or acute infarction. Again noted is
mild prominence of the cerebral sulci and lateral ventricles in keeping with
age related involutional changes. There is no abnormal enhancement after
contrast administration.
Visualized portion of the paranasal sinuses demonstrates retention
cysts/polyps in both maxillary sinuses and mucosal thickening in the bilateral
ethmoid air cells.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Chronic infarcts in the territory of the right PCA and right MCA.
3. Similar supratentorial white matter signal abnormality that is nonspecific,
however likely represents chronic small vessel ischemic disease.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Altered mental status, Fever
Diagnosed with Altered mental status, unspecified
temperature: 100.2
heartrate: 87.0
resprate: 19.0
o2sat: 94.0
sbp: 144.0
dbp: 74.0
level of pain: 4
level of acuity: 2.0 | ___ with PMHx CVA, HTN, MGUS who presented with sleepiness and
weakness. Patient was noted to be febrile for EMS with mild
confusion and CXR consistent with pneumonia. She was initially
started on CTX/azithro but quickly transitioned to finish a
5-day course of cefpodoxime/azithro. She had confusion upon
admission that slowly resolved and was thought most likely to be
toxic metabolic encephalopathy and related to her
pneumonia/bronchitis. She was also found to have hyponatremia
with low serum osmolality and high urine osmolality and sodium,
consistent with SIADH. She was placed on fluid restriction and
had her home lasix restarted. CT chest and MRI head were
completed to r/o pulmonary malignancy or intracranial pathology
as the cause of her SIADH. CT chest was w/o evidence of mass or
consolidation but with multifocal bronchiectasis, and MRI head
was unchanged from prior study. Pt was stable for discharge and
will follow up with her PCP, ___ rehab.
#Community Acquired Pneumonia/Bronchitis: Patient presented with
fever, mild confusion, and CXR consistent with pneumonia.
Patient without risk factors for HAP. Improved with IV CTX and
azithro. She also had a chest CT w/o evidence of pneumonia but
with multifocal bronchiectasis which could have represented
bronchitis. She was transitioned to PO cefpodoxime/azithro and
will finish a 5 day course on ___. She was afebrile and without
SOB, cough or any other respiratory distress in the days leading
up to discharge.
#Hyponatremia
#SIADH: Patient presented with low sodium that dipped as low as
127. Serum osmolality slightly low with high urine osmolality
and sodium. Studies consistent with SIADH most likely from
PNA/bronchitis. After speaking to patient's PCP ___,
___ ahead with evaluation for intracranial pathology or
pulmonary malignancy w/ MRI head and CT chest. MRI head was
unchanged from prior study. CT chest notable for multifocal
bronchiectasis and new severe aortic valvular calcification. She
was fluid restricted and started on Lasix w/ improvement in
sodium.
#Rib pain: Point tender over L lower anterior chest wall
directly over rib. Worse with position changes and palpation.
Likely MSK strain vs costochondritis. Improved with heating
pack, Tylenol, and lidocaine patch.
#Bilateral lower extremity edema: On Lasix for at least ___
years per records but w/o formal documentation of CHF. Normal EF
on TTE in ___ but did have mild AS, AR, MR. ___ was at
baseline and UA was negative. No known history of liver disease
but could consider this as well. Started on home lasix and given
ACE bandages for compression.
#Confusion
#Toxic metabolic encephalitis: Per family seemed to be confused
and off baseline. This was though to be in setting of infection.
This seemed to be improving over the last few days. She had no
history of fall to suggest bleed or focal neuro deficits to
suggest new CVA. This could have represented recrudescence of
CVA symptoms in setting of infection. She also had MRI head
which was negative for any acute intracranial process and was
largely unchanged from prior study. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain, redness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with left leg pain and swelling after a fall on a cactus
this past ___. The patient reports falling down a small 5ft
hill in ___ in the ___ and landing his left leg
on a cactus. He denies any LOC. He had some of the cactus spines
removed in the ED; however, they were unable to remove all the
spines and was told that the remaining cactus spines would
"dissolve." He was discharged with tylenol 3. Upon returning to
___ this past ___, he continued to have pain and swelling
of his left lower leg and was prescribed Keflex by his PCP on
___. He notes ___ sharp pain with movement of the leg. He
obtained an MRI this past ___ which showed cellulitis and
high signal tracts from the subcutaneous tissue to the
anterolateral and posterolateral musculature. He denies any
tingling or numbness of his left lower extremity.
Past Medical History:
- HTN
- ACDF ___, revision ACDF ___
Social History:
___
Family History:
NC
Physical Exam:
Exam on admission:
Right lower extremity:
- Mild swelling with localized erythema surrounding each cactus
spine punture sites (~12)
- No active drainage, induration or ecchymosis; no fluctuance
- Tender to palpation of puncture sites
- Mild pain in anterior leg with ankle dorsiflexion
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 2+ ___ pulses, foot warm and well-perfused
Exam on discharge:
Afebrile
Right lower extremity:
- Mild swelling with improved, though localized erythema
surrounding each cactus spine punture sites (~12)
- No active drainage, induration or ecchymosis; no fluctuance
- Tender to palpation of puncture sites
- Mild pain in anterior leg with ankle dorsiflexion
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 2+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 07:35AM BLOOD WBC-5.4 RBC-4.58* Hgb-13.1* Hct-40.7
MCV-89 MCH-28.6 MCHC-32.2 RDW-12.5 RDWSD-40.7 Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Omeprazole
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth q6hrs Disp #*24 Capsule
Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN pain, fever
5. Docusate Sodium 100 mg PO BID
6. Ibuprofen 400-600 mg PO Q6H:PRN pain
7. Senna 8.6 mg PO BID:PRN constipation
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth Once every 12 hours Disp #*28 Tablet
Refills:*0
9. Calcium Carbonate 500 mg PO QID:PRN Reflux
Take as needed
10. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower extremity cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: History: ___ with left calf pain and swelling.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE
INDICATION: ___ year old man with left calf pain status post cactus needle
injury. MRI with question of foreign body or fluid collection, recommend US.
TECHNIQUE: Grayscale and color ultrasound images were obtained of the
superficial tissues of the left calf.
COMPARISON: MR calf ___.
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left calf in the region of the puncture wounds. No fluid collection or
obvious foreign body was detected.
IMPRESSION:
No fluid collection or obvious foreign body in the left calf in the area of
injury identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Calf pain
Diagnosed with CELLULITIS OF LEG, OPEN WND KNEE/LEG-COMPL, FALL RESULTING IN STRIKING AGAINST SHARP OBJECT, ACC-CUTTING INSTRUM NEC
temperature: 98.4
heartrate: 79.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 84.0
level of pain: 8
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left leg cellulitis and was admitted to the orthopedic
surgery service. The patient was initially given IV fluids and
IV pain medications, and progressed to a regular diet and oral
medication. The patient's home medications were continued
throughout this hospitalization. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications with decreased erythema in his left lower
extremity than his admission with 24 hours vancomycin and ancef.
He was transitioned to PO Bactrim for a 14 day course upon
discharge. The patient is weight bearing as tolerated in the
left lower extremity. The patient will follow up with Dr.
___ routine. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Non-healing right breast burn
Major Surgical or Invasive Procedure:
___: Debridement of right breast wound
History of Present Illness:
___ year old ___ lady with history of burn wound to right
chest after removing a pan of hot meat from the oven. The burn
occured ___ weeks prior to presentation, and has been
persistently non-healing. 5 days prior to presentation she noted
spreading erythema and moderate increase in discomfort. Of note,
she has tried applying toothpaste and various creams to the burn
area.
Past Medical History:
PMH: Varicose veins
PSH: Splenectomy
Social History:
___
Family History:
Noncontributory
Physical Exam:
VS: Temp 98.9, HR 75, BP 121/83, RR 20, SpO2 96% room air
GEN: Pleasant, AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, non-labored breathing.
Breast: 5 x 4 cm area of ulceration above right areola with
dense exudate and surrounding erythema and edema, covered with
xeroform dressing and dry gauze. Maculopapular rash on
superomedial aspect of right breast.
ABDOMEN: Soft, non-tender to palpation, non-distended.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema.
Pertinent Results:
RIGHT BREAST ULTRASOUND (___):
Soft tissue edema with no focal fluid collections.
CXR (___):
1. PICC line tip is in the mid SVC.
2. Lateral radiograph is recommended to further evaluate the
opacity lateral to the left hilum.
PA/LAT CXR (___):
Previously seen left perihilar opacity is no longer visualized.
Medications on Admission:
None
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp
#*24 Capsule Refills:*0
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Non-healing right breast burn
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with 43cm left PICC // Contact name: ___,
___: ___
COMPARISON: None available
FINDINGS:
PICC line tip is in the mid SVC. Heart size is normal. The mediastinal and
hilar contours are normal. The pulmonary vasculature is normal. No pleural
effusion or pneumothorax. Opacity lateral to the left hilum is small.
IMPRESSION:
1. PICC line tip is in the mid SVC.
2. Lateral radiograph is recommended to further evaluate the opacity lateral
to the left hilum. If the lateral film is suspicious, CT chest may be
recommended during this admission.
NOTIFICATION: The findings and recommendation were discussed with general
surgery intern Dr. ___ on the telephone on ___ at 7:00 ___.
Radiology Report
INDICATION: Right breast burn with cellulitis, post debridement.
COMPARISON: Radiograph from ___ at 15:11.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS:
A left-sided PICC terminates at the mid SVC. The heart size is normal. The
hilar and mediastinal contours are within normal limits. There is no
pneumothorax, focal consolidation, or pleural effusion. A previously seen
left perihilar opacity is no longer present.
Moderate degenerative changes are again seen throughout the thoracic spine.
IMPRESSION:
Previously seen left perihilar opacity is no longer visualized.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with INFLAM DISEASE OF BREAST, BURN NOS BREAST, HOT SUBSTANCE ACCID NEC
temperature: 99.3
heartrate: 75.0
resprate: 18.0
o2sat: 95.0
sbp: 132.0
dbp: 72.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ presented to the ___ Emergency department with a
non-healing right breast burn and associated cellulitis. An
ultrasound of the right breast was performed, which showed no
focal fluid collection. She was admitted to the Acute Care
Surgery service for further management. She was started on
intravenous vancomycin and zosyn and taken to the operating room
on ___ for tangential excision of her right breast wound.
Please see the Operative Report for further details. A ___ line
was placed on ___ in anticipation of extended IV antibiotic
requirements, but she was transitioned to oral bactrim and
keflex and ready for discharge on hospital day 4, with
appropriate follow-up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / morphine
Attending: ___.
Chief Complaint:
headache, lightheadness, vertigo, and chest pain
Major Surgical or Invasive Procedure:
Coronary angiography
History of Present Illness:
___ yo woman with CAD s/p CABG ___ and two prior MIs,
paroxysmal afib, on Coumadin, SSS s/p pacemaker placement, who
presents with lightheadness, vertigo, and chest pain.
Patient shares that about a week ago she noticed she was light
headed when walking to the bathroom, and bumped her head on the
side of her bathroom. She was not seen for this. She then
noticed that intermittently over the past few days would feel
light headed with no clear trigger, and it would resolve on its
own. Morning prior to admission, she woke up being lightheaded,
and then shortly thereafter began to experience vertigo. This
began around 10 am, and resolved in the early afternoon once she
was laid flat in the stretcher. Not worsened with head
movements, no associated tinnitus, no change in baseline hearing
loss, and no recent fevers/chills/rhinorrhea/myalgias. Of note,
she shares that over the past few weeks she thinks she may have
been more unsteady than her usual self. Patient also shares she
has a left sided headache, rated ___, throbbing in nature. This
headache started today and she does not often get headaches.
Patient had a CT head at ___, which was negative for acute
hemorrhage.
This afternoon she also had an episode of central chest
pressure. While waiting in triage, sudden onset of substernal
pressure that radiated to her L shoulder. She also experienced
some nausea and the sensation of reflux at this time. Lasted
approximately 2 hrs. Self-limited as received ASA 325 after it
had resolved.
Past Medical History:
Coronary Artery Disease
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Hypothyroidism
Inferior Myocardial Infarction s/p RCA stent ___, s/p PCIs in
___ and ___ s/p PCI LCx ___, LAD ___
Mitral Valve Prolapse
MRSA, nasal swab ___
Myocardial Infarction ___
Paroxysmal Atrial Fibrillation, on Coumadin
Sick Sinus Syndrome s/p permanent pacemaker placement
Urethral prolapse
Past Surgical History:
Appendectomy
Bilateral Cataract surgery
Partial hysterectomy
Right Hip Replacements x2
Social History:
___
Family History:
Father died at ___ of myocardial infarction.
Mother died at ___ of myocardial infarction.
Brother died in his late ___ or early ___ of an myocardial
infarction.
Sister died of myocardial infarction at ___.
Physical Exam:
VS: Tmax 97.8 BP 104/70 (90-120s/50-70s) HR 83 (70-80s) RR 18
SpO2 99% on RA
GENERAL: Sitting comfortably at edge of bed. NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of ~5 cm above sternal angle at 30
degrees.
CARDIAC: Regular rate, irregularly irregular rhythm, normal S1,
physiologically split S2. No murmurs/rubs/gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NT/ND. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: No stasis dermatitis, ulcers. Median sternotomy scar; well
healed.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
___ 07:46AM BLOOD WBC-8.2# RBC-3.58* Hgb-11.2 Hct-34.3
MCV-96 MCH-31.3 MCHC-32.7 RDW-13.3 RDWSD-46.5* Plt ___
___ 07:46AM BLOOD ___ PTT-30.9 ___
___ 07:46AM BLOOD Glucose-141* UreaN-27* Creat-1.1 Na-141
K-3.8 Cl-107 HCO3-20* AnGap-18
___ 09:48PM BLOOD ALT-35 AST-33 CK(CPK)-85 AlkPhos-57
TotBili-0.7
___ 07:46AM BLOOD Calcium-9.8 Phos-4.4 Mg-1.8
___ 12:54AM BLOOD Lactate-1.2
___ 09:48PM BLOOD cTropnT-0.03*
___ 04:25AM BLOOD cTropnT-0.02*
___ 04:25PM BLOOD cTropnT-0.03*
___ 12:47AM BLOOD CK-MB-6 cTropnT-<0.01
___ 07:50AM BLOOD CK-MB-5 cTropnT-<0.01
___ 01:11PM BLOOD CK-MB-5 cTropnT-<0.01
CT chest ___ IMPRESSION:
Several pulmonary nodules, most of which are millimetric in size
and part of which are calcified. The size and shape of these
nodules is unchanged since ___. The nodules are
combined to hilar and mediastinal lymph node calcifications and,
thus, are likely reflecting sequelae of granulomatous disease.
No suspicious lung nodules or masses. Status post sternotomy
___ ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears mildly-to-moderately
depressed (LVEF = 40%) secondary to hypokinesis of the basal
segments and of the apex. Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
right ventricular free wall thickness is normal. The right
ventricular cavity is dilated with borderline normal free wall
function. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. The
mitral valve leaflets are myxomatous. There is moderate
bileaflet mitral valve prolapse. A late systolic jet of Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
___, the findings are similar.
Cath Report ___
Impressions:
1. Single vessel coronary artery disease
2. Patent LIMA to the LAD
3. Patent SVG to the OMB
4. Occluded SVG to the PDA
Recommendations
1. Medical therapy with potential PCI of the RCA with recurrent
symptoms.
CTA head/neck ___
IMPRESSION:
1. Subtle hypointensity in the left internal carotid artery,
likely artifact. If there is clinical concern for dissection,
MRA dissection protocol can be performed for further evaluation.
2. Mild scattered areas of atherosclerosis without any
high-grade stenosis.
3. Multiple pulmonary nodules which are better evaluated on
subsequent chest CT from ___.
CT head ___
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with CAD, afib, on Coumadin, p/w dizziness-imaging
per Neuro recs // evaluate for vessel dissection, intracranial bleed
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 17.4 cm;
CTDIvol = 46.0 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm.
mGy-cm
COMPARISON: Head CT without contrast from ___
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Ill-defined periventricular and subcortical white matter
hypodensities are compatible with sequela of chronic small vessel changes.
Ventricles and sulci are normal in overall size and configuration. The imaged
paranasal sinuses are clear. Mastoid air cells and middle ear cavities are
well aerated. The bony calvarium is intact.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK
INDICATION: ___ woman with CAD, afib, on Coumadin, p/w
dizziness-imaging per Neuro recs; evaluate for vessel dissection, intracranial
bleed.
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
skull base during infusion of 70 mL of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered, curved reformatted
and segmented images were generated. This report is based on interpretation of
all of these images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 76.2 mGy (Head) DLP =
38.1 mGy-cm.
2) Spiral Acquisition 4.2 s, 32.8 cm; CTDIvol = 35.3 mGy (Head) DLP =
1,159.6 mGy-cm.
Total DLP (Head) = 1,198 mGy-cm.
COMPARISON: Reference is made to the CT head and CTA head from the same day.
No prior CTA of the neck is available for comparison.
Reference is made to the CT cervical spine dated ___.
Limited reference is also made to the CTA torso from ___.
FINDINGS:
There is mild atherosclerosis involving bilateral carotid bifurcations without
stenosis by NASCET criteria. Also seen is atherosclerosis of the origin of
bilateral vertebral arteries without any stenosis. There is atherosclerotic
plaque involving the proximal right external carotid artery near the
bifurcation resulting in mild stenosis.
A subtle linear hypointenstiy in the left internal carotid (series 2, image
145) is likely an artifact ; but if clinical concern is high for dissection,
MRA with contrast and fat-suppression is recommended to further evaluate.
Overall alignment of the cervical spine similar to ___ with moderate to
severe multi-level degenerative changes are most prominent at C3 through C5.
A small well corticated ossific fragment at C4-C5 is unchanged (series 602b,
image 26 ; series 2, image 159).
Multiple bilateral pulmonary nodules which are better evaluated on subsequent
chest CT on ___. The left main pulmonary artery measures up to 26
mm on this nondedicated exam and could suggest sequelae of chronic pulmonary
hypertension. The patient has had median sterntomy. A Left-sided dual-lead
cardiac device is noted.
The thyroid gland appears unremarkable.
IMPRESSION:
1. Subtle hypointensity in the left internal carotid artery, likely artifact.
If there is clinical concern for dissection, MRA dissection protocol can be
performed for further evaluation.
2. Mild scattered areas of atherosclerosis without any high-grade stenosis.
3. Multiple pulmonary nodules which are better evaluated on subsequent chest
CT from ___.
RECOMMENDATION(S): (
NOTIFICATION: Finding and impression with recommendation was discussed by Dr.
___ with ___ on ___ at 540 pm on the telephone immediately unpon
reviewing the images.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with ?pulmonary nodules on CTA neck // eval
for pulm nodules
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions.
DOSE: DLP: 342 mGy-cm
COMPARISON: No comparison available. The examination is performed for the
evaluation of incidentally detected lung nodules on a neck CT.
FINDINGS:
Left pectoral ICD. Status post sternotomy. Status post CABG. No incidental
thyroid findings. No supraclavicular, infraclavicular or axillary
lymphadenopathy. Moderate aortic wall and severe coronary calcifications,
mild aortic valve calcifications. No cardiomegaly. No enlarged lymph nodes
in the mediastinum or at the level of the hilar structures. Several
mediastinal and hilar lymph nodes are calcified. No abnormalities in the
posterior mediastinum or in the upper abdomen, with the exception of a small
left kidney and bilateral kidney collecting system calcifications. No
osteolytic lesions at the level of the ribs, the sternum or the vertebral
bodies. Moderate degenerative vertebral disease. No vertebral compression
fractures. Mild bilateral apical scarring, right more than left. The
scarring has several nodular components, most of which are calcified. There
are bilateral small subpleural pulmonary nodules, for example in the right
upper lobe (4, 66). Some of these nodules are calcified, for example in the
middle lobe (4, 146). All of the pulmonary nodules are stable in size and
morphology. There is no evidence of new or growing nodules. The largest
nodule continues to be located in the middle lobe (1, 5) 8 and is completely
calcified. No pleural thickening. No pleural effusions. Small left
Bochdalek hernia, unchanged in size. No pleural thickening, no pleural
effusions. No diffuse lung disease.
IMPRESSION:
Several pulmonary nodules, most of which are millimetric in size and part of
which are calcified. The size and shape of these nodules is unchanged since
___. The nodules are combined to hilar and mediastinal lymph
node calcifications and, thus, are likely reflecting sequelae of granulomatous
disease. No suspicious lung nodules or masses. Status post sternotomy
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, Headache
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 97.6
heartrate: 76.0
resprate: 16.0
o2sat: 99.0
sbp: 144.0
dbp: 80.0
level of pain: 8
level of acuity: 3.0 | ___ yo woman with CAD s/p CABG ___ and two prior MIs,
paroxysmal afib, on Coumadin, SSS s/p pacemaker placement, who
presented with lightheadedness and chest pain.
# NSTEMI: STD in II, III, aVF and TWI in V4-V6 suggestive of
inferolateral ischemia and troponin elevated peaked at 0.03.
Recieved 325 mg ASA in ED and started on heparin gtt. However,
deeping TWI in lateral leads concerning for ___ syndrome,
however repeat troponin negative and CK-MB flat. Nonetheless,
underwent coronary angiography ___, accessed via R femoral, and
found to have occluded saphenous vein graph to PDA- plan was for
medical management and consideration of a chronic total
occlusion procedure. Imdur 30mg daily was added to her regimen
of Metoprolol and atorvastatin. Metoprolol was uptitrated from
25mg to 37.5mg daily for improved HR control. Plavix not
initated as pt already requires coumadin for paroxysmal atrial
fibrillation. Additionally, ECHO was unchanged from ___ (EF
40% secondary to basal and apical hypokinesis, 1+ AR)
#Vertigo/HA: CTbrain and CTA head/neck revealed no
infarction/hemorrhage/posterior circulation defects to suggest a
central cause. No prior episodes or worsening with head
movements to suggest BPPV and no viral prodrome to support
labyrynthtits. ___ interrogated and revealed no arrhythmia to
explain sx. No localizing signs of infection or elevated WBC.
Anginal equivalent cannot be ruled out. Therefore, NSTEMI
work-up as above, received tylenol for supportive care, and
discharged with Neurology ___.
#Pulmonary nodules: Incidental finding of pulmonary nodules on
CTA, therefore underwent CT chest for further characterization
which showed "Several pulmonary nodules, most of which are
millimetric in size and part of which are calcified. The size
and shape of these nodules is unchanged since ___.
The nodules are combined to hilar and mediastinal lymph node
calcifications and, thus, are likely reflecting sequelae of
granulomatous disease. No suspicious lung nodules or masses."
# paroxysmal afib: Home warfarin held in setting of heparin gtt
on admission; res-started day after catheterization. Continued
on home metoprolol, but increased dose.
# SSS s/p PPM: ___ interrogated by EP. No events to explain
dizziness as detailed above.
# Hyperlipidemia: Continued on home atorvastatin
# Hypertension: Continued on home metoprolol. Started on Imdur
as detailed above.
# Depression: Continue celexa
# Hypothyroidism: TSH wnl. Continued on home levothyroxine.
===Transitional issues====
-Pt started on IMDUR 30 mg daily, please monitor SBP as well as
anginal sx in case she would want to pursue PCI in future. Can
uptitrate or stop as needed/tolerated. Orthostatics were
negative on discharge, BP was ___ systolic.
- Consider chronic total occlusion procedure given SVG to RCA
down on LHC.
- CODE: DNR/DNI
- CONTACT: Son, ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
diazepam / Flexeril / Prozac
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with type 1 diabetes on insulin pump and recent left foot
fracture and surgery presents with bilateral leg pain x 3 weeks
and severe lower back pain x 3 days. Pt states that she was in
her usual state of health until ~ 3wk prior, when she felt
bilateral pain in her legs. States that pain is very severe,
goes from her anterior upper thighs down to lateral sides of
both feet during the day and then on posterior surfaces of
calves and hamstrings in the evenings. Pain is constant.
Propping her feet up on pillows helps, and lying down flat
exacerbates the pain. When walking, Pt sometimes experienced
"electric shock" sensations in her feet. Taking warm baths
sometimes provides some relief. No improvement w/ hot packs or
ice packs. Three days ago, Pt then suddenly developed severe
mid-lumbar back pain, which she has never had previously. This
pain is also worse when lying flat. Pt denies any recent falls
or trauma, but did ___ down 14 stairs in ___, when she
feels she also fractured her foot. Pt had seen her PCP in ___
___, who examined her and prescribed some
oxycodone/acetaminophen (Percocets), but these did not work.
Over the last ___ months, she has also noticed a feeling of
incomplete voiding during urination. Pt saw her orthopedic foot
surgeon in clinic today, who instructed her to go to the ED for
evaluation.
In the ED, initial VS were 99.1F, HR 98, 140/97, 18 98%RA. Pt
received hydromorphone 0.5mg iv x4 doses. last dose @ 1735. Pt
had a lumbar and thoracic MRI, which did not any evidence of
cord compression on prelim read. Her neurological exam including
rectal tone was reportedly normal, but she required
hydromorphone and was admitted for pain control.
PVR 70
On transfer, Pt's vitals were: 98.6 °F (Oral), Pulse: 77, RR:
16, BP: 123/70, O2Sat: 99
On arrival to the floor, Pt's vitals were 98.1, 120/72, 86, 18,
97% RA. Pt was sitting upright and reported ___ pain.
.
ROS: Reports fatigue. Denies fevers. Reports having shaking
chills for 2 months. Has had drenching night sweats for ___ year
but states she is not in menopause. Has 8lb intentional
weightloss over ___ year. Denies headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, or vomiting. No
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Reports ___ of diarrhea after visiting her grandson, who was
also ill at the time, a few weeks prior. Reports incomplete
voiding as per HPI. Reports stock-glove distribution of numbness
in feet for years and in hands for months, attributed to her
diabetes. Reports weakness of L ankle and foot and numbness of L
dorsal foot since her operation in ___.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
-type 1 diabetes, on insulin pump since ___
-macrocytic anemia, resolved
-vitamin b12 deficiency
-"blood in kidney"
-benign breast cysts in R breast s/p biopsy
-seizures (after trauma, now off anti-epileptics per neurology)
-fracture of L calcaneus anterior process ___ s/p operative
removal of bone ___ (prescribed oxycodone-acetaminophen
___ q4hrs # 50 on ___ and ___ by ortho)
-R knee arthroscopy ___
-2 x c-sections and total hysterectomy for fibroids ___
Social History:
___
Family History:
-3 brothers and sisters w/ DM 2
-father died of lung cancer at ___, heavy smoker
-paternal grandfather died of lung cancer, non-smoker
-uncle 1 melanoma
-uncle 2 lung cancer
-maternal grandmother emphysema, heavy smoker
Physical Exam:
PHYSICAL EXAM on admission:
VS - 98.1, 120/72, 86, 18, 97% RA
GENERAL - well-appearing woman in NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
LUNGS - CTA bilat
HEART - RRR, nl S1-S2, no m/r/g
BACK - tenderness to palpation of midline lumbar back near L4.
Pain in right mid-lumbar back with axial rotation to right or
flexion to right. Anterior flexion ROM limited to ~45 degrees
from vertical.
ABDOMEN - normal bowel sounds, soft non-tender, non-distended,
no masses, no rebound/guarding
EXTREMITIES - 2+ peripheral pulses (radials, DPs), no edema.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, ___, CNs II-XII intact, muscle strength ___ in
upper and lower extremities except for ___ strength in L ankle
and foot. Sensation intact to fine touch and pinprick throughout
except for dorsal surface of distal R fingers and dorsal surface
of L foot in distal L5 distribution, and plantar surface of L
foot in L5 distribution. No sensory levels on trunk. Anal
sphincter tone normal. No saddle anesthesia. Vibration sense
intact throughout except for L ___ toes. Propioception
intact throughout. DTRs 2+ and symmetric at bilateral biceps and
patellar; right ankle reflex 1+ left ankle reflex absent.
Romberg negative. Straight leg raise negative on left, some R
foot tingling at ~45 degrees from horizontal.
HYSICAL EXAM on discharge:
VS - 98.7, 122/78, 86, 18, 98% RA
GENERAL - well-appearing woman in NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
LUNGS - CTA bilat
HEART - RRR, nl S1-S2, no m/r/g
BACK - tenderness to palpation of midline lumbar back near L4.
Pain in right mid-lumbar back with axial rotation to right or
flexion to right. Anterior flexion ROM limited to ~45 degrees
from vertical.
ABDOMEN - normal bowel sounds, soft non-tender, non-distended,
no masses, no rebound/guarding
EXTREMITIES - 2+ peripheral pulses (radials, DPs), no edema.
SKIN - 3 x 4 cm erythematous, indurated oval plaque on L
shoulder, 3 circular 1cm indurated plaques on inner L upper arm,
one 2 cm indurated plaque on L inner thigh.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, ___, CNs II-XII intact, muscle strength ___ in
upper and lower extremities except for ___ strength in L ankle
and foot. Sensation intact to fine touch and pinprick throughout
except for dorsal surface of distal R fingers and dorsal surface
of L foot in distal L5 distribution, and plantar surface of L
foot in L5 distribution. No sensory levels on trunk. Anal
sphincter tone normal. No saddle anesthesia. Vibration sense
intact throughout except for L ___ toes. Propioception
intact throughout. DTRs 2+ and symmetric at bilateral biceps and
patellar; right ankle reflex 1+ left ankle reflex absent.
Romberg negative. Straight leg raise negative bilaterally.
Pertinent Results:
___ 01:30PM BLOOD WBC-9.5 RBC-4.53 Hgb-13.5 Hct-41.2 MCV-91
MCH-29.9 MCHC-32.9 RDW-13.6 Plt ___
___ 01:30PM BLOOD Neuts-72.4* ___ Monos-3.4 Eos-3.9
Baso-0.4
___ 01:30PM BLOOD ___ PTT-31.2 ___
___ 01:30PM BLOOD ESR-12
___ 01:30PM BLOOD CRP-6.4*
___ 01:30PM BLOOD Glucose-191* UreaN-9 Creat-0.7 Na-137
K-4.0 Cl-101 HCO3-25 AnGap-15
___ 01:30PM BLOOD ALT-24 AST-21 CK(CPK)-64 AlkPhos-61
TotBili-0.4
___ 01:30PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.0
___ 01:30PM BLOOD HCG-<5
HCO3-25 AnGap-12
___ 10:54PM URINE Color-Straw Appear-Clear Sp ___
___ 10:54PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 10:54PM URINE RBC-2 WBC-0 Bacteri-FEW Yeast-NONE Epi-2
___ 06:10AM BLOOD WBC-8.2 RBC-4.19* Hgb-12.6 Hct-38.5
MCV-92 MCH-30.1 MCHC-32.7 RDW-13.8 Plt ___
___ 06:10AM BLOOD Glucose-120* UreaN-12 Creat-0.7 Na-136
K-4.3 Cl-103
___ BLOOD CULTURE X 2 Blood Culture, Routine-PENDING
Medications on Admission:
-insulin (via pump), typically 15 units daily
-metformin 500mg bid
-rosuvastatin 40mg daily
-ezetimibe 10mg daily
-cetirizine prn allergies
-lisinopril 10mg daily
-vitamin b12 500mcg daily
-colesevelam 625 tab, 3 tabs bid
Discharge Medications:
1. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Insulin Pump IR1250 Misc Miscellaneous
7. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for severe pain for 2 weeks: Do not drive or
operate machinery on this medication.
Disp:*50 Tablet(s)* Refills:*0*
8. tizanidine 2 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for back spasm for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
back pain, not otherwise specified
drug rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with low back pain and urinary retention.
Assess for cord compression.
COMPARISON: None available for comparison.
TECHNIQUE: Sagittal IDEAL, T1 and T2 as well as axial T2 images were obtained
without contrast.
FINDINGS: The thoracic spine has normal kyphotic, the lumbar spine has normal
lordotic curvature, vertebral body height, bone marrow signal and alignment.
Height and intrinsic T2 signal of the intervertebral disc is preserved. There
is no evidence of disc herniation or spinal canal or neural foraminal
narrowing. The thoracic cord, the conus and cauda equina have normal
morphology and intrinsic T2 signal. The paraspinous soft tissues are
unremarkable.
IMPRESSION: Normal MRI of the T- and L-spine.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BACK PAIN
Diagnosed with LUMBAGO, PAIN IN LIMB, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERCHOLESTEROLEMIA
temperature: 99.1
heartrate: 98.0
resprate: 18.0
o2sat: 98.0
sbp: 140.0
dbp: 97.0
level of pain: 8.5
level of acuity: 2.0 | ___ with type 1 diabetes on insulin pump and recent left foot
fracture and surgery presents with bilateral leg pain x 3 weeks
and severe lower back pain x 3 days.
# back pain: unclear etiology suspect MSK cause, including
lumbar radiculopathy or muscle strain. Absence of cord
compression on MRI is reassuring. Pt's description of new
urinary retention is concerning, but could be related to taking
opiates. Could also be cauda equina syndrome, but relatively
normal neurological exam reassuring. Pt does have some foot
numbness, but this may be related to prior foot operation. No
evidence of fluid collection on imaging, no leukocytosis, fever,
or other sign of systemic infection. Pt may have strained a
muscle since palpation lateral to spine elicits pain. Other
possibilities include be multiple sclerosis, myositis from
statin, peripheral neuropathy from long standing diabetes. On
admission, Pt had elevated CRP to 6.4 (< 5.0 normal). ESR normal
at 12, CK normal at 64. UA bland except for trace blood. Bladder
scan showed no post void residual (was 70mL when checked in the
emergency department). Etiology of symptoms remains unclear, but
Pt remains stable w/ no evidence of infection. Called PCP, who
was not in, but coverage stated that Pt had a normal EMG of left
lower extremity in ___ and her latest A1c was 6.5% on
___. She was apparently placed on gabapentin 600mg po
tid in ___, which did not help her symptoms. The final read
of Pt's lumbar and thoracic MRI was completely normal with no
evidence of any disc, spinal canal, neural foraminal, spinal
cord, or paraspinous soft tissue disease. Given her long history
of diabetes and description of burning / tingling pain, suspect
that Pt may be suffering from an atypical neuropathy. Since
patient was clinically very stable, have provided reassurance
and medication for pain control including tizanidine and
hydromorphone, and arranged for outpatient neurology follow-up
in two weeks to continue workup. Consider rechecking CRP in one
week given present elevation.
We arranged neurology urgent care for follow-up.
# new onset urticarial rash: lesion on L shoulder seems deep.
Sudden onset suggests drug related rash. Unclear if this has any
relationship to her neurological symptoms, but seems less
likely. Informed patient to monitor rash and expect gradual but
steady resolution over the next several days to 1 week.
Instructed Pt to call PCP if rash is worsening and to discuss w/
PCP at next week's appointment if it fails to improve. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
SVT
Major Surgical or Invasive Procedure:
Radiation therapy
Port placement
History of Present Illness:
___ with h/o metastatic gastric cancer,
DVT/PE (on apixaban), nonischemic CMP (LVEF 50-55% ___, T2DM
(not on insulin), HTN and hyperlipidemia, who presented with
acute-onset dizziness and generalized muscle weakness. Pt first
felt lightheaded (without loss of consciousness) and weakness
while supine in her bed around 3pm yesterday. EMS was called and
pt was found to have tachycardia with a heart rate in the 160s
on
EMS arrival. A 12-lead EKG showed a regular rhythm with no
visible P waves. The patient received 6 mg of IV adenosine with
cardioversion to a normal sinus rhythm, without evidence of
ischemia on the post-cardioversion EKG.
Of note, pt reports additional episodes of dizziness/weakness
dating as early as a year ago. Most recently, she had 6 such
episodes over the past month and fell to the floor 4 times with
loss of consciousness but without ___ trauma.
ED course: stable vitals on arrival (T 98.2, HR 100, 124/69, RR
18, SaO2 100% RA). Pt received a total of 1.5 L of NS (500 mL
was
given by EMS in the field). Pt was also given 2 units of
insulin,
324 mg of ASA, 650 mg of acetaminophen, 2 g of Mg for Mg
repletion, and home meds (including apixaban, carvedilol,
hydralazine, lisinopril, torsemide, spironolactone, oxybutynin,
risperidone, and divalproex).
Cardiology saw pt in the ED, and thought Troponin leak
consistent
with demand ischemia in setting of her SVT and ___ (b/l Cr 0.6),
not consistent with Type I NSTEMI. Cardiology also thought pt
was
not volume overloaded, appeared dry with ___, and agreed with
IVF.
Upon arrival to the floor, the patient appears well and endorses
complete resolution of presenting symptoms since adenosine
administration.
Pt denies fevers, chills, recent changes in appetite, HA,
sensory
change, focal weakness or paresthesia, chest pain, dyspnea,
orthopnea, cough, dysuria, nausea/vomiting,
diarrhea/constipation, or abdominal pain.
Past Medical History:
- DMII (not on insulin)
- Hypertension
- Hyperlipidemia
- Asthma
- Mild Mental Retardation
- Schizoaffective disorder/bipolar Disorder
- Tobacco Abuse
- Obesity
- Left Lower Extremity Cellulitis
- Urinary Incontinence s/p Bladder Stimulator
- Depression
- SVT
- CVA (multiple embolic thought to be ___ hypercoaguability)
- Metastatic gastric cancer c/b gastric bleeding requiring
transfusion, s/p XRT ___
Social History:
___
Family History:
Mother with heart disease. Daughter with asthma.
Physical Exam:
Admission Physical Exam
=========================
VITALS: T 97.9, BP 126/76, HR 88, RR 18, SaO2 95%
GENERAL: lying comfortable in bed, no acute distress
EYES: no ptosis, pupils equal and round, anicteric sclera
CV: RRR, nl S1/S2, no m/r/g, no JVD, no peripheral edema
RESP: CTAB, no rales, wheezing, or rubs
GI: normative bowel sound, soft, tenderness to palpation RUQ/RLQ
GU: no CVA tenderness
NEURO: AAOx3
PSYCH: flat affect, short sentences, delayed speech latency
Discharge Physical Exam
=========================
Pertinent Results:
Admission Labs
==============
___ 10:00PM BLOOD WBC-11.3* RBC-3.10* Hgb-8.2* Hct-27.5*
MCV-89 MCH-26.5 MCHC-29.8* RDW-17.7* RDWSD-56.9* Plt ___
___ 10:00PM BLOOD Neuts-76.8* Lymphs-11.6* Monos-10.7
Eos-0.4* Baso-0.2 Im ___ AbsNeut-8.72*# AbsLymp-1.32
AbsMono-1.21* AbsEos-0.04 AbsBaso-0.02
___ 10:00PM BLOOD Glucose-201* UreaN-23* Creat-1.6* Na-140
K-5.5* Cl-100 HCO3-22 AnGap-18*
___ 10:00PM BLOOD CK(CPK)-76
___ 10:00PM BLOOD Calcium-9.8 Phos-3.6 Mg-1.5*
Discharge Labs:
=================
Micro:
___ 10:40 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 4:19 am BLOOD CULTURE Pending: NGTD
___ 4:53 am URINE CULTURE pending: NGTD
Studies:
CTA ___ ___:
1. Subtle areas of hypoattenuation on the noncontrast CT within
the right
perisylvian parietal lobe and bilateral parasagittal occipital
lobes.
Findings may represent subacute infarcts, which could be further
assessed by MRI if clinically indicated.
2. There is segmental narrowing in the distal branches of the
right middle
cerebral artery suggesting arteriosclerotic disease. Dense
vascular
arteriosclerotic calcifications are visualized in the carotid
siphons
bilaterally with no evidence of occlusion.
3. Additional incidental findings of bilateral pulmonary
nodules, extensive bilateral pulmonary emboli, and mediastinal
lymphadenopathy. Left supraclavicular nodal conglomerate
remains unchanged, findings are better assessed on prior CTA
chest examination.
TTE ___:
The estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The estimated cardiac
index is normal (>=2.5L/min/m2). The right ventricular cavity is
mildly dilated The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal LV systolic function. Mildly dilated RV.
Moderate pulmonary hypertension. Mild tricuspid regurgitation.
Compared with the report of the prior study (images unavailable
for review) of ___ LV systolic function is now normal and
wall motion abnormalities no longer apparent. RV is now dilated
and moderate pulmonary hypertension is now present.
MR ___ ___:
IMPRESSION:
Subacute infarct involving the right frontal lobe, as seen on
the recent ___ CT, with peripheral gyriform enhancement. There
are multiple additional acute and likely subacute infarcts
involving the right frontal lobe, right parietal lobe, bilateral
occipital lobes, and left cerebellum, some of which demonstrate
enhancement. However, given the enhancement, follow-up brain MR
is recommended to exclude the possibility of metastatic disease.
RECOMMENDATION(S): Follow-up imaging to resolution.
PORT ___:
Successful placement of a single lumen chest power Port-a-cath
via the right internal jugular venous approach. The tip of the
catheter terminates in the right atrium. The catheter is ready
for use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Pantoprazole 40 mg PO Q12H
4. Aspirin 81 mg PO DAILY
5. Ditropan XL (oxybutynin chloride) 10 mg oral DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Myrbetriq (mirabegron) 50 mg oral DAILY
8. Potassium Chloride 20 mEq PO DAILY
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID
10. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezy, SOB
11. Carvedilol 37.5 mg PO BID
12. Divalproex (EXTended Release) 500 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Doxazosin 1 mg PO HS
15. HydrALAZINE 100 mg PO TID
16. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
17. Lisinopril 40 mg PO DAILY
18. RisperiDONE 2 mg PO BID
19. Torsemide 30 mg PO DAILY
20. Atorvastatin 80 mg PO QPM
21. Chlorhexidine Gluconate 0.12% Oral Rinse 30 mL ORAL BID
22. Spironolactone 12.5 mg PO DAILY
23. GlyBURIDE 10 mg PO BID
24. Apixaban 10 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Multiple embolic strokes ___ hypercoaguability of malignancy
-SVT
-___
-UTI
-Acute blood loss anemia requiring transfusion ___ metastatic
gastric cancer s/p XRT
-Type II NSTEMI
-HTN urgency
-Type II Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK.
INDICATION: ___ year old woman with new onset left sided weakness and facial
droop//stroke.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of Omnipaque intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 32.7 mGy (Head) DLP =
16.3 mGy-cm.
3) Spiral Acquisition 5.1 s, 40.2 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,247.2 mGy-cm.
Total DLP (Head) = 2,066 mGy-cm.
COMPARISON: CT head ___. CTA of the chest dated ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Hypodensity within the right, perisylvian parietal lobe is noted, new from the
previous examination in which may reflect an evolving subacute infarction. A
left occipital parasagittal hypodensity (02:14) is noted, somewhat more
conspicuous as compared to the previous examination. Similarly, there is
subtle loss of gray-white matter differentiation at the right occipital
parasagittal cortex (___), somewhat less conspicuous as compared to the
prior examination.
There is no evidence of intracranial hemorrhage. The ventricles are mildly
enlarged and prominent. There is incidentally noted a cavum septum pellucidum
at vergae. The basal cisterns remain patent.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
Note is made of bilateral torus mandibularis (image 177, series 3).
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear patent with segmental narrowing in the distal branches of the right
MCA suggesting arteriosclerotic disease (image 21, series 454). No aneurysms
are seen, vascular calcifications are noted involving the bilateral cavernous
internal carotid arteries, without flow limiting stenosis.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized lungs demonstrate in multiple pulmonary nodules, extensive
bilateral pulmonary emboli, and severe confluent mediastinal lymphadenopathy.
Left supraclavicular nodal conglomerate remains unchanged and better depicted
in the dedicated CTA of the chest dated ___.
IMPRESSION:
1. Subtle areas of hypoattenuation on the noncontrast CT within the right
perisylvian parietal lobe and bilateral parasagittal occipital lobes.
Findings may represent subacute infarcts, which could be further assessed by
MRI if clinically indicated.
2. There is segmental narrowing in the distal branches of the right middle
cerebral artery suggesting arteriosclerotic disease. Dense vascular
arteriosclerotic calcifications are visualized in the carotid siphons
bilaterally with no evidence of occlusion.
3. Additional incidental findings of bilateral pulmonary nodules, extensive
bilateral pulmonary emboli, and mediastinal lymphadenopathy. Left
supraclavicular nodal conglomerate remains unchanged, findings are better
assessed on prior CTA chest examination.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with metastatic gastric cancer and presumed
subacute ischemic CVA.// Please evaluate for CVA burden and signs of embolic
events.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 9 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CTA head and neck dated ___.
FINDINGS:
There is a subacute infarct involving the right frontal lobe, as seen on the
recent head CT, which demonstrates peripheral gyriform enhancement.
Additional punctate acute infarct within the right frontal centrum semiovale.
There are multiple additional punctate foci of enhancement with associated T2
hyperintensity involving the right parietal lobe, bilateral occipital lobes,
and left cerebellum.
There is no evidence of hemorrhage, mass effect, or midline shift.
Intracranial vessels are unremarkable in appearance. The ventricles and sulci
are normal in caliber and configuration. Note is made of a cavum septum
pellucidum. The orbits are unremarkable.
IMPRESSION:
Subacute infarct involving the right frontal lobe, as seen on the recent head
CT, with peripheral gyriform enhancement. There are multiple additional acute
and likely subacute infarcts involving the right frontal lobe, right parietal
lobe, bilateral occipital lobes, and left cerebellum, some of which
demonstrate enhancement. However, given the enhancement, follow-up brain MR
is recommended to exclude the possibility of metastatic disease.
RECOMMENDATION(S): Follow-up imaging to resolution.
Radiology Report
INDICATION: ___ year old woman with gastric cancer, DVT/PE, here with ___,
SVT, CVA, GI bleed, now stable awaiting port placement for chemotherapy, will
be bridged with heparin before and after// please place single lumen chest
port for chemo and leave accessed ___ aware
COMPARISON: Chest x-ray ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 40 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl and Versed
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.31 min, 1 mGy
PROCEDURE
1. Right internal jugular approach chest single lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
healthcare proxy. The patient was then brought to the angiography suite and
placed supine on the exam table. A pre-procedure time-out was performed per
___ protocol. The 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 ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The single lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
prolene sutures on either side. 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 port was threaded into
the right side of the heart with the tip in the right atrium. The sheath was
then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous Vicryl sutures. Steri-Strips were used to close the
venotomy incision site. Steri-Strips were applied over the sutures. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking. The tip is in the right atrium.
The port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a single lumen chest power Port-a-cath via the right
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SVT, Weakness
Diagnosed with Supraventricular tachycardia
temperature: 98.2
heartrate: 100.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | ___ PMH of metastatic gastric cancer, DVT/PE (on apixaban),
nonischemic CMP (LVEF 50-55% ___, HTN, developmental delay,
schizoaffective disorder, who presented with acute-onset
dizziness ___ SVT (resolved s/p adenosine), subacute CVA ___
hypercoaguability of malignancy), upper GI bleed ___ known
gastric malignancy), ___, UTI, now s/p port placement.
# Right Subacute CVA:
Patient with acute onset left-sided weakness and left facial
droop concerning for acute stroke on ___. CTA with
hypodensity
in the right ___ region. She was not a candidate for
endovascular clot retrieval. Heparin gtt was started. There was
concern she had not been taking her apixaban at home. She had a
recent TTE in ___ which showed no PFO/ASD with EF 50-55%.
Repeat
here did not show intracardiac thrombus. She has no known
history
of atrial fibrillation and none was found on telemetry. Her left
hemi-paresis resolved during the course of the admission. MRI
___ significant for right frontal lobe subacute infarct
multiple
acute/subacute infarcts in different territories which are high
suggestive of embolic etiology further reinforcing need for
ongoing anticoagulation.
- enoxaparin 90mg q12h
- Continue atorvastatin 80mg
- ___ consults: Will need acute rehab for up to 60 days
- Patient to follow up in outpatient neurology stroke clinic
with
Dr. ___ in ___ weeks after discharge
- Please call ___ for appointment on discharge
# Port
Placed for chemotherapy on ___.
# HTN
Patient with known history of HTN, with HTN urgency on ___
prior to am medications, then improved after receiving
medications and has remained stable since.
- Continue home dose coreg, doxazosin, hydralazine, indur,
lisinopril, spironolactone
# Anemia
# Upper GI Bleed:
Patient with melena and known gastric tumor with daily
transfusion requirement from ___ to ___. Received IV PPI bid,
___ cGY of radiation to stomach in five fractions and
supportive
transfusions. Transfusion requirements significantly decreased
after ___ until stabilization of hemoglobin on ___. Patient was
transitioned back to pantoprazole 40mg bid. On review of ___
iron studies has iron deficiency (Fe/TIBC 13%) from acute on
chronic blood loss and chronic inflammation (ferritin>100). Iron
stores were fully repleted in-house with two injections of
ferric
gluconate. Pt last transfused on ___. Bowel movements by end of
admission were light brown suggesting that oozing has ceased.
- Continue pantoprazole 40mg po bid indefinitely
- Sucralfate 1g qid x10d (ending ___
- Transfuse for Hb<7
# Metastatic Gastric Cancer:
Metastatic to supraclavicular lymph nodes. Plan to start
chemotherapy soon, potentially with FOLFOX. Port placed ___
- will need f/u in ___ wks w/ Dr. ___ in oncology
# SVT:
Patient presented after 5 hrs of PSVT s/p successful
conversion with adenosine with complete resolution of symptoms
with no ischemic changes on EKG. She had short lasting episode
morning on ___ which resolved without intervention. EKG
showedNSR with no ischemic changes. Most likely from underlying
structural heart disease (nonischemic CMP) in the setting of
cancer and recent PE vs. hemorrhagic hypovolemia in setting of
gastric cancer and anticoagulation on heparin.
- Attempt vagal maneuver if SVT recurs
- Continue home carvedilol
# Urinary Retention
# Sacral Nerve Stimulator:
Patient has history of bladder stimulator that was placed in
___
by Dr. ___. She was following with urology here till ___
for adjustments of device. Per guardian patient has not used
this
for many years.
- Hold home oxybutynin and mirabegron
# DVT/PE
- Enoxaparin as above, 1 mg/kg bid
# Cardiomyopathy/HTN:
Has history of non-ischemic cardiomyopathy.
However recent TTE has recovered EF (EF 50% in ___. LVEF on
this admission >55%. No current signs of fluid overload.
- Continue BP meds as above
- Continue holding torsemide as euvolemic, maintaining slight
net
negative balance and weight stable off those medications
# Hyperlipidemia
- Continue home atorvastatin
# T2DM
Patient was restarted home metformin on ___ and sliding scale
coverage has been minimal so likely does not need glyburide on
discharge.
- hold glyburide, continue metformin
# Asthma
- Continue duoneb PRN
# Schizoaffective disorder
Patient is currently functioning at baseline has no evidence of
psychiatric heparin decompensation
- Continue home risperidone and divalproex |
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:
Coronary angiogram ___
History of Present Illness:
___ F w/ hx of DM2, HLD, HTN who presents with chest pain.
She was lying down watching TV the day of presentation when she
acutely had chest pressure ___ in severity that radiated to
both
shoulders. She also felt nausea with some abdominal pain that
she
attributed to gas. She has never had similar chest pressure
before. She was concerned she was having a heart attack and
called EMS. No SOB, dizziness, syncope.
In the ED...
- Initial vitals: 97.1, 60, 187/79, 16, 100% RA. Exam benign
- EKG: per my review NSR, rate 77, q wave in III, isolated ST
elevation in V2, poor R wave progression
- Labs/studies notable for:
12.5 11.8307
>-------<
37.5
___ AGap=15
4.5200.8
Trop-T: 0.62 (MB 19) --> 0.62 --> 0.51 (MB 18) --> 0.48 (MB
13)
UA clean
CXR: No evidence of pneumonia or pulmonary edema.
- Patient was given:
-- Aspirin 324 mm, Atorvastatin 80 mg, IV Heparin bolus and gtt
Started 850 units/hr, zofran, IV nitro gtt (1-->3), Atorvastatin
40 mg
-- FLUoxetine 20 mg, Acetaminophen 650 mg, Aluminum-Magnesium
Hydrox.-Simethicone 30 mL, SCInsulin 4 Units
- Vitals on transfer: 98.0, 92, 127/100, 22, 95% 2L NC
On the floor, patient reports history above. Her chest pain
improved after its initial sudden onset, but she thinks that it
really resolved after she was started on nitro gtt. She has no
prior cardiac history. Otherwise she reports being in her USOH;
no f/c, dysuria, diarrhea, melena, hematochezia. Has puffy legs
at baseline but no frank leg swelling. Feeling anxious.
REVIEW OF SYSTEMS:
10 point ROS negative except as per HPI above.
Past Medical History:
HYPERTENSION - ESSENTIAL
DEPRESSIVE DISORDER
OBESITY UNSPEC
DM type 2 (diabetes mellitus, type 2)
Osteoarthritis, knee
Anatomical narrow angle
Elevated LDL cholesterol level
DM type 2 with diabetic peripheral neuropathy
GERD (gastroesophageal reflux disease)
Low-tension glaucoma, bilateral
Gallstones
Social History:
___
Family History:
Hypertension; Other
Mother ___
Other ___
mother w/ ___
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=====================
VITALS: 98.6PO, 135 / 76R Lying, 83, 17, 90 2L
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. EOMI.
NECK: supple
CARDIAC: RRR, normal S1, S2. premature beats. No
murmurs/rubs/gallops. No thrills, lifts.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, obese, NTND.
EXTREMITIES: soft tissue non pitting edema of ___
SKIN: No rashes noted
DISCHARGE PHYSICAL EXAM
==========================
OBJECTIVE:
Vitals: 24 HR Data (last updated ___ @ 1650)
Temp: 98.1 (Tm 98.9), BP: 126/70 (116-152/70-89), HR: 68
(55-75), RR: 18 (___), O2 sat: 95% (94-97), O2 delivery: Ra
General: Comfortably laying in bed in NAD
HEENT: No JVD appreciable
Lungs: CTAB
CV: RRR no mrg
Abdomen: NABS, ND, soft, NTTP, no grm
Ext: Pulses radial and DP 2+ bilaterally, mild b/l non-pitting
edema.
Pertinent Results:
ADMISSION LABS
==============
___ 02:58AM BLOOD WBC-12.5* RBC-4.33 Hgb-11.8 Hct-37.5
MCV-87 MCH-27.3 MCHC-31.5* RDW-13.3 RDWSD-41.4 Plt ___
___ 02:58AM BLOOD Neuts-79.8* Lymphs-11.5* Monos-5.2
Eos-2.4 Baso-0.6 Im ___ AbsNeut-9.96* AbsLymp-1.44
AbsMono-0.65 AbsEos-0.30 AbsBaso-0.07
___ 11:45AM BLOOD ___ PTT-55.0* ___
___ 02:58AM BLOOD Glucose-238* UreaN-25* Creat-0.8 Na-140
K-4.5 Cl-105 HCO3-20* AnGap-15
___ 06:50AM BLOOD ALT-11 AST-33 AlkPhos-63 TotBili-0.7
___ 02:58AM BLOOD CK-MB-19*
___ 02:58AM BLOOD cTropnT-0.62*
___ 06:00AM BLOOD cTropnT-0.62*
___ 08:55AM BLOOD CK-MB-18* cTropnT-0.51*
___ 06:50AM BLOOD Albumin-3.8 Calcium-10.5* Phos-2.6*
Mg-1.9 Cholest-135
___ 06:50AM BLOOD %HbA1c-6.4* eAG-137*
___ 06:50AM BLOOD Triglyc-144 HDL-50 CHOL/HD-2.7 LDLcalc-56
PERTINENT STUDIES
===================
CHEST XRAY ___
IMPRESSION:
No evidence of pneumonia or pulmonary edema.
CORONARY ANGIOGRAM ___
Coronary Description
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel and is normal. This vessel
bifurcates into the Left Anterior Descending and Left Circumflex
systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is
a 40% smooth stenosis in the proximal segment.
The Diagonal, arising from the proximal segment, is a medium
caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel and is normal.
The ___ Obtuse Marginal, arising from the proximal segment, is a
large caliber vessel.
The ___ Obtuse Marginal, arising from the mid segment, is a
small caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel with mild luminal
irregularities.
The Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel.
Complications: There were no clinically significant
complications.
Findings
Mild coronary artery disease.
Recommendations
Secondary prevention of CAD
Further management as per primary cardiology team.
TTE ___
CONCLUSION:
The left atrial volume index is normal. The right atrial
pressure could not be estimated. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is a small area of regional left
ventricular systolic dysfunction with focal hypokinesis to
akinesis of the distal ___ of the left ventricle (see
schematic) and preserved/normal contractility of the remaining
segments. No thrombus or mass is seen in the
left ventricle. The visually estimated left ventricular ejection
fraction is 45-50%. Left ventricular
cardiac index is low normal (2.0-2.5 L/min/m2). There is no
resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal
descending aorta diameter. The aortic valve leaflets (?#) appear
structurally normal. There is no aortic valve
stenosis. There is trace aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve
prolapse. There is trivial mitral regurgitation. The pulmonic
valve leaflets are not well seen. There is mild
pulmonic regurgitation. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with regional
left ventricular systolic dysfunction c/w CAD, as described
above. Normal right ventricular cavity
size and systolic function.
DISCHARGE LABS
================
___ 06:10AM BLOOD WBC-7.1 RBC-3.87* Hgb-10.8* Hct-35.2
MCV-91 MCH-27.9 MCHC-30.7* RDW-13.7 RDWSD-45.3 Plt ___
___ 06:10AM BLOOD Glucose-175* UreaN-16 Creat-0.8 Na-141
K-4.4 Cl-108 HCO3-24 AnGap-9*
___ 06:10AM BLOOD Calcium-10.3 Phos-2.8 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Lisinopril 5 mg PO DAILY
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
5. MetFORMIN (Glucophage) 850 mg PO BID
6. FLUoxetine 20 mg PO DAILY
7. GlipiZIDE XL 5 mg PO DAILY
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
9. Omeprazole 20 mg PO EVERY OTHER DAY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. FLUoxetine 20 mg PO DAILY
6. GlipiZIDE XL 5 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Lisinopril 5 mg PO DAILY
9. MetFORMIN (Glucophage) 850 mg PO BID
10. Omeprazole 20 mg PO EVERY OTHER DAY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
NSTEMI
SECONDARY DIAGNOSES:
Diabetes mellitus
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with HTN, HLD, DM2 who presents with acute chest
pressure (EKG normal, trop pending) and noted to have WBC 12.5. Has some
SOB.// Eval for consolidation vs. pulm edema
TECHNIQUE: Chest PA and lateral
COMPARISON: CT abdomen pelvis without contrast dated ___
FINDINGS:
Lungs are well expanded and clear. No evidence of pulmonary edema. No
evidence of pneumonia. Note is made of a moderate size hiatal hernia, better
characterized on prior CT in ___. No pleural effusion or pneumothorax.
The hila are unremarkable. The thoracic aorta is tortuous. Cardiomediastinal
silhouette is otherwise unremarkable. No acute osseous abnormalities.
IMPRESSION:
No evidence of pneumonia or pulmonary edema.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Epigastric pain, Nausea
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 97.1
heartrate: 60.0
resprate: 16.0
o2sat: 100.0
sbp: 187.0
dbp: 79.0
level of pain: 7
level of acuity: 3.0 | SUMMARY STATEMENT:
====================
___ female with diabetes, hypertension, hyperlipidemia,
presenting with chest discomfort, positive troponin/NSTEMI with
apical hypokinesis focal akinesis of the distal third of the LV
not consistent w/ single vessel territory with mildly reduced EF
of 45-50% without evidence of
thrombus and only with mild LAD disease on coronary angiogram
(40% at multiple points in the LAD). Pt chest pain free off
nitro drip and was discharged home with follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Seroquel
Attending: ___.
Chief Complaint:
altered mental status, concern for overdose
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
___ presenting with AMS. Found by EMS with multiple pill bottles
open around the floor, with multiple pills on the floor, all
empty. Called her mother, reported SI. Mother called ___
In the ED, "says she took ___ Flexeril, unknown amount of
clonidine. Father's pills include ___, diltiazem, metformin,
citalopram, metoprolol. Her medications include prazosin,
Keppra, Neurontin, clonazepam. Denies acetaminophen, cocaine."
In the ED, initial vitals: 99, 127/83, 130, 12, 98%RA
She received 2mg lorazepam x2, haloperidol 5mg x2 (agitation),
and 2LNS. Urine tox positive for benzos and methadone.
Labs significant for CK 1143, normal electrolytes/Cr, mildly
elevated AST (47) otherwise unremarkable LFTs. Serum
acetaminophen level 11. Mild anemia H/H 11.1/34.4. Repeat CK
increased to 1740.
On transfer, vitals were: 97.9, 115/63, 98, 18, 98% NC
On the floor, patient endorses throat pain, congestion, and
shoulder/muscle pain with onset this morning. She says she has
been stressed the past 2 days because her father is hospitalized
with pneumonia and has not slept. She says she took 1000mg
acetaminophen on 1pm for a headache. She says she takes 15mg
alprazolam per day (10mg in AM, 5mg later), most recently on
___. She originally denied any alcohol consumption for the
past 4 months. She asked for phenobarbital because she had
gotten it in the past, when she was told this was not an
immediate plan and is usually for alcohol withdrawal, she said
"oh, actually I drank alcohol this morning including an entire
bottle of ___, 2 nips of vodka, and a bottle of wine." She
believes that her mother is trying to steal her son from her and
that is the reason why she called the police on her.
Mother, per ___ interpreter
Going through big depression, trying to stop using drugs, cannot
do it on her own, she took a bunch of pills. She had been
telling her for days to take care of the child because she was
no longer able to go on in life. More than 200 pills were on the
floor. Did not witness taking any pills. She says she was taking
her prescribed medications at once, but Mother is concerned she
is not taking them as prescribed. No alcohol in a long time. She
was at ___ 2 months ago for 2 weeks. Dr. ___ at
___ - psychiatrist; last saw in ___ but refilled
medications 1 week ago. Pt lives with father, mother has custody
of son.
ROS: 10-point ROS negative
Past Medical History:
Past medical history:
1) Seizures - she reports history of seizures beginning at age
___, which began in the setting of Xanax abuse (which began at
age ___. She denies any seizures that were not precipitated by
cessation of benzos or EtOH.
2) IVDU - heroin, up to 3gm/day, reports currently sober
3) H/o Cocaine abuse (positive serum tox for cocaine in the
past)
4) Depression, Anxeity - has history of suicide attempts using
her prescription drugs (several years ago), as well as a suicide
attempt with wrist cutting several weeks ago
5) Hepatitis C - patient may have cleared as last HCV VL is
undetectable
6) Neutropenia
7) Rhabdo/crush muscle injury in the setting of heroin use s/p
skin grafting in LLE. Uses a cane for ambulation and has been
unemployed since then.
8) History of tonsillectomy
9) History of rhinoplasty
10) History of orthopedic surgery on right elbow and left foot
after trauma
Past psychiatric history:
Hospitalizations: Several, most recent in ___ at ___, also
___ for dual diagnosis/detox, ___ for depression with
post partum onset
Current treaters and treatment: none
Self-injury: cut left wrist 1 month ago when boyfriend was
incarcerated. Reports suicidal thoughts at the time, reports was
high at the time. Cut superficial and required no medical
attention.
Harm to others: history of fights
Access to weapons: none reported
Social History:
___
Family History:
Cousin with schizophrenia who completed suicide via hanging.
Reported history of schizophrenia in pt's father. Several
cousins with alcohol use disorder.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
GENERAL: Alert, oriented, agitated
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes or lesions
NEURO: no focal neurological deficits, no nystagmus, mild
tremor
DISCHARGE EXAM
==============
VITALS T97.7 TM 99 BP118/70 HR73 RR18 94%RA
GENERAL: Alert, oriented, flat affect
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes or lesions
NEURO: no focal neurological deficits, no nystagmus, no tremor.
Pertinent Results:
ADMISSION LABS
=====================
___ 07:25PM BLOOD WBC-5.5 RBC-4.02 Hgb-11.1* Hct-34.4
MCV-86 MCH-27.6 MCHC-32.3 RDW-15.2 RDWSD-47.5* Plt ___
___ 07:25PM BLOOD Neuts-46.3 ___ Monos-11.8 Eos-4.5
Baso-0.4 Im ___ AbsNeut-2.55 AbsLymp-2.03 AbsMono-0.65
AbsEos-0.25 AbsBaso-0.02
___ 07:25PM BLOOD Plt ___
___ 11:09PM BLOOD ___ PTT-32.2 ___
___ 07:25PM BLOOD Glucose-116* UreaN-8 Creat-0.8 Na-137
K-4.3 Cl-97 HCO3-25 AnGap-19
___ 07:25PM BLOOD ALT-19 AST-47* CK(CPK)-1143* AlkPhos-63
TotBili-0.3
___ 07:25PM BLOOD Albumin-4.1
___ 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-11
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
======================
___ 04:31AM BLOOD WBC-4.3 RBC-3.78* Hgb-10.6* Hct-33.5*
MCV-89 MCH-28.0 MCHC-31.6* RDW-15.1 RDWSD-49.4* Plt ___
___ 04:31AM BLOOD Glucose-95 UreaN-3* Creat-0.5 Na-140
K-4.3 Cl-104 HCO3-29 AnGap-11
___ 04:31AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0
MICROBIOLOGY
================
___ MRSA SCREEN: NEGATIVE
___ Urine culture: No growth
___ Blood culture: No growth
___ Blood culture: No growth
___ Urine Legionella: NEGATIVE
IMAGING
================
CT head ___
1. No evidence for acute intracranial abnormalities. Please
note that evaluation for intracranial infection on noncontrast
CT is limited compared to MRI.
2. Moderate mucosal thickening in the partially visualized left
ethmoid air cells, extending into the left frontoethmoidal
recess with mild mucosal thickening within the inferior left
frontal sinus. Please correlate clinically whether there are
any symptoms of active sinusitis.
CXR ___
In comparison to ___, a new area of consolidation has
developed in the right mid lung, suspicious for developing
pneumonia in the setting of fever. Exam is otherwise unchanged
except for development of moderate gastric distension in the
imaged portion of the upper abdomen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO QID
2. Prazosin 5 mg PO QHS
3. Methadone 90 mg PO DAILY
4. LeVETiracetam 1000 mg PO BID
5. ClonazePAM 1 mg PO TID
6. Venlafaxine XR 150 mg PO DAILY
Discharge Medications:
1. Gabapentin 800 mg PO QID
2. LeVETiracetam 1000 mg PO BID
3. Methadone 90 mg PO DAILY
4. Prazosin 5 mg PO QHS
5. Venlafaxine XR 150 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
7. Levofloxacin 500 mg PO DAILY
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
8. ClonazePAM 1 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
1. Suicide attempt via ingestion of unknown medications
2. Alcohol withdrawal
3. Depression/Anxiety
4. Community Acquired Pneumonia
Secondary
1. Seizure Disorder
2. Hx of IVDU
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with fever to ___ F, rigors // pls eval for
PNA
IMPRESSION:
In comparison to ___, a new area of consolidation has developed in
the right mid lung, suspicious for developing pneumonia in the setting of
fever. Exam is otherwise unchanged except for development of moderate gastric
distension in the imaged portion of the upper abdomen.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with recent ingestion of unknown substances,
report of striking head against wall at home, now with headache, febrile to
___, rigors. Evaluate for intracranial hemorrhage, abscess.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___
FINDINGS:
There is no acute hemorrhage, edema, mass effect, loss of gray/ white matter
differentiation, or pathologic extra-axial collection. Ventricles, sulci, and
basal cisterns are normal in size.
No concerning bone lesion is seen. There is moderate mucosal thickening in
the partially visualized left ethmoid air cells, extending into the left
frontoethmoidal recess with mild mucosal thickening in the inferior left
frontal sinus. Right frontal sinus and partially visualized sphenoid sinuses
are well aerated. Maxillary sinuses are not imaged. Middle ear cavities and
mastoid air cells are well aerated.
IMPRESSION:
1. No evidence for acute intracranial abnormalities. Please note that
evaluation for intracranial infection on noncontrast CT is limited compared to
MRI.
2. Moderate mucosal thickening in the partially visualized left ethmoid air
cells, extending into the left frontoethmoidal recess with mild mucosal
thickening within the inferior left frontal sinus. Please correlate
clinically whether there are any symptoms of active sinusitis.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: SI, Overdose
Diagnosed with Altered mental status, unspecified
temperature: 99.0
heartrate: 130.0
resprate: 12.0
o2sat: 98.0
sbp: 127.0
dbp: 83.0
level of pain: 0
level of acuity: 1.0 | Mrs ___ is a ___ year old woman with a PMH
significant for depression, polysubstance abuse (EtOH and
heroin), seizure disorder NOS who presents with concern for
overdose/SI.
#Overdose:
Presented with concern for overdose/SI after she was found down
next to several empty pill bottles. She was evaluated by
toxicology who didn't feel her presentation didn't fit any
particular toxidrome but she was given N-acetylcysteine given an
elevated acetaminophen level and concern for potential
hepatoxicity given hx of EtOH and HCV. She was started on a
phenobarbital withdrawal protocol after endorsing heavy alcohol
consumption.
#SEPSIS: fever, tachycardia, and leukocytosis.
Initially c/f intracranial process but HA has resolved and no
other signs or symptoms to suggest meningitis. No focal signs of
infection on exam other than sinus congestion. CXR with new
consolidation concerning for developing PNA. Given one dose of
vanc, CFTX, and ACV initially due to concern for meningitis
initially, which was transitioned to Levaquin after CXR findings
and resolution of severe headache. Legionella showed was
negative. She will complete a course of oral antibiotics for
pneumonia.
# Anxiety/Depression:
Patient denies HI/SI currently; however, given circumstances of
her admission, she was evaluated by Psychiatry who determined
that although she lives a high risk life style she was not an
immediate danger to herself in terms of suicide. Home
gabapentin, hydroxyzine, prazosin, trazodone, venlafaxine were
initially held and slowly re-introduced with the recommendations
of psychiatry.
# History of Seizures: Continue home keppra
# Anemia: chronic, improved from last hospital d/c in ___
- continue home iron supplementation
# History of HCV: Treatment naive; last known HCV load 341,000
IU/mL. Repeat viral load ___ was negative. Appears to
have SVR
# H/o heroin abuse: t/b with ___ clinic re dose.
RANSITIONAL ISSUES
-Levofloxacin for PNA D1 ___ Last day ___ for 5 day
course
-Patient will follow up with primary Psychiatrist on sat ___
-Of note patient reports she takes clonidine, however she has no
active prescriptions for this medication. Please clarify and
determine if clinically indicated
-Would recommend that she not receive benzodiazapines as she has
a long history of substance abuse
-Patient had a borderline prolonged QTc between 444-479 during
the admission, would avoid adding QTc prolonging medications
- HCP: Mother ___ cell (preferred) ___
needs ___ interpreter |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
citalopram
Attending: ___.
Chief Complaint:
pelvic and substernal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ yo G0 w/ abdominal and substernal pain x3 days. She
states that the pain starts in the epigastric region and
radiates
diffusely (worst in RLQ). The pain is constant but waxes and
wanes in intensity (10 out of 10 at its worst) and worsened with
movements.
She reports fevers to 103.7 at home that started approx 48hrs
ago
associated with chills. She took ibuprofen and tylenol.
Denies emesis but +dry heaving and nausea. Also endorses
abdominal bloating. Pt reports inability to tolerate PO x 2
days,
but has been taking sips of fluids (feels dehydrated).
She denies dysuria but endorses pressure-type abdominal pain
with
voids. No hematuria. + lower back pain and b/l flank pain. Also
with intermittent chest pressure, nausea, headache. Having light
spotting. Denies abnormal vaginal discharge.
Past Medical History:
OBHx: G1P0 (TABx1, D&C)
GynHx:
- LMP ___
- ?Hx of fibroids
- H/o abnormal pap s/p colposcopy, last pap ___ wnl
- Denies hx of STI (h/o HSV 2 per record review)
PMH: anemia, anxiety
PSH: wrist surgery
All: citalopram
Social History:
___
Family History:
FH: noncontributory
Physical Exam:
On admission:
Physical Exam
Tm 103 (___) Tc 98.1
HR 121 (100s-140s)
BP 1017/69, RR 21, O2sat 100% on RA
Gen uncomfortable appearing
CV tachycardic
Pulm nl resp effort
Abd softly distended, moderately TTP diffusely, worse in lower
quadrants (R>L), +voluntary guarding. no rebound
Back no CVAT. +b/l lower back paraspinal TTP
Pelvic +b/l adnexal discomfort w/ exam (R>L). no CMT. no adnexal
fullness appreciate
On day of discharge:
Objective:
Temp: 99.0 (Tm 99.0),
BP: 115/74 (115-146/72-84),
HR: 106 (94-114),
RR: 18, O2 sat: 95% (93-99), O2 delivery: ra
Fluid Balance (last updated ___ @ 219)
Last 8 hours Total cumulative -75ml
IN: Total 775ml, PO Amt 600ml, IV Amt Infused 175ml
OUT: Total 850ml, Urine Amt 850ml
Last 24 hours Total cumulative 829ml
IN: Total 2779ml, PO Amt 1600ml, IV Amt Infused 1179ml
OUT: Total 1950ml, Urine Amt 1950ml
Physical Exam:
General: NAD, comfortable
CV: RRR
Lungs: slight crackles in bibasilar area, nonlabored breathing
Abdomen: soft, non-distended, tender to palpation in RLQ
without
rebound
Extremities: no edema, no TTP, pneumoboots in place bilaterally
Pertinent Results:
___ 03:35PM BLOOD WBC-12.4* RBC-3.77* Hgb-10.4* Hct-31.8*
MCV-84 MCH-27.6 MCHC-32.7 RDW-13.2 RDWSD-41.1 Plt ___
___ 12:03AM BLOOD WBC-8.2 RBC-3.26* Hgb-9.0* Hct-27.2*
MCV-83 MCH-27.6 MCHC-33.1 RDW-13.2 RDWSD-40.8 Plt ___
___ 06:48AM BLOOD WBC-6.1 RBC-2.99* Hgb-8.2* Hct-25.4*
MCV-85 MCH-27.4 MCHC-32.3 RDW-13.4 RDWSD-41.5 Plt ___
___ 01:35PM BLOOD WBC-6.5 RBC-3.30* Hgb-9.0* Hct-27.9*
MCV-85 MCH-27.3 MCHC-32.3 RDW-13.5 RDWSD-42.3 Plt ___
___ 06:50AM BLOOD WBC-7.1 RBC-3.00* Hgb-8.3* Hct-25.2*
MCV-84 MCH-27.7 MCHC-32.9 RDW-13.7 RDWSD-42.2 Plt ___
___ 03:15PM BLOOD WBC-9.1 RBC-3.32* Hgb-9.0* Hct-28.0*
MCV-84 MCH-27.1 MCHC-32.1 RDW-13.9 RDWSD-43.0 Plt ___
___ 06:29AM BLOOD WBC-8.1 RBC-3.11* Hgb-8.5* Hct-25.6*
MCV-82 MCH-27.3 MCHC-33.2 RDW-13.9 RDWSD-41.9 Plt ___
___ 07:12PM BLOOD WBC-7.4 RBC-3.29* Hgb-8.9* Hct-27.0*
MCV-82 MCH-27.1 MCHC-33.0 RDW-14.0 RDWSD-41.8 Plt ___
___ 06:38AM BLOOD WBC-6.4 RBC-2.87* Hgb-7.8* Hct-23.6*
MCV-82 MCH-27.2 MCHC-33.1 RDW-14.3 RDWSD-42.8 Plt ___
___ 05:45PM BLOOD WBC-7.2 RBC-2.97* Hgb-8.1* Hct-24.7*
MCV-83 MCH-27.3 MCHC-32.8 RDW-14.5 RDWSD-43.6 Plt ___
___ 10:32AM BLOOD WBC-8.4 RBC-3.15* Hgb-8.6* Hct-26.3*
MCV-84 MCH-27.3 MCHC-32.7 RDW-14.6 RDWSD-44.9 Plt ___
___ 03:35PM BLOOD Neuts-77* Bands-17* Lymphs-6* Monos-0*
Eos-0* Baso-0 AbsNeut-11.66* AbsLymp-0.74* AbsMono-0.00*
AbsEos-0.00* AbsBaso-0.00*
___ 12:03AM BLOOD Neuts-82* Bands-11* Lymphs-5* Monos-2*
Eos-0* Baso-0 AbsNeut-7.63* AbsLymp-0.41* AbsMono-0.16*
AbsEos-0.00* AbsBaso-0.00*
___ 06:48AM BLOOD Neuts-75* Bands-13* Lymphs-8* Monos-3*
Eos-1 Baso-0 AbsNeut-5.37 AbsLymp-0.49* AbsMono-0.18*
AbsEos-0.06 AbsBaso-0.00*
___ 01:35PM BLOOD Neuts-88* Bands-4 Lymphs-5* Monos-1*
Eos-1 Baso-1 AbsNeut-5.98 AbsLymp-0.33* AbsMono-0.07*
AbsEos-0.07 AbsBaso-0.07
___ 06:50AM BLOOD Neuts-91.8* Lymphs-5.5* Monos-1.5*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-6.53* AbsLymp-0.39*
AbsMono-0.11* AbsEos-0.02* AbsBaso-0.02
___ 06:29AM BLOOD Neuts-92.2* Lymphs-4.0* Monos-2.1*
Eos-0.4* Baso-0.2 Im ___ AbsNeut-7.43* AbsLymp-0.32*
AbsMono-0.17* AbsEos-0.03* AbsBaso-0.02
___ 07:12PM BLOOD Neuts-91.0* Lymphs-5.1* Monos-2.4*
Eos-0.3* Baso-0.1 Im ___ AbsNeut-6.71* AbsLymp-0.38*
AbsMono-0.18* AbsEos-0.02* AbsBaso-0.01
___ 06:38AM BLOOD Neuts-87.9* Lymphs-6.6* Monos-3.3*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-5.64 AbsLymp-0.42*
AbsMono-0.21 AbsEos-0.02* AbsBaso-0.02
___ 10:32AM BLOOD Neuts-88.0* Lymphs-7.4* Monos-2.6*
Eos-0.8* Baso-0.2 Im ___ AbsNeut-7.35* AbsLymp-0.62*
AbsMono-0.22 AbsEos-0.07 AbsBaso-0.02
___ 01:35PM BLOOD ___ PTT-34.6 ___
___ 01:35PM BLOOD ___
___ 05:45PM BLOOD Ret Aut-0.4 Abs Ret-0.01*
___ 03:35PM BLOOD Glucose-147* UreaN-19 Creat-0.9 Na-132*
K-3.4* Cl-94* HCO3-21* AnGap-17
___ 06:48AM BLOOD Glucose-96 UreaN-14 Creat-0.6 Na-133*
K-3.3* Cl-99 HCO3-23 AnGap-11
___ 01:35PM BLOOD Glucose-90 UreaN-12 Creat-0.6 Na-135
K-3.3* Cl-98 HCO3-24 AnGap-13
___ 06:50AM BLOOD Glucose-88 UreaN-8 Creat-0.5 Na-133*
K-3.3* Cl-99 HCO3-20* AnGap-14
___ 03:15PM BLOOD Glucose-98 UreaN-7 Creat-0.5 Na-134*
K-3.1* Cl-97 HCO3-22 AnGap-15
___ 06:38AM BLOOD Glucose-115* UreaN-5* Creat-0.5 Na-135
K-3.2* Cl-98 HCO3-22 AnGap-15
___ 05:45PM BLOOD Glucose-102* UreaN-4* Creat-0.4 Na-134*
K-3.8 Cl-98 HCO3-26 AnGap-10
___ 10:32AM BLOOD Glucose-124* UreaN-5* Creat-0.4 Na-138
K-3.8 Cl-98 HCO3-27 AnGap-13
___ 03:35PM BLOOD ALT-12 AST-20 AlkPhos-70 TotBili-0.7
___ 05:45PM BLOOD LD(LDH)-243 CK(CPK)-26*
___ 03:35PM BLOOD cTropnT-<0.01
___ 03:35PM BLOOD Lipase-10
___ 03:35PM BLOOD Albumin-3.8 Calcium-9.0 Phos-1.3* Mg-1.7
___ 06:48AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7
___ 01:35PM BLOOD Calcium-8.6 Phos-2.0* Mg-1.8
___ 03:15PM BLOOD Calcium-8.4 Phos-2.4* Mg-1.7
___ 05:45PM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.0 Mg-1.8
Iron-10*
___ 10:32AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.8
___ 05:45PM BLOOD calTIBC-163* Ferritn-272* TRF-125*
___ 03:35PM BLOOD HCG-<5
___ 05:45PM BLOOD ___ Titer-1:80* CRP->300*
___ 05:45PM BLOOD HIV Ab-NEG
___ 08:09AM BLOOD ___ pO2-234* pCO2-38 pH-7.42
calTCO2-25 Base XS-0 Comment-GREEN TOP
___ 03:40PM BLOOD Lactate-2.0
___ 08:09AM BLOOD Lactate-1.5
___ 06:49AM BLOOD Lactate-0.9
Medications on Admission:
ativan, albuterol prn
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Do not exceed 4000mg in 24hours
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth two times a
day Disp #*10 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Take with food. Do not exceed 2400mg in 24hrs
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*0
4. OSELTAMivir 75 mg PO BID Duration: 5 Days
RX *oseltamivir 75 mg 1 capsule(s) by mouth two times a day Disp
#*8 Capsule Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
___ cause sedation. Do not drink or drive.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*4 Tablet Refills:*0
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, cough
8. LORazepam 1 mg PO Q8H:PRN sleep aid/anxiety/nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Hemorrhagic ovarian cyst
Complicated UTI
Influenza A
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with fever admitted w/ complicated UTI/pyelo w/
shortness of breath // atelectasis vs pneumonia
TECHNIQUE: Portable chest AP
COMPARISON: CT chest dated ___
FINDINGS:
The lungs are well expanded. There is a new opacity at the left lung base
with lateral component, consistent with new left pleural effusion. There is
mild bibasilar atelectasis. A calcified granuloma is noted just adjacent to
the right hemidiaphragm. No pulmonary edema. No pneumothorax.
Cardiomediastinal silhouette is normal.
IMPRESSION:
1. New opacity at the left lung base with lateral component is consistent with
a new left pleural effusion.
2. Mild bibasilar atelectasis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with UTI and recent ruptured hemorrhagic cyst
with recurrent fever, worsening flank/abdominal pain, failing IV antibiotic
treatment. Evaluation for hematoma, appendicitis, abscess, hydronephrosis,
pyelonephritis.
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 8.4 s, 0.2 cm; CTDIvol = 143.3 mGy (Body) DLP =
28.7 mGy-cm.
3) Spiral Acquisition 8.7 s, 56.4 cm; CTDIvol = 11.9 mGy (Body) DLP = 661.4
mGy-cm.
Total DLP (Body) = 692 mGy-cm.
COMPARISON: Comparison to CT abdomen/pelvis with contrast from ___.
FINDINGS:
LOWER CHEST: There is streak like atelectasis and compressive atelectasis at
the bilateral lung bases. Stable 8 mm calcified granuloma at the right lung
base (5:10). Few small calcified right hilar lymph nodes are unchanged.
Small bilateral nonhemorrhagic pleural effusions, slightly increased from
prior study. There is no evidence of pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder contains hyperdense biliary
sludge without wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal. There is mild
thickening and enhancement of the peritoneum, which may represent peritonitis.
There has been slight interval increase in small amount of perihepatic and
perisplenic free fluid, measuring simple fluid density.
PELVIS: The urinary bladder and distal ureters are unremarkable. There has
been interval increase in moderate volume free fluid within the pelvis,
measuring simple fluid density. No organized fluid collection identified.
REPRODUCTIVE ORGANS: There is an enlarged, fibroid uterus, with the largest
fibroid again seen in the left lower anterior uterine segment. There is
redemonstration of an ill-defined 13 mm hypodensity within the right adnexa
with mild surrounding fat stranding (5:67), suspicious for a ruptured
hemorrhagic cyst. Prominent gonadal veins and pelvic varices are again noted,
findings which are nonspecific but can be seen in the setting of pelvic
congestion syndrome. The left adnexa is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No significant
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Small fat containing umbilical hernia. The abdominal and pelvic
wall is otherwise within normal limits.
IMPRESSION:
1. Mild thickening and enhancement of the peritoneum, which may represent mild
peritonitis.
2. Slight interval increase in small to moderate volume free fluid within the
abdomen and pelvis measuring simple fluid density, with similar appearance of
a 13 mm rounded hypodense lesion in the right adnexa, findings which likely
represent sequela of a ruptured hemorrhagic cyst.
3. No organized fluid collections identified.
4. Small bilateral pleural effusions with adjacent compressive atelectasis,
slightly increased from prior study.
5. Enlarged fibroid uterus.
6. Prominent gonadal veins and pelvic varices, findings which are nonspecific
but can be seen in the setting of pelvic congestion syndrome. Clinical
correlation is recommended.
7. Hyperdense biliary sludge layering within the gallbladder, without evidence
of surrounding inflammatory change.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Chest pain
Diagnosed with Unspecified ovarian cyst, right side
temperature: 100.8
heartrate: 144.0
resprate: 20.0
o2sat: 100.0
sbp: 116.0
dbp: 65.0
level of pain: 9
level of acuity: 1.0 | Ms. ___ is a ___ yo G1P0 who was admitted to the
gynecology service on ___ with abdominal pain and fevers.
*) Abdominal pain
On HD#0 she had a Pelvic US (___) that showed moderate free
fluid, consistent with ruptured hemorrhagic cyst, 1.2cm simple R
ovarian cyst. She also had a CT A/P (___) that showed moderate
complex fluid in abdomen, 11mm rounded R adnexal structure
consistent with ruptured hemorrhagic cyst. Her Hct was trended
and went from 31.5 on admission and trended down until it was
stable at ___. Her pain was well controlled with
Ibuprofen/acetaminophen/oxycodone prn. By hospital day 4 she was
not requiring and opiate pain medications. Her vital signs
remained stable and her abdominal exam was improving. She was
discharged on HD#5 with PO pain medications and follow-up
scheduled.
*) Fever
Given her abdominal pain and fever on arrival (Tmax 102.9 on
12.24 HD#1) a UA was done on HD#0 (___) that showed positive
nitrites and a few bacteria. A CBC on HD#0 (___) showed WBC 12
and 17 bands. Flu swabs in the ED (___) were negative. She was
started on doxycycline and flagyl. On HD#2 her urine culture
resulted with E. Coli sensitive to ceftriaxone. She was
transitioned to ceftriaxone on HD#1. She respiked a fever on
HD#1 and ID was consulted and vancomycin was added to her
regimen. Her Gonorrhea and chlamydia tests were negative. She
respiked a fever on HD#3 and was continued on ceftriaxone. She
then respiked a fever on HD#4 to 102.6. Blood cultures were
taken multiple times during all febrile episodes and were
negative. ID and medicine were consulted and, given she had
developed URI sx on HD#3 recommended re-screening her with a
respiratory viral panel, including flu. This came back positive
on HD#4 for Influenza A. She was started on Tamiflu and put on
droplet precautions. She remained afebrile for 24hrs and was
dicharged the following day in stable condition with tamiflu, a
10day course of abx for cystitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain and fatigue
Major Surgical or Invasive Procedure:
right heart catheterization
pleurocentesis
History of Present Illness:
This patient is a ___ year old male w/ hx of NSTEMI, HIV (CD4 <
200) not on therapy, DMII, CKD, cardiomyopathy (EF 20%), Burkitt
Lymphoma and Hodgkin's (relapsed) who presents with failure to
thrive. Pt with a week of right sided chest pain under breast
intermittently, not associated w/ exertion. Does not radiate.
Feels like a shock in quality. Lasts for minutes at a time
(usually < 5 min). No chest pain currently and has not been
present for 48hrs. No clear pleuritic component. No hemoptysis.
No calf pain.
.
Pt went to Dr. ___ with cough at the end of ___, with
suspicion of PNA (vs. pulm edema) based upon exam and CXR. Pt
was treated w/ levofloxacin for one week. The patient brought
the prescription with him, but not sure he took it every day.
Pt states that he has had "weakness" for the past week as well,
and states he has not been able to walk to the door (although
denies that the symptoms were secondary to dyspnea). The
patient states he has had loose stools for the past five days,
and last had a loose BM in the ED. The patient explains that he
sometimes gets confused with his medications, and has not taken
his lasix or other medications every day. The patient sleeps
with ___ pillows at night, and has no trouble sleeping flat
without pillows. The patient denies PND. The patient still
reports a cough periodically. Pt has had a poor appetite in the
past week.
.
Hx of CHF with LVEF < 20% on last ECHO in ___. No CAD he knows
of, but hx of NSTEMI in ___ per OMR. No history of blood clots.
.
In the ED, initial vs were:97.8 88 118/88 18 99%.
EKG: 90, sinus, T wave inversions in V2-5, st-t downsloping;
slightly more pronounced from prior.
CXR demonstrated moderate right pleural effusion increased
compared to prior, likely with subpulmonic component with
consolidation at right lung base, pulmonary congestion.
Labs demonstrated troponin negative x1, BNP (7300) elevated from
prior (5000 in ___, hx range (3K-7K). Lactate 2.1. Cr 1.8
(b/l 1.3-1.9). Hct 33.8 (from b/l 32). INR 1.5. LFTs abnl (ALT
319 AST 258 AP 289).
Pt received 750mg IV levoquin and 1L IVF.
Vitals on transfer: 98 84 22 BP 98/70
Pt admitted for chest pain.
.
Review of sytems: Denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- NSTEMI ___ medically managed
- HIV (CD4 198 ___,000 ___
- HIV cholangiopathy
- DM, type II, uncontrolled (most recent HA1c 9.0 on ___
- CKD
- Cardiomyopathy with EF 20% on ___ likely secondary to
doxorubicin, although HIV and/or ischemia may have contributed
- Pleural effusions
- Burkitt's lymphoma (___)
- Hodgkins lymphoma (last cycle ___, stable disease)
Social History:
___
Family History:
Mother with gastric cancer. Father with ___ and ?cancer.
Physical Exam:
On admission:
Vitals: 98.1 120/80 77 16 98%RA
General: NAD, AOx3, pleasant
HEENT: Sclera anicteric, MM dry, poor dentition, dry lips w/
some lesions
Neck: supple, no LAD, JVP 10cm H20
Lungs: good air movement, decreased lung sounds at R lung base,
rare crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley, no CVA tenderness
Ext: warm, well perfused, 2+ pedal pulses, no clubbing, cyanosis
or edema, very dry skin bilaterally on feet and lower
extremities, with no clear diabetic foot ulcers appreciated, dry
skin
Neuro: CNs2-12 intact, 5- strength in lower extremities b/l,
mild decrement in sensation in feet, no pronator drift, no
asterixis
On discharge:
Tm/Tc: 98.2/98.2 HR: ___ BP: ___ RR: 20 (___) 02
sat: 100%
GENERAL: slowly answers questions in quiet voice, AAOx3, able to
answer basic questions, but confused as to why he is in the
hospital. No pain, NAD.
HEENT: mucous membranes moist, minimal cracking to edges of
lips, neck supple, JVP non elevated with pt. seated at 90
degrees, difficult to fully assess d/t neck dressing.
CHEST: Unlabored breathing, no accessory muscles or retractions,
no cough, lungs with bibasilar crackles.
CV: No lifts, heaves, or thrills. RRR, Normal S1, S2. No S3, S4,
murmurs, rubs, or gallops
ABD: Soft, distended, non-tender, BS normo to hyperactive x 4
quadrants. Mild tendernes with deep palpation.
EXT: WWP, legs with slight flaking to ankles, no edema.
SKIN: Skin warm, dry, intact, no pressure sores or rashes.
Bruising to left lateral right foot, below fifth toe,
non-tender.
Access: Portacath (not accessed) to left subclavian, PIVs to
right and left arms, all dressings CDI.
Pertinent Results:
On admission:
___ 03:33PM BLOOD WBC-6.6 RBC-3.52* Hgb-11.4* Hct-33.8*
MCV-96 MCH-32.4* MCHC-33.7 RDW-16.4* Plt ___
___ 03:33PM BLOOD Neuts-41.9* Lymphs-51.5* Monos-4.4
Eos-1.0 Baso-1.1
___ 03:33PM BLOOD ___ PTT-23.7* ___
___ 03:33PM BLOOD Glucose-109* UreaN-37* Creat-1.8* Na-133
K-4.8 Cl-102 HCO3-20* AnGap-16
___ 03:33PM BLOOD ALT-319* AST-258* AlkPhos-289*
TotBili-0.6
___ 03:33PM BLOOD CK-MB-2 proBNP-7345*
___ 03:33PM BLOOD cTropnT-<0.01
___ 03:33PM BLOOD Albumin-3.5 Calcium-9.2 Phos-4.0 Mg-2.1
___ 05:47PM BLOOD Lactate-2.1*
On discharge:
WBC 6.9
RBC 3.92*
Hgb 12.5*
Hct 36.7*
MCV 94
Plt 243
Glucose 184
Urea 57
Creatinine 2.3
Na 134
K 4.6
Cl 91*
HCO3 32
AG 16
ALT 152*
AST 121*
AP 267*
TB 0.3
___ TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is severe global left ventricular hypokinesis.
Quantitative (3D) LVEF = 22%. The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis.
There is abnormal diastolic septal motion/position consistent
with right ventricular volume overload. The aortic root is
mildly dilated at the sinus level. Mild (1+) aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets fail to fully coapt. Moderate to
severe [3+] tricuspid regurgitation is seen. Pulmonary pressures
are likely elevated, but cannot be estimated reliably because of
moderate to severe TR. Appearance of right ventricle suggests
that the RV stroke work index is abnormal. There is a small
pericardial effusion.
IMPRESSION: Severe global biventricular systolic dysfunction
with markedly depressed forward stroke volume. Mild aortic and
mitral regurgitation. Moderate to severe tricuspid
regurgitation.
Compared with the prior study (images reviewed) of ___,
estimated cardiac output is lower. Right ventricle is larger and
RV systolic function is further depressed.
___ CATH:
COMMENTS:
1. Limited resting hemodynamics revealed severely elevated right
and
left-sided filling pressures with RVEDP 25mm Hg, mean PCWP 34mm
Hg.
Moderate pulmonary arterial hypertension with mean PA 40mmHg
secondary
to elevated left-sided pressures with a transpulmonary gradient
of
6mmHg. There was marked respiratory variability throughout
tracings.
2. Severely depressed cardiac output with cardiac index 1.21
with
arterial O2 saturation by pulse oximetry 97% on room air and PA
O2
saturation of 30%.
FINAL DIAGNOSIS:
1. Cardiogenic shock with marked elevation in right and left
heart
filling pressures and low cardiac index.
___ portable abdomen:
SINGLE FRONTAL SUPINE IMAGE OF THE ABDOMEN: The hemidiaphragms
are excluded from the field of view as well as the right lateral
aspect of the abdomen. Limited assessment of the abdomen shows
normal bowel caliber. Assessment for pneumoperitoneum is
extremely limited on this single view. There are calcified right
hemipelvic phleboliths. An electronic metallic device obscures
the proximal aspect of the left femur, possibly the patient's
mobile telephone.
___ liver/gb us:
IMPRESSION:
1. Prominent hepatic veins, right pleural effusion, ascites, and
diffuse
gallbladder thickening consistent with the patient's known
cardiomyopathy and
congestive heart failure.
2. No dilation of the biliary system is seen.
3. Tiny gallbladder polyps / adherent stones without signs of
cholecystitis.
___ pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Few
macrophages.
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a
day
FLUCONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth daily
FUROSEMIDE - 80 mg Tablet - 1 Tablet(s) by mouth twice a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth twice a day
GLIPIZIDE - 10 mg Tablet Extended Rel 24 hr - 1 (One) Tablet(s)
by mouth daily with a 5mg tablet for total daily 15mg dose
GLIPIZIDE - 5 mg Tablet Extended Rel 24 hr - 1 (One) Tablet(s)
by
mouth once a day with a 10mg tablet for total daily 15mg dose
LEVOFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth daily
LISINOPRIL - 2.5 mg Tablet - one Tablet(s) by mouth daily
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg Tablet Extended Release
24 hr - 1 Tablet(s) by mouth daily
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - 400 mg-80 mg Tablet -
1
Tablet(s) by mouth once a day
ASPIRIN [ENTERIC COATED ASPIRIN] - 81 mg Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth daily
FOOD SUPPLEMENT, LACTOSE-FREE [ENSURE] - Liquid - 1 can(s) by
mouth one to three times daily as needed for nutritional
supplement
WHITE PETROLATUM-MINERAL OIL [EUCERIN] - Cream - apply to dry
skin and feet daily
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 8 days: last day ___.
7. nystatin 500,000 unit Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
8. insulin glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime.
9. insulin lispro 100 unit/mL Solution Sig: ___ units
Subcutaneous four times a day: as per sliding scale.
10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
Hold SBP < 90.
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
12. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
13. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. furosemide in 0.9 % NaCl 100 mg/100 mL (1 mg/mL) Solution
Sig: 40-80 mg Intravenous once a day as needed for weight gain
unresponsive to Torsemide adjustment.
16. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day:
Please do not start until creatinine <= 1.8. .
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on Chronic Systolic congestive heart failure
Coronary artery disease
AIDS
Acute on Chronic Kidney injury
Diabetes mellitus, uncontrolled
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive but can be
lethargic after meals.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right-sided chest pain, shock-like in quality. Does not radiate.
Lasts for minutes at a time. Associated with nausea. Please evaluate for
acute process.
TECHNIQUE: Chest radiograph from ___.
FINDINGS: Frontal and lateral radiographs of the chest were obtained. Lung
volumes are slightly low. A moderate right pleural effusion has increased
compared to the prior study from ___, likely with a subpulmonic
component. A concomitant consolidative process at the right lung base cannot
be excluded. There is mild pulmonary vascular congestion without frank
interstitial edema. Mild cardiomegaly is unchanged. The mediastinal contours
are normal. There is no pneumothorax. A right Port-A-Cath ends in the
mid-to-low SVC.
IMPRESSION:
1. Moderate right pleural effusion with a likely subpulmonic component. A
concomitant infectious process at the right base cannot be excluded.
2. Unchanged mild cardiomegaly.
3. Mild pulmonary vascular congestion without interstitial edema.
Radiology Report
LATERAL CHEST
REASON FOR EXAM: Evaluate pleural effusion. Comparison is made with prior
study performed 2 hours earlier.
This is a left lateral decubitus in a patient with right pleural effusion.
Right pleural effusion cannot be evaluated, right lateral decubitus is
recommended.
Radiology Report
REASON FOR THE EXAMINATION: This is a ___ man with HIV disease,
cardiomyopathy, and elevated LFTs. The request is to assess for dilated
biliary system or liver pathology.
COMPARISON: Prior CT examination from ___ and ultrasound from ___.
FINDINGS: Right pleural effusion is seen.
The hepatic veins are prominent. Liver shows no focal or textural
abnormalities.
Small volume gallbladder with diffuse thickened wall is seen, consistent with
third spacing.
A few tiny gallbladder polyps / adherent stones are seen. Negative ___
sign. There is no intrahepatic biliary duct dilatation. CBD measures 0.6 cm.
A simple renal cyst is seen measuring 3.1 x 2.9 x 2.9 cm. This cyst was seen
on prior CT examination. Otherwise, both right and left kidneys are normal
without hydronephrosis or stones.
The spleen is unremarkable measuring 9.5 cm. The pancreas is not well
visualized.
Small periportal lymph node is seen measuring 1.4 x 1.5 x 1 cm.
The visualized portions of the inferior vena cava are normal.
Ascites is seen.
IMPRESSION:
1. Prominent hepatic veins, right pleural effusion, ascites, and diffuse
gallbladder thickening consistent with the patient's known cardiomyopathy and
congestive heart failure.
2. No dilation of the biliary system is seen.
3. Tiny gallbladder polyps / adherent stones without signs of cholecystitis.
Radiology Report
INDICATION: Abdominal distention and right upper quadrant pain.
COMPARISON: CT from ___.
SINGLE FRONTAL SUPINE IMAGE OF THE ABDOMEN: The hemidiaphragms are excluded
from the field of view as well as the right lateral aspect of the abdomen.
Limited assessment of the abdomen shows normal bowel caliber. Assessment for
pneumoperitoneum is extremely limited on this single view. There are
calcified right hemipelvic phleboliths. An electronic metallic device
obscures the proximal aspect of the left femur, possibly the patient's mobile
telephone.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with chest pain after right
thoracocentesis.
Portable AP radiograph of the chest was reviewed in comparison to ___.
Swan-Ganz catheter is at the level of the right ventricle outflow tract. The
Port-A-Cath catheter tip can be seen at the level of cavoatrial junction.
There is enlargement of the left ventricle, unchanged. There is no evidence
of pneumothorax. There is no appreciable pleural effusion demonstrated.
There are mild right lower lobe opacities that might potentially reflect area
of atelectasis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: CP
Diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 97.8
heartrate: 88.0
resprate: 18.0
o2sat: 99.0
sbp: 118.0
dbp: 88.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old male w/ hx of NSTEMI, HIV (CD4 <
200), DMII, CKD, cardiomyopathy (EF 20%), Burkitt Lymphoma and
Hodgkin's who presents with failure to thrive and
decompensated/acute on chronic biventricular heart failure. He
underwent diuresis with lasix and metolazone and was started on
dopamine and milrinone. Pt responded and was transferred to the
floor and was dc-ed to a long-term acute rehabilitation in a
stable condition.
# Hypotension: He became hypotensive the day after admission
with repeat echocardiogram suggestive of low-output heart
failure. He was transferred to the CCU for further care after
small IVF bolus and broad spectrum antibiotics were initiated.
RHC revealed low CO and CI, and right sided failure primarily
due to elevated left sided filling pressures. He was started on
a low dose dopamine infusion and milrinone was initiated which
resulted in improvement in blood pressures, excellent urine
output 10L net negative and weight loss with improvement in
kidney function and liver enzymes c/w fluid overload as cause of
both. He was taken off dopamine and milrinone before transfer to
the floor and pressures were stable after initial hospital
course. He was started on torsemide, lisinopril and metoprolol.
Torsemide was held on discharge due to increase in creatinine
with plan to resume as an outpatient once creatinine returned to
baseline.
# Acute on chronic systolic congestive heart failure: His new
TTE showed low-output biventricular heart failure. He underwent
cardiac catheterization which demonstrated marked elevation in
right and left heart filling pressures and low cardiac index
consistent with CHF. Pt was started on dopamine, milrinone, and
diuresed with IV lasix gtt and metolazone. Was switched to
torsemide prior to discharge after pt was diuresed close to his
dry weight. He was started on metoprolol XL 25 qd and lisinopril
as well as torsemide. Pt became orthostatic day prior to
discharge with a rise in creatinine, and thus torsemide was
held. His diuretics should continue to be titrated since his
fluid balance is difficult to manage. His volume status is
difficult to assess on exam as he rarely has peripheral edema
and tends to hold extra fluid in his abdomen. His weight at
discharge is 60.2 kg.
# Chest Pain: Patient originally complained to EMS of chest pain
but on admission to floor said it resolved two days prior to
admission. He ruled out for ACS.
# Pleural Effusions/Burkitts and Hodgkin's lymphoma: Moderate
right pleural effusion with a likely subpulmonic component on
CXR from ED. DDx included parapneumonic effusion vs. CHF
effusion vs. malignancy (hx of lymphoma). He underwent
thoracentesis which showed no malignant cells and few
macrophages. However, he did have plamcytoid cells and large
atypical cells with basophilic cytoplasm and nucleoli c/w
immunoblasts. The flow cytometry was negative, however.
# Urinary tract infection: He reported dysuria and had a
positive UA. While awaiting urine culture, he was empirically
started on ciprofloxacin which was broadened given his
hypotension. Urine culture was negative and pleural effusion
showed no evidence of infection, thus abx were discontinued with
exception of flagyl.
# Diarrhea: Stool studies showed +ve c.diff so pt was started on
a 14 day course of flagyl.
# Abnormal LFTs: RUQ u/s showed congestive hepatopathy and
ascites. LFTs improved with managment of CHF as above.
# Mouth lesions: His acyclovir was continued and renally dosed.
Pt also with oral thrush; he was continued on nystatin given his
elevated liver enzymes. When his liver enzymes trend down, he
should be restarted on fluconazole.
#HIV. Pt w/ CD4 ___K in ___. Bactrim was
continued for PCP ___. Flucanozole was held as above. Pt
has very limited understanding of his medical condition.
# Chronic kidney disease: Creatinine elevated to 2.5 and pt was
oliguric ___ to poor perfusion from heart failure. Improved
immensely with milrinone and low dose dopamine and lasix.
Continued to diurese on torsemide.
# Type 2 diabetes, poorly controlled, with complications: HA1c 9
most recently.
Continue glargine. Continue to hold glipizide given rising
creatinine
# Neuropathy: Gabapentin was continued but renally dosed.
# Mental status: Pt with no insight into his heart disease or
AIDS. He should have cognitive neurology follow up and
consideration of HIV dementia.
.
.
Code status: Full code
HCP: ___
Relationship: Older brother
Phone number: ___
.
___
1) Continue to titrate diuretics
2) Follow up with Dr. ___
3) Continue to treat for C diff with flagyl, course to be
determined by Dr. ___
4) Follow up with Dr. ___ lymphoma
5) Follow up with Dr. ___ heart failure
6) Cognitive neurology for dementia |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Bactrim / Norvasc / Lipitor / Cortisone
Attending: ___
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ right-handed woman with a history
of
postviral autoimmune enteropathy, chronic CKD, resistant
hypertension, HLD, and recent stroke who presents with increased
left-sided weakness.
She was recently admitted to medicine for recurrent diarrhea
(___), and during that admission developed left-sided foot
drop (___) and was found to have multifocal right MCA territory
strokes. She was started on a heparin drip. CTA showed distal
right M1 occlusion. Telemetry did not reveal a-fib. TTE was
negative for thrombus or ASD/PFO. Heparin was stopped and she
was started on aspirin and Plavix for presumed artery-to-artery
embolism. Her deficits upon discharge included primarily left
leg
weakness ___ everywhere except quadricep, which was ___.
She was at her rehab today, and participated in all of her
morning activities normally. During the afternoon session, her
physical therapist did not think she was as strong as she was in
the morning, and noted that her gait was worse particularly in
the left leg. She was evaluated by a physician at the rehab,
and
transferred to ___, who subsequently
transferred
her here.
She denies any increased weakness, and says she feels at
baseline. She has had no recent fevers, headache, chest pain,
palpitations, dysuria or urine odor/appearance change.
Past Medical History:
Stroke (multifocal right MCA territory)
Autoimmune enteropathy
Chronic kidney disease (baseline Cr 1.6)
Resistant hypertension
Hyperlipidemia
Social History:
___
Family History:
Mother, aunt, and 2 older brother all with HTN. Father had
CAD/MI. Mother and brother also have diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T:96.7 HR:70 BP:158/62 RR:16 SaO2:99
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: Well perfused.
Pulmonary: Breathing comfortably on room air.
Abdomen: Soft, NT, ND.
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Speech is fluent with full sentences
and intact repetition. Verbal comprehension generally intact,
however had some difficulty following directions as part of
exam,
with subtle problems of inattention and possible disinhibition,
though able to name ___ backwards. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ at 5 minutes, and correctly naming the
___
after a category clue. No evidence of hemineglect.
- Cranial Nerves: PERRL 3->2 brisk. VF full to finger movement.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Mildly hard of
hearing. Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 4+ 5 4+ 5 5 ___ 4 3 3 3
R 5 5 5 5 5 ___ 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 1+ 2+ 2+ 2
R 2+ 1+ 2+ 2+ 2
Plantar response extensor on left.
- Sensory: No deficits to light touch or cold bilaterally.
- Coordination: Moderate dysmetria with finger to nose testing
on
left, out of proportion to weakness. Clumsy and irregular rapid
finger tapping on left. Dysdiadokokinesia on left. Toe-to-finger
slower and less facile on left compared to right.
- Gait: Deferred
___ Stroke Scale - Total [2]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 0
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 2
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
DISCHARGE PHYSICAL EXAM
T 97.6-99.9, BP 118-154/60-80, HR 87-91, RR ___, 95-97%RA
Lying in bed in NAD, conversational breathing room air,
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Conversational,
knows why she is in the hospital and can relate overnight
events.
No evidence of hemineglect.
- CN: EOMI, sensation intact bilaterally, pupils 3-->2
bilaterally, symmetric smile
- Strength: delts. biceps, triceps, finger flexion, wrist
extension ___ b/l; finger flexion 4+/5 bilaterally. IPs, R
hamstring, quads b/l ___ Left hanstring 4+; Left TA 5-
No tremor, asterixis
Coordination: FTN left sided mild dysmetria, improved compared
to prior exam
left pronation no drift
Plantar response extensor on left.
- Sensory: No deficits to light touch or cold bilaterally.
- Gait: Deferred
Pertinent Results:
___ 06:00AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.3* Hct-30.3*
MCV-92 MCH-31.3 MCHC-34.0 RDW-12.7 RDWSD-41.9 Plt ___
___ 12:35PM BLOOD PTT-45.1*
___ 12:25AM BLOOD ___ PTT-25.8 ___
___ 06:00AM BLOOD Glucose-113* UreaN-31* Creat-1.2* Na-143
K-4.3 Cl-104 HCO3-27 AnGap-12
___ 12:25AM BLOOD ALT-79* AST-64* AlkPhos-28* TotBili-0.6
___ 06:00AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.8
___ 08:26AM BLOOD %HbA1c-5.4 eAG-108
___ 12:25AM BLOOD LDLmeas-80
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSAT
3. Fenofibrate 145 mg PO DAILY
4. Loratadine 10 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO BID
6. Minoxidil 5 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Pramipexole 0.125 mg PO QHS
9. Simvastatin 40 mg PO QPM
10. Valsartan 320 mg PO DAILY
11. Estrogens Conjugated 0.625 mg PO DAILY
12. Furosemide 40 mg PO DAILY
13. Labetalol 100 mg PO BID
14. Lansoprazole Oral Disintegrating Tab 30 mg Other DAILY
15. MetFORMIN (Glucophage) 1000 mg PO DAILY
16. Nasonex (mometasone) 50 mcg/actuation nasal ASDIR
17. Aspirin 81 mg PO DAILY
18. Clopidogrel 75 mg PO DAILY
19. LOPERamide 2 mg PO QID:PRN diarrhea
20. NIFEdipine CR 60 mg PO DAILY
Discharge Medications:
1. Heparin IV per Weight-Based Dosing Protocol
Indication: Treatment of Other Thromboembolism
Continue existing infusion at 650 units/hr
Therapeutic/Target PTT Range: 60 - 99.9 seconds
Start: Today - ___, First Dose: 1700 hrs
Stop Instructions: When INR 2.0-3.0
2. Ramelteon 8 mg PO QHS:PRN Insomnia
3. Warfarin 3 mg PO DAILY16
4. Pramipexole 0.25 mg PO QHS
5. Aspirin 81 mg PO DAILY
6. Citalopram 40 mg PO DAILY
7. Estrogens Conjugated 0.625 mg PO DAILY
8. Fenofibrate 145 mg PO DAILY
9. Labetalol 100 mg PO BID
Home medication, not taken at the same time as metoprolol
10. Lansoprazole Oral Disintegrating Tab 30 mg Other DAILY
11. LOPERamide 2 mg PO QID:PRN diarrhea
12. Loratadine 10 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO DAILY
14. Metoprolol Tartrate 100 mg PO BID
15. Minoxidil 5 mg PO BID
16. Multivitamins 1 TAB PO DAILY
17. Nasonex (mometasone) 50 mcg/actuation nasal ASDIR
18. NIFEdipine CR 60 mg PO DAILY
19. Simvastatin 40 mg PO QPM
20. HELD- Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSAT This
medication was held. Do not restart Clonidine Patch 0.2 mg/24 hr
until you follow up with your PCP
21. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until creatinine returns to baseline
22. HELD- Valsartan 320 mg PO DAILY This medication was held.
Do not restart Valsartan until creatinine normalizes
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute ischemic stroke
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: Frontal and lateral views
INDICATION: ___ with new weakness. Evaluate for pneumonia.
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Multiple chest radiographs, most recently dated ___.
FINDINGS:
Right upper extremity PICC line has been removed. The lungs are clear without
focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac
and mediastinal silhouettes are stable.
IMPRESSION:
No acute cardiopulmonary abnormalities.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ with known right MCA territory infarct, now with worsening l
sided weakness// ? vascular abnormality
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL Visipaque 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 14.0 s, 14.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
702.4 mGy-cm.
2) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 27.2 mGy (Head) DLP =
13.6 mGy-cm.
3) Spiral Acquisition 4.4 s, 34.2 cm; CTDIvol = 30.8 mGy (Head) DLP =
1,055.7 mGy-cm.
Total DLP (Head) = 1,772 mGy-cm.
COMPARISON: CTA head neck ___, MR head ___
FINDINGS:
Dental amalgam streak artifact limits study.
CT HEAD WITHOUT CONTRAST:
Again seen are areas of hypodensity within the right insular cortex, the right
temporal lobe, and within the right centrum ovale, compatible with known and
now early subacute sites of infarction. There is no evidence of intracranial
hemorrhage. The ventricles and sulci are stable in size and configuration.
The patient is status post functional endoscopic sinus surgery. Mucous
retention cysts are seen in the bilateral maxillary sinuses. The remainder of
the imaged paranasal sinuses, middle ear cavities, and mastoid air cells are
clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is persistent, unchanged complete occlusion of the distal right M1
segment of the middle cerebral artery, prior to the bifurcation, with
suggested partial opacification of distal right MCA M2 superior branch and
distal. The left MCA is widely patent without evidence of stenosis. Again
noted is a hypoplastic right A1 segment of the anterior cerebral artery.
Otherwise, the remainder of the vessels of the circle of ___ and their
principal intracranial branches appear patent without stenosis, occlusion, or
aneurysm formation. Atherosclerotic calcification within the bilateral
cavernous carotid arteries is moderate.
CTA NECK:
Dense atherosclerotic calcifications are again noted at the bilateral carotid
bifurcations, moderate severe on the left with approximately 50% stenosis, and
moderate on the right with less than 50% stenosis. The bilateral internal
carotid and vertebral arteries and their major branches appear patent with no
evidence of stenosis or occlusion.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. Scattered subcentimeter nonspecific
lymph nodes are noted throughout the neck bilaterally and mediastinum ,
without definite enlargement by CT size criteria.
IMPRESSION:
1. Dental amalgam streak artifact limits study.
2. Grossly stable distal right M1 occlusion, with associated and evolving
subacute infarcts of right insular cortex, temporal lobe, and centrum ovale,
without definite evidence of hemorrhagic transformation.
3. No definite evidence of new vascular territorial infarctions or acute
intracranial hemorrhage. Please note MRI of the brain is more sensitive for
the detection of acute infarct.
4. Additional sites of atherosclerotic disease within the bilateral cavernous
and supraclinoid internal carotid arteries, and at the bilateral carotid
bulbs, as detailed above.
5. Nonspecific mediastinal and cervical mildly prominent lymph nodes without
definite enlargement by CT size criteria, likely reactive.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with expanding stroke on CT scan, for further
evaluation.
TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo,
and diffusion-weighted images of the brain were obtained.
COMPARISON: ___ head CT/CTA
___ head CT/CTA and brain MRI.
FINDINGS:
Images are limited by motion artifact.
There is an evolving acute infarction in the right MCA territory, stable in
extent in the insular cortex and right centrum semiovale, but increased in
extent in the posterior right frontal lobe and in the right temporal lobe
compared to the ___ MRI. There is no evidence for associated blood
products. Partial effacement of the atrium of the right lateral ventricle has
not changed significantly. There is no shift of midline structures.
Small foci of high T2 signal in the periventricular, deep, and subcortical
white matter, without associated diffusion abnormality, are grossly unchanged,
likely sequela of chronic small vessel ischemic disease in this age group.
There is persistent paucity of flow voids in the expected location of the
right M2 segment and distal branches, with vasculature better assessed on the
concurrent CTA.
There are mucous retention cyst in the maxillary sinuses and mild mucosal
thickening in the ethmoid air cells.
IMPRESSION:
1. Evolving acute infarction in the right MCA territory, with increased extent
in the right posterior frontal lobe and right temporal lobe, and stable extent
in the right insular cortex and right centrum semiovale. No significant
increase in mass effect.
2. Persistent paucity of flow void in the expected location of the right M2
segment and distal branches, better assessed on the concurrent CTA.
Radiology Report
Study carotid series complete
Reason stroke
Findings. Duplex evaluations for both carotid arteries. Calcified plaques
identified.
The right velocities are 54, 83, 175 in the ICA, CCA, ec respectively. The
ratio is 0.6. This is consistent less than 40% stenosis.
The left velocities are 123, 92, 107 in the ICA, CCA, ec respectively. The
ratio is 1.3. This is consistent less than 40% stenosis.
There is antegrade flow in both vertebral arteries
Impression minimal plaque with bilateral less than 40% carotid stenosis
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Weakness
Diagnosed with Weakness
temperature: 96.7
heartrate: 70.0
resprate: 16.0
o2sat: 99.0
sbp: 158.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with a recent diagnosis of
multifocal right hemispheric stroke with residual left leg
weakness who presents with worsened weakness in the left leg and
arm. Her exam is significant for increased weakness in the
distal left leg at the hamstring and TA and left sided dysmetria
and pronator drift. She was previously started on
dual antiplatelets for presumed artery-to-artery emboli.
Cardioembolism was deemed less likely due to negative TEE and
absence of arrhythmias while on telemetry, however a Holter
monitor had been planned. While in the ED, UA was done to
evaluate for recrudescence of previous strokes, and this was
unremarkable. CTA showed persistent occlusion of the distal
right M1 segment of the
middle cerebral artery, stable from her last admission. MRI
showed evolving acute infarction in the right MCA territory.
Patient was started on a heparin drip as a bridge to Coumadin.
She remained stable on heparin drip and ready for discharge to
___ who will manage her INR ___.
Please follow the patient's INR daily, with goal 2.0-3.0.
Please check daily labs on the patient, and restart her
valsartan and lisinopril when creatinine normalizes.
Please keep an eye on her blood pressure, and increase
medications to keep her goal systolic blood pressure 110-170.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed â () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 80) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
PICC dislodged, FTT, hypoxia
Major Surgical or Invasive Procedure:
left PICC placement ___
History of Present Illness:
Mr. ___ is a ___ year old
man with history of metastatic colon cancer s/p LAR with
ileostomy ___, recently on chemo which was held after recent
admission for SBO with laparotomy now representing from rehab in
the setting of PICC dislodgement and hypoxemia.
Patient had a prolonged month long hospitalization ___
during which time he was diagnosed with SBO for which he had
exlap, reduction of hernia and lysis of adhesions with course
complicated by afib with RVR, hypotension and anemia as well as
hypoxia (thought atelectasis) and malnutrition ultimately
discharged on TPN.
He has been doing ok at rehab with improving mobility it sounds
like, still on TPN. He was recently diagnosed with a UTI with
GNRs in foley though unclear if symptomatic, also started on PO
vancomycin for unclear reasons. Per his family, has been having
intermittent confusion and memory deficits. He was somewhat
confused on ___ and reportedly overnight ___ pulled out his
PICC overnight (? on purpose). He was also diagnosed with
possible UTI and started on levofloxacin this same day. Due to
malpositioning of PICC, he was transferred to the ___ ED for
___ replacement. Of note, also recently diagnosed with large
sacral decubitus ulcers for which he is getting wound care.
In the ED, initial vitals were: 97.7 78 91/54 16 96%RA
Labs notable for WBC 11.3 with 80% polys, H/H 8.4/27.4, plts
548,
Cr 0.8, lactate 1.3, trop <0.01.
He was initially ordered for coags with plan for PICC
replacement
by ___. Unfortunately, overnight, he had acute episode of
respiratory distress with O2 sat to 80% on RA, improved on
facemask with clear lung sounds on exam. Repeat CXR again showed
mild pulmonary edema and increased interstitial and nodular
opacities concerning for superimposed infection. He was given IV
Lasix for possible flash pulmonary edema as well as levofloxacin
for atypical pneumonia.
Oxygen requirement improved to 1L however given persistence and
inability to get PICC placed, decision was made to admit for
further evaluation.
In the ED, he received oxycodone x2, lorazepam, tamsulosin,
phenazopyridine, Lasix IV (40mg), potassium chloride and
levofloxacin.
Vitals prior to transfer: HR 99 117/71 18 96% 1L NC
On the floor, patient reports that he overall feels poorly but
cannot exactly pinpoint. He is slow to respond but appropriate,
oriented to place and year. Reports poor short term memory which
comes and goes.
Review of systems:
(+) Per HPI. 10 point ROS otherwise negative in detail
Past Medical History:
PAST MEDICAL HISTORY:
Atrial fibrillation
Right bundle branch block
Metastatic (stage IV) colon cancer s/p chemotherapy, stopped
___ given recent obstruction
Mediastinal lymphadenopathy 785.6
LAR with diverting ileostomy ___, ___
Hyperlipidemia
H/o prostate cancer
s/p right ureteral stent
Sacral decubitus ulcer, unstageable
Social History:
___
Family History:
Father died when he was baby of aneursym
Mother died of ___
Physical Exam:
Admission Physical:
Vital Signs: 98 PO 128 / 85 100 15 91 1L
General: Alert but slow to respond, oriented, no acute distress
HEENT: Sclerae anicteric, MM dry, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1, split S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
ostomy in RLQ with good output
GU: Foley in place, last changed ___ at atrius
Ext: Warm, well perfused, no edema. Pressure ulcer 3x3.5cm on
right heel. 2 large sacral decubitus ulcers unstageable
Neuro: CNII-XII intact, gait deferred, moving all extremities
Discharge Physical:
97.6 PO systolics ___ Lying 92 20 94 Ra
Cachectic, sitting up in bed, sleepy but oriented and
interactive
MM dry, OP clear
No JVD
CTAB without rhonchi
RRR, no murmurs appreciated
Foley in place
Abdomen with ileostomy in RLQ, pink tissue visualized
No edema
Moving all extremities
Warm, well perfused, no edema. Pressure ulcer 3x3.5cm on right
heel. 2 large sacral decubitus ulcers unstageable
Pertinent Results:
Admission Labs:
================
___ 04:05AM BLOOD WBC-11.3* RBC-3.10* Hgb-8.4* Hct-27.4*
MCV-88# MCH-27.1 MCHC-30.7* RDW-15.6* RDWSD-49.4* Plt ___
___ 04:05AM BLOOD Neuts-80.9* Lymphs-9.4* Monos-7.1 Eos-1.7
Baso-0.4 Im ___ AbsNeut-9.11* AbsLymp-1.06* AbsMono-0.80
AbsEos-0.19 AbsBaso-0.04
___ 04:05AM BLOOD ___ PTT-28.6 ___
___ 04:05AM BLOOD Glucose-80 UreaN-20 Creat-0.8 Na-138
K-3.2* Cl-101 HCO3-25 AnGap-15
___ 11:18AM BLOOD Glucose-98 UreaN-18 Creat-1.0 Na-139
K-4.0 Cl-99 HCO3-28 AnGap-16
___ 04:05AM BLOOD cTropnT-<0.01
___ 04:30AM BLOOD Lactate-1.3
Imaging:
===========
CXR AP ___
1. No pneumothorax, as clinically questioned.
2. Unchanged interstitial and nodular opacities throughout the
lungs and mild perihilar haziness and vascular indistinctness,
concerning for infectious process superimposed on mild
interstitial pulmonary edema.
CXR PICC ___:
1. Left PICC tip in the upper SVC however the catheter appears
looped within the left subclavian vein.
2. Diffuse increased interstitial and nodular opacities
throughout the lungs. Findings could reflect an infectious
process superimposed on mild interstitial pulmonary edema.
Follow up radiographs after diuresis are suggested for further
assessment, or alternatively CT.
ECG: SR, Qtc in 440s, no ischemic changes
CXR ___ PA/Lateral:
The right Port-A-Cath tip ends at the SVC-RA junction,
unchanged. The left
subclavian approach central venous catheter tip ends in the
distal SVC,
unchanged.
Lung volumes have improved in the interim. Bilateral
interstitial thickening and peribronchovascular wall thickening
persists, likely secondary to edema and/or infection. Bilateral
nodular opacities persist. Multifocal opacities are more evident
suggesting multifocal infection. The heart is top-normal in
size. No mediastinal widening. Prominence of the hilar unchanged
from the most recent exam but more pronounced since ___.
Atelectasis at the left lung base is mild, but gradually
improved fomr ___. Biapical pleural thickening and/or
scarring is mild.
A left pleural effusion is small. No right pleural effusion. No
pneumothorax.
A large amount of loculated appearing pneumoperitoneum with
ascites under the right hemidiaphragm is overall similar
appearance to the most recent
radiograph but appears smaller from the radiographic and CT from
___
where it is better evaluated.
IMPRESSION:
1. Interval development of more conspicuous bilateral
parenchymal opacities consistent with multifocal pneumonia. 2.
Persistent but improved edema with a small left pleural effusion
and minimal cardiomegaly.
3. Right loculated pneumoperitoneum and ascites, better
evaluated on prior CT from ___.
Discharge Labs:
=================
___ 06:40AM BLOOD WBC-11.8* RBC-3.47* Hgb-9.3* Hct-30.4*
MCV-88 MCH-26.8 MCHC-30.6* RDW-15.3 RDWSD-48.9* Plt ___
___ 06:40AM BLOOD Glucose-92 UreaN-19 Creat-0.9 Na-140
K-4.0 Cl-101 HCO3-26 AnGap-17
___ 06:40AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fentanyl Patch 125 mcg/h TD Q72H
2. Gabapentin 300 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO BID
4. Amiodarone 200 mg PO BID
5. Dronabinol 10 mg PO BID
6. HYDROmorphone (Dilaudid) 1 mg PO Q6H:PRN Pain - Severe
7. Pantoprazole 40 mg PO Q24H
8. Ferrous Sulfate 325 mg PO TID
9. Ondansetron 4 mg PO TID W/MEALS
10. Ascorbic Acid ___ mg PO BID
11. Vancomycin Oral Liquid ___ mg PO Q6H
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Psyllium Powder 1 PKT PO BID
14. Florastor (Saccharomyces boulardii) 250 mg oral BID
15. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
16. Bisacodyl 10 mg PR QHS:PRN constipation
Discharge Medications:
1. Amiodarone 200 mg PO BID
2. Dronabinol 10 mg PO BID
3. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
4. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
5. HYDROmorphone (Dilaudid) 1 mg PO Q6H:PRN Pain - Severe
6. Levofloxacin 750 mg PO DAILY Duration: 3 Doses
___ for total of 7 days
7. Pantoprazole 40 mg PO Q24H
8. Vancomycin Oral Liquid ___ mg PO Q6H
Please continue through ___ (2 weeks post completion of
levofloxacin)
9. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
10. Ascorbic Acid ___ mg PO BID
11. Bisacodyl 10 mg PR QHS:PRN constipation
12. BuPROPion (Sustained Release) 150 mg PO BID
13. Fentanyl Patch 125 mcg/h TD Q72H
14. Ferrous Sulfate 325 mg PO TID
15. Florastor (Saccharomyces boulardii) 250 mg oral BID
16. Gabapentin 300 mg PO DAILY
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Psyllium Powder 1 PKT PO BID
19. HELD- Ondansetron 4 mg PO TID W/MEALS This medication was
held. Do not restart Ondansetron until ___ due to risk of qtc
prolongation on levofloxacin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Picc dislodgement
Hypoxia due to pneumonia
Cdiff colitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with 45cm left arm DL power PICC.
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Left PICC tip terminates at the upper SVC however the catheter appears to be
looped within the mid subclavian vein. Right-sided Port-A-Cath tip terminates
within the low SVC/right atrial junction. Heart size remains mildly enlarged.
The mediastinal contour is unchanged. Mild perihilar haziness and vascular
indistinctness is noted. Diffuse increased interstitial and nodular opacities
are noted within the lungs, substantially worse compared to the previous
radiograph. No pleural effusion or pneumothorax is clearly noted. There are
no acute osseous abnormalities.
IMPRESSION:
1. Left PICC tip in the upper SVC however the catheter appears looped within
the left subclavian vein.
2. Diffuse increased interstitial and nodular opacities throughout the lungs.
Findings could reflect an infectious process superimposed on mild interstitial
pulmonary edema. Follow up radiographs after diuresis are suggested for
further assessment, or alternatively CT.
Radiology Report
INDICATION: ___ year old man with L PICC malpositioned // L PICC repo
attempt, powerflushed
TECHNIQUE: AP view of the chest
COMPARISON: Chest radiograph ___ at 18:09
FINDINGS:
Left PICC tip remains in the upper SVC, but again demonstrates a loop in the
region of the left subclavian vein. Right-sided Port-A-Cath tip terminates
low SVC. Remainder of the examination is unchanged.
IMPRESSION:
Left PICC tip terminates in the upper SVC, but remains looped within the left
mid subclavian vein.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with sudden onset SOB. // PTX?
TECHNIQUE: Single portable erect AP chest radiograph
COMPARISON: ___
FINDINGS:
The right port catheter terminates in the right atrium. A left PICC
terminates in the right atrium. Previously seen loop in the left PICC tubing
has resolved.
Heart and mediastinum are stable.
Unchanged interstitial and nodular opacities throughout the lungs and mild
perihilar haziness and vascular indistinctness. No pleural effusion. No
pneumothorax.
IMPRESSION:
1. No pneumothorax, as clinically questioned.
2. Unchanged interstitial and nodular opacities throughout the lungs and mild
perihilar haziness and vascular indistinctness, concerning for infectious
process superimposed on mild interstitial pulmonary edema.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with metastatic colon cancer admitted with
hypoxia and concern for pulmonary edema vs infection. Evaluate for pulmonary
edema, worsening infiltrates/nodularity.
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple chest radiographs since ___, the most recent
dated ___.
Reference is made with the CT abdomen and pelvis dated ___.
FINDINGS:
The right Port-A-Cath tip ends at the SVC-RA junction, unchanged. The left
subclavian approach central venous catheter tip ends in the distal SVC,
unchanged.
Lung volumes have improved in the interim. Bilateral interstitial thickening
and peribronchovascular wall thickening persists, likely secondary to edema
and/or infection. Bilateral nodular opacities persist. Multifocal opacities
are more evident suggesting multifocal infection. The heart is top-normal in
size. No mediastinal widening. Prominence of the hilar unchanged from the
most recent exam but more pronounced since ___. Atelectasis at the left
lung base is mild, but gradually improved fomr ___. Biapical pleural
thickening and/or scarring is mild.
A left pleural effusion is small. No right pleural effusion. No
pneumothorax.
A large amount of loculated appearing pneumoperitoneum with ascites under the
right hemidiaphragm is overall similar appearance to the most recent
radiograph but appears smaller from the radiographic and CT from ___
where it is better evaluated.
IMPRESSION:
1. Interval development of more conspicuous bilateral parenchymal opacities
consistent with multifocal pneumonia.
2. Persistent but improved edema with a small left pleural effusion and
minimal cardiomegaly.
3. Right loculated pneumoperitoneum and ascites, better evaluated on prior CT
from ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PICC line eval
Diagnosed with Dyspnea, unspecified
temperature: 97.7
heartrate: 78.0
resprate: 16.0
o2sat: 96.0
sbp: 91.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with history of metastatic
colon cancer s/p LAR with ileostomy ___, recently on chemo
which was held after recent admission for SBO with laparotomy
now representing from rehab in the setting of PICC dislodgement
and hypoxemia.
# Picc dislodgement: Failed attempt at replacement in ED
initially however on repeat imaging after flushing, PICC
appropriately ending in SVC. OK to use.
# Hypoxia: Patient developed acute hypoxia in the ED requiring a
facemask. CXR at the time concerning for mild pulmonary edema vs
infection. He was diuresed with 40mg IV Lasix and started on
levofloxacin for atypical pneumonia. Repeat CXR on ___ with
multifocal opacities thus plan for 7 day course of levofloxacin.
Will need repeat CXR in 4 weeks to ensure resolution of
opacities. Of note, has known pulmonary nodules likely
metastatic disease on prior CT scan in ___. Zofran held due
to Qtc prolongation on levofloxacin and amiodarone. Patient was
weaned to room air on day of discharge.
# Sacral decubitus ulcers: Unstageable. No e/o infection on
exam. Patient was placed in offloading air bed. Wound care
continued. Continued on home fentanyl patch, Tylenol and
dilaudid PO.
#Severe protein-calorie malnutrition: Unable to maintain PO
intake at rehab and prior admission with weight loss. Continued
on diet while inpatient. No TPN given due to PICC malfunction,
will need to be restarted at rehab on return.
#Pseudomonas and Klebsiella in urine: Urine culture for
follow-up of recent apparent UTI at rehab sent on ___ growing
multidrug resistant Pseudomonas and klebsiella only susceptible
to carbapenems. Patient without s/s of UTI thus will not treat
for infection at this time. Suspect this is related to
colonization. Foley changed on this admission.
#Cdiff colitis: Diagnosed at rehab on ___. Confirmed with Dr.
___ treating for Cdiff of ileostomy. Changed dose to
125mg PO q6h per IDSA guidelines. Will need to continue through
___ given treatment with levofloxacin through ___.
#History of afib: Patient had afib with RVR last admission. He
was continued on amiodarone. EKG in sinus rhythm. No indication
for anticoagulation at this time given CHADS2 of 0.
#Anemia: Likely anemia of chronic disease, malnutrition and
recent blood loss from surgeries earlier this month. At
baseline.
# Rectal cancer: s/p LAR in ___ with Dr ___ obstructive
symptoms. S/p ___, C12 FOLFOX, C3 FOLFIRI, and C6 of
rinotecan/cetux last on ___. CT with partial response on
___ and stable disease on ___. Dr. ___ Dr. ___
___ of admission.
# Chronic urinary retention: ___ changed this admission due to
pseudomonas and Klebsiella in urine. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilaudid (PF) / Keflex / morphine / naproxyn /
ceftriaxone
Attending: ___
Chief Complaint:
weakness/lethargy
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
The patient is a ___ woman with a past medical history
of depression/anxiety, hypertension, hyperlipidemia, carcinoid
tumor of the small intestine with metastasis to liver, and left
total knee replacement (in ___, complicated by
recurrent hospitalizations for urosepsis and acute kidney
injury) who presents with weeks of disorientation, worsening
lethargy, and intermittent diplopia and bilateral upper
extremity ataxia. History is obtained from outside hospital and
rehab records, husband, and daughter (OB/GYN at ___ as
patient is unable to provide a history. Over the last several
months, patient has had decreased oral intake and has lost about
30 pounds. During her recovery from her total knee replacement,
she has had recurrent hospitalizations for urosepsis and acute
kidney injury. Over the last several weeks, she has had
increasing lethargy while at the rehab facility. She falls
asleep while talking with people and is frequently disoriented.
She is also been discoordinated when "reaching for cups" and
"putting a straw in her mouth" per husband (patient denies
noticing any symptoms). This occurs with both hands, confirmed
by husband and daughter. She occasionally has double vision
which she states can occur when she is looking at objects
nearby. She reports seeing images side by side and does not know
whether the second image will go away when she closes one eye.
She was referred to the ED for further workup of her poor mental
status including her disorientation and sleepiness, as well as
these new neurologic symptoms. Her daughter reports being
specifically concerned for metastasis or neuro-endocrine
etiology as patient is a history of carcinoid tumor of the colon
with a metastasis to the liver. Otherwise, at the rehab
facility, per the recommendation of the physician there, she has
started tapering her lamotrigine.
On neurologic review of systems, patient denies any lateralized
weakness or numbness, facial droop, urinary or bowel
incontinence.
Past Medical History:
PMH: benign positional vertigo, a cervical radiculopathy,
depression, GERD, hyperlipidemia, hypertension, IBS,
hypothyroidism, obstructive sleep apnea
PSH: vaginal hysterectomy performed for fibroids for leiomyomas
at age ___, lumbar discectomy in ___
Social History:
___
Family History:
Melanoma in her sister (stage uncertain, but sister remains
well).Her mother had pancreatic cancer.Her father had lung
cancer, but was a smoker.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 99.4 142/90 108 20 92 Ra
General: oriented to person and place, states that year is
___
HEENT: sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, no LAD
Lungs: mild crackles bilaterally at the bases, no wheezes,
rales, ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. RLE larger than LLE
Neurologic Examination:
- Mental Status -drowsy but arouses easily to voice. States that
the date is ___. Unable to state the months
the year backwards. Can only state 3 months when sitting the
months of the year forwards. Speaks fluently without any
paraphasic errors. Refuses further language testing including
repetition and comprehension. Unable to provide a cohesive
history and is tangential with history taking. Normal prosody.
No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. Blinks to threat in all
visual quadrants. EOMI, no nystagmus. V1-V3 without deficits to
light touch bilaterally. No facial movement asymmetry. Hearing
decreased to finger rub bilaterally. Mild dysarthria. Palate
elevation symmetric. Trapezius strength ___ bilaterally. Tongue
midline.
- Motor - Normal bulk and tone. No drift. No asterixis. Grossly
intact motor strength throughout.
- Sensory - No deficits to pin bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L ___ 0 0
R ___ 1 0
Plantar response mute bilaterally.
-Coordination - Patient overshoots with finger-nose-finger
testing Bilaterally. There is mild dysmetria present
bilaterally. Patient is slow with rapid alternating movements
bilaterally.
-Gait -deferred per patient preference.
DISCHARGE PHYSICAL EXAM
Vitals: 98.6 121/71 89 18 93 Ra
General: alert and oriented x3
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, anteriorly. Did not listen to lungs posteriorly,
per patient request. No wheezes, rales, ronchi.
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal. No
dysmetria.
Pertinent Results:
ADMISSION LABS
___ 03:20PM BLOOD WBC-4.6 RBC-3.73* Hgb-11.5 Hct-35.8
MCV-96 MCH-30.8 MCHC-32.1 RDW-15.7* RDWSD-55.6* Plt ___
___ 03:20PM BLOOD Neuts-46.9 ___ Monos-5.2 Eos-3.0
Baso-0.4 Im ___ AbsNeut-2.17 AbsLymp-2.00 AbsMono-0.24
AbsEos-0.14 AbsBaso-0.02
___ 03:20PM BLOOD Plt ___
___ 03:20PM BLOOD Glucose-101* UreaN-8 Creat-0.8 Na-143
K-3.8 Cl-103 HCO3-24 AnGap-20
___ 03:20PM BLOOD estGFR-Using this
___ 03:20PM BLOOD ALT-25 AST-69* AlkPhos-131* TotBili-1.2
___ 03:20PM BLOOD cTropnT-<0.01
___ 03:20PM BLOOD Albumin-3.2*
___ 06:10AM BLOOD VitB12-1225*
___ 06:10AM BLOOD TSH-6.5*
___ 06:13AM BLOOD T3-97 Free T4-1.0
___ 06:13AM BLOOD antiTPO-LESS THAN
___ 03:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 12:00AM BLOOD LAMOTRIGINE-17.9
___ 06:10AM BLOOD LAMOTRIGINE-17.9
___ 06:13AM BLOOD VITAMIN B1-WHOLE BLOOD-73 78-185 nmol/L
DISCHARGE LABS
___ 06:19AM BLOOD WBC-3.0* RBC-3.33* Hgb-10.1* Hct-31.6*
MCV-95 MCH-30.3 MCHC-32.0 RDW-15.9* RDWSD-55.2* Plt ___
___ 06:19AM BLOOD Neuts-33.1* Lymphs-57.1* Monos-5.1
Eos-3.4 Baso-0.3 Im ___ AbsNeut-0.98* AbsLymp-1.69
AbsMono-0.15* AbsEos-0.10 AbsBaso-0.01
___ 06:25AM BLOOD H/O Smr-DONE
___ 06:19AM BLOOD Plt ___
___ 06:19AM BLOOD Glucose-111* UreaN-4* Creat-0.7 Na-142
K-3.6 Cl-106 HCO3-26 AnGap-14
___ 06:19AM BLOOD ALT-20 AST-65* AlkPhos-133* TotBili-0.8
___ 06:10AM BLOOD CK-MB-1
___ 06:19AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9
___ 06:10AM BLOOD VitB12-1225*
___ 06:10AM BLOOD TSH-6.5*
___ 06:13AM BLOOD T3-97 Free T4-1.0
___ 06:13AM BLOOD antiTPO-LESS THAN
___ 06:00AM BLOOD PARANEOPLASTIC AUTOANTIBODY
EVALUATION-PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 10 mg PO DAILY
2. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
3. desvenlafaxine 100 mg oral daily
4. Bisacodyl 10 mg PO 2X/WEEK (MO,TH) diarrhea
5. Fleet Enema (Saline) ___AILY:PRN constipation
6. ___ (guaiFENesin) 100 mg/5 mL oral Q6 hours
7. Lactaid (lactase) 1 tab oral before meals
8. LamoTRIgine 75 mg PO QAM
9. LamoTRIgine 100 mg PO QPM
10. Levothyroxine Sodium 75 mcg PO DAILY
11. LOPERamide 2 mg PO QID:PRN diarrhea
12. Milk of Magnesia 30 mL PO Q6H:PRN consipation
13. Omeprazole 20 mg PO BID
14. Simvastatin 40 mg PO QPM
15. Calcium Carbonate 500 mg PO QID:PRN stomach upset
Discharge Medications:
1. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
2. Octreotide Acetate 100 mcg SC Q8H carcinoid
3. ARIPiprazole 7.5 mg PO DAILY
7.5mg for 1 wk (___), then 5mg for 1 wk (___), then
2.5mg for 1 wk (___), then stop
4. LamoTRIgine 75 mg PO BID
5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
6. Bisacodyl 10 mg PO 2X/WEEK (MO,TH) diarrhea
7. Calcium Carbonate 500 mg PO QID:PRN stomach upset
8. desvenlafaxine 50 mg oral daily
9. Fleet Enema (Saline) ___AILY:PRN constipation
10. ___ (guaiFENesin) 100 mg/5 mL oral Q6 hours
11. Lactaid (lactase) 1 tab oral before meals
12. Levothyroxine Sodium 75 mcg PO DAILY
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Milk of Magnesia 30 mL PO Q6H:PRN consipation
15. Omeprazole 20 mg PO BID
16. Simvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-Weakness/lethargy
-Urinary tract infection
SECONDARY DIAGNOSIS:
- Difficulty swallowing
- neutropenia
- Carcinoid tumor of the small intestine with metastasis to
liver
- Schizoaffective disorder
- hypothyroidism
- hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with history of metastatic carcinoid now with 3
month history of failure to thrive and worsening mental status. Evaluate for
intracranial metastatic disease or infection.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: MRI head ___
CTA head and neck ___
FINDINGS:
Postcontrast imaging is nondiagnostic. Remainder of study is moderately
degraded by motion. Within these confines:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. Prominent ventricles and sulci compatible with age-related
involutional changes. Periventricular subcortical T2 and FLAIR hyperintense
foci are nonspecific but likely represent sequelae of small vessel ischemic
disease in this age group. There is no definite post-contrast abnormal
enhancement after contrast administration.
There is mucosal thickening of the right maxillary sinus with an air-fluid
level. There is partial opacification and air-fluid level in the left
sphenoid sinus. There is minimal mucosal thickening of the bilateral ethmoid
air cells. There is partial opacification of the right mastoid air cells.
IMPRESSION:
1. Postcontrast imaging is nondiagnostic. Remainder of study is moderately
degraded by motion. If clinically indicated, consider repeat postcontrast
imaging when patient can tolerate exam.
2. No definite evidence of acute infarct.
3. Within limits of study, no definite intracranial mass or large territory
edema identified.
4. Paranasal sinus disease and nonspecific right mastoid, as detailed above.
5. Atrophy and probable small vessel ischemic changes.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: ___ year old woman with hx metastatic carcinoid who presents with
chronically worsening mental status// Evidence of worsening carcinoid or other
acute process?
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
COMPARISON: MR abdomen with and without contrast ___. CT chest
___
FINDINGS:
Study is significantly limited due to motion and the patient's inability to
tolerate breath-holding.
Lower Thorax: The lower thorax is unremarkable. There is no pericardial or
pleural effusion.
Liver: The liver is enlarged measuring up to 21.6 cm increased from ___ at which time it measured mildly enlarged at 17.5 cm. The liver
demonstrates homogeneously low attenuation throughout, compatible with diffuse
hepatic steatosis. There is a stable hemangioma in segment 8 (19:17). Similar
appearance of a subcentimeter lesion in segment 8 that is bright on diffusion
and T2 weighted imaging (10:15). Stable T2 hyperintense subcentimeter lesion
in the periphery of the right hepatic lobe (15:12) compatible with cyst or
biliary hamartoma.
The liver dome is poorly imaged and a previously described arterially
enhancing lesion in this location cannot be evaluated.
No new focal lesions are seen.
The portal vein, SMV, and splenic vein are patent.
Biliary: The gallbladder is present. There is no intrahepatic or extrahepatic
biliary ductal dilatation.
Pancreas: The pancreas is normal in signal intensity without pancreatic ductal
dilatation or peripancreatic fluid.No pancreatic lesions are seen.
Spleen: The spleen is enlarged at 14.5 cm, unchanged. The signal intensity is
normal. There is no focal lesion seen.
Adrenal Glands: The adrenal glands are normal in shape and size.
Kidneys: The kidneys demonstrate normal corticomedullary differentiation and
are symmetric and normal in size without hydronephrosis.T2 hyperintense
nonenhancing foci are compatible with cysts.
Gastrointestinal Tract: The visualized large and small bowel demonstrate
normal thickness and caliber. Large hiatal hernia.
Lymph Nodes: No gross lymphadenopathy is seen.
Vasculature: The abdominal aorta is normal in size.
Osseous and Soft Tissue Structures: No suspicious osseous lesions are seen.
The body wall is within normal limits.
IMPRESSION:
Study is limited due to motion, the patient's inability to tolerate
breath-holding instructions, and multiple requests by the patient to terminate
the study.
Hepatomegaly, increased from prior study. Diffuse hepatic steatosis. Stable
splenomegaly. The liver dome is poorly imaged and a previously described
arterially enhancing lesion in this location cannot be evaluated.
No evidence of new metastatic disease.
Large hiatal hernia.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old woman with 30 pound weight loss, low PO intake, hx of
carcinoid and esophageal dysmotility// *** PLEASE PERFORM BARIUM SWALLOW PAGE
___ WITH ANY QUESTIONS ***evidence of obstruction?
TECHNIQUE: See below. Scout images were obtained.
DOSE: Acc air kerma: 3 mGy; Accum DAP: 74.72 uGym2; Fluoro time: 00:34.
COMPARISON: CTA chest ___.
FINDINGS:
The study was terminated early as patient could not tolerate the study.
Patient was unable to stand and thus was placed in supine LPO position.
Subsequently patient was asked to drink thin barium contrast through a straw
but despite multiple trials and encouragement, patient was unable to drink the
barium through the straw or swallow. Assess the study was terminated early
and the primary team was contacted. Findings discussed with Dr. ___
via telephone by ___ on ___ @ 4:48pm and 5:30 pm.
On the scout images, soft tissue density projecting over the gastroesophageal
junction is consistent with large hiatal hernia as seen on recent CT. Suture
material from prior small bowel resection is identified in the right lower
quadrant.
IMPRESSION:
Study could not be completed as patient was unable to tolerate the procedure.
Review of prior CTA chest demonstrated mildly dilated upper esophagus with a
large hiatal hernia. Can consider EGD for further assessment for stricture
and if EGD is unable to be performed, can consider insertion of catheter into
the esophagus and injection with contrast for further evaluation of esophageal
anatomy.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 5:30 pm, 30 minutes after discovery of
the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fatigue, Lethargy
Diagnosed with Urinary tract infection, site not specified, Diplopia
temperature: 97.1
heartrate: 82.0
resprate: 16.0
o2sat: 94.0
sbp: 134.0
dbp: 72.0
level of pain: 0
level of acuity: 3.0 | ========================
BRIEF HOSPITAL COURSE
========================
Ms. ___ is a ___ woman with a past medical history of
depression/anxiety, hypertension, hyperlipidemia, carcinoid
tumor of the small intestine with metastasis to liver, and left
total knee replacement (in ___, complicated by
recurrent hospitalizations for urosepsis and acute kidney
injury) who presented with weeks of disorientation, worsening
lethargy, intermittent diplopia, bilateral upper extremity
ataxia, and a 30 pound weight loss. History was obtained from
outside hospital and rehab records, husband, and daughter as
patient was unable to provide a history.
Upon admission, she was ruled out for a stroke and a PE with a
head CT and CTA that were negative for any acute process. A CXR
was without evidence of pneumonia. A UA revealed evidence of a
UTI, and she was treated with 4 days of IV ceftriaxone. Her
ceftriaxone treatment was stopped after 4 days (instead of 5) in
the setting of improving clinical condition and a decreasing
WBC, which hematology/oncology attributed to the initiation of
ceftriaxone. The WBC was increasing upon discharge.
She experienced one day of diarrhea while admitted, and a C.
diff assay was negative. This likely occurred in the setting of
not having received octreotide from ___ until she was
admitted. She also has a history of IBS.
Since the differential diagnosis for her weakness, weight loss,
and lethargy included infectious, metabolic, and neoplastic
etiologies, she received an EEG, a brain MRI with and without
contrast, a liver MRI with contrast, and extensive lab tests
(detailed in the "results" section of the discharge summary).
These were negative for evidence of metastases, seizures, or
metabolic deficiencies. A Lamictal level was measured as 17.9
(reference range of 4.0 - 18.0), and she was discharged on a
lower dose of Lamictal. Per the recommendations of her
oncologist Dr. ___, she was treated with subcutaneous
octreotide during her hospitalization, and discharged on this
medication. It will be discontinued when she is able to receive
a depot injection at her hematology/oncology outpatient
appointment.
Speech and swallow saw her because of her cough and dysphagia.
Though difficulty swallowing was noted on ___ (and she was
unable to complete a barium swallow because of difficulty
swallowing), subsequent workup on ___ identified dysgeusia and
psychogenic causes as a reason for the dysphagia. She was able
to tolerate certain foods and PO medications, administered whole
(not crushed) in vanilla ice cream during her admission.
Psychiatry recommended 75 mg Lamictal BID, 7.5 mg Abilify daily,
and 50mg Pristiq daily, though she was not receiving Pristiq
during this admission because it was nonformulary. She should
use the following regimen regarding taking and tapering her
depression/anxiety medications:
- Taper Abilify as follows: Take Abilify at the 7.5mg dose for
one week (___), then take 5 mg for one week (___),
then take 2.5 mg for one week (___), then stop this
medication.
- Take Pristiq 50 mg daily
- Take Lamictal 75 mg twice a day (BID)
At discharge, she was feeling well and was no longer somnolent.
Her diarrhea had resolved, she had finished a four day course of
IV ceftriaxone for the UTI, and her neutropenia was resolving.
========================
TRANSITIONAL ISSUES
========================
# MEDICATION CHANGES:
- Taper Abilify as follows: Take Abilify at the 7.5mg dose for
one week (___), then take 5 mg for one week (___),
then take 2.5 mg for one week (___), then stop this
medication.
- Take Pristiq 50 mg daily
- Take Lamictal 75 mg twice a day (BID)
- follow up with your outpatient psychiatrist to discuss these
medications
# NEW MEDICATIONS: Octreotide sc TID for her carcinoid tumor.
Cephacol lozenges as needed for sore throat
# ONCOLOGY: Patient has scheduled follow up with Dr. ___
___
# LABS:
- Please check CBC with diff on ___ for ___, and again on
___, to assess for neutropenia. ANC was 980 at discharge
on ___. If the ANC rises above 1000 and white count
normalizies, there is no need to keep evaluating CBC. If white
count does not improve, patient needs to see hematologist listed
above (Dr. ___.
- Please also draw liver function enzymes (LFTs) and a Chemistry
panel WEEKLY to assess for liver and renal function while on
Lamictal.
# NUTRITION: Patient will benefit from 1:1 supervision for all
meals. She requires coaching to eat, and prefers cold foods.
CONTACT: ___, husband, HCP; ___
CODE: full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath/abdominal distention
Major Surgical or Invasive Procedure:
(had EGD just prior to admission on ___
History of Present Illness:
Mr. ___ is a ___ (speaks ___ but conversational in
___ with PMH HTN, DMII, hx ETOH abuse, recent diagnosis of
pancreatic adenocarcinoma (CT ___, not yet on chemo), and
newly diagnosed alcoholic cirrhosis with ascites s/p therapeutic
para on ___ who presents from the PACU after experiencing
shortness of breath and abdominal distention after extubation
after an EGD on ___. Of note, he already has a metal
biliary stent placed that was patent on EGD and so he did not
require ERCP. He desatted to 87% on ra and had diffuse abdominal
discomfort after extubation. Given his large ascites and
significant edema, he was sent to the ED for a therapeutic
paracentesis.
In the ED, vitals: 98 81 104/70 18 100% 2l. Labs significant for
bili 2.3, Hct 36.1, BNP 142. ALT 18 and AST 30. Lipase 837. CXR
showed small pleural effusions and EKG showed sinus rhythm with
no ischemic changes. Troponin was negative. A therapeutic tap
was performed at 4L taken off with 12.5 mg albumin given x 3.
Cultures/cytology sent. He was admitted for diuresis/observation
given his shortness of breath.
Upon arrival to the floor, he stated that his shortness of
breath was completely resolved and he had no abdominal
discomfort. He stated he felt completely back to normal,
although he was very tired. Satting 96% on room air while lying
flat.
Past Medical History:
- Hypertension
- Dyslipidemia
- Diabetes mellitus, type 2: On oral agents
- Tobacco abuse
- Pancreatic mass
Social History:
___
Family History:
- No history of hepatobiliary disease, cancer
- Diabetes mellitus/HTN/HLD runs in family
Physical Exam:
Admission physical:
VS: 98 133/77 84 18 96% ra
General: A thin man lying in bed in no acute distress
HEENT: Normalocephalic, atraumatic, mucous membranes dry,
PERRLA, edentulous, no lymphadenopathy.
Neck: supple
CV: RRR no M/G/R
Lungs: CTAB, no wheezes/crackles, no reduced breath sounds, no
accessory muscle use
Abdomen: Distended, non-tender, liver palpable 3cm below costal
margin. Bandage over paracentesis site in LLQ, clean and dry.
GU: deferred
Ext: 2+ radial pulse, 3+ pitting edema in ___
Neuro: A&O x 3, conversing well, ___ strength in extremities, no
confusion or asterixis
Skin: not visibly jaundiced. Spider angiomata on chest
Discharge physical:
VS: tm 98.1 Tc 98.6 76 18 99% ra
General: A thin man lying in bed in no acute distress
HEENT: Normalocephalic, atraumatic, edentulous
Neck: supple
CV: RRR no M/G/R
Lungs: CTAB, no wheezes/crackles, no reduced breath sounds, no
accessory muscle use
Abdomen: Distended, non-tender, liver palpable 3cm below costal
margin. Bandage over paracentesis site in LLQ, clean and dry.
GU: deferred
Ext: 2+ radial pulse, 3+ pitting edema in ___
Neuro: A&O x 3, conversing well, ___ strength in extremities, no
confusion or asterixis
Skin: not visibly jaundiced. Spider angiomata on chest
Pertinent Results:
Admission labs:
___ 04:19PM BLOOD WBC-9.0 RBC-3.59* Hgb-12.2* Hct-37.4*
MCV-104* MCH-34.1* MCHC-32.7 RDW-15.0 Plt ___
___ 04:19PM BLOOD ___
___ 04:19PM BLOOD UreaN-10 Creat-0.5 Na-134 K-4.6 Cl-97
HCO3-26 AnGap-16
___ 04:19PM BLOOD ALT-23 AST-36 AlkPhos-117 TotBili-2.3*
___ 02:59PM BLOOD Albumin-3.4* Calcium-9.1 Phos-4.3 Mg-2.0
Pertinent labs:
___ 02:59PM BLOOD cTropnT-<0.01
___ 02:59PM BLOOD proBNP-142
___ 04:19PM BLOOD calTIBC-202* Ferritn-419* TRF-155*
___ 04:19PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 04:19PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 04:19PM BLOOD ___
___ 04:19PM BLOOD IgG-942 IgA-414* IgM-487*
___ 02:59PM BLOOD Lactate-1.2
___ Pathology: pending
Micro:
___ 4:15 pm PERITONEAL FLUID PERITONEAL .
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Blood cx: pending
Imaging:
___ CT chest
IMPRESSION:
1. No evidence of intrathoracic malignancy.
2. New small left pleural effusion.
3. Moderate centrilobular predominant emphysema.
4. Calcified mediastinal and right hilar lymph nodes likely
sequela prior
granulomatous disease.
___ CXR
IMPRESSION:
Small left-sided pleural effusion with adjacent atelectasis.
Right basilar
atelectasis.
___ EGD
No esophageal or gastric varices.
Diffuse portal hypertensive gastropathy.
Previous metal biliary stent at the major papilla.
Normal air cholangiogram and excellent flow of bile through the
stent.
Otherwise normal EGD to third part of the duodenum.
Discharge labs:
___ 06:30AM BLOOD WBC-6.5 RBC-3.22* Hgb-10.8* Hct-33.0*
MCV-103* MCH-33.5* MCHC-32.7 RDW-14.3 Plt ___
___ 02:59PM BLOOD ___ PTT-42.1* ___
___ 06:30AM BLOOD Glucose-145* UreaN-9 Creat-0.5 Na-134
K-3.9 Cl-101 HCO3-22 AnGap-15
___ 06:30AM BLOOD ALT-16 AST-28 AlkPhos-87 TotBili-2.1*
___ 06:30AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Furosemide 20 mg PO DAILY
5. Spironolactone 50 mg PO DAILY
6. Ezetimibe 10 mg PO DAILY
Discharge Medications:
1. Ezetimibe 10 mg PO DAILY
2. Furosemide 40 mg PO ONCE Duration: 1 Dose
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Metoprolol Tartrate 50 mg PO BID
4. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
# Shortness of breath
# Alcoholic cirrhosis complicated by ascites and edema
Secondary diagnoses:
# Hypertension
# Dyslipidemia
# Diabetes mellitus, type 2
# Pancreatic adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Dyspnea.
COMPARISON: Radiograph of the chest dated ___ and CT of the chest
dated ___.
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate low lung volumes
resulting in bronchovascular crowding. There is persistent atelectasis at the
right base. There is a small left-sided pleural effusion with some adjacent
atelectasis. There is relative increased elevation of the right
hemidiaphragm, consistent with perihepatic ascites noted on recent CT of the
chest. There is no pneumothorax.
IMPRESSION:
Small left-sided pleural effusion with adjacent atelectasis. Right basilar
atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Dyspnea, POST OP
Diagnosed with OTHER ASCITES, CIRRHOSIS OF LIVER NOS, MALIG NEO PANCREAS NOS, HYPERTENSION NOS
temperature: 98.0
heartrate: 81.0
resprate: 18.0
o2sat: 100.0
sbp: 104.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ (speaks ___ but conversational in
___ with PMH HTN, DMII, hx ETOH abuse, recent diagnosis of
pancreatic ca (not yet on chemo), and newly diagnosed cirrhosis
with ascites s/p therapeutic para on ___ who presents from
the PACU after experiencing shortness of breath and abdominal
distention after extubation after an EGD. Transferred to ED and
then to medicine.
#Shortness of breath: patient experienced shortness of breath
after extubation. Likely hypoxia in the setting of anesthesia
with significant edema/ascites as a contributing factor. Patient
received a 4-L paracentesis in the ED and was admitted for
further diuresis. Upon arrival to the floor, asymptomatic and
satting 96% on ra with no evidence of crackles on exam. CXR did
show a small pleural effusion. Patient began diuresis on ___:
as he strongly wished to return home that day, he received po
lasix 40 mg and 100 mg spironolactone to begin diuresis and was
discharged on these medications.
#Alcoholic cirrhosis complicated by ascites and edema:
___ class C, MELD 6 at admission. Received a 4L tap upon
arrival in the ED. Had 3+ pitting edema in ___. EGD on ___
did not show any varices. No evidence of SBP from peritoneal
fluid analysis. Diuresed per above.
# Hypertension: held home Hctz pending more aggressive diuresis.
Continued metoprolol.
# Dyslipidemia: continued home ezetimibe
# Diabetes mellitus, type 2: on home metformin. Held while in
house, ISS
#Pancreatic adenocarcinoma: Diagnosed via CT on ___,
underwent MRCP in ___ on ___ at which time a common
bile duct stricture was identified within the pancreatic head.
Dr. ___ ERCP and identified portal gastropathy. A
plastic stent was deployed across the 2.5 cm stricture within
the pancreatic head. Brushings demonstrated adenocarcinoma. Not
yet on treatment, has an initial appointment with Dr. ___ in
Heme-onc on ___.
#CODE: Full
#CONTACT: Sister ___: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain and transaminitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC: ___ and back pain
HPI: ___ female with HTN, hypothyroidism presenting with
1 day of abdominal pain and back pain, found to have significant
transaminitis, with ultrasound at ___ significant
for obstructed common biliary duct. The patient was instructed
to come to ___ for further care and arrived by personal car.
In the ED, initial vital signs were 97.7 77 180/95 18 98% on
room
air.
Upon arrival to the floor, the patient tells the story as
follows.
BMP was grossly hemolyzed, with a K of 5.7, BUN/creatinine of
___. CBC WNL with WBC 6.1. ALT 871, AST 77, alk phos 151, T
bili 2.4.
Upon arrival to the floor, the patient was story as follows.
She
reports that on ___ evening, she had onset of epigastric
pain which radiated towards her back. The pain continued to
increase in severity, until involved her whole abdomen,
prompting
her to present to ___. There, she had an
ultrasound, which demonstrated a dilated common bile duct to 11
mm and thickened gallbladder wall. She was instructed to come
to
___.
This evening, approximately ___ ___, she had complete resolution
of her abdominal pain. She has not had further recurrence of
her
abdominal pain.
She denies recent fevers, chills, chest pain, shortness of
breath, nausea, vomiting, constipation, bloody stools, dysuria.
She reports she passed multiple pale colored stools. She denies
rash, skin discoloration, itchiness. She has not eaten in
several days secondary to pain
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
- Hypothyroidism, Hashimoto's
- GERD
- History of grade B esophagitis, currently controlled with
pantoprazole 20 mg once a day.
- hypertension
- Osteoporosis
Social History:
___
Family History:
FAMILY HISTORY: Denies family history of biliary disease.
Physical Exam:
EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes very dry
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Discharge exam:
Well appearing, vital signs stable.
No jaundice.
Abdomen soft, Non tender, non distended.
Pertinent Results:
DATA: I have reviewed the relevant labs, radiology studies,
tracings, medical records, and they are notable for:
___ 09:18PM BLOOD WBC: 6.1 RBC: 4.64 Hgb: 13.6 Hct: 41.0
MCV: 88 MCH: 29.3 MCHC: 33.2 RDW: 14.1 RDWSD: 45.___
___ 09:18PM BLOOD Neuts: 64.2 Lymphs: ___ Monos: 9.3 Eos:
1.6 Baso: 1.0 Im ___: 0.3 AbsNeut: 3.92 AbsLymp: 1.44 AbsMono:
0.57 AbsEos: 0.10 AbsBaso: 0.06
___ 09:45PM BLOOD ___: 10.9 PTT: 26.2 ___: 1.0
___:18PM BLOOD Glucose: 88 UreaN: 17 Creat: 0.8 Na: 135
K: 5.7* Cl: 102 HCO3: 20* AnGap: 13
___ 09:18PM BLOOD ALT: 871* AST: 787* AlkPhos: 151*
TotBili:
2.4* DirBili: 0.5* IndBili: 1.9
Review of OSH records:
RUQ ultrasound (___)
Liver: The liver is echogenic. No intrahepatic bile duct
dilatation.
Gallbladder: The gallbladder is distended with thickened wall to
6 mm. There are gallstones. Negative sonographic ___ sign.
No ___ fluid.
Common bile duct: The common bile duct is dilated up to 11 mm.
No stones.
Pancreas: Unremarkable as visualized.
Impression: Distended gallbladder with multiple gallstones and
wall thickening however negative sonographic ___ sign and no
pericholecystic fluid. The common bile duct is significantly
dilated to 11 mm. This raises suspicion for
choledocholithiasis.
___ labs:
AST 1122, ALT 768, alk phos 118, T bili 2.0
MRCP:
IMPRESSION:
1. Cholelithiasis with mild acute cholecystitis, slightly
improved from ___.
2. Mild extrahepatic biliary dilation, without
choledocholithiasis.
3. Possible osteochondroma arising from the left iliac bone,
which is
partially visualized. Recommend dedicated MSK pelvis MRI for
further
evaluation on an outpatient basis.
RECOMMENDATION(S): Outpatient MSK pelvis MRI.
Discharge labs:
___ 06:55AM BLOOD WBC-6.4 RBC-4.29 Hgb-12.2 Hct-38.6 MCV-90
MCH-28.4 MCHC-31.6* RDW-14.1 RDWSD-46.3 Plt ___
___ 06:55AM BLOOD Glucose-82 UreaN-16 Creat-0.7 Na-143
K-4.1 Cl-107 HCO3-25 AnGap-11
___ 06:55AM BLOOD ALT-642* AST-439* AlkPhos-137*
TotBili-1.3
___ 06:55AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with obstructive transaminitis and suspected
choledocholithiasis// eval choledocholithaisis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Outside facility abdominal ultrasound ___
FINDINGS:
Lower Thorax: Limited evaluation is unremarkable.
Liver: Other than small hepatic cysts measuring up to 5 mm, the liver is
unremarkable.
Biliary: Cholelithiasis is re-demonstrated, with regions of gallbladder wall
thickening and mild pericholecystic fat stranding, compatible with acute
cholecystitis. Findings have slightly improved compared to the prior
ultrasound performed on ___, where luminal distension was noted. CBD is
slightly dilated measuring up to 10 mm (03:24), without choledocholithiasis.
Pancreas: Unremarkable.
Spleen: Unremarkable.
Adrenal Glands: Unremarkable.
Kidneys: Kidneys are unremarkable except for a few simple peripelvic cysts.
Gastrointestinal Tract: There is no bowel obstruction or ascites.
Lymph Nodes: No abdominal lymphadenopathy.
Vasculature: Abdominal aorta is not aneurysmal.
Osseous and Soft Tissue Structures: There is a tubular osseous lesion arising
from the left iliac bone, possibly representing an osteochondroma, however
only partially seen (03:29). An associated T2 hyperintense rounded structure
at the distal margin is suggestive of a cartilaginous cap, which measures up
to 10 mm.
IMPRESSION:
1. Cholelithiasis with findings suggestive of mild acute cholecystitis,
improved from ___.
2. Mild extrahepatic biliary dilation, without choledocholithiasis.
3. Possible osteochondroma arising from the left iliac bone, which is
partially visualized. Recommend dedicated MSK pelvis MRI for further
evaluation on an outpatient basis.
RECOMMENDATION(S): Outpatient MSK pelvis MRI.
NOTIFICATION: The findings and recommendation were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 10:50AM,
5 minutes after discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Calculus of bile duct w/o cholangitis or cholecyst w/o obst
temperature: 97.1
heartrate: 77.0
resprate: 18.0
o2sat: 98.0
sbp: 180.0
dbp: 95.0
level of pain: 1
level of acuity: 3.0 | ___ is a ___ female with HTN, hypothyroidism
presenting with 1 day of abdominal pain and back pain, found to
have significant transaminitis, with ultrasound at ___
___ significant for common biliary duct dilatation to 11
mm. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ascending weakness
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
The pt is a ___ year-old F w/ hx of thyroid CA s/p thyroidectomy,
diverticulosis, and lumbosacral radiculopathy who presents with
recurrent sensory loss and ___ weakness. Hx obtained from pt at
bedside and records from ___.
Pt was initially seen at ___ on ___ due to loss of
pain/temperature sensation in RLE followed by hypersensitivity
to touch over R hemibody up to lower chest. She underwent MRI of
her whole spine which revealed central disc protrusion on R at
T7-T8 but no cord enhancement. Per Spine surgery, she was
recommended for MRI L-spine which pt preferred to have performed
as outpt. She returned the following day due to more profound
sensory loss in her LEs as well as new onset weakness and
dysesthesias ascending up her torso. Neurology was consulted and
pt underwent MRI of entire neuroaxis as well as EMG/NCS and LP.
MRI spine showed subtle increased T2 signal in L C2-C3 but
otherwise these diagnostic studies were unremarkable, with no
elevated cells or protein on CSF studies. Numerous labs were
collected with results all negative or pending (see below). Pt
was started empirically on Solumedrol 1g x 5 days and Gabapentin
(later switched to Lyrica due to fatigue) for treatment of
presumed transverse myelitis. Upon initiation of treatment her
sensorimotor deficits began to improve and pt was discharged to
rehab for ___. At rehab, his strength continued to move closer
to baseline and sensory loss began to recede down LEs.
On ___, following discharge from rehab, pt noticed gradual onset
of decreased sensation and burning to touch over her R torso up
to nipple line. She also developed similar sensory loss in
perineal region with associated urinary retention and lack of
bladder sensation. Over the following few days she developed
significant constipation requiring treatment with Miralax, and
at times was concerned that stool may have come out
spontaneously. Since onset, the burning pain in R torso has
worsened in severity, with no change in distribution. She has
occasionally experienced brief "shocks" or "funny jerks" in
either leg, often when standing up or when lying down in bed.
With these spasms she began to note increasing weakness in her
knees, exemplified by difficulty walking upstairs ("my husband
practically has to carry me"). At her ___ session today, her
therapist noticed similar weakness and recommended she be
evaluated. As such, pt spoke to her PCP who spoke to treating
neurologist at ___, with decision to send pt to BI for
more aggressive intervention (particularly brought up PLEX to
pt).
Since her discharge to rehab, pt has not experienced any new
lower back pain or neck pain. Endorses a moderate occipital
headache this AM which resolved spontaneously. No recent trauma
or falls. Endorses some fatigue but attributes to difficulty
handling her sx. Upon discharge, pt started on Buspar and
Vitamin B12 but otherwise no medication changes or recent
infection. Pt continues to be concerned for an infectious cause
of her sx as she recently travelled out of the country and
sustained multiple insect bites including from mosquitoes.
Neurologic and General ROS negative except as noted above.
Past Medical History:
Thyroid CA s/p thyroidectomy
Diverticulosis
Lumbosacral radiculopathy
Shingles over ?R S3
Migraines
Social History:
___
Family History:
___ cancer (age of onset: ___) in her brother; ___ cancer
(age of onset: ___) in an other family member; ___ cancer in
her brother. Aunt has MS. ___ has ___ (non-severe, no
neurologic manifestations).
Physical Exam:
ON ADMISSION:
Vitals: T: 97.8 P: 82 BP: 138/89 RR: 14 O2sat:98% RA
NIF: -57
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Skull & Spine: Neck movements are full and painless. Lhermitte's
negative. There is no
scoliosis. No midline tenderness throughout spine, w/ burning
pain to palpation over perineal area, difficulty with bearing
down on rectal exam
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5- 5 4+ 5 5 5 5
R 5 ___ ___ 4+ 5 4 5 5 5 5
Adductors and abductors intact
-Sensory: Decreased sensation to PP and temperature up to knee
on L and mid thigh on R, as well as T4-L1 on R and T7-L1 on L,
with associated dysesthesias on R. Vibratory sense and
proprioception intact throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 4* 3
R 2 2 2 4* 3
Plantar response was upgoing bilaterally. 8 beats of clonus on L
and 6 beats of clonus on ___ negative b/l.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or TTF bilaterally.
-Gait: Deferred.
======
Discharge exam unchanged from admission
Pertinent Results:
ADMISSION LABS:
==================
___ 04:25PM BLOOD WBC-4.0 RBC-3.89* Hgb-12.0 Hct-36.0
MCV-93 MCH-30.8 MCHC-33.3 RDW-11.9 RDWSD-40.2 Plt ___
___ 04:25PM BLOOD Neuts-46.1 ___ Monos-12.9 Eos-2.7
Baso-0.5 Im ___ AbsNeut-1.85 AbsLymp-1.50 AbsMono-0.52
AbsEos-0.11 AbsBaso-0.02
___ 04:25PM BLOOD Plt ___
___ 04:25PM BLOOD Glucose-93 UreaN-11 Creat-0.6 Na-145
K-4.0 Cl-109* HCO3-23 AnGap-13
___ 04:25PM BLOOD cTropnT-<0.01
___ 04:25PM BLOOD ALT-21 AST-18 AlkPhos-81 TotBili-0.2
___ 04:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
PERTINENT LABS:
==================
___ 05:20AM BLOOD WBC-3.7* RBC-3.59* Hgb-11.1* Hct-33.2*
MCV-93 MCH-30.9 MCHC-33.4 RDW-11.9 RDWSD-40.1 Plt ___
___ 07:15AM BLOOD WBC-3.9* RBC-3.66* Hgb-11.5 Hct-33.8*
MCV-92 MCH-31.4 MCHC-34.0 RDW-11.9 RDWSD-40.3 Plt ___
CSF:
==================
___ 03:52PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-2 Polys-0
___ ___ 03:52PM CEREBROSPINAL FLUID (CSF) TotProt-20 Glucose-66
DISCHARGE LABS:
==================
___ 07:15AM BLOOD WBC-3.9* RBC-3.66* Hgb-11.5 Hct-33.8*
MCV-92 MCH-31.4 MCHC-34.0 RDW-11.9 RDWSD-40.3 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-103* UreaN-12 Creat-0.6 Na-140
K-4.0 Cl-104 HCO3-24 AnGap-12
___ 07:15AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.9
___ 07:15AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 07:15AM BLOOD HCV Ab-NEG
IMAGING:
==================
___ CXR PA and Lateral: No acute cardiopulmonary process.
___ MRI Cervical and Thoracic:
1. No evidence of cord compression, severe spinal canal stenosis
or
significant neural foraminal narrowing along the entire spine.
2. Disc bulge at C4-C5 which remodels the ventral cord but
without cord signal
abnormality and mild-to-moderate spinal canal stenosis this
level.
3. Central disc protrusion at the 78 which remodels the ventral
cord but
without definitive cord signal abnormality.
4. Multilevel disc bulges along the lumbar spine resulting in
mild to moderate
spinal canal stenosis at L3-L4 and L4-L5.
5. Normal appearance of the spinal cord and no abnormal
enhancement.
EMG:
===================
___: There is electrophysiologic evidence of a very mild,
chronic right lumbosacral polyradiculopathy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BusPIRone 10 mg PO TID
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Liothyronine Sodium 5 mcg PO DAILY
4. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. PredniSONE 60 mg PO DAILY Duration: 3 Doses
Start: Future Date - ___, First Dose: First Routine
Administration Time
Take once per day: 60mgx3 days, 50mgx3 days, 40mgx3 days, 30
mgx3 days, 20mgx3 days, 10 mgx3 days.
This is dose # 1 of 6 tapered doses
2. PredniSONE 50 mg PO DAILY Duration: 3 Doses
Start: After 60 mg DAILY tapered dose
Take once per day: 60mgx3 days, 50mgx3 days, 40mgx3 days, 30
mgx3 days, 20mgx3 days, 10 mgx3 days.
This is dose # 2 of 6 tapered doses
3. PredniSONE 40 mg PO DAILY Duration: 3 Doses
Start: After 50 mg DAILY tapered dose
Take once per day: 60mgx3 days, 50mgx3 days, 40mgx3 days, 30
mgx3 days, 20mgx3 days, 10 mgx3 days.
This is dose # 3 of 6 tapered doses
4. PredniSONE 30 mg PO DAILY Duration: 3 Doses
Start: After 40 mg DAILY tapered dose
Take once per day: 60mgx3 days, 50mgx3 days, 40mgx3 days, 30
mgx3 days, 20mgx3 days, 10 mgx3 days.
This is dose # 4 of 6 tapered doses
5. PredniSONE 20 mg PO DAILY Duration: 3 Doses
Start: After 30 mg DAILY tapered dose
Take once per day: 60mgx3 days, 50mgx3 days, 40mgx3 days, 30
mgx3 days, 20mgx3 days, 10 mgx3 days.
This is dose # 5 of 6 tapered doses
6. PredniSONE 10 mg PO DAILY Duration: 3 Doses
Start: After 20 mg DAILY tapered dose
Take once per day: 60mgx3 days, 50mgx3 days, 40mgx3 days, 30
mgx3 days, 20mgx3 days, 10 mgx3 days.
This is dose # 6 of 6 tapered doses
7. ValACYclovir 1000 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
Transverse myelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with increasing ___ weakness// evaluate for PNA
TECHNIQUE: PA and lateral views the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or edema.
Cardiomediastinal silhouette is within normal limits. Surgical clips noted at
the base of the neck.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: ___ year old woman with hx transverse myelitis with increasing ___
weakness.// evaluate for cause ___ weakness, sensory deficits
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of Gadavist contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: None.
FINDINGS:
CERVICAL:
There is grade 1 anterolisthesis of C4 on C5 and minimal retrolisthesis of C5
on C6. Vertebral body height and alignment is otherwise preserved. There is
multilevel degenerative disc disease, most pronounced at C5-C6 with severe
disc space height loss. Bone marrow signal intensity is within normal limits.
At C4-C5, subluxation and small osteophytes mildly flatten the ventral cord
but without cord signal abnormality. In addition, there facet and
uncovertebral joint osteophytes and ligamentum flavum thickening that produce
no significant neural foraminal narrowing at this level.
At C5-C6, there are intervertebral osteophytes and small facet osteophytes
that mildly narrow the spinal canal without contacting the spinal cord. There
is no significant foraminal narrowing.
At C6-C7, there is bulging of the disc without spinal canal stenosis or neural
foraminal narrowing.
There is no spinal canal stenosis or neural foraminal narrowing at the
remaining cervical levels.
THORACIC:
Vertebral body height and alignment is preserved. There is mild multilevel
degenerative disc disease. Bone marrow signal intensity is within normal
limits.
There is a central disc protrusion at T7-T8 which remodels the ventral cord
but without definitive cord signal abnormality. In addition, there is mild
facet joint arthropathy which results in mild spinal canal stenosis but no
neural foraminal narrowing.
The spinal cord appears otherwise normal in caliber and configuration without
abnormal enhancement after contrast administration.
There is no spinal canal stenosis or significant neural foraminal narrowing at
the remaining thoracic levels.
LUMBAR:
There is grade 1 anterolisthesis of L4 on L5. Vertebral body heights and
alignment is otherwise preserved. There is mild multilevel degenerative disc
disease, most pronounced at L3-L4 with mild-to-moderate disc space height
loss. Bone marrow signal intensity is within normal limits.
The spinal cord appears normal in caliber and configuration. The conus
terminates normally at the T12-L1 level. The cauda equina nerve roots appear
unremarkable. There is no abnormal enhancement after contrast administration.
At L1-L 2, there is no spinal canal stenosis or neural foraminal narrowing.
At L2-L3, there is a shallow disc bulge, facet joint arthropathy with small
bilateral facet joint effusions and moderate ligamentum flavum thickening but
no spinal canal stenosis or neural foraminal narrowing.
At L3-L4, there is disc bulging, facet osteophytes and ligamentum flavum
thickening. Together these produce mild narrowing of the spinal canal. There
is minimal bulging of the disc into the neural foramina bilaterally.
At L4-L5, subluxation, disc bulging, facet osteophytes and ligamentum flavum
thickening produce mild spinal canal narrowing. The traversing L5 nerve roots
are caught between the disc bulge and the superior facet osteophytes
bilaterally. There is mild narrowing of the neural foramina bilaterally.
There are bilateral facet joint effusions due to degenerative disease.
At L5-S1, there is a shallow disc bulge that contacts the traversing S1 nerve
roots. There are bilateral facet osteophytes but no spinal canal stenosis or
neural foraminal narrowing.
IMPRESSION:
1. No evidence of cord compression, severe spinal canal stenosis or
significant neural foraminal narrowing along the entire spine.
2. Disc bulge at C4-C5 which remodels the ventral cord but without cord signal
abnormality and mild-to-moderate spinal canal stenosis this level.
3. Central disc protrusion at the 78 which remodels the ventral cord but
without definitive cord signal abnormality.
4. Multilevel disc bulges along the lumbar spine resulting in mild to moderate
spinal canal stenosis at L3-L4 and L4-L5.
5. Normal appearance of the spinal cord and no abnormal enhancement.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Numbness, Urinary retention
Diagnosed with Weakness, Paresthesia of skin
temperature: 97.8
heartrate: 82.0
resprate: 14.0
o2sat: 98.0
sbp: 138.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | The patient is a ___ female with a history of thyroid cancer s/p
thyroidectomy, diverticulosis, lumbosacral radiculopathy, and
recent presumed transverse myelitis s/p steroid treatment who
presented with recurrent sensory loss/dysesthesia and lower
extremity weakness. Her exam was notable for weakness in
bilateral lower extremities, brisk reflexes in bilateral lower
extremities, upgoing toes, and decreased sensation to pinprick
and temperature up to the level of T6-8.
At ___, the patient was presumed to have transverse
myelitis based on distribution of her sensorimotor deficits,
benign neurodiagnostics, and apparent response to steroid
therapy. An extensive workup was completed at ___ for
inflammatory, infectious, toxo-metabolic, nutritional, and
neoplastic etiologies, with all studies negative or pending at
this point. However, it appears that VZV was not sent.
MRI spine done here was unremarkable other than multilevel disc
bulges. The patient had a normal EMG. LP was repeated. A
definitive diagnosis was not reached, however we plan to
continue to follow the patient in the outpatient setting and
continue workup for inflammatory vs infectious etiology of her
transverse myelitis.
#BLE weakness
#Decreased pain/temperature
#c/f transverse myelitis
-CSF unremarkable
-studies sent for arbovirus, VZV, paraneoplastic antibody panel,
anti GFAP, encephalopathy panel
-ID consulted, recommendations appreciated
-___, ___ pending
-started valacyclovir and prednisone taper
-___ neurology will continue to follow outpatient |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / lisinopril
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with a history of NASH cirrhosis on transplant list
presenting with 3 day history of confusion. Per son and wife,
patient has been taking medications but has just seemed "off"
the last few days. Has slept more yesterday and was not oriented
to time or place. He was unable to dress himself yesterday. Wife
gave lactulose before leaving to hospital. No F/C, CP, SOB,
abdominal pain. No headache or dysuria.
In the ED, initial vital signs were 98.4, 76, 173/75, 18, 99%
RA. Patient was AAOx3. Labs were notable for platelets of 50,
WBC 5.9, Hct 32.1, INR 1.8, Cr 0.9, TBili 6.1. UA was negative
for infection. CXR showed no acute consolidations. Blood
cultures were sent. Ultrasound showed no ascites and patent
vessels but evidence of worsening portal hypertension. Patient
received lactulose 30cc x1 and was admitted to Medicine for
further management. Today patient feels significantly better. He
says he felt more confused yesterday but is at baseline at this
time. He admits to not taking lactulose as prescribed.
Past Medical History:
- Cirrhosis secondary to NAFLD diagnosed in ___
--- Grade I varices on EGD ___
--- Portal hypertensive gastropathy
--- Encephalopathy
- Insulin-dependent diabetes
- Frequent nephrolithiasis
- Hyperlipidemia
- Hypertension
- Idiopathic thrombocytopenia purpura
- OSA not on CPAP
- Diverticulosis (on colonoscopy in ___
- GERD now well-controlled
Social History:
___
Family History:
Patient's mother died at age ___ from melanoma. Also had
Alzheimer's dementia. Patient's father died at ___ from CAD. Also
had mesothelioma.
Physical Exam:
**Admission Exam**
Vitals: 98, 81, 108/46, 18, 97% RA
General: AAOx3, NAD
HEENT: Mildly icteric sclera, MMM, oropharynx clear
Neck: Supple, no JVD, no LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: RRR, nl S1/S2, no MRG
Abdomen: Soft, NTND, positive bowel sounds, no organomegaly
Ext: Warm, well perfused, no cyanosis/clubbing/edema
Skin: Jaundice. No concerning lesions.
Neuro: CN II-XII grossly intact
**Discharge Exam**
Vitals: 98.4 141/60 (120-141/51-61) 73 (62-73) 18 99%
General: laying in bed, no acute distress
HEENT: Mildly icteric sclera, MMM, oropharynx clear
Neck: Supple, no JVD, no LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: RRR, nl S1/S2, no MRG
Abdomen: Soft, nontender, ?distended but normal-size according
to patient, normoactive bowel sounds, no organomegaly
Ext: Warm, well perfused, no cyanosis/clubbing/edema, 2+
dorsalis pedis pulses
Skin: Jaundice. No concerning lesions.
Neuro: CN II-XII grossly intact, no asterixis
Pertinent Results:
**Admission Labs**
___ 04:20PM BLOOD WBC-5.9 RBC-3.02* Hgb-11.2* Hct-32.1*
MCV-106* MCH-36.9* MCHC-34.8 RDW-14.5 Plt Ct-50*
___ 04:20PM BLOOD Glucose-181* UreaN-16 Creat-0.9 Na-138
K-4.7 Cl-106 HCO3-20* AnGap-17
___:20PM BLOOD ALT-28 AST-58* AlkPhos-239* TotBili-6.1*
___ 04:20PM BLOOD Albumin-2.9*
**DISCHARGE LABS**
___ 07:00AM BLOOD WBC-3.0* RBC-2.47* Hgb-9.1* Hct-26.5*
MCV-107* MCH-36.7* MCHC-34.2 RDW-15.1 Plt Ct-32*
___ 07:00AM BLOOD ___ PTT-43.0* ___
___ 07:00AM BLOOD Glucose-216* UreaN-16 Creat-1.0 Na-138
K-4.1 Cl-107 HCO3-27 AnGap-8
___ 07:00AM BLOOD ALT-23 AST-51* AlkPhos-154* TotBili-4.5*
**U/A**
___ 04:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 04:50PM URINE Color-Yellow Appear-Clear Sp ___
**IMAGING**
___ abdominal US
IMPRESSION:
1. New to and fro movement of the main portal vein with partial
reversal of flow in the anterior segment of the right portal
vein, consistent with
worsening portal hypertension. No definite thrombus identified.
2. Cirrhotic liver and splenomegaly.
___ CXR:
IMPRESSION: No radiographic evidence of an acute cardiopulmonary
process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 3 mg PO DAILY
2. Glargine 34 Units Bedtime
3. Lactulose 30 mL PO TID
4. Losartan Potassium 100 mg PO DAILY
please hold for SBP<100
5. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
6. Nadolol 40 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Repaglinide 0.5 mg PO TIDAC
9. Rifaximin 550 mg PO BID
10. Spironolactone 50 mg PO DAILY
11. Ursodiol 300 mg PO BID
12. magnesium gluconate *NF* 30 mg (550 mg) Oral 2 tabs BID
13. Centrum *NF* (multivit & mins-ferrous
glucon;<br>multivit-iron-min-folic acid) 3,500-18-0.4 unit-mg-mg
Oral daily
Discharge Medications:
1. FoLIC Acid 3 mg PO DAILY
2. Glargine 34 Units Bedtime
3. Lactulose 30 mL PO TID
4. Losartan Potassium 100 mg PO DAILY
5. Nadolol 40 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Repaglinide 0.5 mg PO TIDAC
8. Rifaximin 550 mg PO BID
9. Spironolactone 50 mg PO DAILY
10. Ursodiol 300 mg PO BID
11. Centrum *NF* (multivit & mins-ferrous
glucon;<br>multivit-iron-min-folic acid) 3,500-18-0.4 unit-mg-mg
Oral daily
12. magnesium gluconate *NF* 30 mg (550 mg) Oral 2 tabs BID
13. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hepatic Encephalopathy
Seconday: NAFLD, cirrhosis, HTN, diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Altered mental status. Rule out an acute process.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. Lungs are
essentially clear. There is no focal consolidation, pleural effusion or
pneumothorax.
IMPRESSION: No radiographic evidence of an acute cardiopulmonary process.
Radiology Report
HISTORY: Cirrhosis, presenting with altered mental status. Rule out portal
vein thrombosis.
COMPARISON: Prior Doppler/duplex abdominal ultrasound from ___.
FINDINGS:
The liver demonstrates coarse echogenicity and nodular contour, consistent
with known diagnosis of cirrhosis. The gallbladder is unremarkable. The
common bile duct was not visualized. As compared to prior ultrasound from ___, there is new reversal of flow in the anterior segment of the right
portal vein with to and fro movement in the main portal vein. The posterior
segment of the right portal vein is not visualized. The left portal vein is
patent and demonstrates adequate directionality of flow. The right and middle
hepatic veins are patent. The left hepatic vein was not visualized. An
umbilical vein is patent. The IVC is patent. The main hepatic artery is
patent and demonstrates adequate wave forms. The spleen is enlarged,
measuring 16.6 cm. There is no intra-abdominal ascites.
IMPRESSION:
1. New to and fro movement of the main portal vein with partial reversal of
flow in the anterior segment of the right portal vein, consistent with
worsening portal hypertension. No definite thrombus identified.
2. Cirrhotic liver and splenomegaly.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with ALTERED MENTAL STATUS , CHRONIC LIVER DIS NEC
temperature: 98.4
heartrate: 76.0
resprate: 18.0
o2sat: 99.0
sbp: 173.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | Impression: ___ yo M with a history of NASH cirrhosis on
transplant list presenting with 3 days of confusion likely due
to hepatic encephalopathy caused by dehydration and inconsistent
lactulose use.
*ACUTE ISSUES*
# Hepatic encephalopathy: Patient reports inconsistent use of
lactulose at home. This, combined with dehydration, likely
accounts for his confusion on presentation. CXR and UA obtained
in the ED showed no evidence of infection. RUQ ultrasound was
stable aside from some interval worsening of portal
hypertension. Patient was given dose of lactulose in the ED. On
the floor home rifaximin was continued. By morning he was AAOx3
and at baseline mental status. PO fluids were encouraged.
Patient's mental status returned to baseline with lactulose TID
and up to 5 bowel movements a day. Blood cultures pending at
time of discharge. Patient has good insight regarding his use of
lactulose and understands the need to use it BID or TID for a
goal of ___ bowel movements per day. In addition, encouraged
good hydration at home, especially given heat.
*CHRONIC ISSUES*
# Cirrhosis: Secondary to NAFLD. Patient is on the transplant
list. MELD score was 20 on night of admission and 19 at
discharge. Patient was put on ___ g heart healthy/diabetic diet.
# Esophageal varices: Grade I varices on EGD in ___.
Continued home nadolol.
# Coagulopathy: Platelets 50, INR 1.8. No evidence of bleeding
on this admission. Heparin held on HD#2 for platelets of 36.
# Hypertension: Stable. Continued on home lisinopril and
nadolol.
# Diabetes: Patient was continued on home Lantus QHS. With the
exception of repaglinide, home oral hypoglycemics were held
initially. Blood sugars were managed with a low dose Humalog
sliding scale. On HD#2 patient was restarted on home metformin
for blood sugars trending in the 200s despite sliding scale.
*TRANSITIONAL ISSUES*
# Transplant clinic f/u scheduled ___
# Patient to take lactulose BID-TID |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
worsening knee pain and drainage s/p R knee medial meniscus
repair with subchondroplasty of the medial tibial plateau
Major Surgical or Invasive Procedure:
right knee I&D, removal of loose bodies ___, ___
History of Present Illness:
___ year old male recently s/p R knee medial meniscus repair with
subchondroplasty of the medial tibial plateau ___, ___,
presents with worsening knee pain and drainage.
Past Medical History:
Bronchitis, hyperlipidemia, hypertension, migraines, heart
murmur, lichen simplex chronicus, tinea versicolor, s/p R knee
medial meniscus repair with subchondroplasty of the medial
tibial plateau ___, ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Dressing C/D/I
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 03:00AM BLOOD Hct-41.2
___ 06:30AM BLOOD Hgb-13.4* Hct-40.9
___ 06:45AM BLOOD WBC-8.6 RBC-4.83 Hgb-14.4 Hct-44.6 MCV-92
MCH-29.8 MCHC-32.3 RDW-13.2 RDWSD-44.5 Plt ___
___ 02:42PM BLOOD WBC-9.3 RBC-5.00 Hgb-15.1 Hct-46.0 MCV-92
MCH-30.2 MCHC-32.8 RDW-13.2 RDWSD-44.3 Plt ___
___ 02:42PM BLOOD Neuts-57.9 ___ Monos-7.5 Eos-7.9*
Baso-1.5* Im ___ AbsNeut-5.39 AbsLymp-2.20 AbsMono-0.70
AbsEos-0.74* AbsBaso-0.14*
___ 06:30AM BLOOD Creat-1.0
___ 06:45AM BLOOD Glucose-76 UreaN-15 Creat-0.9 Na-138
K-4.8 Cl-100 HCO3-26 AnGap-12
___ 02:42PM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-140
K-5.2 Cl-104 HCO3-25 AnGap-11
___ 06:45AM BLOOD Calcium-9.3 Phos-5.8* Mg-2.2
___ 02:42PM BLOOD CRP-3.8
___ 03:00AM BLOOD Vanco-18.3
___ 02:10AM BLOOD Vanco-13.9
___ 02:42PM BLOOD HoldBLu-HOLD
___ 02:42PM BLOOD GreenHd-HOLD
___ 03:00PM JOINT FLUID TNC-1001* ___ Polys-8
___ Monos-50 Eos-1*
___ 03:00PM JOINT FLUID Crystal-NONE
Medications on Admission:
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Gabapentin 1200 mg PO BID
3. Ibuprofen 800 mg PO Q8H
4. Lisinopril 10 mg PO DAILY
5. meloxicam 7.5 mg oral BID:PRN pain
6. Metoprolol Succinate XL 25 mg PO DAILY
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
8. Sildenafil 100 mg PO DAILY:PRN sexual intercourse
9. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
10. Aspirin 325 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Enoxaparin (Prophylaxis) 40 mg SC DAILY
2. Acetaminophen 1000 mg PO Q8H
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 1200 mg PO BID
6. Lisinopril 10 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Sildenafil 100 mg PO DAILY:PRN sexual intercourse
11. HELD- Ibuprofen 800 mg PO Q8H This medication was held. Do
not restart Ibuprofen until you've been cleared by your surgeon
12. HELD- meloxicam 7.5 mg oral BID:PRN pain This medication
was held. Do not restart meloxicam until you complete your
course of Lovenox injections
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
increased pain and drainage s/p R knee medial meniscus repair
with
subchondroplasty of the medial tibial plateau on ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ with meniscal surgery on ___, p/w 1 day of pink discharge
and tenderness // Any post-op changes?
TECHNIQUE: Frontal, lateral, and sunrise view radiographs of the right knee.
COMPARISON: Fluoroscopic exam ___, MRI ___
FINDINGS:
No fracture or dislocation is seen. Articular surface of the medial tibial
plateau appears preserved. Mild degenerative changes are noted including
peaking of the tibial spines. No significant knee joint effusion. Radiopaque
material projects in the soft tissues medial to the proximal right tibia,
compatible with injected calcium phosphate from recent subchondroplasty.
There is normal osseous mineralization. No suspicious lytic or sclerotic
lesions are identified.
IMPRESSION:
Radiopaque material projecting within the soft tissues over the right medial
tibia compatible with calcium phosphate related to recent subchondroplasty.
Radiology Report
EXAMINATION: CT LOWER EXT W/C RIGHT Q62R
INDICATION: ___ year old man with meniscal repair on ___, used cement,
purulent discharge from site. // Please perform exam from mid femur to
mid-tibia. Any evidence of post-op infection?
TECHNIQUE: Axial CT with contrast from right mid femur to mid tibia with
coronal and sagittal reformats.
DOSE: Acquisition sequence:
1) Spiral Acquisition 19.4 s, 41.1 cm; CTDIvol = 20.6 mGy (Body) DLP =
847.5 mGy-cm.
Total DLP (Body) = 848 mGy-cm.
COMPARISON: Same-day radiograph of the right knee. MR knee ___
FINDINGS:
There is no fracture or dislocation. Adjacent to a surgically created
horizontally oriented tract, approximately 6 cm of globular hyperdense
material is noted outside of the joint with surrounding soft tissue stranding.
Is hyperdense material is seen to extend in close proximity to the overlying
skin surface. Two additional surgical tracks are noted, 1 of which is
oriented towards the joint space. There is a small knee joint effusion.
IMPRESSION:
1. Hyperdense material in the soft tissue outside of the joint space adjacent
to a surgically created horizontally oriented tract, extending to close
proximity to the skin surface medially.
2. Small knee joint effusion.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Knee pain, Wound eval
Diagnosed with Oth complications of procedures, NEC, init, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 97.0
heartrate: 112.0
resprate: 18.0
o2sat: 99.0
sbp: 177.0
dbp: 108.0
level of pain: 8
level of acuity: 3.0 | The patient was admitted to the orthopedic surgery service from
the ED. His knee was aspirated in the ED, which showed no
growth at time of discharge. He was placed on IV antibiotics
and his wound was monitored. The following day, he was taken to
the operating room for above described procedure. Please see
separately dictated operative report for details. The surgery
was uncomplicated and the patient tolerated the procedure well.
Patient continued on IV antibiotics post-operatively.
Postoperative course was remarkable for the following:
POD #1, aspiration cultures showed no growth to date. Vanco
trough was 13.9 and dose was increased to 1250mg every 8 hours.
POD #2, vanco trough was 18.3. Aspiration cultures remained no
growth to date at the time of discharge. Patient cleared ___
without further issues.
Otherwise, pain was controlled with a combination of oral pain
medications. The patient received Lovenox for DVT prophylaxis
starting on the morning of POD#1. The patient was seen daily by
physical therapy. Labs were checked throughout the hospital
course and repleted accordingly. At the time of discharge the
patient was tolerating a regular diet and feeling well. The
patient was afebrile with stable vital signs. The patient's
hematocrit was acceptable and pain was adequately controlled on
an oral regimen. The operative extremity was neurovascularly
intact and the dressing was intact.
The patient's weight-bearing status is partial weight bearing on
the operative extremity with no range of motion of the knee.
___ brace locked in extension (can come out of brace daily
for skin checks).
Mr. ___ is discharged to home with services in stable
condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending: ___
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with a history of recurrent
idiopathic pancreatitis who presents with acute onset of
epigastric abdominal pain consistent with prior episodes of
pancreatitis.
Patient's initial episode of pancreatitis was in ___ and he
has had > 15 episodes since that time. This was initially
attributed to alcohol, but he denies heavy use ___ glasses per
month; last drink 1 month ago). He underwent cholecystectomy in
___ but has continued to have flares of pancreatitis of
unclear etiology. He was followed by Dr. ___ in
Gastroenterology and has had normal triglycerides and normal
IgG4 level.
Mr ___ describes a one day history of rapidly worsening
severe epigastric pain some radiation to back very similar to
prior
pancreatitis episodes. + N/V bilious non blood fluid. Has
continued to make urine, but no recent BMs. For his symptoms, he
reported to ___-M where he was treated symptomatically. Lipase
was 184 (ULN at ___-M is 60). WBC was 12.2 and ___ was 231. Hct
notable was 48. Labs and exam were otherwise normal. Per patient
request, he was transferred to ___. Patient went through the
ED where labs were drawn and he was given 1mg dilaudid. Started
on IVF and then sent to the floor. Upon arrival, Mr ___ was
in severe pain, moaning and unable to provide significant
history until pain meds had been given. Since he was last
discharged from ___, he reports that he has had multiple ERCPs
and MRCPs which were unrevealing to the cause of his recurrent
pancreatitis. Does not report any recent alcohol use.
Past Medical History:
- Recurrent pancreatitis: First episode in ___. Initially
attributed to ETOH however denies significant ETOH intake. (says
___ glasses per month). Per OMR has had > 15 episodes, including
several after cholecystectomy
- Lap Cholecystectomy: ___, path showed chronic
cholecystitis
- Nephrolithiasis
Social History:
___
Family History:
Denies any family history of pancreatic, biliary cancer or
disease, or autoimmune pancreatitis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 159/98 72 20 98/RA
GENERAL: In distress due to pain
HEENT: NCAT EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, 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: Softly distended, diffusely tender worst in epigastric
region without r/g, no hepatosplenomegaly. No flank or
periumbilical hematomas.
EXT: moving all extremities well, no cyanosis, clubbing or
edema
PULSES: 2+ DP pulses bilaterally
SKIN: WWP, no excoriations or lesions, no rashes
DISCHARGE PHYSCIAL
VS - 98.4 104/51 71 18 96%RA
GENERAL: Well appearing M in NAD
HEENT: NCAT EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, scattered wheezes, breathing comfortably without
use of accessory muscles
ABDOMEN: NTND, non acute absdomen that is soft. no
hepatosplenomegaly. No flank or periumbilical hematomas.
EXT: moving all extremities well, no cyanosis, clubbing or
edema
PULSES: 2+ DP pulses bilaterally
SKIN: WWP, no excoriations or lesions, no rashes
Pertinent Results:
ADMISSION LABS
___ 10:40PM BLOOD WBC-13.4*# RBC-4.49* Hgb-14.4 Hct-41.5
MCV-92 MCH-32.1* MCHC-34.7 RDW-12.3 RDWSD-40.9 Plt ___
___ 10:40PM BLOOD Neuts-81.9* Lymphs-11.1* Monos-5.6
Eos-0.7* Baso-0.2 Im ___ AbsNeut-10.93* AbsLymp-1.48
AbsMono-0.75 AbsEos-0.09 AbsBaso-0.03
___ 04:45AM BLOOD ___ PTT-30.5 ___
___ 10:40PM BLOOD Glucose-108* UreaN-12 Creat-0.7 Na-137
K-3.7 Cl-104 HCO3-21* AnGap-16
___ 10:40PM BLOOD ALT-31 AST-29 AlkPhos-87 TotBili-0.8
___ 10:40PM BLOOD Lipase-348*
___ 10:40PM BLOOD Albumin-4.0
___ 04:45AM BLOOD Calcium-8.9 Phos-3.9# Mg-1.6
___ 10:45PM BLOOD Lactate-1.2
DISCHARGE LABS
___ 05:10AM BLOOD WBC-7.5 RBC-4.52* Hgb-14.3 Hct-41.7
MCV-92 MCH-31.6 MCHC-34.3 RDW-12.3 RDWSD-41.3 Plt ___
___ 05:10AM BLOOD Glucose-76 UreaN-7 Creat-0.7 Na-138 K-3.8
Cl-100 HCO3-23 AnGap-19
___ 04:45AM BLOOD ALT-29 AST-22 LD(LDH)-143 AlkPhos-85
TotBili-0.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute Recurrent Pancreatitis
Tobacco Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ with pancreatitis and hypoxia // infiltrate? ARDS?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
There is no focal consolidation. The cardiomediastinal silhouette is
unremarkable. No pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Acute pancreatitis, unspecified
temperature: 98.6
heartrate: 61.0
resprate: 22.0
o2sat: 91.0
sbp: 150.0
dbp: 100.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ is a ___ man with a history of recurrent
idiopathic pancreatitis who presents with acute onset of
epigastric abdominal pain consistent with prior episodes of
pancreatitis.
# Acute Pancreatitis, Recurrent: BISAP 0. Patient with typical
epigastric pain and lipase 3x ULN at OSH. Previous EUS c/w
changes typical of chronic pancreatitis. His OSH labs were
concerning for Hct of 48, suggesting significant ___ spacing,
but he is HDS and Hct has improved on arrival here. Pt has
previously undergone a fairly extensive work-up for acute
pancreatitis. Trigger for current episode is unclear; LFTs do
not suggest choledocolithiasis, no significant EtOH, no
hypercalcemia, no recent instrumentation, and no culprit
medications. Previous CCY for suspected stones. Prior IgG4 level
was normal, making autoimmune etiologies less likely. ___ levels
slightly higher than previous, but not at pathologic levels.
Patient was given aggressive volume repletion with LR and his
pain was controlled with IV hydromorphone. He was able to eat a
low-fat solid diet 24hrs after admission without recurrent pain.
TRANSITIONAL ISSUES
===================
-Patient should follow up with a pancreatitis specialist,
referred to ___ to make an appointment in ___
Pancreas clinic
-Patient counseled on quitting smoking cigarettes. Please
continue to endorse and encourage. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Adhesive Tape / Ativan / Cephalexin / Dilaudid / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
L groin abscess
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ ___ year old man with past medical history significant
for
viral myocarditis (___) s/p orthotopic heart transplant,
complicated by ESRD due to tacrolimus toxicity (___) s/p kidney
transplant now on prednisone / sirolimus / azathioprine,
diabetes
mellitus on insulin pump, cirrhosis due to HCV (treated with
SVR), partial generalized seizures, and frequent abscesses who
presented from ___ clinic on ___ due to recurrent inguinal
abscess and feeling unwell.
He noticed a small "pimple like" area 3 days ago, and this has
happened multiple times so he waited until his scheduled ID apt
in ___ with Dr. ___. During that time it had gotten larger,
started to become sore and he had temperatures above his usual
97 degrees, in the 99.5 range.
Of note, he had an admission at ___ in ___ - he was given IV
vancomycin and pip-tazo before transition to oral levofloxacin
(10 day course). He underwent drainage with culture on ___
revealing the growth of a Staph lugdenensis which was
susceptible to oxacillin, doxycycline but resistant to
erythromycin and clindamycin.
One week later (first week of ___ - Admitted BI without
intervention, treated with doxycycline and continued on PO
vancomycin for C.diff prophylaxis. He was discharged then
readmitted the next day ___ with recurrent fevers,
treated with IV antibiotics with no new positive cultures, and
discharged with plans to complete the 14 day doxycycline course.
Opiates were discontinued.
This current groin infection is slightly different than his
previous, because the redness is more diffuse, but in the past
it remained better circumscribed.
In the ED initial vitals were 7 98.8 86 165/102 19 100% RA
Labs/studies notable for Cr of 1.6. Normal LFTs. Trop <0.01.
Patient was given morphine, ondansetron, 2L IVF and home
medications (furosemide, atorvastatin, amiloride, verapamil,
propranolol, keppra).
Vitals on transfer:
On the floor he still feels general malaise, and still has
throbbing in his groin. No rigors. No drenching sweats. He also
has general abdominal pain, dull all over and feels nauseous
without vomiting. Last BM was 2 days ago.
Dr. ___ written for doxy and po vanc prior to their
re-evaluation and decision to go to ED, so he never started
those outpatient meds.
Past Medical History:
1. Heart transplant ___ (due to viral myocarditis)
2. Kidney transplant ___ (due to ESRD of tacro toxicity)
3. HCV Cirrhosis no s/p Harvoni and Ribavarin with SVR (___)
4. History of rejection early post transplant.
5. Steroid-induced diabetes mellitus, insulin dependent.
6. Seizure disorder.
7. Anxiety.
8. Dynamic left ventricular outflow tract obstruction,
improved.
9. Recurrent episode of pulmonary edema with diastolic
dysfunction.
10. Chronic C. difficile.
11. Remote history of massive GI bleed.
12. Remote history of bleed after renal biopsy.
13. History of osteomyelitis x2.
14. Presumed pulmonary hemorrhage ___.
15. Gout.
16. Multiple admissions for infectious issues.
17. Peptic Ulcer Disease
18. Cutaneous abscess of groin
19. OSA on CPAP
Social History:
___
Family History:
No family history of cardiac disease
Physical Exam:
==============
ADMISSION EXAM
==============
VS: 98.4, 122/78, 83, 18, 93% on RA
GENERAL: Well developed, well nourished, in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink.
NECK: Supple. JVP of ~8 cm.
CARDIAC: Regular rate and rhythm. Normal S1, S2. distant heart
sounds
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, mildly tender, moderately distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. 2+ DP pulses.
SKIN: Groin with 2cm erythematous induration and 2cm of
surrounding soft erythema near the left inguinal crease. tender
to palpation. not draining anything. No involvement of scrotum.
Scattered acne lesions across back and chest. Diffuse verruca
across hands, face, etc.
==============
DISCHARGE EXAM
==============
Vs: 97.5-98.4 ___ 18 96-100% on CPAP
I/O: ___ 24hr
Weight 75.8 kg <-- 75.5 (last weight at ___ 76.9)
GENERAL: Well developed, well nourished, in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink.
NECK: Supple. JVP of ~7 cm.
CARDIAC: Regular rate and rhythm. Normal S1, S2. distant heart
sounds
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, mildly tender, moderately distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. 2+ DP pulses.
SKIN: Groin with 1cm erythematous induration and 2cm of
surrounding soft erythema near the left inguinal crease.
Improved tenderness to palpation. not draining anything. No
involvement of scrotum. Scattered acne lesions across back and
chest. Diffuse verruca across hands, face, etc.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 03:35PM BLOOD WBC-9.6# RBC-5.70# Hgb-17.1# Hct-52.0*#
MCV-91 MCH-30.0 MCHC-32.9 RDW-13.6 RDWSD-45.5 Plt ___
___ 03:35PM BLOOD Neuts-82* Bands-0 Lymphs-5* Monos-12
Eos-0 Baso-1 ___ Myelos-0 AbsNeut-7.87*
AbsLymp-0.48* AbsMono-1.15* AbsEos-0.00* AbsBaso-0.10*
___ 03:35PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
___ 03:35PM BLOOD Plt Smr-NORMAL Plt ___
___ 05:45PM BLOOD Glucose-130* UreaN-25* Creat-1.6* Na-139
K-4.0 Cl-102 HCO3-22 AnGap-19
___ 03:35PM BLOOD AST-29 TotBili-1.2
___ 05:45PM BLOOD cTropnT-<0.01
___ 05:45PM BLOOD Albumin-4.5
___ 05:45PM BLOOD rapmycn-14.9
___ 05:45PM BLOOD Lactate-1.5
=================
PERTINENT IMAGING
=================
--------------------
SOFT TISSUE U/S OF L GROIN (___): Skin thickening with
subcutaneous edema and no drainable fluid collection identified.
--------------------
==============
DISCHARGE LABS
==============
___ 06:30AM BLOOD WBC-8.5# RBC-5.37 Hgb-16.1 Hct-49.1
MCV-91 MCH-30.0 MCHC-32.8 RDW-13.3 RDWSD-45.0 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-113* UreaN-21* Creat-1.7* Na-143
K-3.4 Cl-96 HCO3-26 AnGap-24*
___ 06:30AM BLOOD Calcium-9.8 Phos-4.6* Mg-2.0
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO QHS
2. aMILoride 2.5 mg PO QPM
3. Atorvastatin 10 mg PO QPM
4. AzaTHIOprine 25 mg PO DAILY
5. Calcitriol 0.5 mcg PO DAILY
6. ClonazePAM 1 mg PO QAFTERNOON
7. ClonazePAM 1.5 mg PO QHS
8. Doxycycline Hyclate 100 mg PO Q12H
9. Gabapentin 300 mg PO TID
10. LACOSamide 250 mg PO BID
11. LevETIRAcetam 1500 mg PO BID
12. Mirtazapine 45 mg PO QHS
13. PredniSONE 15 mg PO EVERY OTHER DAY
14. Propranolol 30 mg PO TID
15. Sirolimus 1.5 mg PO 5X/WEEK (___)
16. Sirolimus 1 mg PO 2X/WEEK (MO,FR)
17. Vancomycin Oral Liquid ___ mg PO Q6H
18. Verapamil 40 mg PO TID
19. Zolpidem Tartrate 10 mg PO QHS
20. Co Q-10 (coenzyme Q10) 200 mg oral DAILY
21. Furosemide 40 mg PO BID
22. Potassium Chloride 20 mEq PO BID
23. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) UNKNOWN ORAL
DAILY
24. Tretinoin 0.05% Cream 1 Appl TP QHS
25. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Basal rate minimum: 0.59 units/hr
Basal rate maximum: 1.8 units/hr
Bolus minimum: ___ units
Bolus maximum: 12 units
Target glucose: ___
Fingersticks: QAC and HS
Discharge Medications:
1. Ondansetron 4 mg PO DAILY nausea Duration: 4 Doses
Please do not use more than once a day.
RX *ondansetron 4 mg 1 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
2. vancomycin 125 mg oral Q6H Duration: 21 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*82 Capsule Refills:*0
3. Doxycycline Hyclate 100 mg PO BID Duration: 6 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*12 Capsule Refills:*0
4. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Basal rate minimum: 0.59 units/hr
Basal rate maximum: 1.8 units/hr
Bolus minimum: ___ units
Bolus maximum: 12 units
Target glucose: ___
Fingersticks: QAC and HS
5. Potassium Chloride 30 mEq PO BID
Hold for K > 4.5
6. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) pill 1 ORAL
DAILY
7. Sirolimus 1 mg PO DAILY
Daily dose to be administered at 6am
8. Allopurinol ___ mg PO QHS
9. aMILoride 2.5 mg PO QPM
10. Atorvastatin 10 mg PO QPM
11. AzaTHIOprine 25 mg PO DAILY
12. Calcitriol 0.5 mcg PO DAILY
13. ClonazePAM 1 mg PO QAFTERNOON
14. ClonazePAM 1.5 mg PO QHS
15. Co Q-10 (coenzyme Q10) 200 mg oral DAILY
16. Furosemide 40 mg PO BID
17. Gabapentin 300 mg PO TID
18. LACOSamide 250 mg PO BID
19. LevETIRAcetam 1500 mg PO BID
20. Mirtazapine 45 mg PO QHS
21. PredniSONE 15 mg PO EVERY OTHER DAY
22. Propranolol 30 mg PO TID
23. Tretinoin 0.05% Cream 1 Appl TP QHS
24. Vancomycin Oral Liquid ___ mg PO Q6H
25. Verapamil 40 mg PO TID
26. Zolpidem Tartrate 10 mg PO QHS
27.Outpatient Lab Work
Name of provider to follow up: ___
ICD-9: V42.1 (Hx of heart transplant)
Please go to an outpatient lab on the morning of ___ to have
RAPAMYCIN TROUGH checked before your morning dose of sirolimus.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Left groin abscess
SECONDARY:
Heart and kidney transplant recipient
Diabetes mellitus, on insulin pump
Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ with renal transplant // eval for abscess, appendicitis
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: None.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is mild
caliectasis in the upper pole. No perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.61 to 0.68, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 98 cm per second. Vascularity is symmetric throughout transplant.
The transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Essentially normal renal transplant ultrasound.
Radiology Report
EXAMINATION: CT abdomen/pelvis without IV contrast
INDICATION: ___ with renal transplant and abdominal pain
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.Oral contrast was administered. Coronal and sagittal reformations
were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 601 mGy-cm.
COMPARISON: ___ noncontrast CT abdomen/pelvis
FINDINGS:
LOWER CHEST: Imaged lung bases are clear. There is no pleural or pericardial
effusion. Coronary artery calcifications are noted. Evidence of prior CABG
includes median sternotomy wires. Heart is mildly enlarged.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is subtle nodularity overlying the hepatic capsule. There is no
evidence of focal lesions within the limitations of an unenhanced scan. There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: There is borderline splenomegaly measuring 13.3 cm. The spleen shows
normal attenuation throughout, without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The native kidneys are markedly atrophic, but otherwise unremarkable.
A right lower quadrant transplanted kidney appears grossly unremarkable
without focal lesions within limitations of this unenhanced scan. No evidence
of hydronephrosis or nephrolithiasis. No ureterolithiasis. Mild perinephric
stranding is unchanged and likely postsurgical fibrosis.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted, particularly in the coronary arteries.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No etiology identified for the patient's reported symptoms.
2. Subtle nodularity of the hepatic capsule and borderline splenomegaly may
reflect cirrhosis and portal hypertension. Clinical correlation required.
NOTIFICATION: The updated findings regarding potential cirrhosis were
discussed with ___, M.D. by ___, M.D. on the telephone on
___ at 10:31 ___, approximately 15 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: GROIN, SOFT TISSUE
INDICATION: ___ year old man with groin abcess // drainable fluid collection?
TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the
superficial tissues of the left groin.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left groin. There is a moderate amount of skin thickening and subcutaneous
edema within the subcutaneous tissues left groin. No drainable fluid
collection is identified.
IMPRESSION:
Skin thickening with subcutaneous edema and no drainable fluid collection
identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Malaise, Fatigue
Diagnosed with Generalized abdominal pain
temperature: 98.8
heartrate: 86.0
resprate: 19.0
o2sat: 100.0
sbp: 165.0
dbp: 102.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ ___ year old man with past medical history significant
for
viral myocarditis (___) s/p orthotopic heart transplant,
complicated by ESRD due to tacrolimus toxicity (___) s/p kidney
transplant now on prednisone / sirolimus / azathioprine,
diabetes mellitus on insulin pump, cirrhosis due to HCV (treated
with SVR), partial generalized seizures, and frequent abscesses
who presented from ___ clinic on ___ due to recurrent inguinal
abscess and feeling unwell.
============
ACUTE ISSUES
============
# L groin Skin/Soft Tissue infection: Was given vanc/zosyn
overnight due to high risk location and immunnosuppresion.
Afebrile throughout his hospital stay, without spreading
erythema. Ultrasound negative for a drainable fluid collection.
ID consulted, recommended one day of vanc coverage only
followed by a 1-week course of doxycycline BID.
# Hypokalemia: To 2.9 prior to discharge. Repleted with 120
mEq PO K divided, resumed home diuretics as below.
=====================
CHRONIC/STABLE ISSUES
=====================
# Heart transplant: Initially held diuretics (amiloride,
furosemide) given infection and IVF in ED. Restarted on HD1 at
home dose. Continued home propranolol, verapamil, atorvastatin,
prednisone, sirolimus, azathioprine.
# Renal Transplant: Discussed with renal transplant team.
Sirolimus levels drawn, pending at time of discharge. Continued
calcitriol.
# DM on insulin pump
He had no red flags, no unexplained highs or lows. He had placed
his rate to 0 overnight due to low PO intake and demonstrated
appropriate pump use. MS appropriate, cognitively appropriate.
___ consulted for management of pump, Pt managed well.
# Anxiety/Insomnia: Continued home clonazepam
# Seizure disorder: Continued home AEDs, no recent seizures
# Home meds: Continued allopurinol
===================
TRANSITIONAL ISSUES
===================
# CODE: Full
# CONTACT:
- ___ (Father): ___
- ___ (Mother): ___
# Pt to complete a 7-day course of doxycycline 100mg BID.
# Follow-up appointment to be had with ID specialist (___) 1
week after discharge.
# Sirolimus 11.2 on ___. Decreased from 1.5mg 5x/week and 1mg
2x/week to 1mg daily. To have repeat sirolimus trough on ___
before AM dose.
# Increased standing potassium repletion from 20mg BID to 30mg
BID.
# Blood cultures pending at time of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transfer, s/p assault. Neck/throat pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
History was obtained via ___ interpreter, who was present
for the entire interview and physical. The patient is a ___ w/
no PMHx who presents from an OSH with reports of a sexual and
physical attack two days ago, following which she was held
against her will. Pt reports that over the past several days she
was struck in her head multiple times and additionally strangled
and kneed in the chest and abdomen. She fell to the ground
following these attacks and believes she may have lost
consciousness during episodes when she was choked. During one
episode, pt reports that she was thrown or pushed across the
room
during which point she fell and hit her head and left arm. In
between these physical attacks, she reports several episodes of
forced, unprotected vaginal intercourse.
Ms. ___ reports being able to free herself earlier yesterday
following which time she presented to an OSH where initial
workup was notable for a normal CT head, cspine, abdomen and
pelvis. CTA neck demonstrated a 1.3cm pocket of air in the soft
tissues of the right posterior trachea at the level of T1.
Pt reports pain with swallowing as well as pain across the top
of her forehead, her posterior L shoulder extending to her left
hand with reported weakness in grasp. She additionally reports
pain in her LUQ and LLQ. She has had intermittent nausea and
vomiting once, but no fevers, hematuria, constipation,
hematochezia, hematemesis, or abdominal bloating. She had one
episode of pink
tinged sputum, but denies coughing blood.
Past Medical History:
PMHx: none
PSHx: Denies, but mentioned liposuction.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
98.0 86 111/64 18 100
GEN: Well-developed, well-nourished adult woman in mild distress
HEENT: Traumatic injury medially, under hairline above forehead.
Petechiae across eyelids. Bruises present bilaterally on neck
and across upper chest.
Pupils equal, round, reactive to light. Wears contact lenses.
Ears - Light reflex present
CV: Regular rate, regular rhythm, no murmurs
Pulm: Clear to auscultation bilaterally. Normal excursion, no
respiratory distress. There is a yellowing bruise over the
medial left breast. Pt reports tenderness to palpation along
sternum but there is no obvious deformity. Pt reports
musculoskeletal pain over lateral rib cage bilaterally.
Abdomen: soft, tender, non distended. LUQ and LLQ tenderness. No
rebound or guarding.no masses noted.
EXT: warm and well perfused. Diffuse bruising across left hand
which appears swollen. Minimal bruising over right knee. ROM is
full, but slowed in LUE due to pain.
Back: Vertebral tenderness along length of spine, especially
cervical, T2-T4, and lumbar spine. This pain is predominantly
along the paraspinal muscles.
Neuro: A&Ox3, no focal neurologic deficits.
Discharge Physical Exam:
VS: 97.8 PO 94 / 61 R Lying 72 16 96 Ra
GEN: well developed, well nourished.
HEENT: PERRL. EOMI. Bruising and swelling under chin/upper neck,
tender to palpation. Mucus membranes pink/moist. Bruising across
upper chest.
CV: RRR
PULM: Clear to auscultation bilaterally.
ABD: Soft, non-tender, non-distended. Active Bowel sounds.
EXT: warm and dry. ___ pulses. bruising left hand. Small
bruise over right knee.
NEURO: A&Ox3. Follows commands and moves all extremities equal
and strong.
Pertinent Results:
Studies OSH ___:
CT head: no e/o traumatic injury
CT Cspine: no e/o traumatic injury, no misalignment
CT chest/abdomen/pelvis: no e/o injury within chest, abdomen,
pelvis
CTA neck: 1.3cm pocket of air in the soft tissues of the right
posterior trachea at the level of T1. no fluid collection, no
fat stranding.
Plain film of L hand/wrist: no e/o traumatic injury or
misalignment
___ 06:18AM BLOOD WBC-9.6 RBC-4.36 Hgb-13.4 Hct-39.5 MCV-91
MCH-30.7 MCHC-33.9 RDW-12.4 RDWSD-41.0 Plt ___
___ 11:55AM BLOOD WBC-11.2* RBC-4.43 Hgb-13.5 Hct-39.5
MCV-89 MCH-30.5 MCHC-34.2 RDW-12.0 RDWSD-38.6 Plt ___
___ 06:18AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-145
K-4.3 Cl-110* HCO3-23 AnGap-12
___ 11:55AM BLOOD Glucose-114* UreaN-9 Creat-0.7 Na-142
K-4.2 Cl-108 HCO3-18* AnGap-16
___ 06:18AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
___ 11:55AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.4
___ 12:20PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-150* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM*
___ 12:20PM URINE Color-Red* Appear-Clear Sp ___
___ 12:20PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-3
___ Urine Culture:
___ 12:20 pm URINE
URINE CULTURE (Preliminary):
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Do not exceed 4000 mg/24 hours. ___ take liquid formula if it is
easier to swallow.
Discharge Disposition:
Home
Discharge Diagnosis:
swelling of the soft tissues of the right posterior trachea at
the level of T1
ecchymosis neck and upper chest
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT
INDICATION: ___ year old woman s/p assault w/ shoulder pain, evaluate for
fx/dislocation.
TECHNIQUE: Frontal, oblique, axillary view radiographs of the left shoulder.
COMPARISON: Outside hospital CT of the chest.
FINDINGS:
There is no fracture or dislocation involving the glenohumeral or AC joint.
There are no significant degenerative changes. No suspicious lytic or
sclerotic lesions are identified. No periarticular calcification or
radio-opaque foreign body is seen.
IMPRESSION:
No acute fracture or dislocation.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Assault, RCI
Diagnosed with Encounter for exam and obs following alleged adult rape, Unspecified injury of neck, initial encounter, Asslt by strike agnst or bumped into by another person, init
temperature: 98.0
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: 111.0
dbp: 64.0
level of pain: Unable
level of acuity: 2.0 | Ms. ___ is a ___ yo F who presented to outside hospital with
report of physical and sexual assault. At outside hospital she
had imaging of her head, neck, chest, abdomen and left
hand/wrist that were negative for acute fractures. CTA was
notable for 1.3 cm pocket of air in the soft tissues of the
right posterior trachea at the level of T1. The patient was
evaluated at the outside hospital by the SANE (Sexual assault
nurse examiners) and given prophylactic antibiotics and PEP kit.
The patient was admitted to the surgical floor for respiratory
monitoring, further trauma evaluation, and social work planning
with the ___ violence prevention (___).
Pain was well controlled with oral tylenol. Diet was
progressively advanced as tolerated to a regular diet with good
tolerability. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. The patient was educated about HIV prophylaxis given her
risk of exposure and declined continuing the medication. The
patient was provided with information to follow up lab test
results from outside hospital.
The patient was seen and evaluated by physical and occupational
therapy who recommended discharge to home with outpatient
cognitive neurology as needed.
Social work and CVPR were actively involved in formulating a
safe discharge plan with the patient. Discharge to a hotel and
follow up in ___ clinic was arranged for the day following
hospital discharge. Please see their notes for further details.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. The patient was escorted by a member of the
CVPR and social work to hotel to help facilitate safety. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Urecholine / Vancomycin / Ceftazidime / Meperidine Hcl
/ Latex / Bactrim / Gentamicin
Attending: ___.
Chief Complaint:
Rigors and Fever
Major Surgical or Invasive Procedure:
None (___)
History of Present Illness:
___ y/o F PMH significant for hollow viscous s/p multiple bowel
resections c/b short gut syndrome on TPN c/b multiple line
infections with most recent being Burkholderia cepacia (___)
who is being admitted with fevers.
The patient reported the day of admission that she had rigors
and fevers to ___ for which she took acetaminophen 1300mg PR
that helped her symptoms initially. The patient then also
developed a ___ headache without neck stiffness, photophobia,
or phonophobia. She also has ___ b/l flank pain that she is
unsure whether this has occurred with her previous infections.
The patient reports that this current presentation feels very
similar to her previous presentations, just more severe. She
denies any rhinorrhea, cough, SOB, DOE, CP, palpitations, N/V/D.
Of note, the patient has had CVL line infections secondary to
Burholderia cepacia with most recent in ___ that was obtained
from swabs, but cannot find positive blood cultures. Infectious
disease was consulted at that time and recommended that the
patient have the CVL removed, but the patient refused and she
was treated with meropenem through the line in ___. There was
concern given that she had recrudescence of the same infection
rather than new infection given that sensitivity pattern was the
same. As per the patient, she had her hickman removed in ___
and replaced.
In the ED, initial vs were: T99.1 HR:88 BP:118/58 RR:18 O2 Sat
100%. Labs were remarkable for leukopenia with PMNs 91.4, L4.1,
H&H 10.8/32.1 with thrombocytopenia to 81. Chem 7 with K 3.0,
BUN/Cr ___. INR 3.0. lactate 1.1. UA was unremarkable. Blood
and urine cultures. CXR was performed that showed no evidence of
pneumonia. Surgery was consulted in the ED and recomended that
blood cultures were drawn peripherally as well as through the
CVL, but were concerned about potential line infection. Patient
was given vancomycin and zosyn and the patient manages her own
IVF (reportedly 3L NS, but patient reports she takes 8L daily in
addition to her TPN at home). The patient's arrival to the floor
was delayed >2 hours as the patient wished to go to a private
room on ___, but none was available. Vitals on Transfer:98.9 89
116/73 18 100% RA
On the floor, vs were: T102.4 P93 BP104/52 R18 O2 sat98%RA. The
patient requests that she be placed into a private room as she
needs to frequent the bathroom overnight.
Past Medical History:
1. Congenital hollow viscous organ syndrome, s/p multiple bowel
surgeries, with short gut syndrome on chronic TPN.
2. Multiple pulmonary embolism on Coumadin.
3. Multiple central line infections.
4. Remote history of grand mal seizures, last one ___ years ago.
5. Prior SVC syndrome with two stents placed in the SVC.
6. Status post multiple abdominal bowel surgeries.
7. Status post cholecystectomy.
8. TIA, presumed due to paradoxical embolus dislodged from
flushing central venous line.
9. NSTEMI, presumed due to paradoxical embolus dislodged from
flushing central venous line.
10. S/p closure of PFO by minimally invasive surgical approach
___: Dr. ___.
11. Post-operative pericardial tamponade due to hemorrhage from
supratherapeutic INR status post pericardiocentesis (___).
12. Chronic venous insufficiency with lower extremity
varicosities.
Social History:
___
Family History:
Her children also have congenital viscous organ syndrome.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
Vitals- T102.4 P93 BP104/52 R18 O2 sat98%RA
General- Alert, oriented, no acute distress
HEENT- PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear
Neck- supple, full ROM, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- RRR, normal S1 + S2, II systolic murmur heard best at apex,
No rubs, gallops, hickman present with minimal erythema,
non-tender to palpation
Abdomen- soft, NABS, minimal diffuse tenderness throughout no
rebound or guarding.
Ext- warm, well perfused, 2+ pulses, 2+ RLE edema to shin>LLE no
clubbing, cyanosis
Neuro- CNs2-12 intact, motor function grossly normal
.
Pertinent Results:
ADMISSION LABS:
========================================
___ 07:00PM BLOOD WBC-3.7* RBC-3.59* Hgb-10.8* Hct-32.1*
MCV-90 MCH-30.1 MCHC-33.6 RDW-14.4 Plt Ct-81*
___ 07:00PM BLOOD Neuts-91.4* Lymphs-4.1* Monos-3.4 Eos-1.0
Baso-0.1
___ 07:00PM BLOOD ___ PTT-57.8* ___
___ 07:00PM BLOOD Glucose-105* UreaN-12 Creat-0.5 Na-139
K-3.0* Cl-109* HCO3-25 AnGap-8
___ 07:00PM BLOOD ALT-20 AST-25 AlkPhos-77 TotBili-2.1*
___ 05:54AM BLOOD Calcium-6.8* Phos-3.0 Mg-1.1*
___ 07:00PM BLOOD Albumin-3.6
___ 07:14PM BLOOD Lactate-1.1
___ 05:54AM BLOOD HCG-<5
___ 05:54AM BLOOD WBC-1.52*# RBC-3.21* Hgb-9.8* Hct-28.3*
MCV-88 MCH-30.7 MCHC-34.8 RDW-14.5 Plt Ct-57*
___ 05:54AM BLOOD ___ ___
.
.
DISCHARGE LABS:
========================================
.
.
RELEVANT MICRO/PATH:
========================================
___ 6:43 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
.
.
IMAGING:
========================================
___ CXR) FINDINGS:A vascular stent in the SVC is in
unchanged position. A double-lumen catheter extends past the
stent and into the right atrium, further than it has
previously been located. The lungs are clear. Cardiac
silhouette is normal in size. There is no pleural effusion or
pulmonary edema. There is no pneumothorax.
IMPRESSION:
1. No evidence of pneumonia.
2. Vascular stent within the ___ with double lumen venous
catheter terminating
within the right atrium, further than on the prior study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO BID
hold for SBP<100
2. HYDROmorphone (Dilaudid) ___ mg IM Q3H:PRN pain
hold for sedation, rr<10
3. Warfarin 30 mg PO DAILY16
Discharge Medications:
1. CefTAZidime-Heparin Lock 1.___AILY
CefTAZidime 0.5mg/mL
+ Heparin 100 Units/mL
2. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 1 gram 2 grams IV daily Disp #*26 Each
Refills:*0
3. Furosemide 20 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg IM Q3H:PRN pain
5. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
6. Outpatient Lab Work
INR twice weekly and fax results to ___
7. Warfarin 20 mg PO DAYS (FR)
8. Warfarin 25 mg PO DAYS (___)
9. Potassium Chloride (Powder) 40 mEq PO DAILY:PRN low potassium
Hold for K >
RX *potassium chloride 20 mEq 2 packets by mouth daily Disp #*10
Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Sepsis
Hypokalemia
Coagulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Fever.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Multiple prior studies most recently ___.
FINDINGS:
A vascular stent in the SVC is in unchanged position. A double-lumen catheter
extends past the stent and into the right atrium, further than it has
previously been located. The lungs are clear. Cardiac silhouette is normal
in size. There is no pleural effusion or pulmonary edema. There is no
pneumothorax.
IMPRESSION:
1. No evidence of pneumonia.
2. Vascular stent within the SVC with double lumen venous catheter terminating
within the right atrium, further than on the prior study.
Radiology Report
HISTORY: Hickman, difficulty accessing. Gram negative bacteremia. Evaluate
right subclavian vein for thrombosis.
COMPARISON: Ultrasound dated ___.
TECHNIQUE: Grayscale and doppler ultrasound evaluation was performed on the
right upper extremity veins.
FINDINGS:
The right internal jugular and axillary veins are patent and compressible with
transducer pressure. There is normal flow with respiratory variation in the
bilateral subclavian veins. The right brachial, basilic and cephalic veins are
patent, compressible with transducer pressure and show normal flow and
augmentation.
IMPRESSION:
No evidence of DVT in the right upper extremity veins.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Dyspnea, evaluation for pulmonary edema.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. Vascular stent and central venous access line in situ. Minimal areas
of atelectasis at the lung bases, but no evidence of pneumonia or larger
pleural effusions. No pulmonary edema. Mild cardiomegaly. No pneumothorax.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED
temperature: 99.1
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 58.0
level of pain: 6
level of acuity: 3.0 | ___ with significant for hollow viscous s/p multiple bowel
resections c/b short gut syndrome on TPN c/b multiple line
infections with most recent being Burkholderia cepacia (___)
admitted with rigors, fevers and headache found to have
Klebsiella bacteremia.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___, ___ speaking only, with h/o dCHF, HTN,
HLD, presenting from Cardiologist's office with atrial flutter
to 150. Reports SOB, but no CP. Denies this has happened before
and no h/o afib. He had initially presented with several weeks
of fatigue. He had recently stopped takign hydralazine because
it gave him palpitations. Otherwise compliant with meds.
.
In the ED, initial vitals were HR 151 (no others available)
Labs and imaging significant for troponin <0.01, normal chem 10,
normal CBC, normal UA,
Patient given diltiazem 20mg IV and 30mg PO, with subsequent
drop in HR to 71 (still in aflutter). Also given ASA325. He then
broke out of aflutter and was transferred to the floor in sinus
bradycardia.
Vitals on transfer were 98.0 111/71 56 22 100%RA.
.
On arrival to the floor, patient is in NAD, feels well, at
baseline. He denies CP, palpitations, or SOB.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Hypertension on multiple agents. No evidence of secondary
causes from extensive workup in ___ including an MRA of the
abdomen. Normal electrolytes. Normal cortisol.
- BPH: PSA 2.5, enlarged prostate on exam.
- Pseudogout and OA.
- Hyperlipidemia.
- Chronic diastolic congestive heart failure with an ejection
fraction of 70%.
Social History:
___
Family History:
both his parents have passed away, but he says of old age. He
also has numerous siblings in ___ who he says are in good
health. When questioned about whether they have any disease, he
says he does not think that they do or does not know of it.
Physical Exam:
Admission exam
VS: T=97.5 BP=154/75 HR=62 RR=18 O2 sat= 97%ra
GENERAL: ___ male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Popliteal 2+ DP 2+ ___ 2+
Left: Popliteal 2+ DP 2+ ___ 2+
Discharge exam
VS: T=96.9 BP=134/78 HR=55 RR=18 O2 sat= 97%ra
GENERAL: ___ male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Popliteal 2+ DP 2+ ___ 2+
Left: Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
Admission labs
___ 10:55AM BLOOD WBC-7.5 RBC-6.86* Hgb-16.4 Hct-49.1
MCV-72* MCH-23.8* MCHC-33.3 RDW-14.7 Plt ___
___ 10:55AM BLOOD Neuts-69.2 ___ Monos-6.5 Eos-1.9
Baso-1.0
___ 10:55AM BLOOD ___ PTT-32.2 ___
___ 10:55AM BLOOD Glucose-134* UreaN-19 Creat-1.1 Na-137
K-3.8 Cl-95* HCO3-33* AnGap-13
___ 10:55AM BLOOD cTropnT-<0.01
___ 10:55AM BLOOD Calcium-10.1 Phos-2.8 Mg-2.1
___ 03:28AM BLOOD calTIBC-360 Ferritn-49 TRF-277
___ 03:28AM BLOOD %HbA1c-6.2* eAG-131*
Discharge labs
___ 03:28AM BLOOD WBC-7.4 RBC-5.63 Hgb-13.5* Hct-38.9*#
MCV-69* MCH-24.1* MCHC-34.8 RDW-14.9 Plt ___
___ 03:28AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL
___ 03:28AM BLOOD Glucose-120* UreaN-15 Creat-0.8 Na-137
K-3.3 Cl-99 HCO3-27 AnGap-14
___ 03:28AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.8 Iron-100
Studies
CXR ___: PA and lateral views of the chest. No prior. The
lungs are
essentially clear, noting mild bibasilar atelectasis.
Costophrenic angles are sharp. Cardiac silhouette is enlarged.
Hypertrophic changes are seen in the spine. Osseous and soft
tissue structures are otherwise unremarkable.
TTE ___: pending
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
DOXAZOSIN - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime Take 1
tab daily for 3 days, then 2 tab daily for 3 days, then 3 tab
daily for 3 days, then 4 tab daily for 3 days, then 5 tab daily
if tolerated.
HYDRALAZINE - (Not Taking as Prescribed) - 100 mg Tablet - 1.5
Tablet(s) by mouth twice a day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - one Tablet(s) by mouth once
a day
IBUPROFEN - 400 mg Tablet - 1 Tablet(s) by mouth every eight (8)
hours with food as needed for pain
LISINOPRIL - 40 mg Tablet - 1 (One) Tablet(s) by mouth twice a
day
NAPROXEN - 250 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for knee pain
ROSUVASTATIN [CRESTOR] - 40 mg Tablet - 1 Tablet(s) by mouth
daily
Medications - OTC
ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily
Discharge Medications:
1. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. doxazosin 1 mg Tablet Sig: Five (5) Tablet PO HS (at
bedtime).
3. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
4. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
INR check on ___
Call and page results into ___
Associates ___ clinic: ___. They will be
in touch with you soon about the pager number.
10. Outpatient Lab Work
INR check on ___
Call and page results into ___
Associates ___ clinic: ___. They will be
in touch with you soon about the pager number.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary: atrial flutter, recently started on coumadin
secondary: diastolic congestive heart failure, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ male with tachycardia, question cardiomegaly.
FINDINGS: PA and lateral views of the chest. No prior. The lungs are
essentially clear, noting mild bibasilar atelectasis. Costophrenic angles are
sharp. Cardiac silhouette is enlarged. Hypertrophic changes are seen in the
spine.
IMPRESSION: Cardiomegaly without overt pulmonary edema.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: TACHYCARDIA
Diagnosed with ATRIAL FLUTTER
temperature: nan
heartrate: 151.0
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 1.0 | Mr ___ is a ___, ___ speaking only, with h/o dCHF, HTN,
HLD, presenting with atrial flutter to 150.
.
# Atrial flutter. New onset. Pt reported 2 days of feelign
palpitations prior to going to cardiology appointment on ___,
where he was foudn to be in aflutter on EKG. He was sent to the
ED. where he got dilt 20mg IV x1 and 30mg POx1. He then
spontaneously converted to sinus bradycardia with rate in ___,
and felt much better. He got a TTE which was pending at time of
discharge. He was admitted for possible ablation, but he wanted
to think and learn about it more, and EP could not schedule it
anytime soon, so he was discharged. He was started on coumadin,
and will f/u in ___ ___ clinic, with ___ assistance to
start. He was started on metoprolol succinate for rate control.
Amlodipine was held for the time being given his HR had been on
the low side (50's), and normotensive, but wanted to add
metoprolol succinate. Further f/u with Dr ___ further
treatment or possible ablation.
.
ELECTROPHYSIOLOGY CONSULT RECS: the best treatment for this is
ablation. They do not recommend a strategy of rate control.
.
# Diastolic CHF: euvolemic during admission. Continued home
meds, ASA81
.
# Hypertension: has been hard to control as an outpatient.
Continued clonidine 0.2mg PO BID, HCTZ 25mg PO qday, lisinopril
40mg daily. Amlodipine 10mg daily was held. Metoprolol succinate
25mg daily was started. Amlodipine can be re-added in the near
future if HR and BP tolerate.
.
# Hyperlipidemia: at goal, continue crestor 40mg daily
.
# Microcytosis: MCV noted to be 72, with hct 49 and normal RDW.
Unclear what this means, as he does not have anemia. Iron
studies were checked and did not show iron deficiency. Smear
shows microcytosis, anicytosis, and hypocytosis, which is most
consistent with fe deficiency vs thalassemia. Consider
hemoglobin electropheresis in outpatient setting, though as
non-anemic, likely of no clinical significance.
.
# BPH: continue doxazosin
.
# Pseudogout/osteoarthritis: ibuprofen and naproxen prn
.
# Pre-diabetes: hgbA1c was 6.4% on ___. On this admission
it is 6.2%, consistent with pre-diabetes. Further care per PCP.
.
=================================
TRANSITIONAL ISSUES
# Started on coumadin: will have ___ come to visit day after
discharge. INR to be drawn ___ and ___ and faxed to ___
___ clinic.
# Aflutter: further care per cardiologist, EP recommends
ablation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o F w/ PMHx ___, not no
immunosuppression for the past 2 months, who presents with lower
abdominal pain.
Patient states that abdominal pain started around a week ago. It
is located in the lower parts of her stomach, and described as
cramping. It was progressively worsening. The day prior to
admission she also developed nausea and had an episode of
vomiting. She otherwise reports no fevers or chills, no diarrhea
or bloody bowel movements.
On review of records, patient was last seen in GI clinic on
___. At that time she was taking Humira with seemingly good
affect. However, patient reports that since that visit she
developed a worsening rash around her left ear, and around 2
months ago her Humira was stopped. She had a colonoscopy in ___
with significant ulceration and friability in the distal 5cm of
the terminal ileum.
In the ED:
Initial vital signs were notable for: T 97.5, HR 100, BP 102/69,
RR 18, 100% RA
Exam notable for:
Abd: There is tenderness over the suprapubic and RLQ with some
mild guarding. There is no rebound tenderness. Negative
Rovsing's. Negative ___.
Labs were notable for:
- CBC: WBC 9.8 (65%n), hgb 12.3, plt 392
- Lytes:
141 / 101 / 7 AGap=15
-------------- 96
4.4 \ 25 \ 0.5
- LFTs: AST: 8 ALT: <5 AP: 73 Tbili: <0.2 Alb: 3.6
- lipase 12
- CRP 90
- lactate 0.9
Studies performed include:
- CT a/p with approximately 25 cm long continuous diseased
segment of distal and terminal ileum demonstrating acute on
chronic inflammation compatible with Crohn disease, in a similar
distribution to that seen on the prior MR enterography. There is
upstream bowel dilatation without frank obstruction. No fluid
collections or fistulas.
Consults: GI was consulted, recommending patient be NPO,
cipro/flagyl, send cdiff, avoid nsaids/opioids. They will staff
in AM.
Patient was given: none
Vitals on transfer: T 98.8, HR 88, BP 105/74, RR 16, 97% RA
Upon arrival to the floor, patient recounts history as above.
She
states that she is hungry, but does not have much pain or
nausea.
She is hoping to go home in the morning.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- crohns, diagnosed ___
- anxiety
- depression
- B12 deficiency
- iron deficiency
- anemia
- ?psoriasis
- s/p c section
Social History:
___
Family History:
Brother has ___ disease. No FH of colon
cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: T 98.1, HR 82, BP 93/61, RR 16, 96 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, moderately tender to palpation
in lower quadrants, L>R, without rebound or guarding. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: RRR no m/r/g
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present
MSK: No erythema or swelling of joints
SKIN: No rashes or ulcerations noted
EXTR: wwp no edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 05:05PM WBC-9.8 RBC-4.85 HGB-12.3 HCT-39.6 MCV-82
MCH-25.4* MCHC-31.1* RDW-15.9* RDWSD-47.9*
___ 05:05PM NEUTS-65.6 ___ MONOS-7.9 EOS-0.8*
BASOS-0.4 IM ___ AbsNeut-6.44* AbsLymp-2.47 AbsMono-0.78
AbsEos-0.08 AbsBaso-0.04
___ 05:05PM PLT COUNT-392
___ 05:05PM GLUCOSE-96 UREA N-7 CREAT-0.5 SODIUM-141
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
___ 05:05PM ALT(SGPT)-<5 AST(SGOT)-8 ALK PHOS-73 TOT
BILI-<0.2
___ 05:05PM LIPASE-12
___ 05:05PM ALBUMIN-3.6
___ 05:05PM CRP-90.0*
INTERVAL DATA:
___ 10:30AM STOOL CDIFPCR-POS* CDIFTOX-POS*
___ 05:05PM BLOOD CRP-90.0*
___ 05:57AM BLOOD CRP-66.6*
___ 06:41AM BLOOD CRP-43.0*
___ 06:32AM BLOOD CRP-13.8*
- ___ CT a/p w/ contrast:
1. Approximately 25 cmlong continuous diseased segment of distal
and terminal ileum demonstrating acute on chronic inflammation
compatible with Crohn disease, in a similar distribution to that
seen on the prior MR enterography. There is upstream bowel
dilatation without frank obstruction. No fluid collections or
fistulas.
2. Reactive mesenteric lymphadenopathy in the right lower
quadrant.
3. Normal appendix.
- ___ Colonoscopy:
- Mild erythema and few erosions in the whole colon.
- Polyp (2 mm) in the rectum
- Narrowing at the IC valve. Significant ulceration and
friability in the distal 5cm of the terminal ileum. There
appeared to be sparing from 5cm-10cm until another narrowing
that
could not be traversed due to a combination of looping and
narrowing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin ___ mcg PO DAILY
2. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
40 mg daily for now. Dr. ___ to determine final plan
RX *prednisone [Deltasone] 20 mg 2 tablet(s) by mouth once a day
Disp #*42 Tablet Refills:*0
2. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. Vancomycin Oral Liquid ___ mg PO QID
for 12 more days
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*48 Capsule Refills:*0
4. Cyanocobalamin ___ mcg PO DAILY
5. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
C diff infection
Crohns flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with RLW and suprapubic painNO_PO
contrast// ? appendicitis
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.6 s, 48.2 cm; CTDIvol = 5.4 mGy (Body) DLP = 260.2
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
Total DLP (Body) = 263 mGy-cm.
COMPARISON: MR enterography ___, CT abdomen pelvis ___..
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
few tiny scattered hypodensities are seen in the liver, the largest in the
left hepatic lobe at the dome measures 5 mm, all too small to characterize,
potentially tiny biliary hamartomas or cysts. No evidence of suspicious focal
lesions. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. A long continuous segment of
the distal and terminal ileum spanning approximately 25 cm demonstrates
circumferential wall thickening and mural stratification with mucosal
hyperenhancement, adjacent fat stranding, and Vasa recta prominence. Findings
are compatible with acute on chronic Crohn disease, in a distribution similar
to that noted on the prior MRI. There is resultant luminal narrowing with
mild upstream small-bowel dilation. No fluid collections or fistulous. Small
amount of interloop fluid. The colon and rectum are within normal limits. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small volume free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: Multiple enlarged right lower quadrant ileocolic lymph nodes
measuring up to 1.5 cm are likely reactive. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Minimal atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Approximately 25 cmlong continuous diseased segment of distal and terminal
ileum demonstrating acute on chronic inflammation compatible with Crohn
disease, in a similar distribution to that seen on the prior MR enterography.
There is upstream bowel dilatation without frank obstruction. No fluid
collections or fistulas.
2. Reactive mesenteric lymphadenopathy in the right lower quadrant.
3. Normal appendix.
Gender: F
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Other specified noninfective gastroenteritis and colitis, Right lower quadrant pain
temperature: 97.5
heartrate: 100.0
resprate: 18.0
o2sat: 100.0
sbp: 102.0
dbp: 69.0
level of pain: 7
level of acuity: 3.0 | SUMMARY:
___ y/o F w/ PMHx ___, not on immunosuppression for the past
2 months, who presented with lower abdominal pain and was found
to have a c diff infection and a Crohns flare. She was started
on PO vancomycin for C diff infection and steroids for Crohns
flare. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
melena/hematochezia
Major Surgical or Invasive Procedure:
Endoscopy ___
Severe esophagitis in the lower third of esophagus
Ulcers in the first part of the duodenum and area of the papilla
Diverticula in the first part of the duodenum and second part of
the duodenum
Heaped up and shaggy in the whole duodenum compatible with
duodenitis
A covered metal stent was seen protruding from the CBD. With the
use of a side viewing scope, we determined that there was no
post-sphincterotomy bleeding.
History of Present Illness:
___ with PMH HTN, HLD, CAD s/p stent RCA X 4, prior duodenal
ulcer c/b bleeding, and polycythemia ___ who presents with
upper abdominal pain and melanotic stools for the last 3 weeks.
He has noted melanotic stools ___ over this period. Last
melanotic BM was this morning at 9am. Epigastric cramping
abdominal pain comes and goes. He has been unable to tolerate po
for the last 3 days because of emesis of food. Patient did have
one episode of coughing up a quarter size amount of dark blood
three weeks ago. He decided to finally come into the hospital
because of increased dizziness when walking though he denies any
falls. Patient denies any chest pain, shortness of breath, sick
contacts, dysuria, night sweats.
Patient has been taking 1 cap Motrin a day which he alternates
with Aleve (unknown dose), 2 pills a day. He takes nsaids for
arthritic pain in his legs. He reports compliance with all of
his medications including his PPI.
Of note, patient does have hx of UGI bleed in ___ at which
time he was admitted to ___. He had black stools X 2 days
and was admitted to ICU for upper GIB and hypotension. EGD
showed large duodenal ulcer without active bleeding at that
time. Patient was thought to be noncompliant with his PPI. At
that time patient cardiologist recommended d/c of cardiac meds
at which time pts stools became guaiac negative.
Patient was also recently seen at ___ (___) for
ascending cholangitis secondary to choledocholithias found to
have klebsiella bacteremia ___ bottles). At that time, he was
also reportedly having melena (h/h: 10.4/32.6 on ___ -->
8.6/29.7 on ___. He underwent ERCP and EGD on ___. EGD
showed grade D reflux esophagitis with no signs of active
bleeding and ERCP confirmed ascending cholangitis w multiple CBD
stones/debris. He underwent sphincterotomy w extraction followed
by stenting to optimize drainage. He was discharged on 10 day
course of ciprofloxacin and plan was for outpatient ccy. Melena
resolved during admission. Patient also to have outpatient ERCP
with Dr. ___ in 4 weeks for biliary stent
removal with repeat EGD at that time. Of note, patient was noted
to have wbc 27k on admission which downtrended during
hospitalization though remained elevated at 26k on dsicharge.
Vitals in the ED: 0 97.8 88 100/42 16 98% 3L Nasal Cannula
Rectal exam: melenotic stool
Rehab labs (today, ___: Hb 7, Hct 21, WBC 23.9 , plt 990 (plt
749 on ___, INR 1
Labs notable for: h/h 6.3/20.8, creat 1.7 (creat 1.0 on
___, bun 43, wbc 20.4, inr1.1, lip 61
Patient given:
1 unit prbc in ED
___ 16:31 IV Pantoprazole 80 mg
___ 16:31 IVF 1000 mL LR 1000 mL
___ 16:58 IV Pantoprazole
___ 19:23 IV Pantoprazole, rate continued at 8 mg/hr
Vitals prior to transfer: Today 19:30 0 98.3 94 106/41 20 96%
Nasal Cannula
On the floor, patient has no complaints
Review of Systems:
(+) per HPI
Past Medical History:
-PVD s/p angioplasty to ___
-Hypertension
-Hyperlipidemia
-CAD ___: s/p RCA stent x2; ___: 2 additional DES to RCA)
Per ___ records, the pt underwent a stress test in early ___
with +inferior ischemia on stress EKG. He underwent cath in
___ showing mid RCA disease and an occluded OM1. The LAD,
L-main, L-Cx were patent. He had 2 overlapping stents placed in
the RCA but then per report was not compliant with his DAPT and
cardiac meds. He then required re-cath in ___ showing
re-stenosis of his RCA. He was re-PTCA'ed with 2 DES placed to
RCA.
- TTE (EF 45%, inferior akinesis per ___ records)
-Polycythemia ___
-H/O UGIB ___ duodenal ulcer (1.5 cm, ___ - no active
bleeding)
-___ esophagus
- Esophageal strictures, with food impaction x 4 prior; + egd
___
-Prostate cancer s/p radiotherapy
- ?OSA
Social History:
___
Family History:
Denies family history of MI or colon cancer
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
Vitals - T98 115/42 92 18 96%1L NC
___: NAD, oriented x 3, pleasant
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pale conjuntiva,
dry MMM, poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, no murmurs, gallops, or rubs
LUNG: mild end expiratory wheezing, CTAB, no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: soft, obese, mild periumbilical ttp, neg ___ sign
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, sensation intact throughout b/l ___,
___ strength on testing of deltoids, triceps, biceps, finger
grip strength, hip flexors, extensors, flexion/extension toes
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE:
===========================
Vitals - Temp 98.5, BP 123/38, HR 66, RR 18, 97% RA
___: NAD, oriented x 3, pleasant
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pale conjuntiva,
dry MMM, poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, no murmurs, gallops, or rubs
LUNG: Lungs clear to auscultation bilaterally, no wheezes,
rales, rhonchi, breathing comfortably without use of accessory
muscles
ABDOMEN: soft, obese, abdomen non-tender in mid-epigastric
region, neg ___ sign
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, sensation intact throughout b/l ___,
___ strength on testing of deltoids, triceps, biceps, finger
grip strength, hip flexors, extensors, flexion/extension toes
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION:
====================
___ 03:50PM BLOOD WBC-20.4*# RBC-2.84* Hgb-6.3*# Hct-20.8*#
MCV-74*# MCH-22.1*# MCHC-30.0* RDW-24.2* Plt ___
___ 03:50PM BLOOD Neuts-86.1* Lymphs-8.6* Monos-4.0 Eos-0.7
Baso-0.7
___ 03:50PM BLOOD Glucose-98 UreaN-43* Creat-1.7* Na-135
K-5.0 Cl-105 HCO3-20* AnGap-15
___ 03:50PM BLOOD cTropnT-0.02*
___ 06:50AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:13PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:50AM BLOOD Ferritn-11*
LABS ON DISCHARGE:
==================
___ 01:25PM BLOOD WBC-19.3* RBC-4.06* Hgb-9.4* Hct-31.7*
MCV-78* MCH-23.3* MCHC-29.8* RDW-21.9* Plt ___
___ 06:50AM BLOOD Neuts-82.7* Lymphs-11.2* Monos-4.4
Eos-1.2 Baso-0.5
___ 07:35AM BLOOD Glucose-88 UreaN-17 Creat-0.8 Na-134
K-4.9 Cl-104 HCO3-25 AnGap-10
___ 06:50AM BLOOD LD(LDH)-394*
___ 07:35AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7
___ 7:35 am SEROLOGY/BLOOD CHEM ___ ___.
HELICOBACTER PYLORI ANTIBODY TEST (Pending):
STUDIES:
=========
___ EGD:
Esophagus:
Mucosa: Severe esophagitis with no bleeding was seen in the
lower third of esophagus.
Stomach: Normal stomach.
Duodenum:
Mucosa: Diffuse continuous heaped up and shaggy mucosa with no
bleeding were noted in the whole duodenum compatible with
duodenitis.
Excavated Lesions Two cratered non-bleeding 15mm ulcers were
found in the first part of the duodenum and area of the papilla.
These were clean-based without stigmata of bleeding. No
intervention was performed. A few non-bleeding diverticula with
large opening were found in the first part of the duodenum and
second part of the duodenum.
Other A covered metal stent was seen protruding from the CBD.
With the use of a side viewing scope, we determined that there
was no post-sphincterotomy bleeding.
Impression: Severe esophagitis in the lower third of esophagus
Ulcers in the first part of the duodenum and area of the papilla
Diverticula in the first part of the duodenum and second part of
the duodenum
Heaped up and shaggy in the whole duodenum compatible with
duodenitis
A covered metal stent was seen protruding from the CBD. With the
use of a side viewing scope, we determined that there was no
post-sphincterotomy bleeding.
Otherwise normal EGD to third part of the duodenum
Recommendations: High dose PPI 40mg BID indefinitely
Avoid all NSAIDs
Patient needs f/u with ___ for EGD to re-evaluate healing of
ulcers, esophageal biopsies, and stent pull within the next
month
Send H pylori serology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen Dose is Unknown PO Q12H
2. Ibuprofen Dose is Unknown PO DAILY
3. Simvastatin 40 mg PO QPM
4. cilostazol 50 mg oral BID
5. Magnesium Oxide 500 mg PO DAILY
6. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN
arthritic pain
7. Doxazosin 4 mg PO HS
8. NIFEdipine CR 30 mg PO DAILY
9. Vitamin B-1 (thiamine HCl) 50 mg oral daily
10. Dexilant (dexlansoprazole) 60 mg oral BID
11. Lisinopril 5 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Aspirin 81 mg PO DAILY
14. Cyanocobalamin 1000 mcg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. FoLIC Acid 1 mg PO DAILY
17. Metoprolol Tartrate 25 mg PO BID
18. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
19. Prasugrel 10 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO BID
2. Simvastatin 40 mg PO QPM
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Doxazosin 4 mg PO HS
7. FoLIC Acid 1 mg PO DAILY
8. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN
arthritic pain
9. Lisinopril 5 mg PO DAILY
10. Magnesium Oxide 500 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. NIFEdipine CR 30 mg PO DAILY
13. Prasugrel 10 mg PO DAILY
RX *prasugrel [Effient] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
14. Vitamin B-1 (thiamine HCl) 50 mg oral daily
15. Vitamin D 1000 UNIT PO DAILY
16. Omeprazole 40 mg PO TWICE DAILY
RX *omeprazole 20 mg 2 capsule(s) by mouth twice a day Disp
#*120 Capsule Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Duodenitis
Duodenal Ulcers (non-bleeding)
Esophagitis
Secondary:
Polycythemia ___ cholangitis due to choledocolithiasis
PVD s/p angioplasty to ___
Hypertension
Hyperlipidemia
CAD ___: s/p RCA stent x2; ___: 2 additional DES to RCA)
Ejection fraction of 45%
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ year old man with chest pain/epigastric pain, h/o duodenal
ulcer // Eval for cardiopulmonary process, obtain view below diaphragm to
look for free air
TECHNIQUE: Chest Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac silhouette is top-normal. Coronary artery
stenting is noted. Mediastinal contours are unremarkable. The aortic knob is
calcified. No evidence of free air is seen beneath the diaphragms.
IMPRESSION:
No acute cardiopulmonary process. No evidence of free air beneath the
diaphragms.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GIB, Transfer
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 97.8
heartrate: 88.0
resprate: 16.0
o2sat: 98.0
sbp: 100.0
dbp: 42.0
level of pain: 0
level of acuity: 2.0 | ___ with history of prior duodenal ulcer presents with upper
abdominal pain and melanotic stools for the last 3 weeks in the
setting of nsaid use and recent ERCP.
# Acute blood loss anemia
# Upper GI Bleed
Mr. ___ was admitted to the hospital for melanotic bowel
movements and acute blood loss anemia from an UGI source of
bleeding. EGD performed on ___ revealed esophagitis,
duodenitits, and healing duodenal ulcers. This was thought
related to daily NSAID use and hemostasis was confirmed.
Transfused a total of 2 units of RBC's while in the hospital
with appropriate Hg/Hct response. He was started initially on IV
pantroprazole twice dialy and transitioned to 40 mg omeprazole
twice daily indefiniately per GI recs. Post-spincterotomy bleed
was also considered in the setting of patient's recent ERCP and
sphincterotomy at ___ recently in early ___ though a
side viewing scope used during EGD did not show
post-sphincterotomy bleeding. He should follow up with ___ for
repeat ERCP. Patient was counseled to discontinued all NSAIDS
moving forward and was dicharged on 40 mg omeprazole twice daily
indefinately. H. Pylori serum serologies were also checked and
pending at time of discharge.
# Microcytic Anemia
Acute blood loss anemia on chronic microcytic anemia. Work up
revealed low ferritin and low serum iron in the setting of upper
GI bleed as above. Patient presented with Hg of 6.3 on admission
and received 2 units PRBC's with improvement of hemoglobin to
9.4 at time of discharge.
# History of recent ascending cholangitis ___
choledocholithiasis:
Patient treated with ERCP w/biliary sphincterotomy and stone
extraction at ___ on ___ with temporary metal stent in
place to facilitate drainage. Patient completed course of
ciprofloxacin prior to admission to ___ and remained afebrile
throughout his hospital course. During endoscopy side viewing
scope did not show post-sphincertomty bleeding. Patient
scheduled for follow up for ERCP and repeat endscopy with Dr.
___ at ___ on ___ with need for interval
cholecystectomy as well.
# CAD s/ 4 stents to the RCA:
Patient with history of 4 stents to the RCA. Patient with chest
pain on ___ at time of admission thought to be secondary to
demand ischemia in setting of tachycardia with likely GI bleed.
EKG obtained and unchanged from prior. Trops and CK-MB X 3
negative.
At time of admission it was unclear whether patient had been on
prasugrel. It was held initially in setting of GI bleed as above
though restarted at time of discharge. Patient was discharged on
daily aspirin, prasugrel, and statin.
# Leukocytosis:
Mr ___ presented with leukocytosis to 20.4 at time of
admission in setting resolving cholangitis and polycythemia ___
NOT on hydroxyurea. Leukocytosis downtrended to 16 prior to
admission. He remained afebrile and was without any obvious
source of infection.
# Polycythemia ___:
Patient with both leukocytosis and thrombocytosis on admission
and prior history of polycythemia ___ not on hydroxyurea since
___ per pharmacy records. Patient should follow up with
outpatient hematology oncology to determine if hydroxyurea
should be restarted as he is high risk for thrombotic event.
# Acute Renal Failure:
Mr. ___ presented with acute kidney injury and BUN
disproportionately elevated in setting of GI bleed. Patient
received IV fluids while in the hospital as well as 2 units
packed RBC's as above with improvement ___ prior to
discharge.
# HTN:
Mr. ___ antihypertensives including nifedipine and
lisinopril were intially held in setting ___ and GI bleed
above though metoprolol was continued. All antihypertensive
medications were restarted at time of discharge.
# PVD:
Mr. ___ had prior history of PVD on cilostazol. Cilostazol
was held this hospital course and stopped in setting of GI bleed
above. Consideration or risks/benefits to restart this
medication upon follow up should be made given the need for
other anti-platelet agents patient is on including aspirin and
prasugrel.
# OSA?:
Patient with questionable history of OSA and need for
supplemental O2 at night. Patient should have outpatient sleep
study to determine if he has known OSA. |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Pmhx of obesity, Pre-DM, HTN who presents with left sided
weakness and numbness, noted upon awakening this morning.
Patient
reports that yesterday he was in his usual state of health
without any complaints. He woke up this morning and felt that
his
left leg was numb. When he got out of bed he also felt that his
arm was numb. Upon getting dressed and ready for church, it
became more evident that his hand was weak. He also noted he was
walking with a limp because of his left leg. He proceeded to get
in the car to go to church, feeling that he could not grip the
steering wheel well with his left hand. He denied any headache.
After making it to church, he decided to ___ to the nearest
hospital. At OSH CT head was performed and negative, he was
transferred to ___ for stroke workup.
On arrival, ___ was 3 by ED staff, and given LKN from
yesterday
without evidence of LVO by exam, ___ code stroke was called.
Patient underwent CT and CTA head and neck and neurology was
consulted.
Patient reported the above, adding that he does not have any
headache or dizziness. He does tell me that sometimes he feels
his heart racing, this has been going on for the past week or
so.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. ___ night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. ___ recent change in bowel or bladder habits.
___
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
___
Obesity
HTN, not on medications
Social History:
___
Family History:
Dad has diabetes, ___ history of stroke
Physical Exam:
PHYSICAL EXAMINATION on admission.
====================
Vitals: T 98.6 HR 82 BP 197/114 RR 20 O2 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, ___ scleral icterus noted, MMM, ___ lesions noted in
oropharynx
Neck: Supple, ___ carotid bruits appreciated. ___ nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, ___ M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, ___ masses or
organomegaly noted.
Extremities: ___ edema.
Skin: ___ rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were ___ paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was ___
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch bilaterally and with
pinprick
VII: Perhaps subtle L-NLFF, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. ___ pronator drift
bilaterally.
___ adventitious movements, such as tremor, noted. ___ asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4 5- ___- 4- 4- 4 4- 3 3
R 5 ___ ___ 5 5 5 5
-Sensory: ___ extinction or neglect. Decreased sensation on the
left arm and leg by "25%" to pinprick. Vibratory sensation of 5
seconds at the toes and fingers on the left. Cold sensation
reduced on the left involving proximal and distal arms and legs.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute on the left, flexor on the right.
-Coordination: ___ intention tremor, ___ dysdiadochokinesia noted.
___ dysmetria on FNF or HKS bilaterally.
-Gait: Did not ambulate
===============
Physical exam at discharge unchanged with the exception of
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
4+/5 on L & ___ on right.
and decreased pinprick sensation on L by 10% of right, but same
on light touch.
Pertinent Results:
___ 07:00AM BLOOD WBC-5.0 RBC-5.00 Hgb-14.7 Hct-45.8 MCV-92
MCH-29.4 MCHC-32.1 RDW-13.2 RDWSD-44.0 Plt ___
___ 07:00AM BLOOD ___ PTT-31.6 ___
___ 07:00AM BLOOD Glucose-100 UreaN-13 Creat-1.0 Na-144
K-3.8 Cl-105 HCO3-26 AnGap-13
___ 07:00AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.1
___ 06:30AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1 Cholest-204*
___ 06:30AM BLOOD VitB12-270
___ 06:30AM BLOOD %HbA1c-5.9 eAG-123
___ 06:30AM BLOOD Triglyc-155* HDL-29* CHOL/HD-7.0
LDLcalc-144*
___ 06:30AM BLOOD TSH-2.1
___ 05:10PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 05:10PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 05:10PM URINE Color-Straw Appear-Hazy* Sp ___
___ 05:10PM URINE AmorphX-OCC*
___ 05:10PM URINE Hours-RANDOM
___ 05:10PM URINE Uhold-HOLD
====================
EXAMINATION: STROKE PROTOCOL (BRAIN W/O) ___ MR HEAD
INDICATION: History: ___ with possible stroke// Stroke?
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial
imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique
were then
obtained.
COMPARISON CT head ___.
FINDINGS:
There is ___ evidence of hemorrhage, edema, masses, mass effect,
midline shift
or infarction. There are a few nonspecific supratentorial white
matter
T2/FLAIR hyperintensities, which may represent sequela of
microangiopathy.
The ventricles and sulci are normal in caliber and
configuration.
There is mucosal thickening in the ethmoid air cells and a
mucous retention
cyst in the right maxillary sinus.
IMPRESSION:
1. ___ intracranial infarct, hemorrhage or mass.
2. Focus of high signal in the anterior medulla on the diffusion
images
without corresponding abnormality on the ADC map (5:7 and 4:7)
appears to be artifactual.
EXAMINATION: MR CODE CORD COMPRESSION PT27 MR SPINE
INDICATION: ___ year old man with left sided numbness and
weakness// eval for
cervical pathology to explain left sided symptoms eval for
cervical
pathology to explain left sided symptoms
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR
technique,
followed by axial T2 imaging.
COMPARISON: CT head and neck from ___.
FINDINGS:
Alignment is normal. Vertebral body and intervertebral disc
signal intensity
appear normal. The spinal cord appears normal in caliber and
configuration.
There is ___ evidence of spinal canal or neural foraminal
narrowing. There is
___ evidence of infection or neoplasm.
IMPRESSION:
Unremarkable cervical spine MR. ___ evidence of cord compression.
============
TTE
CONCLUSION:
The left atrial volume index is normal. The right atrium is
moderately enlarged. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
normal regional and global left
ventricular systolic function. The visually estimated left
ventricular ejection fraction is 55%. There
is ___ resting left ventricular outflow tract gradient. ___
ventricular septal defect is seen. Tissue Doppler
suggests a normal left ventricular filling pressure (PCWP less
than 12mmHg). Normal right ventricular
cavity size with normal free wall motion. The aortic sinus
diameter is normal for gender with normal
ascending aorta diameter for gender. There is a normal
descending aorta diameter. There is ___ evidence
for an aortic arch coarctation. The aortic valve leaflets (?#)
appear structurally normal. There is ___ aortic
valve stenosis. There is ___ aortic regurgitation. The mitral
valve leaflets appear structurally normal with
___ mitral valve prolapse. There is trivial mitral regurgitation.
The pulmonic valve leaflets are normal.
The tricuspid valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. The
estimated pulmonary artery systolic pressure is borderline
elevated. There is a trivial pericardial
effusion.
IMPRESSION: Limited subcostal images/unable to assess for
presence of atrial septal defect in
subcostal view. Mild symmetric left ventricular hypertrophy with
globally preserved biventricular
systolic function. ___ clinically significant valvular disease.
Borderline pulmonary hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*3
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*90
Tablet Refills:*3
3. Hydrochlorothiazide 12.5 mg PO DAILY
Primary Care provider should taper, previously taking
RX *hydrochlorothiazide 12.5 mg 1 tablet(s) by mouth once a day
Disp #*30 Capsule Refills:*1
4. MetFORMIN (Glucophage) 500 mg PO BID
Have your primary care provider increase to previous dose
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
5.Outpatient Physical Therapy
ICD-10-CM I6___.81 acute Ischemic stroke
Evaluation and Treatment.
6.Outpatient Occupational Therapy
ICD-10-CM I6___.81 acute Ischemic stroke
Evaluation and Treatment.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with neuro symptoms// Stroke?
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.4 mGy-cm.
2) Spiral Acquisition 5.4 s, 42.8 cm; CTDIvol = 13.3 mGy (Body) DLP = 569.1
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 32.7 mGy (Body) DLP =
16.3 mGy-cm.
Total DLP (Body) = 587 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: MR head ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction,hemorrhage,edema,ormass. The ventricles
and sulci are normal in size and configuration.
There is a mucous retention cyst in the right maxillary sinus. The visualized
portion of the paranasal sinuses, mastoid air cells,and middle ear cavities
are otherwise clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is a 4 mm infundibulum or tiny aneurysm at the left ICA terminus
(3:286). There is atheromatous calcification of the carotid siphons
bilaterally. The vessels of the circle of ___ and their principal
intracranial branches appear otherwise normal without stenosis, occlusion, or
aneurysm formation greater than 3mm. The dural venous sinuses are patent.
CTA NECK:
Bilateral carotid and vertebral artery origins are patent.
There is no evidence of internal carotid stenosis by NASCET criteria.
The carotidandvertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. 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 stenosis, occlusion, or dissection.
Radiology Report
EXAMINATION: STROKE PROTOCOL (BRAIN W/O) T7742 MR HEAD
INDICATION: History: ___ with possible stroke// Stroke?
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT head ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. There are a few nonspecific supratentorial white matter
T2/FLAIR hyperintensities, which may represent sequela of microangiopathy.
The ventricles and sulci are normal in caliber and configuration.
There is mucosal thickening in the ethmoid air cells and a mucous retention
cyst in the right maxillary sinus.
IMPRESSION:
1. No intracranial infarct, hemorrhage or mass.
2. Focus of high signal in the anterior medulla on the diffusion images
without corresponding abnormality on the ADC map (5:7 and 4:7) appears to be
artifactual.
Radiology Report
EXAMINATION: MR CODE CORD COMPRESSION PT27 MR SPINE
INDICATION: ___ year old man with left sided numbness and weakness// eval for
cervical pathology to explain left sided symptoms eval for cervical
pathology to explain left sided symptoms
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: CT head and neck from ___.
FINDINGS:
Alignment is normal. Vertebral body and intervertebral disc signal intensity
appear normal. The spinal cord appears normal in caliber and configuration.
There is ___ evidence of spinal canal or neural foraminal narrowing. There is
___ evidence of infection or neoplasm.
IMPRESSION:
Unremarkable cervical spine MR. ___ evidence of cord compression.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: R Weakness
Diagnosed with Anesthesia of skin, Weakness, Essential (primary) hypertension
temperature: 98.6
heartrate: 82.0
resprate: 20.0
o2sat: 97.0
sbp: 197.0
dbp: 114.0
level of pain: 0
level of acuity: 2.0 | Patient presented with acute onset left-sided weakness, found to
have a acute ischemic stroke in the brainstem, patient's risk
factors included hyperlipidemia, diabetes, obesity, and likely
hypertension. Work-up included imaging of the brain, and labs to
look for risk factors. Patient was started on aspirin, and
atorvastatin as prevention for recurrent stroke.
======================================
Mr. ___ is a ___ Year old Male with PMH of Hypertension,
___ who is admitted to the Neurology stroke service
with acute onset L sided weakness and decreased sensation
secondary to an acute ischemic stroke likely in the anterior
medulla. His stroke was most likely secondary to small vessel
disease in the setting of hypertension, ___, obesity
and hyperlipidemia vs. cardioembolism. His deficits improved
greatly prior to discharge with mild residual left-sided
weakness and mild decreased sensation to pinprick by 10% of
baseline. Cervical imaging was negative for alternative
compressive etiology. Patient's TTE indeterminate for PFO/ASD,
and will be discharged on 4 weeks of telemetry/ziopatch to
evaluate A-fib.
He will continue to home ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per admitting MD
___ w/ recently diagnosed metastatic
pancreatic cancer (on gem/abraxane), SIADH, AFib, HTN, who p/w
syncope.
He was admitted last week ___ for fatigue and a Na of 118 and
discharged yesterday on ___. He was initially admitted to the
ICU for hyponatremia thought to be due to both poor solute
intake
and SIADH. Na improved with hydration and then fluid
restriction.
He also was found to have a LLE cellulitis c/b bullae and
treated
w/ abx and unroofing by podiatry. He was also noted to have
severe malnutrition, seen by nutrition, and weakness, cleared
for
discharge by ___.
He left the hospital yesterday and was found down by his wife in
the bathroom. He was taken to ___ where a ___ and
C-spine CT was neg for acute process. He was then transferred
here for continuity. On arrival to our ED, he felt otherwise
well
w/o any acute complaints per the ED notes. VS 98, HR ___, BP
130s, RR 18, 100% on RA. Seems he may have been in RVR per ED
physician notes intermittently but not documented.
On arrival to 11R, his main c/o was "I feel frustrated,"
spending
"a lot of time sitting around waiting, waiting... things keep
getting delayed... I was supposed to get chemo but then they had
to get my labs right first... and I am due in two days for
chemo..." He denied any pain. He has no recollection of the
events re passing out but admits to passing out. His wife had
unfortunately just left and was not reachable on her cell x 2
___ and left her a VM to call back for collateral
Subsequent Note...
Pt's wife returned my phone calls.
She states around 6:15 am today, she "heard a loud thud."
"within
a split second, heard him say 'I'm in here,'" she ran into the
bathroom and found him in the bathroom laying on his left side
in
between the toilet and shower. He was awake and trying to get
up.
She thinks he was trying to get onto the toilet and must have
lost his balance as his pajamas were down to his ankles and hit
his face. He did not defecate or urinate on himself. She helped
lift him up and sit on the toilet. He later went back to bed.
She
notes he is confused but the same as prior since his cancer
diagnosis, not more so than usual. She saw blood on his cheek
and
mouth. No e/o tonic clonic activity nor acute worsening of his
baseline confusion.
She notes he has "hardly had anything to eat." He did not take
lisinopril last night nor any of his meds this am. She called
EMT
and they took him to ___.
In light of this collateral, I suspect he more so had a fall
from
gneralized weakness, poor PO intake, and difficulty ambulating
w/
the foot dressing, and less likely a syncopal episode, seizure.
or CVA.
Past Medical History:
As per admitting MD:
PAST MEDICAL HISTORY:
#Pancreatic cancer w/ likely liver metastases
#HTN
#HLD
#Osteoarthritis
#Hyponatremia (from presumed SIADH - followed by endocrinology
with prior extensive w/u, may see a neurologist soon)
#Low testosterone
#GERD
#s/p R ankle surgery, hernia repair, and CTR.
Social History:
___
Family History:
As per admitting MD
As per admitting MD:
Mother - MI in ___, lived to ___. Father had a pacemaker, unsure
indication.
Grandfather with possible prostate CA.
Physical Exam:
Admission:
General: NAD, Resting in bed comfortably, ambulating in room
well, limping on his heel
HEENT: MM dry, no OP lesions, neck supple w/o TTP along
cervical
spine, there is a small non-tender fluid collection overlying
left upper mandible w/ overlying erythema and telengiectasia
CV: ___, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors, RLE dressing C/D/I and erythema
w/in marked borders is mild
SKIN: No notable rashes on trunk nor extremities, numerous
lentigines on upper ext, no ecchymosis on back or scalp or EXT
NEURO: CN III-XII intact, strength b/l ___ intact, speech is
clear and fluent, can make needs known, A&O to place, person,
___ not clear on events yesterday (that is being
discharged) but knows he is due for chemo in two days
PSYCH: Thought process logical, linear, future oriented
ACCESS: Chest port site intact w/o overlying erythema, accessed
and dressing C/D/I
Discharge:
General: Comfortable, in NAD, sitting in bed, calm
EYES: Anicteric, PERRLA
HENT: Mucous membranes moist, OP clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
CV: Regular rate and rhythm, no murmurs, rubs, or gallops
Chest: Right-sided port in place, no tenderness to palpation or
surrounding erythema
Abdomen: normoactive bowel sounds. Soft. Nondistended. No
tenderness to palpation throughout
Extremities: 2+ peripheral pulses, no C/C/E. L heel 3x3inch
bullae s/p unroofing with erythema extending along plantar
surface of midfoot (unchanged from prior admission in size but
erythema now dull)
Pertinent Results:
Admit:
___ 04:29PM BLOOD WBC-5.2 RBC-3.72* Hgb-11.4* Hct-32.0*
MCV-86 MCH-30.6 MCHC-35.6 RDW-13.4 RDWSD-41.5 Plt ___
___ 05:24AM BLOOD Glucose-143* UreaN-11 Creat-0.7 Na-130*
K-4.0 Cl-91* HCO3-24 AnGap-15
___ 05:24AM BLOOD ALT-47* AST-25 AlkPhos-237* TotBili-0.5
___ 05:24AM BLOOD Calcium-8.6 Phos-4.4 Mg-2.0
___ 04:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:29PM BLOOD cTropnT-<0.01
___ 04:29PM BLOOD Lipase-26
DischargE:
___ 06:16AM BLOOD WBC-4.6 RBC-3.51* Hgb-10.9* Hct-30.2*
MCV-86 MCH-31.1 MCHC-36.1 RDW-13.2 RDWSD-40.8 Plt ___
___ 06:16AM BLOOD ___ PTT-31.2 ___
___ 06:16AM BLOOD Glucose-101* UreaN-9 Creat-0.8 Na-127*
K-3.9 Cl-93* HCO3-23 AnGap-11
___ 06:16AM BLOOD ALT-51* AST-36 AlkPhos-228* TotBili-0.6
___ 06:16AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
Micro:
URINE CULTURE (Final ___: NO GROWTH.
Imaging:
___ CTH/CSpine:
Reportedly negative for acute process
CXR ___:
No acute cardiopulmonary process.
CTH ___:
There is no evidence of acute intracranial process or
hemorrhage.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with metastatic pancreatic cancer, syncope// Eval
edema, consolidation
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Right-sided Port-A-Cath terminates in the low SVC/cavoatrial junction, without
evidence of pneumothorax.No focal consolidation, pleural effusion, or evidence
of pneumothorax is seen. The cardiac and mediastinal silhouettes are stable
and unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with unwitnessed fall on apixaban.// Evaluate for
bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
Total DLP (Head) = 856 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of infarction,intracranial hemorrhage,edema,or mass.
There is prominence of the ventricles and sulci suggestive of involutional
changes. Periventricular white matter hypodensities are nonspecific but may
reflect the sequelae of chronic microangiopathy. Punctate vascular
atherosclerotic calcifications are seen in the carotid siphons bilaterally.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
There is no evidence of acute intracranial process or hemorrhage.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Hypo-osmolality and hyponatremia
temperature: 96.1
heartrate: 70.0
resprate: 19.0
o2sat: 100.0
sbp: 142.0
dbp: 77.0
level of pain: 1
level of acuity: 2.0 | ___ PMH of recently diagnosed metastatic pancreatic cancer (on
gem/abraxane), SIADH, AFib, HTN, recent admission for
hypovolemic
hyponatremia + left foot cellulitis, presented 1 day after
discharge s/p mechanical fall from profound deconditioning, had
additional mechanical fall during hospitalization ___
impulsiveness, now discharging to rehab for nutrition, physical
therapy, with close nursing monitoring with plan for outpatient
oncology followup
#Mechanical Fall
Pt's wife provided clear history of mechanical fall which goes
with his known deconditioning and limited mobility. Extensive
workup suggested that patient was at recent baseline without any
metabolic/infectious/traumatic concerns but remained severely
deconditioned. During stay he had additional mechanical fall
despite fall precautions in place as he gets easily
frustrated/anxious and acts impulsively. In this case he wanted
to get up to use the sink and didn't want to wait for nurses,
ended up falling as he felt that the floor was slippery despite
having hospital socks. Given head strike and apixaban had
additional CTH which was negative. Patient counseled extensively
that he needs to adjust to his new normal and accept that he
needs assistance with movement. I educated patient, wife,
daughter that any of these falls could lead to a fracture which
would significantly set him back, and patient agreed to try
better to cope/behave. Will need continued fall precautions,
maximized nutrition, and daily ___ at rehab.
#Hyponatremia
Recent admission for hypovolemic hyponatremia. Has SIADH at
baseline unclear secretory source. Presented/Discharged at Na
approximate to his recent (roughly 128). To be continued on 1.2
L fluid restriction at rehab, w/ ensure for improved solute
intake. Next CHEM to be checked on ___.
#Left foot cellulitis/bullae
Noted on last admission. Per podiatry, callous on patient's left
foot likely caused skin disruption leading to bullae/cellulitis.
Is s/p unroofing of bullae on ___ on PO abx with improvement in
appearance of erythema (now dull). Patient is to continue Abx
(Bactrim/Keflex) for total 14 day course (ending ___. Needs
daily dressing changes by nursing and continued trending of foot
appearance to ensure erythema continues to retreat from
demarcated borders and resolves. Needs outpatient podiatry f/u
for re-evaluation and shoe inserts to offload affected area and
trim toenails.
#Constipation
Ongoing issues with severe constipation likely related to his
chemotherapy + decreased PO intake. Lactulose works best for
patient when needed.
#Metastatic Pancreatic Ca
Recently diagnosed pancreatic cancer ___. Follows with
oncologist Dr. ___ was updated during stay. Started on
C1D1 gem/abraxane ___ but had several medical complications
as explained above following first cycle. Given severe
deconditioning and above acute issues, will need re-evaluation
in early ___ by outpatient oncologist Dr ___ in ___
prior to determining whether or not he will tolerate further
chemo.
#Paroxysmal Atrial fibrillation
Recently hospitalized from ___ after port placement,
which was complicated by development of atrial fibrillation with
RVR. During hospitalization he was started on Eliquis given
CHADS2VASC 3 and hypercoagulability from pancreatic Ca in
consultation with cardiology. Not on rate control given HR in
___ and was in NSR prior to discharge. Continued on apixaban
during stay despite falls as they are preventable with
behavioral change. If he continues to fall due to inability to
improve his behavior, discontinuation of apixaban can be
considered.
#HTN
Orthostatics intermittently positive per BP measurements thought
patient denied symptoms and falls were clearly mechanical as
above. Lisinopril held in any case as no longer appears to need
it.
#Severe protein calorie malnutrition
Nutrition consulted given severe malnutrition. Was given
thiamine/folate/ensure during stay. Will need close nutritional
f/u at rehab.
#Transaminitis:
Stable, likely from hepatic mets, statin held on discharge. LFTs
to be trended in outpatient setting before consideration of
re-initiating statin.
#Anemia
Stable, likely ___ malignancy + chemotherapy. No e/o
internal/external bleeding. CBC to be trended at rehab, next on
___.
I personally spent 58 minutes preparing discharge paperwork,
educating patient/family, answering questions, and coordinating
care with outpatient providers |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Levofloxacin / trazodone / Ativan / Augmentin / Haldol / iv
contrast dye
Attending: ___.
Chief Complaint:
constipation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ year old female with a h/o constipation,
abdodinal pain, SB, lysis of adhesions, renal cell carcinoma s/p
left nephrectomy, hypertension, diabetes, vascular dementia, HF,
CVA, and ESRD on HD ___, afib who presents with eight days of
constipation. Per the patient, she passed flatus yesterday
though the daughter does not think she has. She takes 4 senna, 4
docolax, lenses, and lactulose daily as her bowel regimen. Her
daughter has tried a suppository without initiating a bowel
movement. She follows a strict diet due to dialysis that has not
changed and consists of rice krispy cereal and eggs. She takes
in 1500 mL of water per day at the most. She has been on
dialysis for ___ years. She stopped urinating approximately one
month ago. She started medical marijuana around six months ago
but otherwise has not had new changes in medication.
In the ED, initial vitals were: 96.6 | 68 | 117/51 | 18 | 100%
NC
Labs notable for:
*Hb 10.7
*Cr 4.8, K5.2
Imaging notable for:
KUB: Moderate fecal loading throughout the colon and rectum. No
evidence for bowel
obstruction or free intraperitoneal air.
Patient was given:
___ 13:32 PR Fleet Enema 1 Enema
___ 15:16 IV HYDROmorphone (Dilaudid) .5 mg
___ 19:53 PO/NG Polyethylene Glycol 17 g
___ 19:53 PO/NG Lactulose 30 mL
___ 00:18 PO LevETIRAcetam 250 mg
___ 00:18 PO/NG Amiodarone 200 mg
___ 00:18 PO/NG Docusate Sodium 200 mg
___ 00:18 PO/NG Gabapentin 600 mg
___ 00:18 PO Pantoprazole 40 mg
___ 00:18 PO/NG Senna 8.6 mg
___ 00:18 PO/NG Lactulose 30 mL
___ 00:23 SC Insulin 8 Units
Per RN received: Given 3 soap suds enemas & 2 fleet enemas w/no
effect.
Vitals prior to transfer: 98.1 | 65 | 137/54 | 18 | 100% RA
Past Medical History:
- dCHF (EF 50% in ___, 1+ AR, 2+ MR, 3+ TR
- paroxysmal atrial fibrillation, not on anticoagulation
- GI bleed ___
- syncope
- hypertension
- s/p left nephrectomy for ___ in ___
- renal artery stenosis s/p stenting x 2 (___) and
angioplasty ___
- ESRD on HD TTS via LUE fistula. Non-anuric
- T2DM on insulin
- PAD
- h/o breast cancer dx ___, s/p lumpectomy and tamoxifen
- gout, no crystal proven
- s/p hysterectomy
- s/p bilateral knee replacements
Social History:
___
Family History:
- h/o HTN
- parents and daughter with DM
- denied heart disease history previously
Physical Exam:
ON ADMISSION:
===================
Vital Signs: 97.1 | 148/52 | 67 | 18 | 100% RA
General: Alert, minimally verbal in no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Distended, normal bowel sounds. Soft, diffusely tender.
Palpable fecal loading.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moves 4 extremities at will
AT DISCHARGE:
====================
VS T 98.2 HR 58-65 BP 100-112/41-48 RR 18 SpO2 98% RA
General: undergoing HD, mildly agitated
HEENT: sclera anicteric, MMM
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, distended, diffusely tender to palpation, bowel
sounds present, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, no edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ON ADMISSION:
=====================
___ 03:13PM BLOOD WBC-9.0# RBC-3.23* Hgb-10.7* Hct-36.0
MCV-112* MCH-33.1* MCHC-29.7* RDW-13.9 RDWSD-57.1* Plt ___
___ 03:13PM BLOOD Glucose-182* UreaN-52* Creat-4.8* Na-134
K-5.2* Cl-89* HCO3-28 AnGap-22*
___ 10:24AM BLOOD Calcium-7.7* Phos-7.7* Mg-2.2
___ 03:13PM BLOOD TSH-2.0
___ 03:24PM BLOOD ___ pO2-32* pCO2-54* pH-7.36
calTCO2-32* Base XS-2
ON DISCHARGE:
=======================
___ 06:45
COMPLETE BLOOD COUNT
Red Blood Cells 2.93* 3.9 - 5.2 m/uL W
Hemoglobin 9.9* 11.2 - 15.7 g/dL W
Hematocrit 31.1* 34 - 45 % W
MCV 106* 82 - 98 fL W
MCH 33.8* 26 - 32 pg W
Platelet Count 136* 150 - 400 K/uL W
___ 06:45AM BLOOD Glucose-175* UreaN-71* Creat-7.0*#
Na-126* K-3.9 Cl-84* HCO3-24 AnGap-22*
IMAGING:
=======================
UNI-LAT BRACHIAL ___
IMPRESSION:
Successful arteriogram of the left upper extremity and left AV
graft
fistulogram. No inflow arterial stenosis was found. Mild
stenoses in the
arterial limb of the graft and in the brachiocephalic vein.
ABDOMEN (SUPINE & ERECT) ___
IMPRESSION:
Moderate fecal loading throughout the colon and rectum. No
evidence for bowel obstruction or free intraperitoneal air.
ABDOMEN (SUPINE ONLY) ___:
IMPRESSION:
Nonobstructive bowel gas pattern. Mild to moderate amount of
fecal load in the proximal and mid colon.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze, dyspnea
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 400 mg PO TID
7. Isosorbide Dinitrate 10 mg PO TID
8. Lactulose 30 mL PO BID
9. LevETIRAcetam 250 mg PO BID
10. Lidocaine 5% Patch 1 PTCH TD QPM back
11. Nephrocaps 1 CAP PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Pravastatin 80 mg PO QPM
14. Ranitidine 75 mg PO QHS
15. Sarna Lotion 1 Appl TP QID:PRN itch
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. Simethicone 40-80 mg PO QID:PRN bloating
18. Vitamin D ___ UNIT PO DAILY
19. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B
complex) 1 TAB oral DAILY
20. Amiodarone 150 mg PO BID
21. Polyethylene Glycol 17 g PO DAILY:PRN constipation
22. Senna 17.2 mg PO BID
23. Linzess (linaclotide) 290 mcg oral DAILY
24. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
25. melatonin unknown sublingual QHS
Discharge Medications:
1. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 650 mg PO Q8H:PRN pain
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze, dyspnea
4. Amiodarone 150 mg PO BID
5. Aspirin 81 mg PO DAILY
6. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B
complex) 1 TAB oral DAILY
7. Bisacodyl 10 mg PR QHS:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Gabapentin 400 mg PO TID
10. Lactulose 30 mL PO BID
11. LevETIRAcetam 250 mg PO BID
12. Lidocaine 5% Patch 1 PTCH TD QPM back
13. Linzess (linaclotide) 290 mcg oral DAILY
14. Nephrocaps 1 CAP PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Pravastatin 80 mg PO QPM
18. Ranitidine 75 mg PO QHS
19. Sarna Lotion 1 Appl TP QID:PRN itch
20. Senna 17.2 mg PO BID
21. sevelamer CARBONATE 800 mg PO TID W/MEALS
22. Simethicone 40-80 mg PO QID:PRN bloating
23. Vitamin D ___ UNIT PO DAILY
24. HELD- Isosorbide Dinitrate 10 mg PO TID This medication was
held. Do not restart Isosorbide Dinitrate until primary care
physician followup and low blood pressures improved
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Constipation
SECONDARY DIAGNOSES:
End-stage renal disease on hemodialysis
Type 2 Diabetes
Vascular Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with chronic constipation with abd distension
and continued constipation // Please eval for interval change in fecal load
TECHNIQUE: Three views of the abdomen and pelvis
COMPARISON: Radiograph ___.
FINDINGS:
Nonobstructive bowel gas pattern. Moderate amount of fecal loading in the
proximal and mid colon. No evidence of free air. A vascular stent and
surgical clips in the mid abdomen are unchanged.
IMPRESSION:
Nonobstructive bowel gas pattern. Mild to moderate amount of fecal load in
the proximal and mid colon.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Abd pain, Constipation
Diagnosed with Dehydration
temperature: 96.6
heartrate: 68.0
resprate: 18.0
o2sat: 100.0
sbp: 117.0
dbp: 51.0
level of pain: ua
level of acuity: 3.0 | Ms. ___ is an ___ year old female with a h/o constipation,
abdominal pain, SBO with lysis of adhesions, renal cell
carcinoma s/p left nephrectomy, diabetes, vascular dementia,
dCHF, CVA, ESRD on HD ___, and Afib not on anticoagulation,
who presents with eight days of constipation and abdominal pain;
course as below:
# Constipation: KUB with no evidence of obstruction or free air.
She is followed by Dr. ___ in GI clinic for chronic
constipation and has known slow GI transit. She is also on
multiple constipating meds such as gabapentin and oxycodone at
home. TSH was normal. At home, she is being treated with
Bisacodyl, Docusate Sodium, Lactulose, Simethicone ___
Polyethylene Glycol, Senna 17.2 mg PO BID, and Linzess
(linaclotide). She was continued on home medications with more
frequent dosing of miralax, lactulose, as well as Golytely.
Digital rectal exam did not reveal impacted stool. She had
several bowel movements while in the hospital, with some
improvement in her abdominal pain. Repeat KUB showed reduction
of fecal load and no signs of distal obstruction. She was
discharged on ___ with the following changes in her bowel
regimen: ContinueD home regimen and add Align probiotics.
CHRONIC ISSUES
#Seizure disorder: She was continued on levitiracetam.
#Atrial fibrillation: She is not on anticoagulation. She was
continued on metoprolol
and amiodarone.
#ESRD on HD ___ via LUE fistula: Underwent inpatient
dialysis on ___ and ___. She was continue on sevelamer,
nephrocaps.
#T2DM: She was initially put on lower dose of lantus, until PO
intake improved. Humalog ISS was continued.
#HTN: Her systolic BPs were 90-100s, so isosorbide dinitrate was
held while inpatient.
#Neuropathic pain: She was continued home gabapentin. The
patient no longer taking nortriptyline at home.
#GERD: She was continued home on pantoprazole and ranitidine.
#Psych: Has dementia and doesn't speak much. While inpatient,
she was frequently shouting but unable to describe what was
bothering her. Per daughter, pt not taking home olanzapine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Lipitor /
Verapamil / Lescol / Etodolac / Rofecoxib / Valdecoxib
Attending: ___.
Chief Complaint:
"occipital intraparenchymal hemorrhage and
right visual field cut"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old right-handed female with a
history of coronary artery disease, osteoporosis, asthma and
right occipital hemorrhage (___) from amyloid angiopathy who
now
presents with headache and vision loss. Yesterday (___)
afternoon while doing some strenuous yardwork (cutting/hauling
branches) she developed a bilateral dull headache with the left
side being more intense sharp pain than the right side. She
then
noticed that her left eye seemed to be "frozen." Thereafter,
she
says that she lost vision in her left eye and began bumping into
furniture. She did not want to go to the hospital yesterday.
Headache persisted this morning and she took aspirin 81mg
without
relief. She also developed some nausea but no weakness, no
sensory changes or confusion.
She eventually agreed to be taken to ___
today where head CT showed a left occipital intraparenchymal
hemorrhage without any midline shift or herniation. She was
given IV dilaudid and reglan and transferred to ___ ED for
further care. In the ED, initial blood pressure was 121/72 and
she was given IV zofran, morphine and tylenol. Neurology was
consulted for further management.
On neuro ROS, the pt endorses dull bilateral headache, loss of
vision in her left eye, no blurred vision, no diplopia, no
dysarthria, no dysphagia. No vertigo, no tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness or parasthesiae. No
bowel or bladder incontinence or retention. No unsteadiness
with
ambulation but is bumping into walls/furniture.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. No cough
or shortness of breath. Denies chest pain or tightness,
palpitations. No nausea or vomiting. No diarrhea,
constipation.
No abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-right occipital intraparenchymal hemorrhage (biopsy confirmed
amyloid angiopathy)-brought on by vigorous snow shoveling.
-osteoporosis
-asthma
-coronary artery disease
-hypertension and hyperlipidemia (mentioned in cardiology
records)
Social History:
___
Family History:
Mother died of stroke in her ___. Father had asthma
and emphysema. Brother died of heart attack in his ___.
Physical Exam:
At admission:
Vitals: T: 98.5 P: 74 R: 20 BP: 121/72 SaO2: 94% on 2L.
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rash or lesions.
Neurologic:
-Mental Status: Alert, oriented x 2. Tells me her name, ___
and ___ but cannot remember month or day. Able to relate
history without difficulty but at time confuses order of events
from yesterday. Able to name ___ forwards but not backwards. .
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able
to name both high and low frequency objects. Not able to test
reading secondary to visual field deficits. Could identify
single letters of words without difficulty. Speech was not
dysathric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall ___ at 5
minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. Dense right homonymous hemianopia
and spotty left peripheral field deficit. Funduscopic exam
revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. 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,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was downgoing bilaterally.
-Coordination: No tremors. No dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally but does pass point slightly
secondary to her vision loss.
-Gait: Deferred gait and Romberg for bedrest. Was walking
normally earlier in the day per family.
At discharge:
Neuro: Dense right homonymous hemianopia and left peripheral
visual field deficit, no motor deficits. Mood is anxious and
frequently tearful
Pertinent Results:
___ 07:38PM WBC-10.6 RBC-4.53 HGB-14.2 HCT-42.2 MCV-93
MCH-31.4 MCHC-33.7 RDW-12.9
___ 07:38PM NEUTS-75.1* ___ MONOS-4.3 EOS-1.4
BASOS-0.7
___ 07:38PM PLT COUNT-186
___ 07:38PM ___ PTT-31.5 ___
___ 07:38PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:38PM GLUCOSE-106* UREA N-9 CREAT-0.6 SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
___ 05:30AM BLOOD WBC-7.6 RBC-3.84* Hgb-12.2 Hct-35.7*
MCV-93 MCH-31.7 MCHC-34.1 RDW-12.7 Plt ___
___ 05:30AM BLOOD Glucose-104* UreaN-9 Creat-0.5 Na-139
K-3.2* Cl-103 HCO3-32 AnGap-7*
___ 05:30AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
___ 07:38PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ECG:
Sinus rhythm. Diffuse ST-T wave abnormalities most noticably in
the
anterolateral leads. Cannot rule out underlying myocardial
ischemia. Compared to the previous tracing of ___ wave changes persist. Clinical correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 ___ 29 2 40
___ NCHCT:
IMPRESSION:
1. Left occipital intraparenchymal hemorrhage with extension
into the
extra-axial space. Mild-to-moderate surrounding vasogenic edema
and sulcal and left lateral ventricle effacement. Slight
effacement of the left ambient cistern is noted but with overall
relatively little mass effect.
2. New but chronic-appeearing focus of encephalomalacia in the
left anterior frontal lobe.
EEG:
FINDINGS:
ABNORMALITY #1: Occasional bursts of right posterior quadrant
___ Hz
delta frequency activity were seen.
ABNORMALITY #2: In the most electrographically awake-appearing
portions
of this tracing, a symmetric ___ Hz theta frequency background
was
seen.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as the patient was
unable to
cooperate.
INTERMITTENT PHOTIC STIMULATION: The technologist inadvertently
did not
perform this activation procedure; if clinically warranted, a
repeat
tracing to obtain photic stimulation will be provided.
SLEEP: Periods of a more symmetric ___ Hz theta frequency
background
were seen along with periods of a slower (but still symmetric) 6
Hz
theta frequency background were seen. This variability may be
due to
periods of relative drowsiness and wakefulness, though clinical
correlate through video review did not appreciably demonstrate a
change
in clinical state.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate
of 72 bpm.
IMPRESSION: This is an abnormal EEG due to the presence of
occasional
bursts of slowing seen involving the right posterior quadrant
superimposed upon a slow background. The former abnormality may
represent a focal area of subcortical disturbance, while the
slow
background is more consistent with a larger, subcortical, deep
midline
abnormality. No frank epileptiform activity was seen during this
recording, but if the patient has frequent symptoms, continuous
EEG
recording with event monitoring and spike and seizure detection
algorithms may provide additional diagnostic information
Portable NCHCT:
IMPRESSION: Intraparenchymal hemorrhage with small extraaxial
component in
the left occipital lobe is unchanged compared with prior exam,
without
significant mass effect.
___ NCHCT:
IMPRESSION:
Essentially unchanged left occipital lobe hemorrhage and small
left subdural hemorrhage given differences in scan technique.
___ NCHCT:
IMPRESSION:
1. No significant interval change in size of the left occipital
lobe
intraparenchymal hemorrhage with continued mass effect on the
occipital horn of the left lateral ventricle, unchanged.
2. Small subdural hematoma overlying the left parietal lobe is
less
conspicuous on the present study.
3. No new intracranial hemorrhage or infarction.
___ ___:
IMPRESSION:
1. Little change in comparison to prior study from yesterday
with no
significant change in the interval size of the left occipital
intraparenchymal
hemorrhage with continued mass effect on the occipital horn of
the left
lateral ventricle.
2. Stable appearance of small subdural hematoma overlying the
left parietal lobe.
Medications on Admission:
albuterol prn wheezing
Discharge Medications:
1. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6
hours) as needed for cough.
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ puff Inhalation q4hrs as needed for shortness of breath or
wheezing.
8. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain: for headache. Limit to < 4 grams per
day.
9. oxycodone 5 mg Tablet Sig: ___ Tablet PO every ___ hours as
needed for Pain: Please use as breakthrough if acetaminophen is
not effective.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left occipital lobe hemorrhage
amyloid angiopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro: Dense right homonymous hemianopia and left peripheral
visual field deficit, no motor deficits. Mood is anxious and
frequently tearful
Followup Instructions:
___
Radiology Report
INDICATION: Left occipital intracranial hemorrhage on outside head CT.
Please provide second read.
COMPARISON: Comparison is made to head CT performed ___.
TECHNIQUE: Non-contrast axial images were obtained through the brain. No
further reformations provided.
FINDINGS: There is a 2.3 x 1.7 cm left occipital lobe hemorrhage with a
mild-to-moderate amount of surrounding vasogenic edema and extension of
hemorrhagic contents into the extraxial space. Extraaxial hemorrhage tracks
along left frontal lobe and measures 5mm at its greatest depth. Trace
hyperattenuation layering along right frontal lobe sulcus (2:56) indicating
subarachnoid hemorrhage. There is associated effacement of the occipital horn
of the left lateral ventricle as well as the left occipital and parietal lobe
sulci. The remaining sulci and ventricles are minimally prominent, consistent
with age-related parenchymal involution. No appreciable shift of midline
structures evident. There is slight effacement of the left ambient cistern
but without compression of the brain stem.
Encephalomalacia related to a previous right occipital lobe hematoma is
evident as well as a right parietal burr hole and appears similar aside from
more extensive regional atrophy. A second area of encephalomalacia noted in
left frontal lobe is new compared to next preceding study. Periventricular
white matter hypodensities are consistent with small vessel ischemic disease.
The mastoid air cells, middle ear cavities and paranasal sinuses are clear.
No soft tissue swelling evident.
IMPRESSION:
1. Left occipital intraparenchymal hemorrhage with extension into the
extra-axial space. Mild-to-moderate surrounding vasogenic edema and sulcal and
left lateral ventricle effacement. Slight effacement of the left ambient
cistern is noted but with overall relatively little mass effect.
2. New but chronic-appeearing focus of encephalomalacia in the left anterior
frontal lobe.
Radiology Report
INDICATION: ___ female with left occipital hemorrhage and prior right
occipital lobe biopsy with diagnosis of amyloid angiopathy. Evaluate for
progression of bleed.
COMPARISON: NECT on ___ as well as multiple head CTs from
___ and ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the head
without administration of IV contrast in a portable CT scanner.
FINDINGS: Acquisition was made in a portable CT scanner and no scout was
provided, limiting radiologic evaluation. Allowing for these limitations, a
discrete focus of intraparenchymal hemorrhage is noted in the left occipital
lobe with perilesional edema which appears unchanged with respect to prior CT,
allowing for difference in angulation and plane of acquisition. An
extra-axial component of the hemorrhage is also unchanged and noted in our
study in image 1:18. The sulci in the left cerebral hemisphere appear
minimally effaced as well as the lateral ventricle, but no shift of midline
structures is present. A focus of encephalomalacia in the right occipital
lobe is secondary to known old hemorrhagic stroke. There is mild ex vacuo
dilatation of the right lateral ventricle as well. A burr hole in the right
occipital bone is secondary to prior biopsy that yielded the diagnosis of
amyloid angiopathy.
Otherwise, periventricular white matter changes suggest sequela of chronic
small vessel ischemic disease. There is preservation of gray-white matter
differentiation in the parietal and frontal lobes. The basal cisterns appear
patent. The paranasal sinuses, mastoid air cells and middle ear cavities are
clear.
IMPRESSION: Intraparenchymal hemorrhage with small extraaxial component in
the left occipital lobe is unchanged compared with prior exam, without
significant mass effect.
Radiology Report
INDICATION: ___ woman with occipital hemorrhage and surrounding
cytotoxic edema, question worsening edema.
COMPARISON: Portable head CT from ___ at 8 a.m.
TECHNIQUE: MDCT images were acquired through the head without contrast.
FINDINGS:
Again noted is a left occipital lobe intraparenchymal hemorrhage measuring 3.6
x 3.6 cm (previously measuring 3.6 x 3.2 cm). This is associated with a small
left subdural hemorrhage more cranial to the occipital hemorrhage. Evidence
of an old right occipital lobe infarct is also noted, unchanged. No new areas
of hemorrhage are noted. The ventricles and sulci are normal in size and
configuration. The visible paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION:
Essentially unchanged left occipital lobe hemorrhage and small left subdural
hemorrhage given differences in scan technique.
Radiology Report
INDICATION: Amyloid angiopathy with occipital hemorrhage. Worse headache
this morning. Assess size of hemorrhage and extent of swelling.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material.
COMPARISON: CT head from ___.
FINDINGS: As before, there is a large intraparenchymal hemorrhage centered
within the left occipital lobe, not appreciably changed in size allowing for
differences in technique. A small subdural hematoma overlying the left
parietal region is less conspicuous on the present study (2:23). There is no
new intracranial hemorrhage. Compression of the occipital horn of the left
lateral ventricle is not significantly changed. The ventricular size is
otherwise stable. There is no acute large vascular territorial infarction.
Evidence of an old right occipital lobe infarction is unchanged. The
visualized portions of the paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION:
1. No significant interval change in size of the left occipital lobe
intraparenchymal hemorrhage with continued mass effect on the occipital horn
of the left lateral ventricle, unchanged.
2. Small subdural hematoma overlying the left parietal lobe is less
conspicuous on the present study.
3. No new intracranial hemorrhage or infarction.
Radiology Report
INDICATION: Evaluation of patient with hemorrhagic stroke for interval
change.
COMPARISON: Multiple prior CTs heads including the most recent from ___ at 10:15.
FINDINGS: There is a little interval change in comparison to prior study from
the day before. As before, there is a large intraparenchymal hemorrhage in
the left occipital lobe, not significantly changed in size and allowing for
differences in technique and angulation. A small subdural hematoma overlying
the left parietal region also appears stable (2A:21). There is no evidence of
new intracranial hemorrhage or shift of the normally midline structures.
Effacement of the occipital horn of the left lateral ventricle appears stable
and ventricular size is otherwise stable. Evidence of an old right occipital
infarction is again noted. The visualized portions of the paranasal sinuses
and mastoid air cells are clear.
IMPRESSION:
1. Little change in comparison to prior study from yesterday with no
significant change in the interval size of the left occipital intraparenchymal
hemorrhage with continued mass effect on the occipital horn of the left
lateral ventricle.
2. Stable appearance of small subdural hematoma overlying the left parietal
lobe.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: OCCIPITAL BLEED
Diagnosed with INTRACEREBRAL HEMORRHAGE, HX OTHER CIRCULATORY DISEASE, ASTHMA, UNSPECIFIED
temperature: 98.5
heartrate: 74.0
resprate: 20.0
o2sat: 94.0
sbp: 121.0
dbp: 72.0
level of pain: 1
level of acuity: 2.0 | ___ is a ___ year old right-handed female with a
history of coronary artery disease, osteoporosis, asthma and
right occipital hemorrhage (___) from amyloid angiopathy who
now presents with headache and vision loss. Her neurological
exam is significant for right homonymous hemianopia and spotty
left peripheral field deficit. She is also having some mild
memory deficits and inability to perform ___ backwards both of
which are reportedly new according to her family. These are most
likely due to her anxiousness and has improved prior to
discharge. Head CT shows a left occipital intraparenchymal
hemorrhage. Her right visual field deficits are consistent with
the hemorrhage in the left occipital cortex. The left peripheral
field deficits are chronic deficits due to the prior right
occipital hemorrhage in ___. The most likely etiology of her
hemorrhage is from cerebral amyloid angiopathy.
.
NEURO: Amyloid angiopathy with new occipital hemorrhage
- mannitol used initially for symptomatic improvement. Weaned
off.
- HA pain control with acetaminophen and oxycodone prn.
Anxiousness is a large contributing factor
- cont celexa 20mg po daily to help with mood and rehabilitation
- completed 1 week of anti-sezire prophylaxis with Keppra. No
need to continue at this time
- goal SBP 140-160, hydralazine 10mg prn SBP>170
.
GI: Patient is on regular diet but has been intermittently
nauseated. Concern about how many calories she is taking in.
- I and O's and calorie count. Starting Enlive and magic cup
supplements
- nutrition consult following
- started remeron 15mg po qhs for appetite stimulus and further
mood improvement
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chief Complaint: shortness of breath
Reason for MICU transfer: respiratory distress requiring
intubation
Reason for CCU transfer: PEA arrest x2, need for mechanical
circulatory support
Major Surgical or Invasive Procedure:
tPa lysis for PE
intubation
central line
A line
V-V right-sided tandem heart
A-V ECMO
History of Present Illness:
___ y/o M with no ___ transferred from ___ to
___ ___ after massive PE with hemodynamic collapse. Pt
does not have any known significant PE risk factors other than a
flight from ___ to ___ on ___. Pt reported flu-like
illness for 2 weeks and two days of dyspnea.
Presented to OSH this morning, a CTA was done that showed
diffuse segmental and subsegmental PEs involving all lobes. The
pt was hypotensive in the ED, so tPA 50mg was given. He was
started on a heparin drip and given ___ fluid. He was intubated
prior to transfer to ___ ED.
In ED here, he received an additional 50 mg tPA. He had a
___ in ED and was urgently transferred to MICU. On
arrival to MICU (7am ___ pt PEA arrested and underwent one
round of CPR and epinephrine with ROSC. He was briefly off of
pressors and HD stable after arrest. During this window, bedside
Echo showed dilated, blown RV, PASP ~50, ventricular
interdependence, no pericardial effusion, LV underfilling.
Pt then grew hemodynamically unstable again, uop dropped off to
0 ___. He then became bradycardic and hypotensive again
and subsequently PEA arrested again. He was coded for about 10
additional minutes with post arrest period of about 30 minutes.
Prior to transfer to cath lab, pt was only on levophed and was
paralyzed due to ventilator dyssynchrony. He was initially
difficult to ventilate with PaCO2 of 45 w/ minute ventilation of
19L/min. Since paralysis, ABG improved to 7.29/30/264/15.
Labs significant for transaminitis w/ AST/ALT close to 1000, LDH
~1500, tbili 2.2, cr. 2.2, lactate 10, INR >2. trop < 0.01, BNP
16.8K, fibrinogen 48, plt 130.
He has a triple lumen in R groin and R femoral a-line.
Of note, a repeat echo was not done after second round of CPR.
This is significant given tpa administration and risk for
pericardial effusion. This showed worsening dilation of RV w/
evidence of severe pulmonary HTN. There was no pericardial
effusion.
Given RV failure and hemodynamic instability, pt was transferred
to cath lab for right tandem heart device to unload RV with
bypass from left femoral vein to PA.
After placement of right tandem heart and paralysis, patient's
hemodynamics and ventilation improved. Post-cardiac arrest team
was consulted and given lack of significant regain of
consciousness after ___ PEA arrest, they have recommended 24
hours of neuroprotective hypothermia.
REVIEW OF SYSTEMS
Unable to obtain due to being intubated and sedated
Past Medical History:
None
Social History:
___
Family History:
no family h/o VTE
Physical Exam:
On arrival to CCU:
VS: 97.4 ___ 30 100% (on ventilator, AC, PEEP 5, FiO2 70%)
GENERAL: intubated / sedated / paralyzed
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: unable to assess JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. tachycardic, regular rhythm, normal S1, loud P2. No m/r/g.
No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. Mottling of b/l feet. Dopplerable ___
pulses b/l.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
On Discharge:
VS: 97.6, 95, 130/56, 18, 92 on ventilator
GENERAL: intubated / sedated
HEENT: NCAT. Pupils reactive to light. Nares with dried blood
and gauze stopper in place. Unable to assess oral mucosa given
trach tube in place, however small amt dried blood obtained with
suctioning.
NECK: RIJ in place; LIJ in place
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Rate in ___, regular rhythm, normal S1, soft S2. S3
present. S4 heard. No m/r/g. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
ventilated. Diffuse coarse rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. NABS. No abdominial
bruits.
EXTREMITIES: preserved cap refill, resolved mottling of lower
extremities. Dopplerable ___ pulses b/l. 2+ edema of lower
extremities to mid thighs. Edema of hands bilaterally. L. groin
with hematoma not expanding beyond previously marked borders, no
bleeding.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
On admission:
___ 05:15AM BLOOD WBC-13.2* RBC-5.04 Hgb-16.9 Hct-50.0
MCV-99* MCH-33.6* MCHC-33.8 RDW-13.2 Plt ___
___ 05:15AM BLOOD Neuts-84.1* Lymphs-9.9* Monos-5.1 Eos-0.6
Baso-0.4
___ 05:15AM BLOOD ___ PTT-150* ___
___ 08:53AM BLOOD Fibrino-48*
___ 05:15AM BLOOD Glucose-158* UreaN-30* Creat-2.5* Na-139
K-5.2* Cl-103 HCO3-12* AnGap-29*
___ 05:15AM BLOOD ALT-734* AST-713* AlkPhos-66 TotBili-2.8*
___ 05:15AM BLOOD ___
___ 05:15AM BLOOD cTropnT-<0.01
___ 05:32AM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-10
FiO2-100 pO2-423* pCO2-46* pH-7.07* calTCO2-14* Base XS--16
AADO2-244 REQ O2-48 -ASSIST/CON Intubat-INTUBATED
___ 05:32AM BLOOD Lactate-5.2*
Pertinent interval labs:
___ 01:45PM BLOOD WBC-20.0* RBC-4.27* Hgb-14.0 Hct-40.7
MCV-95 MCH-32.8* MCHC-34.4 RDW-13.5 Plt ___
___ 06:00AM BLOOD WBC-11.7* RBC-4.24* Hgb-13.8* Hct-41.4
MCV-98 MCH-32.6* MCHC-33.4 RDW-13.2 Plt Ct-96*
___ 11:07AM BLOOD WBC-8.5 RBC-3.44* Hgb-11.1* Hct-33.8*
MCV-98 MCH-32.2* MCHC-32.8 RDW-13.3 Plt Ct-86*
___ 05:34AM BLOOD WBC-13.3* RBC-3.35* Hgb-10.6* Hct-30.8*
MCV-92 MCH-31.7 MCHC-34.5 RDW-16.0* Plt ___
___ 02:56AM BLOOD WBC-20.8* RBC-3.12* Hgb-9.9* Hct-29.9*
MCV-96 MCH-31.8 MCHC-33.1 RDW-15.8* Plt Ct-71*
___ 12:18AM BLOOD WBC-21.1* RBC-3.17* Hgb-9.9* Hct-30.4*
MCV-96 MCH-31.1 MCHC-32.4 RDW-16.2* Plt Ct-78*
___ 11:07AM BLOOD ___ PTT-150* ___
___ 12:54PM BLOOD ___ PTT-99.9* ___
___ 04:05AM BLOOD ___
___ 04:10PM BLOOD Glucose-152* UreaN-37* Creat-2.0* Na-144
K-3.9 Cl-111* HCO3-15* AnGap-22*
___ 03:14PM BLOOD Glucose-111* UreaN-27* Creat-1.3* Na-137
K-3.8 Cl-104 HCO3-25 AnGap-12
___ 11:59PM BLOOD Glucose-225* UreaN-61* Creat-1.3* Na-142
K-4.5 Cl-102 HCO3-33* AnGap-12
___ 11:11AM BLOOD Glucose-127* UreaN-48* Creat-1.2 Na-144
K-4.5 Cl-101 HCO3-32 AnGap-16
___ 12:18AM BLOOD Glucose-136* UreaN-47* Creat-1.0 Na-145
K-4.5 Cl-104 HCO3-29 AnGap-17
___ 06:00AM BLOOD ALT-4980* AST-7972* AlkPhos-51
TotBili-1.7*
___ 06:15PM BLOOD ALT-1451* AST-416* AlkPhos-56
TotBili-3.4*
___ 06:13AM BLOOD ALT-565* AST-116* AlkPhos-91 TotBili-4.3*
DirBili-3.3* IndBili-1.0
___ 12:18AM BLOOD ALT-191* AST-61* AlkPhos-117 TotBili-3.3*
Selected ABGs:
___ 07:37AM BLOOD Type-ART pO2-403* pCO2-36 pH-7.22*
calTCO2-16* Base XS--12 -ASSIST/CON
___ 10:23AM BLOOD Type-ART Temp-36.6 pO2-197* pCO2-45
pH-7.15* calTCO2-17* Base XS--13
___ 08:25PM BLOOD Type-ART Temp-33.8 ___ Tidal V-500
PEEP-5 FiO2-50 pO2-134* pCO2-25* pH-7.43 calTCO2-17* Base XS--5
-ASSIST/CON Intubat-INTUBATED
___ 12:24AM BLOOD Type-ART Temp-34 ___ Tidal V-500
PEEP-5 FiO2-50 pO2-69* pCO2-24* pH-7.49* calTCO2-19* Base XS--2
-ASSIST/CON Intubat-INTUBATED Vent-CONTROLLED
___ 03:15PM BLOOD Type-ART pO2-115* pCO2-22* pH-7.36
calTCO2-13* Base XS--10
___ 11:18AM BLOOD Type-ART Temp-34.1 Tidal V-500 PEEP-8
FiO2-50 pO2-137* pCO2-35 pH-7.45 calTCO2-25 Base XS-1
Intubat-INTUBATED Vent-CONTROLLED
___ 04:56AM BLOOD Type-ART Temp-37 pO2-90 pCO2-54* pH-7.36
calTCO2-32* Base XS-2 Intubat-INTUBATED
___ 10:05AM BLOOD Type-ART Temp-37.2 pO2-73* pCO2-51*
pH-7.48* calTCO2-39* Base XS-12 Intubat-INTUBATED
___ 08:28AM BLOOD Type-ART pO2-63* pCO2-50* pH-7.50*
calTCO2-40* Base XS-12
___ 06:24AM BLOOD Type-ART ___ Tidal V-450 FiO2-100
pO2-92 pCO2-47* pH-7.48* calTCO2-36* Base XS-9 AADO2-585 REQ
O2-95 -ASSIST/CON Intubat-INTUBATED
___ 03:50AM BLOOD Type-ART FiO2-80 pO2-57* pCO2-50*
pH-7.46* calTCO2-37* Base XS-9 AADO2-473 REQ O2-79
___ 09:56PM BLOOD Type-ART pO2-96 pCO2-58* pH-7.38
calTCO2-36* Base XS-6
Lactate trend:
___ 09:32AM BLOOD Lactate-10.4* K-4.9
___ 01:53PM BLOOD Lactate-8.2*
___ 04:30AM BLOOD Lactate-3.0*
___ 09:29AM BLOOD Lactate-2.4*
___ 01:30PM BLOOD Lactate-8.5*
___ 12:40AM BLOOD Lactate-3.9*
___ 07:37AM BLOOD Lactate-2.4*
___ 07:24AM BLOOD Lactate-1.5
___ 12:28AM BLOOD Lactate-2.1*
___ 10:18AM BLOOD Lactate-2.9*
___ 12:44PM BLOOD Lactate-3.0*
___ 06:02PM BLOOD Lactate-2.2*
=
=
=
=
=
=
=
=
================================================================
IMAGING/OTHER STUDIES:
___:
CHEST CTA:
1. Bilateral pulmonary emboli in the segmental and smaller
pulmonary arteries with evidence of right heart strain and
pulmonary hypertension. No pulmonary infarct and no occult
malignancy in the chest.
2. Gallbladder wall edema is nonspecific. Recommend clinical
correlation
ECHO ___
Left ventricular wall thicknesses and cavity size are normal.
Left ventricular systolic function is hyperdynamic (EF>75%). The
right ventricular cavity is markedly dilated with severe global
free wall hypokinesis. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of earlier in
the day of ___, the right ventricular cavity is now larger
and the estimated PA systolic pressure is higher. A catheter is
now seen in the RA/RV cavity.
LOWER EXTREMITY VENOUS U/S ___:
Nearly occlusive deep vein thrombus extending from the left
distal superficial femoral vein to the popliteal vein. Only one
posterior tibial vein on the left is seen, the other posterior
tibial vein and the peroneal veins are not well seen and may be
occluded as well. The right and left common femoral and
proximal superficial femoral veins were not accessible for
imaging.
EEG ___:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of a severe diffuse encephalopathy without clear focal
or lateralized features. The background changed during the
record. It went from a moderately severe to a more severe
attenuation of signals. There were no focal or lateralized
features and it is suspected that this is all related to a
change in medication.
CXR ___:
There is an endotracheal tube whose distal tip is 4 cm above the
carina,
appropriately sited. There is a coiled tubular device
projecting over the
left superior mediastinum which is unchanged. Previously seen
large caliber catheter projecting over the right heart and into
the main pulmonary outflow tract has been pulled back several
centimeters with the distal lead tip in the proximal right
atrium. Please correlate clinically. The patchy opacities
Throughout both lung fields described previously have improved
somewhat, now less apparent. There remains a small right-sided
pleural effusion. The endotracheal tip and side port are within
the stomach.
ECHO ___:
IMPRESSION: Severe Right ventricular cavity dilation with severe
biventricular global systolic dysfunction. Marked pulmonary
artery hypertension. Moderate-severe tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
the left ventricular function has slightly improved.
ECHO ___:
IMPRESSION: Focused study. Markedly dilated right ventricle with
severe global hypokinesis (relative sparing of the apex=
___ sign). Severe pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
the right ventricular systolic function appears slightly
improved (basal free wall). The estimated pulmonary pressure is
similar.
CXR ___:
IMPRESSION: Significantly increased left upper lobe
opacification without
evidence of volume loss, concerning for underlying lobar
pneumonia. Improved background pulmonary edema. Stable right
lower lobe opacification likely reflecting atelectasis and small
pleural effusion.
CXR ___:
Indwelling support and monitoring devices are unchanged in
position. Marked interval improved aeration in the right lower
lobe compared to the prior study, but continued diffuse airspace
opacification throughout the majority of the left lung with
relative sparing of the left lung base. These findings may be
due to asymmetrical pulmonary edema with or without co-existing
infection. Cardiomediastinal contours are stable in appearance
with persistent right-sided cardiac enlargement.
Discharge:
___ 11:18AM BLOOD WBC-24.8* RBC-2.98* Hgb-9.5* Hct-28.6*
MCV-96 MCH-31.7 MCHC-33.0 RDW-15.8* Plt Ct-85*
___ 11:18AM BLOOD ___ PTT-59.7* ___
___ 11:18AM BLOOD Glucose-122* UreaN-48* Creat-1.0 Na-143
K-4.4 Cl-102 HCO3-29 AnGap-16
___ 06:00AM BLOOD ALT-170* AST-64* AlkPhos-124 TotBili-2.9*
___ 11:18AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.5
___ 12:47PM BLOOD Type-ART Temp-36.5 ___ Tidal V-450
PEEP-14 pO2-98 pCO2-51* pH-7.44 calTCO2-36* Base XS-8
Intubat-INTUBATED
___ 02:22AM BLOOD Lactate-2.1*
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q6H:PRN fever/pain
2. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Calcium Gluconate sliding scale (Critical Care-Ionized
calcium) IV Sliding Scale
5. CefePIME 2 g IV Q8H
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL BID
7. Cisatracurium Besylate 0.06-0.30 mg/kg/hr IV DRIP INFUSION
Duration: 24 Hours
8. Docusate Sodium (Liquid) 100 mg PO BID
9. Epoprostenol 0.05 mcg/kg/min IH ASDIR
10. Vancomycin 1000 mg IV Q 12H
11. Tobramycin 580 mg IV Q24H
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
13. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
15. Senna 1 TAB PO BID:PRN Constipation
16. Fentanyl Citrate 100-500 mcg/hr IV DRIP TITRATE TO RASS -3
Allow bolus: Yes Bolus: 50 mcg MR X2 Q1H PRN
17. Furosemide ___ mg/hr IV DRIP INFUSION
18. Heparin IV per Weight-Based Dosing Guidelines
19. Magnesium Sulfate Replacement (Critical Care and Oncology)
IV Sliding Scale
20. Midazolam ___ mg/hr IV DRIP TITRATE TO RASS -2 Light
Sedation. Briefly awakens to voice (eye opening) < 10 seconds
Allow bolus: Yes Bolus: 1 mg MR X2 Q1H PRN
Patient must have adequate airway support prior to
administration of dose.
21. Potassium Chloride Replacement (Critical Care and Oncology)
IV Sliding Scale
22. Oxymetazoline ___ SPRY NU EVERY OTHER DAY Duration: 6 Days
23. Pantoprazole 40 mg IV Q24H
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Massive pulmonary embolism
Acute systolic congestive heart failure
Cardiogenic shock
Hypoxemic respiratory failure
Ventilator-associated pneumonia
Acute kidney injury
Acute hepatic failure
Pulseless electrical activity cardiac arrest
Discharge Condition:
Intubated and sedated
Followup Instructions:
___
Radiology Report
HISTORY: Intubation.
FINDINGS: In comparison with the earlier study of this date, there has been
placement of an endotracheal tube with its tip just above the clavicle,
approximately 7 cm above the carina.
No change in the appearance of the heart and lungs.
Radiology Report
INDICATION: Dyspnea, hypotension, found to have PE on outside hospital CT.
This is a second read request of a CTA performed at ___ on
___ at 2:21 a.m.
TECHNIQUE: Multidetector CT acquisition of the chest was performed with 100
mL Optiray intravenous contrast in the arterial phase. Images are presented
for display in the axial plane at 3 mm and 1.5 mm collimation. Coronal
reformations were provided for review.
FINDINGS: Contrast bolus timing optimally opacifies the pulmonary arteries.
Multiple filling defects are seen throughout the segmental and smaller
pulmonary arteries of all lobes of both lungs. Enlargement of the right
atrium and right ventricle with leftward bowing of the intraventricular septum
is concerning for right heart strain. Per review of the ___
medical record, these findings are concordant with the echo performed
___. There is no pulmonary infarction and no evidence of occult
malignancy in the chest. No pleural or pericardial effusion. Mild mediastinal
edema is nonspecific.
Mild heterogeneity in the lungs may reflect areas of air trapping. Airways
are patent to the subsegmental levels bilaterally. The thoracic aorta is
normal in caliber, measuring 3.1cm at the ascending portion. The main
pulmonary artery is enlarged to 3.8 cm suggesting pulmonary hypertension. No
pathologically enlarged axillary, mediastinal, or hilar lymph nodes are
identified. No nodules are seen in the thyroid gland.
No bone finding suspicious for infection or malignancy is seen.
This study is not tailored for subdiaphragmatic evaluation. Gallbladder wall
edema is nonspecific.
IMPRESSION:
1. Bilateral pulmonary emboli in the segmental and smaller pulmonary arteries
with evidence of right heart strain and pulmonary hypertension. No pulmonary
infarct and no occult malignancy in the chest.
2. Gallbladder wall edema is nonspecific. Recommend clinical correlation.
Radiology Report
HISTORY: Known pulmonary embolism, assess for DVT.
COMPARISON: None available.
FINDINGS:
The right and left common femoral and proximal superficial femoral veins were
not accessible for imaging. There is normal compression of the left mid
superficial femoral vein. There is a nearly occlusive thrombus seen in the
left distal superficial femoral vein and popliteal vein. Only one posterior
tibial vein on the left is seen, the other posterior tibial and paired
peroneal veins of the left leg are not well seen.
There is normal compression in the right mid and distal superficial femoral
and popliteal veins. There is normal flow in the right posterior tibial and
peroneal veins.
IMPRESSION:
Nearly occlusive deep vein thrombus extending from the left distal superficial
femoral vein to the popliteal vein. Only one posterior tibial vein on the
left is seen, the other posterior tibial vein and the peroneal veins are not
well seen and may be occluded as well. The right and left common femoral and
proximal superficial femoral veins were not accessible for imaging.
Radiology Report
HISTORY: Massive PE status post right TandemHeart. Confirm placement of
tubes.
CHEST, SINGLE AP SUPINE PORTABLE VIEW.
An ET tube is present -- the tip lies approximately 2.6 cm above the carina.
An additional tube loops over the upper mediastinum and may represent a coiled
NG tube. Additional thin leads overlying the right upper chest extend
cephalad beyond the edge of the film and may lie outside the patient.
The cardiomediastinal silhouette is unchanged, with a prominent right heart
border and stable prominence of the mediastinal silhouette. Two large
catheters are present, one corresponds to a right IJ approach and loops over
the cardiac silhouette. Another extends from the inferior edge of the film
and overlies the right heart.
Allowing for low lung volumes, doubt overt CHF. Probable minimal atelectasis
in the left mid zone and at both bases. No effusion identified.
IMPRESSION:
1) ETT tip ~ 2.6 cm above carina.
2) Linear density coiled in esophagus -- please see report of film obtained
later the same day. After discussion with the house officer, this is
currently thought to represent a temperature probe.
3) Cardiomediastinal silhouette unchanged.
Radiology Report
HISTORY: Massive PE, right TandemHeart, worsening oxygenation, edema.
CHEST, TWO VIEWS.
Compared with ___ at 1820, there is new patchy opacity in both lungs,
scattered throughout the lung on the right and centered about the left hilum
on the left. The ET tube is in satisfactory position, approximately 3.4 cm
above the carina. Tubes over the right heart from both superior and inferior
approach are unchanged. Tubes coiled over the superior mediastinum noted. No
pneumothorax detected. No effusion.
IMPRESSION:
1) Developing bibasilar patchy opacities, ? edema or other alveolar process,
such as ARDS, infection, or possibly hemorrhage. Clinical correlation
requested.
2) Tubing coiled over superior mediastinum.
Findings discussed with the covering house officer, Dr. ___, at the
time of discovery at approximately 12:55 p.m. on the day of the exam ___,
phone). Based on that, the tubing coiled in the upper mediastinum is thought
to represent a temperature probe, rather than an NG tube.
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: ___ man with pulmonary embolism.
FINDINGS: Comparison is made to prior radiograph from ___.
There is an endotracheal tube whose distal tip is 4 cm above the carina,
appropriately sited. There is a coiled tubular device projecting over the
left superior mediastinum which is unchanged. Previously seen large caliber
catheter projecting over the right heart and into the main pulmonary outflow
tract has been pulled back several centimeters with the distal lead tip in the
proximal right atrium. Please correlate clinically. The patchy opacities
throughout both lung fields described previously have improved somewhat, now
less apparent. There remains a small right-sided pleural effusion. The
endotracheal tip and side port are within the stomach.
Radiology Report
REASON FOR EXAMINATION: Cardiogenic shock, on ECMO, assessment of ET tube
placement.
AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is approximately 5.3 cm above the carina. There is suspicion
for coiled NG tube in the oropharynx/proximal esophagus with the distal tip
being at the stomach. The ECMO tube terminates at the proximal right atrium.
The patient continues to be in pulmonary edema with bilateral pleural
effusions.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Right ventricular failure, patient on ecmo, evaluation for
interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the coiling of one of the
two esophageal devices is present in unchanged manner. The other monitoring
and support devices are also unchanged. Moderate cardiomegaly that is
unchanged, likely associated to small pleural effusions, right more than left.
Mild pulmonary edema. Atelectasis at the lung bases, but no evidence of new
parenchymal opacities.
Radiology Report
INDICATION: Pulmonary embolism, right ventricular failure, status post new
left internal jugular venous catheter.
COMPARISON: Comparison is made to chest radiograph performed the same day.
FINDINGS: Endotracheal tube stable in position. Enteric catheter courses
below the left hemidiaphragm and out of view. An incompletely visualized
coiled tubular structure in the upper esophagus, better depicted on the ___ radiograph and appears to correspond with a coiled temperature probe.
Findings were discussed with Dr. ___ at that time by Dr. ___.
New left-sided central venous catheter terminates in the mid-to-distal SVC.
There is a stable mild-to-moderate pulmonary edema with bilateral, right
greater than left pleural effusions. Cardiomediastinal and hilar contours are
unchanged.
IMPRESSION:
1. Temperature probe coiled within the upper esophagus.
2. Central venous catheter in mid SVC. No pneumothorax.
3. Stable pulmonary edema and bilateral pleural effusions, small on left and
moderate on right.
Radiology Report
HISTORY: Massive PE on ECMO. Interval change.
TECHNIQUE: Single portable AP radiograph of the chest.
COMPARISON: Multiple prior radiographs of the chest most recent ___.
FINDINGS:
The lung apices are not included on this study. A large diameter right-sided
central catheter terminates in the right atrium. A left-sided central
catheter terminates in the mid SVC. An NG tube has its side port terminating
in stomach however the tip travels inferiorly terminating out of few.
Low lung volumes are unchanged. There is bilateral mild to moderate pulmonary
edema. Cardiomediastinal contours are unchanged. The small left pleural
effusion is improved. The right hemidiaphragm is obscured suggesting layering
pleural effusion, atelectasis, or pulmonary infarct. There are no new focal
opacities. Incompletely visualized coiled tubular structure in the upper
esophagus is redemonstrated, and was previously described to be a temperature
probe.
IMPRESSION:
1. Moderate pulmonary edema is unchanged.
2. Small left pleural effusion is improved.
3. Right lower lung opacity may represent pleural effusion, atelectasis, or
pulmonary infarct.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Massive PE, ecmo, evaluation.
COMPARISON: ___, 804.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of a coil temperature device. The appearance of the lung parenchyma is
constant as compared to the previous image. Hyperlucent left lung base but
without direct indication for a pneumothorax. Unchanged appearance of the
perihilar lung parenchyma and of the heart. No pleural effusions.
Radiology Report
INDICATION: Massive pulmonary embolism, now on ECMO.
COMPARISON: CXR ___ through ___ CTA ___
FINDINGS: A frontal supine view of the chest was obtained portably. The
endotracheal tube ends 4.6 cm above the carina. The upper enteric tube
courses below the diaphragm with the tip out of view. A coiled structure in
the upper esophagus has been previously described on multiple prior studies as
a coiled temperature probe. The left internal jugular catheter ends in the
upper SVC. A large bore right internal jugular ECMO catheter ends in the
right atrium. Bilateral parenchymal opacities have increased compared to
___, due to worsening edema, now moderate-severe. Cardiac and
mediastinal silhouettes are stable with right heart enlargement.
IMPRESSION:
1. Temperature probe remains coiled in the upper esophagus.
2. Worsening moderate-severe pulmonary edema.
Radiology Report
INDICATION: Massive pulmonary embolism, on ECMO. Assess for interval change.
COMPARISON: Comparison is made to multiple prior chest radiographs, most
recently dated ___.
FINDINGS: There has been interval removal of the temperature probe. The
endotracheal tube terminates 5.5 cm above the carina. The enteric catheter
courses below the left hemidiaphragm and out of view. The right internal
jugular ECMO catheter terminates in the right atrium.
There is increased opacification of the left upper lobe with air bronchograms
and without evidence of associated volume loss. Finding may represent
asymmetric pulmonary edema; however, there is a concern for developing
infectious process. There is a stable right lower lobe opacification, which
likely reflects atelectasis and small pleural effusion . Possibly trace
effusion on the left.
IMPRESSION: Significantly increased left upper lobe opacification without
evidence of volume loss, concerning for underlying lobar pneumonia. Improved
background pulmonary edema. Stable right lower lobe opacification likely
reflecting atelectasis and small pleural effusion.
___ discussed findings with Dr ___ on ___ via telephone
at time of discovery.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Indwelling support and monitoring devices are unchanged in
position. Marked interval improved aeration in the right lower lobe compared
to the prior study, but continued diffuse airspace opacification throughout
the majority of the left lung with relative sparing of the left lung base.
These findings may be due to asymmetrical pulmonary edema with or without
co-existing infection. Cardiomediastinal contours are stable in appearance
with persistent right-sided cardiac enlargement.
Radiology Report
INDICATION: Massive pulmonary embolism, on ECMO. Evaluate for interval
change.
COMPARISON: Chest radiographs on ___, 26, and 28, ___.
FINDINGS: AP portable view of the chest. Right internal jugular ECMO
catheter terminating in the right atrium is unchanged in position. A left
internal jugular central venous line ends in the mid SVC. Endotracheal tube
ends 6.2 cm above the carina. There is continued increased opacification of
the left upper lobe with air bronchograms. The right upper lobe opacity has
worsened compared to yesterday. No pleural effusion. Heart size is stable.
No pneumothorax.
IMPRESSION: Increase in bilateral upper lobe consolidations, may represent
pneumonia or hemorrhage.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: INTUBATED PE
Diagnosed with PULM EMBOLISM/INFARCT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ y/o M with no ___ transferred from ___ to
___ ___ after massive PE with hemodynamic collapse.
# Massive PE w/ right heart failure and hemodynamic collapse:
Pt. presented with 2-month h/o worsening DOE acutely worsened 2
days prior to presentation and was found to have segmental and
subsegmental PEs in all lobes resulting in right heart failure
and hemodynamic collapse. This resulted in PEA arrest x3 w/
ROSC. He received a total of 100mg tpa. After ___ PEA arrest in
the MICU, he was transferred to the CCU for mechanical
hemodynamic support. He initially was placed on V-V right-sided
tandem heart to try to unload the right ventricle. The next day
he had a ___ PEA arrest and the decision was made to transition
him to A-V ECMO on ___. Lower-extremity ultrasounds showed
large clot burden in left deep veins, so IVC filter was placed.
He underwent post-arrest neuroprotective hypothermia x48 hours
and was rewarmed to 37C as of 7AM on ___. Weaning trial of ECMO
on ___ resulted in desaturation. He was maintained on ECMO flow
rate of 2.8L/min since then. Serial TTEs showing improved LVEF,
yet continued RV overload and hypokinesis. Milrinone was started
on ___. Inhaled prostacyclin (Flolan) initiated on ___, which
resulted in significant improvement in PaO2 and decreased PASP.
On ___, ECMO flow turned to max settings in the setting of
continued hypoxemia. Patient's hemodynamics improved
significantly even with minimal ECMO support. However, he
continued to have poor oxygen saturation, requiring FiO2
settings between 80-100%. Patient was transferred to ___ for
further management.
# Hypoxemic respiratory failure: Initially secondary to
extensive dead space in setting of massive PE burden. Gas
exchange had begun to improve and his FiO2 was being weaned.
Pulmonary mechanics remained excellent, so gas exchange was the
limiting factor in terms of respiratory barriers to extubation.
Morning of ___, patient became progressively hypoxic and had
PEEP increased to 10 with resultant worsening of hemodynamics.
CXR was consistent with pulmonary edema and patient received
40mg IV Lasix. Since then, ECMO was started as described above.
On ___, FiO2 was uptitrated to 100% for PaO2 in ___. Otherwise
his pulmonary mechanics remained excellent with no evidence of
ARDS or other acute pulmonary process. CXR showed pulmonary
edema. He was diuresed 2L negative with Lasix gtt on ___ with
improvement in oxygenation. On ___, inhaled prostacyclin
(Flolan) was started with resulting significant improvement in
oxygenation, allowing FiO2 to be weaned to 70% with PaO2 of 150.
On ___, patient developed increasing respiratory secretions,
exam was significant for ronchi in LUL, he became increasingly
hypoxic. CXR showed left upper lobe, lobar pneumonia. He was
started on vancomycin, cefepime, and tobramycin. Sputum culture
grew MSSA and pan-sensitive Enterobacter cloacae. In setting of
continued hypoxia, PEEP was increased to 14 and patient was
re-paralyzed on ___ to improve ventilator synchrony. He was
also positive 6 liters length of stay so was placed on lasix
drip as pulmonary edema was also thought to be contributing to
his respiratory failure.
#Metabolic alkalosis: in setting of contraction from diuresis.
This improved with stopping diuresis and aggressive
potassium/magnesium repletion.
# S/p PEA arrest x3: Caused by obstruction of RV outflow ___
massive PEs. Patient did not spontaneously regain consciousness
after ___ PEA arrest, so would benefit from neuroprotective
hypothermia protocol. Used goal temperature of 34C instead of
usual 33C as patient has many other reasons to be coagulopathic
and want to minimize bleeding risk in patient with ___ catheter
in femoral vein. Rewarmed to 37C as of 7AM on ___. Paralytics
were d/cd on ___ at 5:30PM. Versed stopped on ___ and patient
moving all 4 extremities and withdrawing to pain. Resedated with
versed ___ vent dyssynchrony. In setting of ongoing
dyssynchrony, patient was reparalyzed on ___. Continuous EEGs
showed no evidence of seizure activity.
# Coagulopathy: Patient has a variety of coagulopathies. These
include liver failure, tPa, heparin gtt, as well as hypothermia.
No evidence of DIC on labs or peripheral smear. He has had
some difficulty with hemostasis after ___ catheter in place, now
resolved. Also had epistaxis overnight. He was crossmatched
for 4 units. No evidence of DIC on smear. Has had several
episodes of epistaxis, most recently morning of ___. This was
treated with oxymetazoline and packing and hemostasis was
achieved. No evidence of bleeding around multiple access sites.
# Thrombocytopenia 4T score is 2 making HIT low probability.
Therefore, would not be appropriate to send HIT Ab given high
likelihood of false positive. Much more likely explanation is
mechanical platelet destruction from ECMO. Transfuse for goal
Plt greater than 100K. Patient required nearly daily platelet
transfusions to keep plt count greater than 100K.
# Anemia likely ___ hemolysis caused by ECMO. Will continue
monitoring and transfusion as described above.
# Acute hepatic failure - Likely ___ combination of congestive
hepatopathy and shock liver. This eventually resolved with
improvement in hemodynamics as described above.
# ___ - Likely ___ ATN in setting of hypotension during
___ periods. Patient became anuric for several hours,
but responded well to bolus of 160mg IV Lasix with 1L UOP
initially. Now autodiuresing with excellent UOP (4L/day).
Creatinine now back to baseline. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Aspirin
Attending: ___
Chief Complaint:
right facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old right handed woman who presented
to
the BI ED after she started having right facial numbness and
droop from the prior evening around 5 pm. She states that around
5 she noticed that her right face felt like it was tingling. She
was still able to move that side of the face and was having no
difficulty smiling. She went to bed and when she awoke she felt
the same feeling as if there was novocaine on that side. She
would touch it with her hand and could feel the warmth of her
face on her left hand, but her face did not sense the hand being
present. She looked in the mirror and noted that her right face
was drooping. She sipped on some water, but felt that there was
drooling from her right face. She was able to use her right hand
as well as walk. She did not notice any weakness of the leg or
arm. During examination in the ED (around 8:30 am) she said she
was now unable to lift her leg on the right despite having
walked
into the ED. She also noticed numbness on the right leg. She has
had no language deficits, with no difficulty speaking, reading,
writing or understanding what others are saying. Over the past
few days she has had no illnesses or infectious symptoms. She
was
able to go to sleep last night. She has had seizures in the past
mostly with visual hallucinations with secondary generalization.
She noticed no shaking of the affected limb.
She has SLE complicated by lupus nephritis, myopericarditis,
multiple embolic infarcts and seizure disorder. She has had
embolic strokes in the past in the right parietal, occipital,
and
temporal lobes and left cerebellum and vermis. She states that
she has no residual deficits secondary to these infarct. She
describes her seizures as presenting with a visual hallucination
in the right upper quadrant of a basket of bunnies that travels
horizontally across the field of vision to the left and then is
followed by LOC. She is confused and post-ictal following these
episodes. She has had EEG which showed an isolated sharp
transient in the left anterior to midtemporal region. Her last
seizure was in ___ after her Keppra was decreased to 500
BID. She has had no additional events since returning to 1000
BID.
She has been on coumadin in the past, but developed a
disseminated zoster infection and had an intrabdominal
hemmorrhage and had to be taken off. She subsequently developed
seizures and underwent a brain MRI, which showed bilateral
confluent periventricular white matter
hyperintensity consistent with a posterior reversible
leukoencephalopathy syndrome. This had occurred in the context
of some worsening renal functions and vomiting.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
SLE, lupus nephritis, myopericarditis, pleural effusion,
multiple
embolic infarcts, seizure disorder, and upper GI bleed.
Social History:
___
Family History:
Father - sarcoid
Mother - healthy
Physical Exam:
At admission:
Vitals: 98.6 60 115/75 20 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: absent pinprick sensation over the right face
VII: Right facial droop with diminished excursion.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Right sided pronator
drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 4 5 4+ 4+ 5 4+ 3 5 3 2 3 2
-Sensory: diminished pinprick on the right leg > arm.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor on the right.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
At discharge:
Neuro: Exam is intact and normal with the exception of
hyperrelexia bilaterally in upper and lower extremities,
slightly more so on right compared to left. (both sides have
adductors and pectorialis reflexes. right side has 3 beats of
clonus at patellar and ankle.)
Pertinent Results:
___:45AM BLOOD WBC-3.7* RBC-4.29 Hgb-13.4 Hct-39.5
MCV-92 MCH-31.3 MCHC-33.9 RDW-13.0 Plt ___
___ 04:35AM BLOOD WBC-5.9# RBC-3.91* Hgb-12.6 Hct-36.1
MCV-92 MCH-32.2* MCHC-34.9 RDW-13.3 Plt ___
___ 07:45AM BLOOD Neuts-53.0 ___ Monos-10.7 Eos-1.9
Baso-0.8
___ 07:45AM BLOOD ___ PTT-28.2 ___
___ 04:35AM BLOOD ESR-2
___ 04:35AM BLOOD Glucose-100 UreaN-12 Creat-0.9 Na-139
K-4.1 Cl-110* HCO3-19* AnGap-14
___ 01:37AM BLOOD CK(CPK)-33
___ 01:37AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:35AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.6
___ 04:35AM BLOOD C3-PND C4-PND
___ 08:55AM URINE Color-Straw Appear-Clear Sp ___
___ 08:55AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:55AM URINE RBC-4* WBC-6* Bacteri-NONE Yeast-NONE
Epi-<1
___ 08:55AM URINE UCG-NEGATIVE
Urine cultures x2 and blood cultures x2 are pending. NGTD
NCHCT:
IMPRESSION: No evidence of acute process. Patchy calcifications
in each
parotid suggesting a chronic or prior inflammatory process.
CTA Head and Neck:
IMPRESSION:
1. No evidence of ischemia.
2. Normal vasculature without evidence of thrombosis or
dissection.
MRI brain with and without contrast:
IMPRESSION:
1. No evidence of acute infarct, intracranial hemorrhage or
space-occupying lesion.
2. No abnormal leptomeningeal or parenchymal enhancement.
CXR 1 view:
IMPRESSION: No evidence of acute cardiopulmonary abnormalities.
Medications on Admission:
Imuran 100 mg daily
Plaquenil 400 mg daily
Keppra 1000 mg BID
Pantoprazole 40 mg BID
Trazadone PRN
Discharge Medications:
1. azathioprine 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO once
a day.
3. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Transient ischemic attack
lupus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: Exam is intact and normal with the exception of
hyperrelexia bilaterally in upper and lower extremities,
slightly more so on right compared to left. (both sides have
adductors and pectorialis reflexes. right side has 3 beats of
clonus at patellar and ankle.)
Followup Instructions:
___
Radiology Report
HEAD CT
HISTORY: Prior stroke in the setting of lupus, presenting with paresthesias
and facial droop.
COMPARISONS: MR study from ___ and earlier head CT from ___.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no evidence for intra- or extra-axial hemorrhage. There
is no mass effect, hydrocephalus or shift of the normally midline structures.
The ventricles, cisterns and sulci are unremarkable without effacement. The
brain parenchyma is unremarkable. Small calcifications within each partly
visualized parotid gland suggest a chronic or post-inflammatory process. The
visualized paranasal sinuses and mastoid air cells appear clear.
IMPRESSION: No evidence of acute process. Patchy calcifications in each
parotid suggesting a chronic or prior inflammatory process.
Radiology Report
INDICATION: New right-sided facial droop, right pronator drift, and a history
of lupus.
COMPARISONS: CT head ___ at 7:55 a.m. MRI head ___.
MRI/MRA head ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without contrast material. Subsequently, rapid axial imaging was performed
from the aortic arch through the brain during the infusion of Omnipaque
intravenous contrast material. Images were then processed on a separate
workstation with display of curved reformats, 3D volume-rendered images, and
maximum intensity projection images.
FINDINGS:
HEAD CT: There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. The ventricles and sulci are normal in size and configuration.
The basal cisterns are patent. No fractures are identified. A small
retention cyst is present in the left maxillary sinus. The remaining
paranasal sinuses are clear. The soft tissues are unremarkable.
HEAD CTA: The carotid and vertebral arteries and their major branches are
patent without evidence of thrombosis, occlusion, dissection, or stenosis.
There is no evidence of aneurysm formation or other vascular abnormality. The
diameter of the right proximal internal carotid artery is 6.5 mm; the diameter
of the right distal internal carotid artery is 3.9 mm. The diameter of the
left proximal internal carotid artery is 6.9 mm; the diameter of the left
distal internal carotid artery is 4.2 mm. The major veins are patent without
evidence of venous thrombosis.
The apices of the lungs are clear. The thyroid is unremarkable. There is no
lymphadenopathy. The cervical spine is unremarkable without significant
degenerative disease.
IMPRESSION:
1. No evidence of ischemia.
2. Normal vasculature without evidence of thrombosis or dissection.
Radiology Report
STUDY: MRI head without and with contrast.
CLINICAL HISTORY: ___ woman with lupus/ stroke/ PRES.
COMPARISON STUDY: Multiple prior MRI head, the most recent dated ___ and
CTA head dated ___.
TECHNIQUE: Sagittal T1, axial T1, T2, FLAIR, gradient echo and
diffusion-weighted images were obtained of the brain prior to administration
of contrast. Axial T1 and sagittal MP-RAGE images were obtained after
administration of contrast with coronal and axial reconstructions.
FINDINGS:
The brain parenchyma appears normal. There is no evidence of acute infarct,
intracranial hemorrhage or space-occupying lesion. The ventricles, extra-axial
CSF spaces and cortical sulci appear normal. There is no abnormal
leptomeningeal or parenchymal enhancement. Brainstem and cerebellum appear
normal.
There is minimal FLAIR hyperintensity in the right posterior parietal lobe and
right occipital lobe which likely represents sequela of prior PRES.
The normal major intracranial flow voids are patent. Tiny polyp/ retention
cyst is noted in the left maxiilary sinus. Rest of the visualized paranasal
sinuses and mastoid air cells are clear. The orbits and osseous structures are
unremarkable.
IMPRESSION:
1. No evidence of acute infarct, intracranial hemorrhage or space-occupying
lesion.
2. No abnormal leptomeningeal or parenchymal enhancement.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: SLE, prior stroke, febrile.
Cardiomediastinal contours are normal. The lungs are clear. There is no
pneumothorax or pleural effusion.
IMPRESSION: No evidence of acute cardiopulmonary abnormalities.
Radiology Report
Study: Carotid Series Complete
Reason: ___ year old woman with lupus p/w fevers and new murmur and carotid
bruits
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is no plaque seen in the ICA . On the left there is no plaque
seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 101/20, 96/34, 91/26, cm/sec. CCA peak systolic
velocity is 135 cm/sec. ECA peak systolic velocity is 110 cm/sec. The
ICA/CCA ratio is .74 . These findings are consistent with no stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 108/22, 98/35, 98/32, cm/sec. CCA peak systolic
velocity is 166 cm/sec. ECA peak systolic velocity is 177 cm/sec. The ICA/CCA
ratio is .65 . These findings are consistent with no stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression: Right ICA no stenosis.
Left ICA no stenosis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R FACIAL NUMBNESS
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, FACIAL WEAKNESS, SKIN SENSATION DISTURB, MUSCSKEL SYMPT LIMB NEC, SYST LUPUS ERYTHEMATOSUS
temperature: 98.6
heartrate: 60.0
resprate: 20.0
o2sat: 97.0
sbp: 115.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | ___ year-old right handed woman with a history of SLE, multiple
embolic infarcts, seizure d/o and GI hemorrhage who presents
this morning after symptoms of right facial numbness and then
right sided weakness. Initially her neurological exam was
concerning for right facial droop and hemiparesis. Brain imaging
showed no acute infarcts. All her blood work was within normal
limits. By the next morning the patient felt back to her
baseline and her neurological exam was normal with the exception
of hyperreflexia throughout, worse on the right. The suspected
etiology of her transient weakness and numbness is a TIA,
transient ischemic attack. She will be started on clopidogrel
75mg po daily to help decrease her risk of strokes in the
future. The patient was discharged home with follow with Dr.
___ in neurology clinic.
Of note, the patient was febrile overnight to 101. However she
remained asymptomatic with no leukocytosis and a normal ESR. It
is assumed this fever is related to her lupus as she
occasionally has these at home. Blood and urine cultures sent
are NGTD. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa
Attending: ___.
Chief Complaint:
siezures
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo M with HIV/AIDS and Burkitt's lymphoma refractory to
multiple lines of chemotherapy, including three cycles of
DA-EPOCH, M-R IVAC/R-CODOX, ESHAP, and most recently R-GDP
starting ___ who presented to the ED following siezures at home
found to have acute on chronic SDH and diabetic ketoacidosis.
Patient recently admitted to ___ service with headache after
being found to have new acute on chronic left hemispheric
subdural
hematoma measuring 3 mm in greatest thickness. After extensive
discussion, patient was transitioned to DNR/DNI and hospice care
was established.
Approximately 2 to 3 AM this AM, patient suffered 4 spontaneous
episodes of several minutes of tonic-clonic seizure activity.
EMS was called and patient was transferred to the ED, his last
siezure resolving en route. On arrival to the ED, patient vitals
were: 97.7 146 142/82 18 98% RA. Found to be in diabetic
acidosis, started on insulin drip. Head CT revealed acute on
chronic subdural hemmorage. Neurosurgey intially consulted but
deferred given goals of care defined no neurosurgical
intervention desired. Patient admitted to ICU for treatment of
DKA and advanced goals of care dicussion.
On arrival to ICU, patient unresponsive and tachypneic. Health
care proxy expressing that patient strongest wish "not to die in
hospital." Hospice worker seen on exiting ED, mentioned he may
be able to be cared for in hospice house. HCP wishes to have
patient transferred, understands risk of dying en route.
Past Medical History:
PAST MEDICAL HISTORY:
-HIV most recent VL less than 20 copies/mL (___) and CD4
count 500 on ___. Started on HAART Truvada/Raltegravir)
___ with peak VL ~40,000
-Recurrent polymicrobial sinus infection s/p molar extraction
c/b maxillary sinus perforation in ___
-Chronic intermittent sinus tachycardia, no h/o abnl EKG/TTE
-DM
-Dyslipidemia
-GERD
-OSA
PAST ONCOLOGIC HISTORY:
___: Presented to OSH with severe back and cp with CTA
Chest/Abdomen not revealing PE/aortic dissection but with
minimal LAD; transferred to ___ for leukocytosis
-___: BM Bx: BONE MARROW EXTENSIVELY INFILTRATED BY ___
LYMPHOMA, 90% involvement. Concurrent flow cytometry of
peripheral blood sample documented the presence of
CD20 bright cells the co-expression of CD10 and CD19, and bright
surfame membrane immunoglobulin light chain.
-___: CT Pelvis: No LAD
-___: BONE MARROW BIOPSY-extensive involvement by Burk___'s
lymphoma
-___: Made DNR/DNI, transitioned to hospice care with
primary oncology team
Social History:
___
Family History:
No history of hematologic or oncologic conditions.
Physical Exam:
GENERAL: Middle aged male, unresponsive and tachypneic
HEENT: Sclera anicteric, R pupil fixed and dilated, L pupil
sluggish response
NECK:
LUNGS: CTAB without wheezing or rhonchi
CV: tachycardic, regular rhythm, nl s1 and s2 no MRG
ABD: soft, nt, nd
EXT: No cyanosis or peripheral edema noted
Pertinent Results:
SEROLOGY:
___ 05:10AM BLOOD WBC-11.4*# RBC-3.03* Hgb-9.0* Hct-26.0*#
MCV-86 MCH-29.7 MCHC-34.6 RDW-16.4* RDWSD-50.4* Plt Ct-7*#
___ 05:10AM BLOOD Neuts-22* Bands-1 ___ Monos-8
Eos-9* Baso-0 ___ Metas-5* Myelos-1* Promyel-2* NRBC-13*
Other-9* AbsNeut-2.62 AbsLymp-4.90* AbsMono-0.91* AbsEos-1.03*
AbsBaso-0.00*
___ 05:10AM BLOOD Plt Smr-RARE Plt Ct-7*#
___ 05:10AM BLOOD ___ PTT-37.5* ___
___ 10:20AM BLOOD Glucose-629* UreaN-58* Creat-1.4* Na-140
K-5.9* Cl-105 HCO3-18* AnGap-23*
___ 05:10AM BLOOD Calcium-10.4* Phos-6.7*# Mg-2.4
___ 10:31AM BLOOD ___ pH-7.34*
___ 07:49AM BLOOD ___ pH-7.32*
___ 05:16AM BLOOD Type-ART pO2-131* pCO2-20* pH-7.31*
calTCO2-11* Base XS--13
___ 10:31AM BLOOD Glucose-GREATER TH Na-137 K-5.7* Cl-103
calHCO3-16*
___ 07:49AM BLOOD Glucose-GREATER TH Lactate-12.2* Na-136
K-6.7* Cl-97 calHCO3-16*
___ 10:31AM BLOOD O2 Sat-54
MICRO:
___ 06:25AM URINE Color-Straw Appear-Clear Sp ___
___ 06:25AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:25AM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 06:25AM URINE Mucous-RARE
IMAGING:
___. Bilateral subdural hematoma are increased compared to
___.
Thickness of subdural hematoma is increased to 8 mm from 3 mm
before. Mixed
density in of the left subdural hematoma suggests acute on
chronic component.
No significant mass effect is identified except local sulcal
effacement and
possible minimal effacement of frontal horns of lateral
ventricles.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. Lorazepam ___ mg PO Q4H:PRN Anxiety/nausea
3. OLANZapine 5 mg PO QHS
4. Raltegravir 400 mg PO BID
5. Dexamethasone 4 mg PO Q12H
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Diazepam Intensol (diazepam) 5 mg/mL oral Q3H:PRN seizures
8. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
9. Lorazepam ___ mg SL Q4H:PRN seizures
10. Glargine 8 Units Breakfast
Discharge Medications:
1. Lorazepam 0.5-4 mg IV Q2H:PRN siezure like activity, anxiety,
agitation
2. HYDROmorphone (Dilaudid) 0.25-3 mg IV Q1H:PRN pain,
agitation, dsypnea
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY: ___'s Lymphoma, Diabetic Ketoacidosis
Secondary: AIDS/HIV
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with recent acute on chron sdh now w eizure pls eval
for new acute bleed // History: ___ with recent acute on chron sdh now w
eizure pls eval for new acute bleed
TECHNIQUE: Contiguous axial images of the brain were obtained after the
uneventful administration of Omnipaque intravenous contrast. Thin
bone-algorithm reconstructed images and coronal and sagittal reformatted
images were then produced.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head without contrast ___
FINDINGS:
Acute on chronic subdural hematomas along the bilateral cerebral convexities
have increased since ___, measuring up to 8 mm on the right, and
10 mm on the left (5mm previously). Acute on chronic parafalcine subdural
hematoma has also increased in, measuring up to 10 mm axially. There is mild
mass effect on both cerebral hemispheres, with 4 mm leftward midline shift,
but no impending herniation. The gray-white matter differentiation remains
preserved.
Moderate, chronic thickening of the right maxillary sinus with evidence of
prior sinus surgery. Few left mastoid air cells are opacified.
IMPRESSION:
Bilateral acute on chronic subdural hematomas have increased slightly since ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure, R Weakness, Slurred speech
Diagnosed with NIDDM UNCONTROLLED W/KETOACID, LONG-TERM (CURRENT) USE OF INSULIN, OTHER CONVULSIONS, SUBDURAL HEMORRHAGE
temperature: 97.7
heartrate: 146.0
resprate: 18.0
o2sat: 98.0
sbp: 142.0
dbp: 82.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ yo man with Burkitt's Lymphoma (diagnosed
___ s/p multiple rounds of maximized chemotherapy, HIV (on
HAART), and DMII on home hospice presenting after siezure
activity at home found to have acute on chronic subdural
hemmorage and diabetic ___ transferred to ICU for
further management of diabetic ketoacidosis and GOC discussion.
On arrival to ICU, further discussion of goals lead to decision
to transfer to hospice home. Patient provided comfort care with
ativan and dilaudid, which will be continued at hospice home.
#Goals of care:
Upon further discussion of clinical status and patient's desired
goals of care, health care proxy wishes to transfer patient to
hospice house for further care. While ideal would have patient's
mother present, cites patient's strongest desire would be to
"die outside the hospital" and understands patient may pass
prior to this time. Understands tenous clinical status and
understands risk that patient may pass en route to hospice
house. Hospice workers consulted in ICU, arranged plan for
immediate transport to hospice house. Outpatient prescriptions
provided for pain control, dyspnea control with hyrdomorpphone,
anxiety and siezure control with ativan as needed. Health care
proxy and friend voice understanding of plan, shift focus of
care exclusively to comfort.
-Transfer to hospice home as soon as possible
-hydromorphone 0.5-3 mg IV q1h PRN pain, dyspnea, agitation
-ativan 0.5-4 mg IV q2h PRN siezure like activity, anxiety
#Diabetic ketoacidosis: HHS vs DKA with gap acidosis of unclear
origin. No evidence of abd pain or AMS at this time. Transferred
for insulin management and monitoring while on gtt. Discontinue
active treatment in setting of above goals of care discussion.
#Burkitt's Lymphoma. Diagnosed in ___ with CNS and extensive
BM involvement, resistant to multiple chemotherapy regimens. On
home hospice.
#SDH:
No neurosurgical intervention desired. On dexamethasone at home,
given additional dose in ED. No seizure acitivty after EMS
transferred. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ yo right handed male, previously healthy
who presents with his second episode of acute onset of vertigo,
ataxia, and vomiting. Patient reports that after lunch he was
leaving work and felt "woozy". He then had relatively acute
onset vertigo. He felt that the world was spinning and it
persisted all positions and was also present when his eyes were
closed. He reports that this has made him very nauseous and has
vomited several times. He denies headache, vision changes,
dysarthria, dysphagia, change in hearing. He got home and
vomited several times, despite lying down and trying to rest.
While walking to the car to come to the ED his daughters were on
each side of him and he was very wide based and staggering back
and forth. His sxs persisted for about 3 hours. They have
subsided significantly since arriving in the ED.
He has had one previous similar episode about a month ago. Again
while he was walking home from work. He rested at home and the
sxs eventually subsided.
Review of Systems: On neuro ROS, lightheadedness, vertigo,
dizziness as above. Denies ataxia, HA, loss of vision, diplopia,
dysarthria, dysphagia, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel incontinence. Gait
problems with ataxia as above.
On general review of systems, He denies any URI sxs, rhinorrhea.
He denies recent fever or chills. No night sweats or recent
weight loss or gain. Denies shortness of breath, palpitations,
chest pain. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias.
Past Medical History:
none
Social History:
___
Family History:
No strokes, seizures or migraines.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.8, HR 68, BP 139/72, RR 18, O2 98% RA
General: Awake, cooperative, in NAD.
HEENT: NC/AT, no sclera icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted.
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to hospital, person, and date.
Attentive. Language appears fluent in ___. Speech is normal
and verrified with family. Following commands appropriately. No
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3 mm and brisk. VFF to confrontation. Fundoscopic
exam reveals sharp disc margins, but difficult due to nystag.
III, IV, VI: EOMI with left beating nystagmus in all directions
of gaze, including primary. No diplopia.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Negative Head thrust test.
-Motor: Normal bulk, tone throughout. No pronator drift. No
tremor or other adventitious movements. No asterixis noted. Nml
finger tapping.
Delt Bic Tri FFl FE IO IP Quad Ham TA ___
L 5 5 ___ 5 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5 5
-Sensory: Intact and symmetric sensation to light touch and
sharp.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor b/l.
-Coordination: No dysmetria on FNF or heel to shin.
-Gait: Mildly wide based, no obvious ataxia. Falls to either
side on tandem gait. No Rhomberg.
Physical Exam on Discharge:
unchanged from above
Pertinent Results:
Labs:
___ 06:25PM WBC-19.7* RBC-4.58* HGB-14.6 HCT-42.2 MCV-92
MCH-31.9 MCHC-34.7 RDW-13.0
___ 06:25PM NEUTS-84.5* LYMPHS-10.1* MONOS-3.0 EOS-2.1
BASOS-0.2
___ 06:25PM GLUCOSE-151* UREA N-19 CREAT-1.0 SODIUM-139
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17
___ 05:30AM BLOOD %HbA1c-5.8 eAG-120
___ 05:30AM BLOOD Triglyc-48 HDL-60 CHOL/HD-2.5 LDLcalc-80
Imaging:
Non contrast head CT
FINDINGS: There is no CT evidence for acute intracranial
hemorrhage, mass effect, edema, or hydrocephalus. There is
preservation of gray-white matter differentiation. The basal
cisterns appear patent. The ventricles and sulci are normal in
caliber and configuration. Mucosal thickening is seen in the
ethmoid air cells. The remainder of the visualized portions of
the paranasal sinuses and mastoid air cells appear well aerated.
Few arterial calcifications are seen. No acute bony
abnormality is detected.
IMPRESSION: No acute intracranial process.
Chest xray ___. Slight blurring in the medial portion of the left
hemidiaphragm and
Preliminary Reportadjacent vague opacity may represent
atelectasis or pneumonia.
2. Nodular opacity in the left lower lobe laterally. Recommend
oblique views for better assessment.
Chest xray ___
With the exception of the nodular opacity in the left lower
lung, the
lungs are clear without evidence of airspace consolidation,
pleural effusions, or pneumothorax. No pulmonary edema.
Overall cardiac contours are stable. In the absence of more
remote chest films to document stability of the opacity in the
left lower lobe, further imaging evaluation with a dedicated CT
scan should be considered.
Radiology Report
INDICATION: ___ male with acute dizziness.
COMPARISON: None available.
TECHNIQUE: Axial CT images through the head were acquired without intravenous
contrast. Coronal, sagittal, and thin slice bone reconstructed images were
created and reviewed.
FINDINGS: There is no CT evidence for acute intracranial hemorrhage, mass
effect, edema, or hydrocephalus. There is preservation of gray-white matter
differentiation. The basal cisterns appear patent. The ventricles and sulci
are normal in caliber and configuration. Mucosal thickening is seen in the
ethmoid air cells. The remainder of the visualized portions of the paranasal
sinuses and mastoid air cells appear well aerated. Few arterial
calcifications are seen. No acute bony abnormality is detected.
IMPRESSION: No acute intracranial process.
Radiology Report
INDICATION: Vertigo, question of pneumonia.
COMPARISON: None available.
FINDINGS: PA and lateral views of the chest. There is a small nodular
opacity projecting over the left lower lobe. There is slight blurring of the
medial portion of the left hemidiaphragm and adjacent vague opacity that may
represent pneumonia or atelectasis. Otherwise, the lungs are clear. No
pleural effusion or pneumothorax. The cardiomediastinal contours are normal.
IMPRESSION:
1. Slight blurring in the medial portion of the left hemidiaphragm and
adjacent vague opacity may represent atelectasis or pneumonia.
2. Nodular opacity projecting over the left lower lobe laterally. Recommend
oblique views or chest CT for better assessment.
These findings were discussed with Dr. ___ at 12:15am on ___ by
telephone.
Radiology Report
PA AND LATERAL CHEST FROM ___ AT 9:22
CLINICAL INDICATION: ___ with ataxia and vertigo and increasing white
count, left lung nodule, question pneumonia.
Comparison is made to the patient's previous studies dated ___ at
21:42.
PA and lateral views of the chest ___ at 9:22 are submitted.
IMPRESSION:
1. With the exception of the nodular opacity in the left lower lung, the
lungs are clear without evidence of airspace consolidation, pleural effusions,
or pneumothorax. No pulmonary edema. Overall cardiac contours are stable.
In the absence of more remote chest films to document stability of the opacity
in the left lower lobe, further imaging evaluation with a dedicated CT scan
should be considered.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: N&V, DIZZY
Diagnosed with VERTIGO/DIZZINESS
temperature: 97.8
heartrate: 68.0
resprate: 18.0
o2sat: 98.0
sbp: 139.0
dbp: 72.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ yo right handed male, generally healthy
who presents with his second episode of acute onset vertigo,
ataxia, and vomiting that remains unclear whether it represents
a peripheral or central process.
# Neurologic: The patient's symptoms have essentially completely
resolved with only nystagmus and some unsteadiness on tandem
gait. This temporal profile is more consistent with a peripheral
etiology, however it is difficult to prove on exam alone.
Ataxia and vomiting were prominent in the patient's history and
may suggest a cerebellar TIA. Suspicion for stroke/TIA was quite
low. Risk factors checked: HbA1c 5.8, LDL 80. TTE deferred
given low suspicion for ischemic infarct. Attempted to obtain
MRI, but patient did not tolerate it. Most likely, symptoms
were due to a transient vestibular neuronitis. Will f/u with Dr.
___ in neurology clinic.
# Cardiovascular: Monitored on telemetry, no aberrant rhythms
observed.
# Pulm: Incidental left lower lobe pulmonary nodule observed.
Will need this followed by PCP (emailed regarding this issue) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Tetracycline
Attending: ___.
Chief Complaint:
right both bone fracture from pedestrian vs automobile.
Major Surgical or Invasive Procedure:
___: Open reduction internal fixation of right both bone
fracture.
History of Present Illness:
This patient is a ___ year old female who complains of R forearm
fracture. She was struck by an oncoming car while she was
crossing the street, reportedly by the mirror of the car. Did
fall backwards but denies head injury, neck injury and has no
complaints other than R forearm pain. Seen at ___,
radiographs demonstrated severely anglate and comminuted both
bone fractures.
Past Medical History:
htn, chol, niddm
Social History:
___
Family History:
non contributory
Physical Exam:
On Admission:
General Evaluation Exam
Sensorium: Awake (x) Awake impaired () Unconscious ()
Airway: Intubated () Not intubated ()
Breathing: Stable (x) Unstable ()
Circulation: Stable (x) Unstable ()
Musculoskeletal Exam
Neck Normal (x) Abnormal () Comments:
Spine Normal (x) Abnormal () Comments:
Clavicle
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Shoulder
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Arm
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Elbow
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Forearm
R Normal () Abnormal (x) Comments: grossly deformed and
swollen
L Normal (x) Abnormal () Comments:
Wrist
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Hand
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Pelvis
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Hip
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Thigh
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Knee
R Normal (x) Abnormal () Comments:
L Normal () Abnormal () Comments:
Leg
R Normal (x) Abnormal () Comments:
L Normal (xx) Abnormal () Comments:
Ankle
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Foot
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Urethral Bleeding Yes () No (x)
Vaginal Bleeding Yes () No (x)
Rectal Tone Normal (x) Abnormal ()
Bulbocavernosus Present () Absent ()
Reflexes
___
Patellar:
___
Clonus:
Vascular:
Radial R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Ulnar R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Femoral R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Poplitea R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
DP R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
___ R Palpable (x) Non-palpable () Doppler ()
L Palpable (xx) Non-palpable () Doppler ()
Neuro:
Deltoid R (x) L (x)
Biceps R (x) L (x)
Triceps R (x) L (x)
Wrist Flx R () L (x)
Wrist Ext R () L (x)
Finger Flx R (x) L (x)
Finger Ext R (x) L (x)
Thumb Ext R (x) L (x)
___ DIP R (x) L (x)
Index Abd R (x) L (x)
Thumd Add R (x) L (x)
Quad R (x) L (x)
Ant Tib R (x) L (xx)
___ R (x) L (x)
Peroneal R (x) L (x)
___ R (x) L (x)
On Discharge:
Gen: Patient is in no acute distress, she is alert and oriented,
RUE: She is in a soft dressing, clean dry and intact, SILT M U
R distributions, EPL FPL Intrinsics fire, 2+ radial pulses,
fingers are warm and well perfused.
Pertinent Results:
On Admission:
___ 10:05PM BLOOD WBC-15.2* RBC-4.06* Hgb-10.9* Hct-32.5*
MCV-80* MCH-26.7* MCHC-33.5 RDW-13.3 Plt ___
___ 10:05PM BLOOD Neuts-87.8* Lymphs-9.0* Monos-2.7 Eos-0.2
Baso-0.3
___ 10:05PM BLOOD ___ PTT-30.7 ___
___ 10:05PM BLOOD Glucose-269* UreaN-18 Creat-0.7 Na-137
K-4.0 Cl-102 HCO3-25 AnGap-14
On Discharge:
___ plain films of right forearm: Expected postop images
post ORIF of right distal radius and ulnar fractures.
___ 07:00AM BLOOD WBC-12.9* RBC-3.91* Hgb-10.3* Hct-32.2*
MCV-82 MCH-26.4* MCHC-32.1 RDW-13.6 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-138
K-3.4 Cl-99 HCO3-26 AnGap-16
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Magnesium Oxide 400 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Levothyroxine Sodium 150 mcg PO DAILY
4. GlipiZIDE 5 mg PO QAM
5. GlipiZIDE 10 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
hold for SBP < 110, HR < 60
8. Pravastatin 40 mg PO DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
hold for SBP < 110, HR < 60
Discharge Medications:
1. GlipiZIDE 5 mg PO QAM
2. GlipiZIDE 10 mg PO QHS
3. Hydrochlorothiazide 12.5 mg PO DAILY
hold for SBP < 110, HR < 60
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
hold for SBP < 110, HR < 60
6. Magnesium Oxide 400 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Pravastatin 40 mg PO DAILY
9. Acetaminophen 650 mg PO Q6H
10. Aspirin 325 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ capsule(s) by mouth Every 4 hours Disp
#*70 Capsule Refills:*0
13. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right both bone forearm fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Post-ORIF.
COMPARISON EXAM: Forearm radiographs, ___.
STUDY: 3 views right wrist.
There are three external plates with screws transfixing a right displaced mid
radius and ulnar fracture and a second minimally displaced distal ulnar
fracture. There is no sign of hardware loosening or failure. There is good
anatomic alignment. There is no new fracture or dislocation.
IMPRESSION: Expected postop images post ORIF of right distal radius and ulnar
fractures.
Radiology Report
STUDY: Right forearm intraoperative study, ___.
CLINICAL HISTORY: Patient with right forearm fracture. ORIF.
FINDINGS: Comparison is made to prior study from ___.
Multiple images of the right forearm from the operating room demonstrates
interval placement of large fracture plates fixating a compound fracture of
the ulna and of the mid shaft of the right radius. There is good anatomic
alignment. There are no signs for hardware-related complications. Please
refer to the operative note for additional details.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ARM VS CAR
Diagnosed with FX DISTAL RADIUS NEC-CL, MV COLL W PEDEST-PEDEST
temperature: 96.8
heartrate: 96.0
resprate: 18.0
o2sat: 97.0
sbp: 176.0
dbp: 81.0
level of pain: 3-4
level of acuity: 2.0 | The patient was admitted to the orthopaedic surgery service on
___ with a right both bone forearm fracture. Patient was
taken to the operating room and underwent ORIF. Patient
tolerated the procedure without difficulty and was transferred
to the PACU, then the floor in stable condition. Please see
operative report for full details.
Musculoskeletal: prior to operation, patient was non weight
bearing in the right upper extremity and was maintained in the
same post operatively. Throughout the hospitalization, patient
worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to **oxycodone
**with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was hemodynamically stable
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: Aspirin 325mg daily, and was encouraged to get up
and ambulate as early as possible.
At the time of discharge on ___, POD #2, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on Aspirin 325mg
for DVT prophylaxis for 4 weeks post-operatively. All questions
were answered prior to discharge and the patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of CAD, recent diagnosis of cystic abdominal mass,
who presents as a transfer from an outside hospital with
epigastric pain, nausea and vomiting. She developed abdominal
pain yesterday morning (the day of presentation to OSH), then it
became increasingly severe in the afternoon. Describes this as
___, non-radiating, and so severe she made herself vomit.
Describes it as "just there," and constant. She denies fevers,
chills, diarrhea, or change in her stools. The day before, she
had eaten a lot of cheese at an event, but denies any alcohol
use.
She presented initially to ___ where labs were
notable for a lipase of greater than ___. A chest x-ray
performed that showed no acute process. EKG was unremarkable.
She was given dilaudid 0.8mg then 0.5mg IV, ondansetron 4mg IV,
famotidine 20mg IVx1. She was sent here for further evaluation.
Initial VS in the ED: 3 99.6 92 128/63 16 98% RA.
Patient was given no further medications. RUQ u/s showed hepatic
steatosis, dilated pancreatic duct unchanged, and no evidence of
cholelithiasis or cholecystitis. VS prior to transfer: 3 98.7 95
119/46 16 100%.
On the floor, she continues to have mild pain, "there just a
little" but overall does not feel well. She also has a mild
headache. She says she is tired and frustrated from having to
tell her story so many times.
Past Medical History:
-Right breast cancer status-post lumpectomy
-Hyperlipidemia
-Coronary artery disease status-post NSTEMI ___ years ago without
intervention
-Abdominal mass, on MRCP showed a tubular cystic lesion in the
___ part of the duodenum with dilatation of the dorsal
pancreatic duct and pancreas divisum. CEA, ___ wnl. EUS
tubular discrete anechoic lesion, c/w cyst
Social History:
___
Family History:
No family history of GI or pancreatic malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.5 BP: 152/67 P: 93 R: 20 O2: 99%RA
General: pleasant female, appears mildly uncomfortable, alert,
lying in bed holding abdomen
HEENT: EOMI, NCAT, MMM
Neck: supple, no JVD
CV: RRR, nl S1 S2, no murmurs
Lungs: CTAB
Abdomen: +BS, soft, non-distended, TTP in epigastric region
without rebound or guarding, no RUQ pain, neg ___
Ext: warm, dry, no edema, 2+ DP pulses
Neuro: oriented x3, CN2-12 grossly intact, moving all
extremities, gait deferred
Skin: warm, dry, no rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2, 118/54, 100, 18 pain ___
General: NAD, pleasant
HEENT: sclera anicteric, MMM
Neck: supple
CV: RRR, nl S1 S2, no murmurs
Lungs: CTAB
Abdomen: +BS, soft, non-distended, TTP in epigastric and RUQ
region without rebound or guarding
Neuro:A+Ox3, CN2-12 grossly intact
Skin: warm, dry, no rashes
Pertinent Results:
ADMISSION LABS:
___ 06:15AM ___ PTT-24.4* ___
___ 06:15AM WBC-8.6 RBC-3.63* HGB-10.5* HCT-31.8* MCV-88
MCH-28.9 MCHC-33.0 RDW-13.8
___ 06:15AM TRIGLYCER-121
___ 06:15AM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-1.9
___ 06:15AM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-56 TOT
BILI-0.4
___ 06:15AM GLUCOSE-114* UREA N-11 CREAT-0.6 SODIUM-139
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-23 ANION GAP-13
IMAGING:
- RUQ U/S (___): IMPRESSION: 1 Diffusely echogenic liver is
compatible with hepatic steatosis although other chronic liver
conditions such as liver cirrhosis and fibrosis cannot be
excluded. 2. Dilated pancreatic duct unchanged from prior exams
and better assessed in recent MRCP. 3. No cholelithiasis or
cholecystitis.
- MRCP (___): IMPRESSION: 1. There is pancreas divisum
ductal morphology with dilatation of the pancreatic duct and a
small santorinicele present, unchanged from previously. The
cystic lesion within the duodenum has decreased in size,
possibly related to the recent aspiration. This lesion most
likely represents cystic dystrophy of the duodenum wall. There
has been interval development of marked thickening and
inflammation of the duodenum wall consistent with duodenitis.
2. Hepatic steatosis. 3. Unchanged 0.7 cm angiomyolipoma in the
lower pole of the right kidney.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. fenofibrate *NF* 160 mg Oral daily
4. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. fenofibrate *NF* 160 mg Oral daily
5. Simethicone 80 mg PO QID:PRN gas, bloating
RX *simethicone [Gas-X] 80 mg 1 tab by mouth four times a day
Disp #*30 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Abdominal pain, duodenitis
Secondary: hyperlipidemia, coronary artery disease, cystic mass
in the duodenum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ with pancreatitis and RUQ abd pain. Evaluate for acute GB
pathology or other intrabdominal process.
COMPARISON: CT abdomen and pelvis from ___ and MRCP from ___
TECHNIQUE: Grayscale and color Doppler images were obtained of the abdomen.
FINDINGS:
The liver is diffusely echogenic with no focal lesions. There is no
intrahepatic biliary duct dilatation. The gallbladder is unremarkable without
stones. The common bile duct is not dilated, measuring 5 mm. The portal vein
is patent with hepatopetal flow. The head and body of the pancreas are
unremarkable. The pancreatic tail could not be visualized due to bowel gas
artifact. There is global dilatation of the pancreatic duct up to 7 mm. The
cystic structure in the duodenal wall that was seen on prior MRCP could not be
assessed with ultrasound due to bowel gas. The spleen is not enlarged
measuring 8.6 cm. The right and left kidney measure 11.0 cm. There is no
hydronephrosis, nephrolithiasis, or focal lesions bilaterally. The aorta is
non aneurysmal. Limited views of the inferior vena cava are unremarkable.
There is no evidence of ascites.
IMPRESSION:
1. Diffusely echogenic liver is compatible with hepatic steatosis although
other chronic liver conditions such as liver cirrhosis and fibrosis cannot be
excluded.
2. Dilated pancreatic duct unchanged from prior exams and better assessed in
recent MRCP. A known cystic lesion in the duodenum could not be assessed.
3. No cholelithiasis or cholecystitis.
Radiology Report
HISTORY: Recent diagnosis of abdominal mass. Transferred from outside
hospital with epigastric pain, nausea and vomiting. Elevated lipase
concerning for acute pancreatitis. Please assess for growth abdominal mass.
TECHNIQUE: Multiplanar T1 and T2 weighted imaging was obtained on a 1.5 T
magnet, including dynamic 3D imaging obtained prior to, during and subsequent
to the intravenous administration of 0.1 mmol/kg of Gadavist (7 ml).
1 mL of Gadavist with 50 mL of water was administered orally prior to the
procedure.
COMPARISON: MRCP ___, CT ___ and ultrasound ___.
FINDINGS:
The liver is of normal signal and morphology on T2 weighted imaging. There is
no significant signal drop-off on out of phase imaging when compared to in
phase T1 weighted imaging consistent with fatty deposition. No focal hepatic
lesion. No intrahepatic biliary dilatation. There is an accessory left
hepatic artery arising from the left gastric artery with an accessory right
hepatic artery arising directly from the celiac trunk at the level of the
bifurcation. The portal and hepatic veins are patent. Normal appearance of
the gallbladder, no gallstones, no evidence of cholecystitis. As previously
noted there is a low insertion of the cystic duct into the common bile duct
(7, 3).
There is pancreas divisum ductal morphology. The main pancreatic duct is
dilated measuring up to 8 mm with a small santorinicele noted, unchanged from
the prior study. No evidence of acute pancreatitis on the current study. No
focal lesion is identified within the pancreatic head. The cystic lesion
within the ___ part of the duodenum has markedly decreased in size now
measuring 2.3 x 0.9 cm compared to at least 5 cm on the prior study. There is
marked wall thickening and inflammatory stranding involving the duodenum
consistent with duodenitis. No fluid collections.
Normal appearance of the spleen. No adrenal lesion. The kidneys enhance
symmetrically. No hydronephrosis. The 0.7 cm T1 and T2 hyperintense lesion
at the the lower pole of the right kidney which demonstrates signal drop-off
on out of phase imaging, consistent with a small angiomyolipoma is unchanged.
Bilateral simple renal cysts are noted. No suspicious renal lesion.
The visualized small and large bowel are otherwise unremarkable. No
significant upper abdominal or retroperitoneal lymphadenopathy. The
visualized lung bases are unremarkable. No destructive bone lesion.
IMPRESSION:
1. There is pancreas divisum ductal morphology with dilatation of the
pancreatic duct and a small santorinicele present, unchanged from previously.
The cystic lesion within the duodenum has decreased in size, possibly related
to the recent aspiration. This lesion most likely represents cystic dystrophy
of the duodenum wall. There has been interval development of marked
thickening and inflammation of the duodenum wall consistent with duodenitis.
2. Hepatic steatosis.
3. Unchanged 0.7 cm angiomyolipoma in the lower pole of the right kidney.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: EPIGASTRIC PAIN
Diagnosed with ACUTE PANCREATITIS
temperature: 99.6
heartrate: 92.0
resprate: 16.0
o2sat: 98.0
sbp: 128.0
dbp: 63.0
level of pain: 3
level of acuity: 3.0 | ___ with PMH of CAD, recent diagnosis of abdominal mass, who
presents as a transfer from an outside hospital with epigastric
pain, nausea and vomiting, elevated lipase concerning for acute
pancreatitis.
# Adbominal Pain: On admission her clinical picture of severe
onset epigastric pain with nausea, vomiting, and elevated lipase
was consistent with acute pancreatitis. She underwent RUQ U/S,
which was negative for either cholelithiasis or cholecystitis.
She denies any alcohol intake and her triglycerides were WNL.
She does have a cystic mass in the duodenum, which was thought
to be a potential cause of this episode. MRCP was performed, and
showed pancreas divisum, decreased size of the cystic lesion
within the duodenum which likely represents cystic dystrophy
of the duodenum wall, and interval development of duodenitis.
She was treated supportively with IVF, NPO, anti-emetics, and
pain medications. Her pain resolved and her diet was slowly
advanced. On discharge she was tolerating a regular diet.
# Anemia: her hematocrit dropped approximately 8 points over the
course of this admission. Her baseline per OSH records appears
to be ~38. She had no evidence of bleeding, and has been HD
stable. This was felt to be unlikely related to hemorrhagic
conversion of pancreatitis. Her crit remained stable in the low
30's.
# Cystic Duodenal Lesion: Pt currently seeing GI for evaluation
of abdominal mass, found to have cystic lesion on EUS with
pathology only notable for duodenal bulb mucosa. CEA and ___
were negative on prior work-up. Repeat MRCP was performed, and
the result is as described above. She will continue to follow
with her outpatient GI for additional manamgement of this issue.
CHRONIC ISSUES:
# CAD: Continued aspirin, BB, statin.
# HLD: ___ level WNL. Continued statin. Restarted fibrate on
discharge.
# Elevated BP: Her blood pressure was intermittently elevated on
this admission, but she denies any history of HTN, and would
like this removed from her chart. Elevated BP could be related
to pain.
TRANSITIONAL ISSUES:
- additional work-up of known cystic duodenal mass
- additional work-up of anemia |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Fosamax / Penicillins
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
___ : Endovascular thoracic aortic repair.
History of Present Illness:
___ otherwise healthy who complains of back pain x 10 days.
Patient reported pain is spasm like, located relatively midline
in the mid thoracic region. Pain is non-radiating, no
exacerbating factors, only relieved w lying completely flat and
slight relief w oxycodone. No prior episodes of
back/chest/abdominal pain in past. Went to a chi___ about
1
week ago and experienced worsening pain since then. Presented to
___ this evening after talking w her PCP. A CTA
Chest
was performed which demonstrated a reported 1.9cm ulcer of the
descending thoracic aorta. She was transferred to ___ for
further management. Patient denies any chest pain, shortness of
breath, abdominal pain, nausea, vomiting, motor deficits,
paresthesias, fevers, chills, BRBPR or melena.
Past Medical History:
None. Specifically questioned and denies hx of heart disease,
HTN, HLD, pulmonary disease, peripheral vascular disease,
chronic kidney disease
Past surgical history
cholecystectomy ___ years ago, appendectomy at age ___
Social History:
___
Family History:
Family History: Daughter died of metastatic cancer in her ___
(unknown primary). Mother died of gastric cancer.
Physical Exam:
Temp: 97.5 HR: 79 BP: 134/70 RR: 14 94% RA
Gen: No distress, lying in bed
HEENT: non traumatic, anicteric
CV: regular rate, no murmurs, rubs, gallosp
Resp: clear to auscultation bilaterally
Abd: soft non tender non distended
Groins: soft, no sign of hematoma
Ext: palpable pulses bilaterally
Pertinent Results:
___:54AM BLOOD WBC-12.2*# RBC-3.66* Hgb-11.0* Hct-32.5*
MCV-89 MCH-30.2 MCHC-34.0 RDW-13.1 Plt ___
___ 01:59AM BLOOD Hct-35.4*
___ 02:54AM BLOOD WBC-8.1 RBC-3.74* Hgb-11.0* Hct-34.0*
MCV-91 MCH-29.3 MCHC-32.3 RDW-13.1 Plt ___
___ 02:50AM BLOOD WBC-9.0 RBC-4.02* Hgb-11.7* Hct-36.3
MCV-90 MCH-29.2 MCHC-32.3 RDW-13.1 Plt ___
___ 04:54AM BLOOD Glucose-81 UreaN-11 Creat-0.6 Na-135
K-3.4 Cl-97 HCO3-27 AnGap-14
___ 01:59AM BLOOD Glucose-133* UreaN-6 Creat-0.5 Na-133
K-3.6 Cl-97 HCO3-30 AnGap-10
___ 02:54AM BLOOD Glucose-69* UreaN-11 Creat-0.6 Na-135
K-4.0 Cl-103 HCO3-23 AnGap-13
___ 02:50AM BLOOD ALT-22 AST-28 LD(LDH)-190 AlkPhos-90
Amylase-79 TotBili-0.2
CTA torso ___
CTA TORSO:
Atherosclerotic mural calcifications are seen throughout the
aorta and its major branches. Assessment of the venous
vasculature is limited by the timing of contrast.
Again seen is an intramural hematoma starting at the level of
the descending aorta with a focal penetrating ulcer along the
anterolateral aspect (02:47), unchanged from previous
examination. Focal ulceration measuring 2.3 x 0.9 cm (02:47)
(previously 2.3 x 0.9 cm). The descending aorta at this level
measures 3.8 x 3.8 cm (02:47) (previously 3.8 x 3.5 cm). No
dissection flap identified. The intramural hematoma extends
along the posterior aspect of the descending aorta and extends
anterolaterally to just above the renal arteries. No soft tissue
stranding. No retroperitoneal hematoma. The celiac axis and SMA
are
patent. The ___ is not definitely seen. A replaced right hepatic
artery is noted arising from the aorta at the level of the
celiac axis (2:88). Bilateral single renal arteries are patent.
No intramural hematoma at the level of the renal arteries.
Bilateral common iliac arteries, external iliac arteries,
internal iliac
arteries are patent without dissection or aneurysmal dilatation.
The left
common femoral artery and superficial femoral artery are patent.
The right common femoral artery is patent.
Just distal to the takeoff of the right profunda artery, the
right superficial femoral artery is occluded (2: 205).
MRI Spine ___
IMPRESSION:
. No epidural hematoma.
. Very mild disc bulges and small herniations at several levels
but no spinal canal or neural foraminal stenosis
Medications on Admission:
none
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*12
2. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
please limit intake to less than 4000 mg in 24hrs
RX *acetaminophen 650 mg 1 tablet(s) by mouth q6hr prn Disp #*30
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
you may stop taking it once you are off pain medication and are
having regular bowel movements
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
4. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*6
5. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*6
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
please do not drive or operate heavy machinery within 6 hrs of
taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hrs prn Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Symptomatic thoracic aortic ulcer with intramural hematoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA TORSO
INDICATION: ___ year old woman with backpain, found to have 1.9cm thoracic
aorta ulcer. Scan down to the thighs past the iliac bifurcations
TECHNIQUE: MDCT images were obtained through the torso, initially without
contrast, and subsequently in the arterial phase after administration of 130
cc of IV Omnipaque contrast. Axial images were interpreted in conjunction
with coronal, sagittal, and MIP reformats.
DLP: 423.63 mGy-cm
COMPARISON: Reference CT torso ___.
FINDINGS:
CTA TORSO:
Atherosclerotic mural calcifications are seen throughout the aorta and its
major branches. Assessment of the venous vasculature is limited by the timing
of contrast.
Again seen is an intramural hematoma starting at the level of the descending
aorta with a focal penetrating ulcer along the anterolateral aspect (02:47),
unchanged from previous examination. Focal ulceration measuring 2.3 x 0.9 cm
(02:47) (previously 2.3 x 0.9 cm). The descending aorta at this level measures
3.8 x 3.8 cm (02:47) (previously 3.8 x 3.5 cm). No dissection flap identified.
The intramural hematoma extends along the posterior aspect of the descending
aorta and extends anterolaterally to just above the renal arteries. No soft
tissue stranding. No retroperitoneal hematoma. The celiac axis and SMA are
patent. The ___ is not definitely seen. A replaced right hepatic artery is
noted arising from the aorta at the level of the celiac axis (2:88). Bilateral
single renal arteries are patent. No intramural hematoma at the level of the
renal arteries.
Bilateral common iliac arteries, external iliac arteries, internal iliac
arteries are patent without dissection or aneurysmal dilatation. The left
common femoral artery and superficial femoral artery are patent. The right
common femoral artery is patent.
Just distal to the takeoff of the right profunda artery, the right superficial
femoral artery is occluded (2: 205).
CHEST:
The thyroid is normal.No axillary, supraclavicular, mediastinal, or hilar
lymph node enlargement. The heart and mediastinum are normal. No pericardial
effusion.The airways are patent to the subsegmental levels. Bibasilar
atelectasis is noted with small bilateral pleural effusions. No pneumothorax.
ABDOMEN:
A 2.0 x 1.3 cm (2:63) segment 7 lesion is stable from 24 hr prior and
consistent with a cyst. No additional hepatic lesions identified. Mild
intrahepatic biliary dilatation noted most prominent within the left lobe of
the liver, unchanged from previous exam. The CBD is again noted to be ectatic
measuring 1.7 cm (2:91) (previously 1.6 cm). The gallbladder is not visualized
and likely surgically absent however no clips identified in the gallbladder
fossa. The portal vein, SMA, and splenic vein are patent. The gallbladder,
pancreas, spleen, and right adrenal gland is normal. The left adrenal gland
is slightly nodular, similar to previous examination. The kidneys enhance
symmetrically and are without suspicious solid mass.
The stomach is grossly unremarkable in appearance.The small and large bowel
are normal in caliber and without evidence of wall thickening. The appendix is
not visualized however no evidence of acute appendicitis. Few sigmoid
diverticula seen without evidence of acute diverticulitis. No retroperitoneal
or mesenteric lymph node enlargement by CT size criteria.No free abdominal
fluid, abdominal wall hernia, or pneumoperitoneum.
PELVIS:
The bladder is unremarkable. No pelvic side-wall or inguinal lymph node
enlargement.No free pelvic fluid is identified. The uterus and left ovary are
unremarkable. The right ovary is not visualized.
OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen
within the visualized thoracolumbar spine. No focal lytic or sclerotic lesion
concerning for malignancy.
IMPRESSION:
1. Stable descending aorta intramural hematoma, age indeterminate, with
unchanged penetrating ulcer just distal to the aortic arch.
2. Occluded right superficial femoral artery.
3. Mild intrahepatic biliary dilatation with ectatic CBD is nonspecific and
unchanged from 24 hours prior, may be age related or from previous
cholecystectomy.
4. Nodular left adrenal gland.
5. Sigmoid diverticulosis without evidence of acute diverticulitis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 6:21 ___. Multiple attempts made throughout
the day to contact primary team.
Radiology Report
EXAMINATION: MR lumbar spine without contrast.
INDICATION: ___ year old womanPOD 2-TEVAR // Post epidural ___ pull out
pain and parasthesia.stat MR to ___ epidural hematoma
TECHNIQUE: MRI of the lumbar spine was performed without intravenous
contrast, as per the standard departmental protocol.
COMPARISON: CTA torso ___
FINDINGS:
The vertebral body height and alignment is maintained. The bone marrow has a
normal signal intensity. The intervertebral discs have normal height and
signal intensities.
T12-L1:There is no disc herniation, or spinal canal or neural foraminal
stenosis.
L1-L2: There is a mild diffuse disc bulge with a shallow central disc
protrusion but no spinal canal or neural foraminal stenosis.
L2-L3: There is no disc herniation, or spinal canal or neural foraminal
stenosis.
L3-L4: There is no disc herniation, or spinal canal or neural foraminal
stenosis.
L4-L5: There is a mild diffuse disc bulge with a shallow central disc
protrusion but no significant spinal canal or neural foraminal stenosis. Mild
to moderate facet degenerative changes
L5-S1: There is a broad-based disc protrusion but no significant spinal canal
or neural foraminal stenosis. Mild to moderate facet degenerative changes
The conus medullaris and cauda equina have normal morphology and signal
intensities. The conus medullaris terminates at L1-L2 level.
There is no epidural hematoma or other spinal canal fluid collection.
There is ligamentum flavum thickening and facet arthropathy at multiple
levels.
There are a few lower thoracic perineural cysts.
There is a simple appearing cyst in the left kidney.
There are postsurgical changes of endovascular abdominal aortic repair.
IMPRESSION:
1. No epidural hematoma in the lumbar spine.
2. Mild disc bulge, mild to moderate facet degenerative changes, in
particular at L4-5 and L5-S1 levels; no significant spinal canal or neural
foraminal stenosis.
Other details as above
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Back pain
Diagnosed with RUPTUR THORACIC ANEURYSM, BACKACHE NOS
temperature: 98.3
heartrate: 80.0
resprate: 14.0
o2sat: 96.0
sbp: 182.0
dbp: 84.0
level of pain: 4
level of acuity: 2.0 | This is a ___ year old previously healthy woman who presented
with back pain and hypertension was found to have a thoracic
aortic ulcer, she was treated conservatively at first however
due to her ongoing symptoms she underwnet thoracic aortic
stenting with lumbar drainage. She was stable after that. She
developed a headache following lumbar drain removal. Epidural
hematoma was ruled out with an MRI and the patient was
eventually transferred to the floor where she did well and was
discharged. Her hospital course by system is described below:
Neuro: The patient initially presented with back pain. There was
some confusion about the source of the back pain as the patient
had had chronic back pain and was seeing a chiropracter. Her
pain persisted through HD ___ and was improved following the
TEVAR. Following removal of the lumbar drain the patient
complained of a headache and numbness in her feet which was
concerning for epidural hematoma however the MRI ruled this out
and the patient remained neurologically intact without deficit
throughout the hospitalization.
CV: When the patient was initally admitted she was hypertensive
briefly requiring a labeltalol drip. She was transferred to the
CVICU on HD#1. An aline was placed for careful blood pressure
monitoring and control. She remained in CVICU until undergoing
the TEVAR. Afterwards she returned to ___. She was
hemodynamically stable although requiring intermittent
hydralazine PRN for blood pressures above 140s. She was started
on an ace inhibitor and betablocker and these were titrated
upprior to discharge. Additionally she was started on an
aspirin.
Resp: There were no acute respiratory issues. The patient had a
small oxygen requirement post-TEVAR however this was weaned off
without any diuresis. She was sating adequately on room air
prior to discharge.
GI: The patient was initally made NPO when she was admitted. She
ate briefly and then was made NPO again prior to her procedure.
Following the TEVAR her diet was advanced appopriately. She did
have some decreased appetite but it returned eventually and she
was taking adequate nutrition by the time of discharge.
Renal/Gu: The patient's kidney function was stable throughout
the hospitalization. She was catheterized following the TEVAR
and this remained until prior to discharge when it was removed
and she voided spontaneously.
Heme: The patient was given subcutaneous heparin prophylaxis for
DVT. She was also started on an aspirin.
ID: No active issues:
Endo: No active issues |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfur, Elemental / Celebrex
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with history of IBS, temporal arteritis on
long term prednisone, status post cholecystectomy, hypertension,
sphincter of Oddi dysfunction presents with abdominal pain and
rectal bleeding.
She states she is a snow bird and has been living all winter in
___. The winter has been very hard for her and she had more
than 10 admissions to a hospital in ___ for sepsis from
ecoli
she does not know the source, pneumonia, shingles, influenza.
She
was trying to reestablish care here in ___ and her PCP is at
___.
She states she has been having low volume rectal bleeding for a
year worse in the last month in the setting of being ill. She
endorses being a patient of Dr. ___ the last ___
years.
Yesterday evening she had sudden onset of left lower quadrant
pain. At first she thought it was some kind of food poisoning
but
as it worsened she called her gastroenterologist office and
described her pain and rectal bleeding, she was noted to have a
worsening anemia hemoglobin had down trended from 12.1-->10.3
(___ records) and they recommended she come to the
emergency room for evaluation and repeat labs.
On arrival to the emergency room vitals were T-max 97.9, heart
rate 92, blood pressure 149/53, respiratory rate 18, satting
100%
on room air labs were drawn which were hemolyzed, her CBC she
was
noted to have a white blood cell count of 8.5 a hemoglobin of
10.3 platelets of 218. LFTs showed a mildly elevated AST
otherwise were unremarkable. UA was negative. She underwent a
CT scan of the abdomen which was read as acute uncomplicated
diverticulitis involving the sigmoid colon. She was given 1 L
of
LR, 4 mg IV morphine, 1 mg IV Dilaudid, and ceftriaxone/flagyl
and admitted to medicine for further care.
On arrival to the floor she is sleepy but states she is feeling
much better.
14 point review of systems reviewed with patient and negative
except per HPI
Past Medical History:
S/P CHOLECYSTECTOMY
___ ESOPHAGUS
GASTROESOPHAGEAL REFLUX
IRRITABLE BOWEL SYNDROME
S/P SPHINCTEROTOMY FOR SOD
AORTIC INSUFFICIENCY
BLADDER DYSFUNCTION
BASAL CELL CARCINOMA
H/O CLOSTRIDIA DIFFICILE
Temporal Arteritis on long term prednisone
Social History:
___
Family History:
___: Colon CA
Physical Exam:
Admission Exam
-----------------
VS: PO 110 / 64 76 20 95 2L NC
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, mildly tender in LLQ, no
masses
or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. appropriate affect
GU: no catheter in place
Discharge Exam
-----------------
VS: Temp 97.5 BP 138/77 HR 70 RR 18 SpO2 95% on RA
General Appearance: pleasant, comfortable, no acute distress,
sitting in chair
ENT: left ear with old blood in ear canal, no active shingles
lesions
Respiratory: CTA b/l with good air movement throughout
Gastrointestinal: soft, non-distended, mildly tender in LLQ,
Extremities: no cyanosis, clubbing or 1+ edema in the lower
extremities bilaterally
Pertinent Results:
Admission Labs
----------------
___ 09:20AM BLOOD WBC-8.5 RBC-3.93 Hgb-10.3* Hct-34.5
MCV-88 MCH-26.2 MCHC-29.9* RDW-16.8* RDWSD-54.1* Plt ___
___ 10:15AM BLOOD ___ PTT-24.3* ___
___ 09:20AM BLOOD Glucose-88 UreaN-12 Creat-0.8 Na-138
K-8.6* Cl-106 HCO3-20* AnGap-12
___ 09:20AM BLOOD ALT-<5 AST-122* AlkPhos-39 TotBili-0.4
___ 09:20AM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.4 Mg-2.2
___ 05:40AM BLOOD calTIBC-359 VitB12-1510* Folate-17
Ferritn-101 TRF-276
Imaging
---------
CT ABD & PELVIS WITH CONTRAST (___)
IMPRESSION:
Mild sigmoid diverticulitis.
Chest X-ray (___)
IMPRESSION:
No evidence of pulmonary edema. Left basilar opacities could
reflect atelectasis and/or pneumonia.
Discharge Labs
----------------
___ 05:42AM BLOOD WBC-8.4 RBC-3.35* Hgb-8.8* Hct-28.9*
MCV-86 MCH-26.3 MCHC-30.4* RDW-16.3* RDWSD-51.9* Plt ___
___ 05:42AM BLOOD Glucose-101* UreaN-18 Creat-0.7 Na-142
K-4.1 Cl-104 HCO3-25 AnGap-13
___ 05:42AM BLOOD LD(LDH)-294*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. PredniSONE 20 mg PO DAILY W/ FOOD
3. Escitalopram Oxalate 5 mg PO DAILY
4. LORazepam 0.5 mg PO QHS:PRN insomnia
5. Meclizine 25 mg PO Q8H:PRN dizziness
6. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO BID
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*15 Tablet Refills:*0
4. Miconazole 2% Cream 1 Appl TP BID
5. OSELTAMivir 75 mg PO Q24H
RX *oseltamivir 75 mg 1 capsule(s) by mouth once a day Disp #*10
Capsule Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*12 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
RX *polyethylene glycol 3350 17 gram/dose 1 dose by mouth once a
day Refills:*0
8. Escitalopram Oxalate 5 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Meclizine 25 mg PO Q8H:PRN dizziness
11. Metoprolol Succinate XL 25 mg PO DAILY
12. PredniSONE 20 mg PO DAILY W/ FOOD
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diverticulitis
Hemorrhoids
Rectal bleeding
Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with abd pain, LLQ tenderness,?diverticulitis, other acute
process
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration. Oral
contrast was not administered.Coronal and sagittal reformations were performed
and reviewed on PACS.
DOSE: Total DLP (Body) = 1,422 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: Mild bibasilar atelectasis. Otherwise, visualized lung fields
are within normal limits. There is no evidence of pleural or pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
dilatation. The CBD is prominent, likely secondary to cholecystectomy.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: Moderate-sized hiatal hernia. Otherwise, the stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. There is extensive colonic diverticulosis. There
extensive soft tissue stranding and fascial thickening adjacent to the mid
sigmoid colon, compatible with acute diverticulitis. There is no evidence of
extraluminal air or focal fluid collection. No evidence of fistula formation.
The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There are mild-to-moderate degenerative changes of the thoracolumbar
spine, most prominent at T12-L1. There is no evidence of worrisome osseous
lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Mild sigmoid diverticulitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new oxygen requirement ?pulm edema// ?pulm
edema
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Left basilar opacities are present. There is no evidence of pulmonary edema,
a pneumothorax or large pleural effusion. The size of the cardiac silhouette
is enlarged. There appears to be a hiatal hernia. Degenerative changes are
present around the shoulders bilaterally.
IMPRESSION:
No evidence of pulmonary edema. Left basilar opacities could reflect
atelectasis and/or pneumonia.
Moderate to large hiatal hernia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Lower abdominal pain
Diagnosed with Dvtrcli of lg int w/o perforation or abscess w/o bleeding, Gastrointestinal hemorrhage, unspecified, Left lower quadrant pain
temperature: 97.9
heartrate: 92.0
resprate: 18.0
o2sat: 100.0
sbp: 149.0
dbp: 53.0
level of pain: 10
level of acuity: 3.0 | ___ woman with history of IBS, status post
cholecystectomy, sphincter of Oddi dysfunction s/p
sphincterotomy presents with abdominal pain and BRBPR found to
have acute uncomplicated diverticulitis with iron deficient
anemia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex, Natural Rubber
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Cystoscopy with right ureteral stent placement
History of Present Illness:
The patient is a ___ female w/PMHx COPD on ___ O2 via
nasal cannula, hypertension, depression, and chronic pain
presenting with abdominal pain and found to have obstructing
nephrolithiasis.
She was in her USOH until 1 week PTA when she developed right
lower quadrant abdominal pain, associated with nausea (belching
but no vomiting), and decreased PO intake. The pain is RLQ to R
mid abdomen, ___, without radiation. No fevers or chills.
Last
bowel movement was 3 days ago, only a small amount of gas since
the, but she attributes this to not having eaten much and
doesn't
feel constipated. No dysuria. No other acute issues. She came
to the ___ ED.
In the ED: triage vitals T 98.3, HR 77, BP 146/68, RR 17, O2 sat
92% on (unclear amount of O2, perhaps 3L?). Exam show no abd
pain, labs were obtained showing ___, CT A/P done showing R
obstructing nephrolithiasis, given IVF, Urology consulted,
planned cystoscopy and R ureteral stent placement today. Pt
kept
NPO. UA w/o signs of infection, so no abx given.
Seen on the floor she's doing quite well, denies significant
pain
at this time. No prior history of nephrolithiasis. We
discussed
her plan of care.
ROS: [x] As per above HPI, otherwise reviewed and negative in
all
systems
Primary Care Provider:
___, DO -- ___, ___
Other providers:
___ ___ -- Dr. ___ -- Dr. ___
Past Medical History:
#COPD on home O2
#Asthma
#Hypertension
#Depression, anxiety
#Lumbar spinal stenosis
#Cataracts
#H/o breast cancer, ___ diagnosed in ___, was invasive,
treated
with just surgery, has had 2 recurrences since then, most
recently in ___, says she has never had radiation or chemo,
is on anastrozole, last saw ___ Oncology, Dr. ___, in
___
PSHx:
#s/p CCY
#s/p hysterectomy
#s/p breast cancer related surgeries
#Tonsillectomy as a child
Social History:
___
Family History:
Sister had renal failure, was on peritoneal dialysis, died of
lung cancer (was a smoker)
Mother had uterine cancer
No h/o nephrolithiasis
Physical Exam:
Admission Exam
VS: T 98.0, BP 131/69, HR 62, RR 18, O2 sat 92% on 2L NC
Lines/tubes: PIV
Gen: elderly woman lying in bed, alert, cooperative, moving her
arms and legs, consistent with restless legs syndrome, NAD
HEENT: anicteric, MMM, PERRL
Neck: supple
Chest: equal chest rise, fair air movement, with decr breath
sounds at the bases bilaterally, otherwise CTAB, no WOB or cough
Cardiovasc: RRR, no m/r/g
Abd: soft, NTND
GU: no CVAT
Extr: WWP, no edema
Skin: no rashes noted on limited exam
Neuro: no obvious focal neurological deficits
Psych: normal affect
Discharge Exam
VS WNL
Gen: elderly woman lying in bed, NAD
HEENT: anicteric, MMM, PERRL
Neck: supple
Chest: CTA B/L
Cardiovasc: RRR, no m/r/g
Abd: soft, NTND
GU: no CVAT, no suprapubic TTP
Extr: WWP, no edema
Skin: no rashes noted on limited exam
Neuro: no obvious focal neurological deficits
Psych: normal affect
Pertinent Results:
___ 06:38AM URINE HOURS-RANDOM
___ 06:38AM URINE UHOLD-HOLD
___ 06:38AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:38AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 06:38AM URINE RBC-25* WBC-4 BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 06:38AM URINE MUCOUS-RARE*
___ 12:10AM LACTATE-0.8
___ 12:05AM GLUCOSE-124* UREA N-34* CREAT-1.7* SODIUM-139
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-31 ANION GAP-10
___ 12:05AM estGFR-Using this
___ 12:05AM ALT(SGPT)-12 AST(SGOT)-21 ALK PHOS-69 TOT
BILI-0.4
___ 12:05AM LIPASE-32
___ 12:05AM cTropnT-<0.01
___ 12:05AM ALBUMIN-4.0 CALCIUM-9.9 PHOSPHATE-4.4
MAGNESIUM-2.1
___ 12:05AM WBC-8.4 RBC-3.84* HGB-11.6 HCT-36.0 MCV-94
MCH-30.2 MCHC-32.2 RDW-13.2 RDWSD-45.4
___ 12:05AM NEUTS-86.6* LYMPHS-5.0* MONOS-7.7 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-7.30* AbsLymp-0.42* AbsMono-0.65
AbsEos-0.01* AbsBaso-0.01
___ 12:05AM PLT COUNT-187
IMAGING
CXR -- IMPRESSION: No acute intrathoracic process. Evidence of
chronic pulmonary disease.
CT A/P -- IMPRESSION: Moderate right hydroureteronephrosis
secondary to an obstructing 4 mm stone in the mid right ureter.
3 mm nonobstructing stone also seen in the left lower renal
pole.
No left hydronephrosis.
DISCHARGE LABS
___ 06:45AM BLOOD WBC-5.0 RBC-3.47* Hgb-10.4* Hct-32.7*
MCV-94 MCH-30.0 MCHC-31.8* RDW-13.1 RDWSD-45.0 Plt ___
___ 06:45AM BLOOD Glucose-87 UreaN-32* Creat-1.3* Na-143
K-4.0 Cl-100 HCO3-29 AnGap-14
___ 12:05AM BLOOD Glucose-124* UreaN-34* Creat-1.7* Na-139
K-4.4 Cl-98 HCO3-31 AnGap-10
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Sertraline 100 mg PO DAILY
5. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
6. TraZODone 200 mg PO QHS
7. Anastrozole 1 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. magnesium 1 unk oral DAILY
10. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
11. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. amLODIPine 10 mg PO DAILY
3. Anastrozole 1 mg PO DAILY
4. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
5. magnesium 1 unk oral DAILY
6. Sertraline 100 mg PO DAILY
7. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
8. TraZODone 200 mg PO QHS
9. Vitamin D 1000 UNIT PO DAILY
10. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until creatinine
returns to baseline
11. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until Creatinine returns to baseline
Discharge Disposition:
Home
Discharge Diagnosis:
R obstructing nephrolithiasis s/p R ureteral stent placement
(___)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with abd pain, RLQ tenderness// ?acute process,
appendicitis, infiltrate
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest from ___. Chest radiograph from ___.
FINDINGS:
The cardiomediastinal and hilar contours are normal. No focal consolidations
are seen. There is no pulmonary edema or pleural abnormality. Hyperexpansion
of the lungs with flattening hemidiaphragms is consistent with chronic
pulmonary disease.
IMPRESSION:
No acute intrathoracic process. Evidence of chronic pulmonary disease
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with abd pain, RLQ tendernessNO_PO
contrast// ?acute process, appendicitis, infiltrate
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 5.7 s, 44.6 cm; CTDIvol = 17.0 mGy (Body) DLP = 756.0
mGy-cm.
Total DLP (Body) = 772 mGy-cm.
COMPARISON: CT chest from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. There is a small fat containing
Bochdalek hernia.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Subcentimeter hypodensities in the spleen are too small to
characterize.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The right kidney is mildly bigger than the left and has a delayed
nephrogram. There is moderate right hydroureteronephrosis secondary to an
obstructing 4 mm stone in the mid right ureter (2:35, 601:27), associated with
right perinephric fat stranding. A 3 mm nonobstructing stone is also seen in
the left lower pole (02:24). Bilateral simple renal cysts are noted, with
additional sub subcentimeter hypodensities are too small to characterize, but
likely represent cysts.
GASTROINTESTINAL: Again seen is a small hiatus hernia. The stomach is grossly
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. Diverticulosis of the sigmoid colon is noted,
without evidence of wall thickening and fat stranding.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: A small umbilical hernia containing fat is noted.
IMPRESSION:
Moderate right hydroureteronephrosis secondary to an obstructing 4 mm stone in
the mid right ureter. 3 mm nonobstructing stone also seen in the left lower
renal pole. No left hydronephrosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Right lower quadrant pain
temperature: 98.3
heartrate: 77.0
resprate: 17.0
o2sat: 92.0
sbp: 146.0
dbp: 68.0
level of pain: 9
level of acuity: 3.0 | ___ woman w/PMHx COPD on ___ O2 at home, hypertension,
depression/anxiety, presenting with abdominal pain and found to
have right-sided obstructing nephrolithiasis and ___.
#4 mm obstructing nephrolithiasis, right
#3 mm nonobstructing stone also seen in the left lower renal
pole.
Initial UA revealed 25 RBC with no evidence of infection. CT A/P
revealed moderate right hydroureteronephrosis secondary to an
obstructing 4 mm stone in the mid right ureter and a 3 mm
nonobstructing stone also seen in the left lower renal pole with
no left hydronephrosis. Given lack of leukocytosis, afebrile and
no evidence of stranding around the R kidney, uncomplicated R
obstructing nephrolithiasis was confirmed. Urology placed a R
ureteral stent on ___ with improvement of UOP, slowly
improvement in hematuria, and complete resolution of pain. She
tolerated a regular diet with no pain with urination at time of
discharge.
___: Presented with ___ (Cr 1.7 from baseline 1.0). Would
not expect ___ from unilateral obstructing kidney stone but
patient endorses poor PO fluid intake ___ pain) from the
obstructing kidney stone. With IVF hydration her Cr improved
from 1.7 to 1.3. Encouraged the patient to continue to hydrate
with a plan to recheck her Cr one week from discharge with her
PCP (confirmed baseline Cr 0.9 to 1.0 as of ___
Chronic
#COPD on home O2
#Asthma
remained on her home ___. Encouraged to continue to ambulate to
prevent any atelectasis. Plan to resume all her home inhalers.
#Hypertension: Continued home amlodipine but held home HCTZ and
Lisinopril given normotension and resolving ___. Will recheck Cr
in one week upon discharge to document resolution ___ then
can serially resume Lisinopril and HCTZ as BP allows.
#Depression, anxiety
-continue home sertraline and trazodone
#H/o breast cancer
-continue home anastrozole
#Possible constipation
-bowel regimen
#Advance Care Planning:
Health Care Proxy: step-son and niece as per OMR
Care Preferences: see Basic advance care planning preferences
note dated ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Nitrofurantoin / Cephalosporins / Reglan /
Ciprofloxacin / Percocet / codeine / gabapentin / baclofen
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
This is a ___ female with PMHx CAD s/p CABG, DM2, ESRD
on HD (___), HFpEF, recurrent UTIs and recent admission for
pneumonia and GIB who is presenting with dyspnea. She did have
her dialysis session today. She reports that she started
experiencing dyspnea at around 4 pm on ___. She reports that it
feels like "when they don't take off enough fluid" for HD.
She denies fevers, chills, cough, chest pain, nausea, vomiting,
diarrhea.
In the ED, initial vitals: 97.8 74 158/49 16 97% RA
-Labs significant for:
WBC 9.1 Hgb 9.2 Hct 28.2 Plt 237
Na 135 K 5.0 Cl 98 CO2 23 BUN 35 Cr 3.7
Trop-T: 0.09 ___: 14817
pH 7.35 pCO2 49 pO2 31 HCO3 28
On transfer, vitals were: 96.7 70 166/69 28 100% RA
On arrival to the MICU, patient is on CPAP but reports that she
feels as though her breathing has improved.
Review of systems:
(+) Per HPI
(-) Denies fever, chills,chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency.
Past Medical History:
- ESRD - likely ___ DM and HTN, on HD (initiated ___
- Diabetes mellitus type II- last A1C 7.6% in ___
complicated by diabetic nephropathy,gGastroparesis (confirmed by
motility studies ~ ___, and neurogenic bladder (with
incomplete bladder emptying)
- Coronary artery disease s/p CABG in ___ (LIMA to LAD and SVG
to OM1 and OM2)
- HFpEF
- Moderate pulmonary hypertension
- Hypertension
- Hypercholesterolemia
- Recurrent UTI - Polymicrobial - failed suppressive
fosphomycin therapy in ___ - (previously with highly-resistent
Klebsiella and Citrobacter with sx of ascending infection, tx
with IV aztreonam)
- Hx. of abdominal pain - unclear etiology, possibly related to
constipation vs. bowel ischemia
- Hx. of diverticulitis
- Hx. of gallstones without cholecystitis
- Hx of GIB
- Hx. of lung nodules
- LBP due to herniated disk
- Depression
Social History:
___
Family History:
Alcoholism, coronary artery disease, and diabetes. No history of
blood clots
Physical Exam:
Admission:
Vitals: T: 98.2 BP: 167/76 P: 70 R: 21 O2: 100% CPAP ___
GENERAL: sleepy but arousable, oriented, no acute distress but
dyspneic on conversation
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP 15 cm
LUNGS: normal anterior breath sounds
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, trace pitting edema
Discharge:
Vitals: Tm 98.4 HR 60-63 BP 103-167/30-66 RR 18 O2 sat 99-100%
RA
Weight: 64.9kg. Post-HD weight: 62.5kg
Exam:
GENERAL: Alert, oriented, sitting upright at edge of bed in no
respiratory disress. Speaking full sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
NECK: supple, JVP 6-7cm H2O.
LUNGS: CTAB with soft breath sounds
CV: RRR, normal S1, loud S2 and audible P2, ___ pansystolic
murmur, loudest the RUSB and LUSB. Increases with deep breath.
ABD: soft, non-tender, mildly distended, normal bowel sounds, no
rebound tenderness or guarding, no organomegaly.
EXT: RUE AVF c/d/I. Warm, well perfused, 2+ pulses, trace
pitting edema
Pertinent Results:
ADMISSION LABS:
___ 12:10AM BLOOD WBC-9.1 RBC-2.72* Hgb-9.2* Hct-28.2*
MCV-104* MCH-33.8* MCHC-32.6 RDW-16.9* RDWSD-62.8* Plt ___
___ 12:10AM BLOOD Neuts-72.8* Lymphs-16.0* Monos-9.3
Eos-1.0 Baso-0.3 Im ___ AbsNeut-6.62* AbsLymp-1.45
AbsMono-0.84* AbsEos-0.09 AbsBaso-0.03
___ 12:10AM BLOOD Glucose-139* UreaN-35* Creat-3.7*# Na-135
K-5.0 Cl-98 HCO3-23 AnGap-19
___ 03:41AM BLOOD CK(CPK)-23*
___ 12:10AM BLOOD CK-MB-2 ___
___ 03:41AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9
___ 12:30AM BLOOD ___ pO2-31* pCO2-49* pH-7.35
calTCO2-28 Base XS--1
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-7.0 RBC-2.45* Hgb-8.2* Hct-25.1*
MCV-102* MCH-33.5* MCHC-32.7 RDW-16.6* RDWSD-62.4* Plt ___
___:15AM BLOOD Glucose-138* UreaN-75* Creat-5.5* Na-133
K-4.4 Cl-95* HCO3-20* AnGap-22*
___ 07:15AM BLOOD Calcium-7.8* Phos-3.8 Mg-2.0
IMAGING:
CXR ___:
Findings suggestive of mild volume overload with likely
asymmetrical edema
pattern. Superimposed infection in the left lung cannot be
excluded, and
short-term follow-up radiographs may be helpful in this regard.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN Constipation
5. Carvedilol 6.25 mg PO BID
6. Cetirizine 5 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 100 mg PO TID
9. Nephrocaps 1 CAP PO DAILY
10. Pravastatin 80 mg PO QPM
11. Senna 8.6 mg PO BID:PRN constipation
12. sevelamer CARBONATE 1600 mg PO TID W/MEALS
13. Clotrimazole Cream 1 Appl TP BID
14. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 3X/WEEK
15. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Glargine 24 Units Breakfast
Glargine 24 Units Bedtime
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain
4. Aspirin 81 mg PO DAILY
5. Bisacodyl 10 mg PO DAILY:PRN Constipation
6. Carvedilol 6.25 mg PO BID
7. Cetirizine 5 mg PO DAILY
8. Clotrimazole Cream 1 Appl TP BID
9. Docusate Sodium 100 mg PO BID
10. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 3X/WEEK
11. Gabapentin 100 mg PO TID
12. Nephrocaps 1 CAP PO DAILY
13. Pantoprazole 40 mg PO Q12H
14. Pravastatin 80 mg PO QPM
15. Senna 8.6 mg PO BID:PRN constipation
16. sevelamer CARBONATE 1600 mg PO TID W/MEALS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: CHF Exacerbation
SECONDARY: Pulmonary Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ female with PMHx CAD s/p CABG, DM2, ESRD on HD
(___), HFpEF, p/w dyspnea consistent with CHF Exacerbation. R/o PNA as
trigger for CHF. Thanks! // R/o PNA R/o PNA
IMPRESSION:
Comparison to ___. No relevant change is noted. Sternal wires in
correct alignment. Overall low lung volumes with mild cardiac enlargement but
no evidence of overt pulmonary edema. No pleural effusions. No pneumonia, no
pneumothorax.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 97.8
heartrate: 74.0
resprate: 16.0
o2sat: 97.0
sbp: 158.0
dbp: 49.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with history of CAD s/p CABG, DM2,
ESRD on HD (___), HFpEF, recurrent UTIs and recent admission
for pneumonia and GIB who presented with dyspnea requiring CPAP
and 1 night in the MICU.
# Acute on chronic diastolic heart failure exacerbation: Patient
presented with dyspnea requiring CPAP and ICU admission, most
likely related to volume overload. She did have HD session day
of admission but felt as though they did not take enough fluid
off. Her weight on admission was 65.5 kg (dry weight thought to
be around 63 kg). She was weaned from CPAP overnight on ___,
prior to ultrafiltration. On ___, she had 2L removed via
ultrafiltration. On ___, she had an additional 1L removed via
ultrafiltration. On ___, she had hemodialysis. Her symptoms
were improved. Discharge weight was 62.5 kg. Etiology of her CHF
exacerbation was most likely dietary indiscretion. Infectious
etiologies were ruled out (CXR negative, no urinary symptoms, no
cough or URI symptoms). Her severe pulmonary hypertension
(recently diagnosed) may also have been contributing to her
dyspnea. She has pulm followup for this scheduled with Dr.
___.
# Hypertension: She had uncontrolled hypertension during her
hospitalization with SBPs in 160-170s. She was asymptomatic. Her
amlodipine was increased from 5mg to 10mg daily. Her Carvedilol
was maintained at 6.25mg BID since her HRs were 55-60s.
# Anemia: patient noted to have a stable anemia, likely
multifactorial due to kidney failure and chronic disease. She
had some loose stools with a few visible flecks of blood but no
change in Hgb. She has known hemorrhoids. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo male with a history of myxofibrosarcoma s/p cycle 3 AIM
who
is admitted with neutropenic fever. The patient states the
fevers
started overnight. He also has felt very fatigued. He denies any
sore throat, cough, shortness of breath, nausea, abdominal pain,
diarrhea, or dysuria. He is mildly constipated. Of note he was
last admitted from ___ for cycle 3 AIM and gave
himself pegfilgrastim at home after discharge.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- ___: Noted mild increase in the size and discomfort in his
right thigh. He noticed while sitting that there was an
apparent
mass, which impeded his ability to move the leg and caused pain
while he was sitting. He eventually sought care with his
primary
care physician who ordered imaging studies. These demonstrated
a
large heterogeneous enhancing mass in the right thigh.
- ___, MRI right lower extremity showed a 32 cm
mass involving the medial aspect of the right upper thigh. The
mass enhances on contrast administration and is heterogeneous in
nature.
- ___, biopsy under image guidance. Pathology from
this procedure showed myxofibrosarcoma, intermediate grade;
cytokeratin, MNF116, S100, desmin and SMA were all negative.
- ___: Completed pre-operative chemoradiation
with doxorubicin weekly continuous infusion (cumulative dose
95mg/m2; 211mg), and total radiation dose of 50 Gy.
-___. Resection by Dr. ___, one area of
medial margin was focally positive.
- ___. Due to positive margins had reoperation with
reconstruction of right thigh
vascularized tissue, nerve coaptation, free muscle left thigh to
the right thigh extensor reconstruction. Fiducials also placed
at the site of positive margin at the time of surgery.
- ___: Post-operative planning for stereotactic
radiation to resection site was planned, however due to ongoing
poor wound healing in the previously irradiated flaps and prior
negative margins, decision made to hold off on further radiation
therapy
- ___: CT Chest reveals multiple pulmonary nodules up to
1.5cm mostly in the right lung, highly suspicious for metastatic
disease
- ___ Lung wedge pathology: metastatic high-grade malignancy
most consistent with metastatic sarcoma
- ___ Cycle 1 AIM with pegfilgrastim
- ___ Admitted with neutropenic fever.
- ___ Cycle 2 AIM with pegfilgrastim
- ___ Cycle 3 AIM with pegfilgrastim
PAST MEDICAL HISTORY:
- Hypertension
- Diabetes mellitus, non-insulin dependent (on glipizide,
metformin)
- Childhood asthma
- Arthritis
- Gout
- Hyperlipidemia
Social History:
___
Family History:
Father: colon cancer
Other cancers in the family: Sister with breast cancer, brother
with skin cancer
Physical Exam:
General: NAD
VITAL SIGNS: T 98 BP 100/60 RR 16 HR 80 O2 98%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: Abrasion on left thigh.
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
___ 02:20PM BLOOD WBC-0.5*# RBC-2.37* Hgb-6.9* Hct-20.1*
MCV-85 MCH-29.1 MCHC-34.3 RDW-14.8 RDWSD-45.5 Plt Ct-19*#
___ 02:20PM BLOOD Neuts-33* Bands-6* ___ Monos-19*
Eos-0 Baso-1 ___ Metas-1* Myelos-0 AbsNeut-0.20*
AbsLymp-0.20* AbsMono-0.10* AbsEos-0.00* AbsBaso-0.01
___ 05:58AM BLOOD WBC-1.1*# RBC-2.32* Hgb-6.8* Hct-20.2*
MCV-87 MCH-29.3 MCHC-33.7 RDW-14.6 RDWSD-46.7* Plt Ct-18*
___ 05:58AM BLOOD Neuts-49 Bands-7* ___ Monos-10
Eos-2 Baso-3* ___ Myelos-1* AbsNeut-0.62*
AbsLymp-0.31* AbsMono-0.11* AbsEos-0.02* AbsBaso-0.03
___ 09:59AM BLOOD WBC-1.6* RBC-2.89* Hgb-8.5* Hct-25.0*
MCV-87 MCH-29.4 MCHC-34.0 RDW-14.6 RDWSD-45.1 Plt Ct-18*
___ 05:58AM BLOOD ___ PTT-31.7 ___
___ 05:58AM BLOOD Glucose-94 UreaN-15 Creat-1.0 Na-140
K-3.6 Cl-109* HCO3-24 AnGap-11
___ 02:20PM BLOOD ALT-35 AST-18 AlkPhos-97 TotBili-0.5
___ 02:20PM BLOOD Albumin-3.8 Calcium-8.4 Phos-3.2 Mg-1.9
CXR: No significant interval change when compared to the prior
study. Persistent right basal pleural effusion and atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN HEADACHE, PAIN, FEVER
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO QHS
4. Loratadine 10 mg PO DAILY
5. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Senna 8.6 mg PO BID:PRN constipation
10. Aspirin 81 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Simvastatin 40 mg PO QPM
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous ONCE
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Gabapentin 600 mg PO QHS
3. Loratadine 10 mg PO DAILY
4. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Senna 8.6 mg PO BID:PRN constipation
10. Simvastatin 40 mg PO QPM
11. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Neutropenic Fever
Myxofibrosarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with recent chemo and fever. // pneumonia?
TECHNIQUE: AP AND LATERAL CHEST RADIOGRAPHS.
COMPARISON: Chest radiographs ___
FINDINGS:
A right-sided Port-A-Cath terminates in the mid to distal SVC. A right basal
opacity likely reflects a combination of pleural fluid/thickening and
atelectasis, this is unchanged compared to the prior study. Left lung appears
grossly clear. The cardiomediastinal contour is unchanged in appearance.
Multilevel degenerative changes noted in the thoracic spine. No pneumothorax
seen.
IMPRESSION:
No significant interval change when compared to the prior study. Persistent
right basal pleural effusion and atelectasis.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Neutropenia, unspecified, Fever presenting with conditions classified elsewhere
temperature: 98.0
heartrate: 97.0
resprate: 16.0
o2sat: 100.0
sbp: 135.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | ___ yo male with a history of myxofibrosarcoma s/p cycle 3 AIM
who was admitted with neutropenic fever. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
captopril
Attending: ___
Chief Complaint:
acute onset shortness of breath while showering then became
unresponsive, found to have left basal ganglia hemorrhage at
outside hospital
Major Surgical or Invasive Procedure:
Bronchoscopy, cerebral angiogram, tracheotomy,placed downsized
to a 6.
History of Present Illness:
___ no past medical history per family who presented to OSH
after complaining of acute onset shortness of breath while
showering then became unresponsive, found to have left basal
ganglia hemorrhage.
Per EMS patient was found unresponsive and hypoxic with pink
frothy sputum. He was down for approximately 6 minutes.
Unknown how hypoxic he was. He was intubated on the scene. At
the outside hospital Noncon head CT showed 3 x 4 cm left basal
ganglia hemorrhage with no mass-effect or midline shift. He was
given 1 g IV Keppra and transferred to ___ via med flight. He
was started on nicardipine at the outside hospital but
reportedly blood pressure was 130s to 140s there, per outside
hospital records seems they had wanted to keep his blood
pressure less than 120. During the med flight he received 3%
hypertonic saline, rocuronium due to fighting the vent last
received at 11:30 ___ on ___, fentanyl, and propofol.
Per outside hospital report and patient's family who is at
bedside he was complaining of shortness of breath and chest
heaviness for several weeks. He frequently has shortness of
breath with exertion which they felt was related to his weight.
They also noted that he had been much more fatigued lately and
was sleeping 10+ hours a night and they would fall asleep on the
couch later in the day. He also was falling asleep during
conversations which was abnormal for him. He also was
complaining of more headaches though has baseline posterior
headaches. Per family he was not complaining of any blurry
vision, double vision, dizziness, nausea vomiting. They also
deny that he had any recent infections. Denies him having any
fevers, chills, night sweats, coughing, abdominal pain,
diarrhea, or burning when he peed. They deny any recent travel
outside of the country. His wife describes very loud breathing
when he is sleeping possibly due to obstructive sleep apnea
though he does not have a diagnosis.
Per family he is healthy and has not seen a doctor takes no
medications. The only thing he takes over-the-counter is Aleve
which she has been taking quite frequently recently. He has
baseline constipation.
ROS, patient is unable to answer review of systems questions of
see above for ROS obtained from family.
Past Medical History:
Obesity
Otherwise healthy per family
Social History:
___
Family History:
No family history of strokes or bleeds
Per patient's son aunt and uncle both have passed away from
heart
attacks.
Physical Exam:
Physical Exam on admission:
Vitals: T98, HR80, SBP 157/75, RR22, 100% RA
General: intubated and sedated
HEENT: NC/AT, no scleral icterus noted, MMM, ETT in place
Neck: Supple, No nuchal rigidity
Pulmonary: intubated
Cardiac: warm, well-perfused
Abdomen: soft, non-distended, obese
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Patient was examined ~10 minutes off of
sedation.
He opens his eyes briefly to noxious stimulation, will attend
examiner and family on the left side, not on the right. Does
not
follow commands, axial or appendicular in ___ or ___.
-Cranial Nerves: PERRL ___ sluggish bilaterally, looks fully to
the left, does not look to the right, no clear blink to threat
bilaterally, face appears symmetric around the ET tube,
initially
on exam there is no cough or corneal reflex but after 10 minutes
or so off of sedation patient opens his eyes to noxious and has
a
cough.
-Motor: Normal bulk, tone throughout.
Right upper extremity: Plegic to noxious stimulation
Right lower extremity plegic to noxious stimulation
Left upper extremity: Localizes sluggishly to noxious
stimulation, spontaneous distal finger movements
Left lower extremity: Plegic to noxious
-Sensory: Does not clearly react to noxious stimulation on the
right upper and lower extremity or left lower extremity, reacts
to noxious in the left upper extremity
-DTRs:
No clonus, toes are mute bilaterally
-Coordination: Unable to assess
-Gait: Unable to assess
Physical Exam at Discharge:
___ 1123 Temp: 98.4 PO BP: 128/89 HR: 83 RR: 20 O2 sat: 93%
O2 delivery: Ra FSBG: 132
Physical Exam:
General: Awake, alert, no acute distress
Tongue and lip swelling improving,
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple, No nuchal rigidity
Cardiac: warm, well-perfused
Abdomen: soft, non-distended, obese
Extremities: No ___ edema.
Neurologic:
MS: Awake, looking around room, spontaneously moving L side.
CN: EOMI, pupil 4->3 and brisk. R facial weakness.
Motor/Sensory:
RUE: plegic, not withdrawing from pain
LUE: Full range of motion and strength.
RLE: plegic, not withdrawing from pain
LLE: Full range of motion and strength.
Pertinent Results:
___ 05:48AM BLOOD WBC-6.6 RBC-3.39* Hgb-10.1* Hct-31.1*
MCV-92 MCH-29.8 MCHC-32.5 RDW-12.0 RDWSD-40.6 Plt ___
___ 11:57PM BLOOD WBC-5.3 RBC-4.15* Hgb-12.4* Hct-36.2*
MCV-87 MCH-29.9 MCHC-34.3 RDW-12.6 RDWSD-39.8 Plt ___
___ 04:01AM BLOOD Neuts-57.4 ___ Monos-10.4 Eos-5.9
Baso-0.3 Im ___ AbsNeut-5.25 AbsLymp-2.31 AbsMono-0.95*
AbsEos-0.54 AbsBaso-0.03
___ 12:05AM BLOOD ___ PTT-27.0 ___
___ 09:25AM BLOOD ___ PTT-32.8 ___
___ 02:45AM BLOOD ___
___ 01:26AM BLOOD ___
___ 05:48AM BLOOD Glucose-155* UreaN-35* Creat-1.0 Na-141
K-4.4 Cl-97 HCO3-31 AnGap-13
___ 11:57PM BLOOD Glucose-165* UreaN-22* Creat-1.4* Na-144
K-3.6 Cl-105 HCO3-26 AnGap-13
___ 01:08AM BLOOD ALT-40 AST-25 AlkPhos-99 TotBili-0.3
___ 05:48AM BLOOD Calcium-9.9 Phos-4.4 Mg-2.0
___ 11:57PM BLOOD Albumin-3.7 Calcium-8.8 Phos-1.8* Mg-1.7
___ 05:25AM BLOOD %HbA1c-6.5* eAG-140*
___ 05:25AM BLOOD Triglyc-259* HDL-21* CHOL/HD-7.1
LDLcalc-77
___ 05:25AM BLOOD TSH-1.2
___ 05:25AM BLOOD CRP-2.9
___ 01:53AM BLOOD C3-232* C4-38
___ 11:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 02:21AM BLOOD Type-ART pO2-95 pCO2-38 pH-7.45
calTCO2-27 Base XS-2
___ 03:03PM BLOOD C1 ESTERASE INHIBITOR, FUNCTIONAL
ASSAY-Test
___ 05:25AM BLOOD SED RATE-Test
___ 10:57AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 04:22PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:57AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG
Radiology:
___ CXR: Decreased lung volumes with increased opacities at each
lung base. These are probably due to atelectasis in context.
Other etiologies such as aspiration or developing pneumonia
cannot be excluded, however.
___ MR Head: Left frontal intraparenchymal hemorrhage with
surrounding vasogenic edema are again seen with stable mass
effect, include minimal rightward shift of midline structures,
near complete effacement of the frontal horn and body of
the left lateral ventricle, and mild effacement and rightward
shift of the third ventricle.
2. Slow diffusion along the margins of the hemorrhage,
particularly along the medial margin, suggesting an underlying
acute to early subacute infarct.
3. There is an additional small acute to early subacute infarct
in the posterior left temporal lobe, and a late subacute to
chronic infarct with chronic blood products in the right basal
ganglia. These findings suggest embolic etiology of infarcts,
though hypertensive etiology may also be considered.
4. Within the anteromedial aspect of the left frontal
hemorrhage,
there is a 3 mm aneurysm, the origin of which is difficult to
localize due to distortion of the vessels. Diagnostic
considerations include a pre-existing aneurysm within
the new infarct, which subsequently bled, versus a septicembolic
infarct with a secondary mycotic aneurysm.
___ Head CT: Stable left frontal parenchymal hemorrhage with
stable edema and stable minimal rightward shift of midline
structures.
2. Stable near complete effacement of the frontal horn and body
of the left lateral ventricle. Left temporal horn has slightly
increased in size. Stable mild effacement and mild rightward
shift of the third ventricle.
___ CTA Chest: No evidence of pulmonary embolism.
2. Mal-positioned endotracheal tube terminates at the proximal
right main stem bronchus and should be retracted at least 3 cm.
3. Mild pulmonary edema.
4. Subsegmental atelectasis at both lung bases.
___ BLE u/s: No evidence of deep venous thrombosis in the right
or left lower extremity veins.
___ CTA Head: Large intraparenchymal hemorrhage centered in the
left basal ganglia with extension to the frontal and temporal
lobes with 3 mm of rightward midline shift. There is no evidence
of aneurysm or vascular malformation.
2. Fluid in the paranasal sinuses is probably related to the
nasogastric tube
___ Unilat UP ext veins:
IMPRESSION:
1). No evidence of deep vein thrombosis in the right upper
extremity.
2). Mild nonspecific soft tissue edema in right antecubital
fossa. No increased vascularity to suggest the presence of
inflammation.
___ Unilat lower ext veins:
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ Chest (Portable AP):
IMPRESSION:
The ostomy is in place. Left PICC line tip is at the level of
mid SVC. The up of tube tip is in the stomach. Heart size and
mediastinum are unchanged. There unchanged appearance of
elevated
right hemidiaphragm and bilateral retrocardiac opacities most
likely representing atelectasis. No definitive new
consolidation
to suggest interval development of infection demonstrated. No
definitive pneumothorax.
Transthoracic Echo ___:
moderate pulmonary hypertension with a moderately dilated right
ventricle
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
2. amLODIPine 10 mg PO DAILY
3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
4. Cetirizine 10 mg PO DAILY
5. Heparin 5000 UNIT SC BID
6. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
7. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB
8. Labetalol 400 mg PO BID
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Acute hemorrhagic stroke
Dysphagia
Hypoxic respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with intubation// Assess location of ET tube
Assess location of ET tube
IMPRESSION:
Compared to chest radiograph ___ one.
Endotracheal tube has been repositioned, now nearly 3 cm from the carina.
Cyst previous left lower lobe collapse has improved, but still severely
atelectatic. Pleural effusions small if any. Heart size top-normal. No
pneumothorax.
Esophageal drainage tube ends in the upper stomach.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ is a ___ yo M with left basal ganglia IPH,
minimal mass effect and no midline shift. No underlying vascular abnormality.
No acute neurosurgical intervention indicated. Admitted to Stroke Neurology
and presented to SICU for critical care management.// Eval for PE, concern
while at the outside hospital
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.4 s, 31.7 cm; CTDIvol = 15.2 mGy (Body) DLP = 480.6
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
Total DLP (Body) = 484 mGy-cm.
COMPARISON: Chest radiographs dated ___ and ___.
FINDINGS:
Lines and tubes:
The endotracheal tube terminates at the proximal right stem bronchus and
should be retracted at least 3 cm. An enteric tube courses along the
esophagus and is demonstrated at the proximal stomach. A right-sided central
venous catheter terminates at the right atrium.
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is subsegmental atelectasis at both lower lungs. There
is subtle diffuse ground glass opacity with interlobular septal thickening
representing mild pulmonary edema. Airways are patent to the level of the
segmental bronchi bilaterally. No bronchial wall thickening, bronchiectasis
or mucous plugging.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen demonstrates a mildly patulous
esophagus with a small amount of retained fluid.
BONES:No acute fractures. No suspicious osseous abnormality is seen.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Mal-positioned endotracheal tube terminates at the proximal right main stem
bronchus and should be retracted at least 3 cm.
3. Mild pulmonary edema.
4. Subsegmental atelectasis at both lung bases.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:17 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with ICH now with central line access// Central
line placement Contact name: ___: ___ Central line
placement
IMPRESSION:
Comparison to ___, 09:12 peer the endotracheal tube and the feeding
tube are in correct stable position. The patient has received the new right
internal jugular vein catheter. The course of the catheter is unremarkable,
the tip projects at the level of the cavoatrial junction. No pneumothorax or
other complication. Normal size of the heart. Mild retrocardiac atelectasis.
Stable appearance of the lung parenchyma.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with ICH// Patient with ICH, assess DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with IPH// interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.4 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CTA head dated earlier same day.
FINDINGS:
Again seen is a left frontal intraparenchymal hemorrhage measuring 3.5 x 3.1
cm, unchanged in size from prior when measured in the same fashion.
Surrounding vasogenic edema has decreased in density but remains unchanged in
extent. There is stable near complete effacement of the frontal horn and body
left lateral ventricle, with slight increase in the size of the temporal horn.
The third ventricle is partially effaced and mildly shifted to the right,
unchanged. Right lateral ventricle is not dilated. Stable minimal rightward
shift of midline structures. Basal cisterns remain preserved.
No concerning osseous findings. Endotracheal tube is noted on the scout
image. Nasogastric tube is partially included on CT images. There is fluid
in the nasal cavity and nasopharynx. There is increased fluid in the left
maxillary and right sphenoid sinuses. There is also mucosal thickening in the
ethmoid, maxillary, and sphenoid sinuses. These findings are likely secondary
to endotracheal and nasogastric intubation. Mastoid air cells appear grossly
well-aerated. The orbits appear unremarkable.
IMPRESSION:
1. Stable left frontal parenchymal hemorrhage with stable edema and stable
minimal rightward shift of midline structures.
2. Stable near complete effacement of the frontal horn and body of the left
lateral ventricle. Left temporal horn has slightly increased in size. Stable
mild effacement and mild rightward shift of the third ventricle.
Radiology Report
CLINICAL HISTORY ___ year old man with left BG hemorrhage// eval left basal
ganglia hemorrhage. Possible associated aneurysm
EXAMINATION: Left internal carotid artery arteriogram.
Three dimensional rotational angiography left internal carotid and
postprocessing on separate work station with concurrent physician supervision
with images being used for final interpretation.
Left external carotid artery arteriogram.
Right internal carotid artery arteriogram.
Right common carotid artery arteriogram.
Left vertebral artery arteriogram.
Right common femoral artery arteriogram and Angio-Seal closure of right common
femoral artery puncture site.
ANESTHESIA: ANESTHESIA: The patient was already intubated with IV propofol.
TECHNIQUE: OPERATORS: Dr. ___ performed the entire procedure..
PROCEDURE: Patient was brought to the Angiography suite. IV sedation was
given. Patient was already intubated access was gained to the right common
femoral artery using a Seldinger technique and a 6 ___ long vascular sheath
was placed in the right common femoral artery. The above-mentioned vessels
were catheterized and AP lateral filming with three-dimensional rotation
angiography performed. This revealed no evidence of aneurysm arteriovenous
malformation dural AV fistula or vasculitis a right common femoral artery
arteriogram was done and a 6 ___ Perclose used for closure of the right
common femoral artery puncture site.
FINDINGS:
Right internal carotid artery arteriogram shows filling of the right internal
carotid artery along the cervical, petrous, cavernous, supraclinoid segment
the anterior and middle cerebral arteries are seen well with no evidence of
aneurysm arteriovenous malformation or dural AV fistula.
Right common carotid artery arteriogram shows that the right external carotid
artery fills well with no evidence of dural AV fistula.
Left external carotid artery arteriogram shows filling of the left external
carotid artery with no evidence of dural AV fistula.
Left internal carotid arteriogram shows that the left internal carotid artery
fills well along the cervical, petrous, cavernous, supraclinoid segment
anterior and middle cerebral arteries fill well with no evidence of aneurysm
or arteriovenous malformation. There is no evidence of vasculitis.
Left vertebral artery arteriogram shows filling of the left vertebral artery
and both PCAs with no evidence of arteriovenous malformation, dural AV
fistula, aneurysm or vasculitis.
Right common femoral artery arteriogram shows no evidence of stenosis.
IMPRESSION:
No structural vascular lesion to account for left hemispheric hemorrhage.
RECOMMENDATION(S): Follow-up with noninvasive imaging in ___ months.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p hemorrhagic stroke now intubated// Assess
lung volumes, effusion, ET tube location
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with stable cardiomediastinal silhouette. Support lines
and tubes are unchanged. Small bilateral effusions left greater than right
are also unchanged. There is stable subsegmental atelectasis in the left
lower lobe and near complete atelectasis in the right middle and right lower
lobes.
Radiology Report
EXAMINATION: Chest radiograph, portable AP view.
INDICATION: Hemorrhagic stroke.
COMPARISON: Prior study from earlier on the same day.
FINDINGS:
Endotracheal tube terminates about 2.5 cm above the carina. Orogastric tube
terminates in the stomach. A right internal jugular catheter extends into the
upper right atrium. Cardiac, mediastinal and hilar contours appear stable.
Lung volumes are decreased with increased basilar opacities that are likely
due to atelectasis. No visible pneumothorax or pleural effusion.
IMPRESSION:
Decreased lung volumes with increased opacities at each lung base. These are
probably due to atelectasis in context. Other etiologies such as aspiration
or developing pneumonia cannot be excluded, however.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ICH and NG tube.// NG placement
IMPRESSION:
In comparison with the study of ___, the nasogastric tube now extends to
the mid body of the stomach, before coiling back on itself to lie in the upper
stomach pointed to the hemidiaphragm. The overall appearance is quite similar
to the prior examination. Little change in the appearance of the heart and
lungs except for better visualization of the left hemidiaphragmatic contour in
decreasing retrocardiac opacification.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ICH who is intubated and failed RSBI// Pt
failed RSBI Pt failed RSBI
IMPRESSION:
Comparison to ___. The monitoring and support devices are in stable
position. Moderate cardiomegaly persists. Moderate atelectasis at the right
lung bases is unchanged. Mild pulmonary edema is stable. No new parenchymal
abnormalities are noted.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ is a ___ yo M with left basal ganglia IPH,
minimal mass effect and no midline shift. No underlying vascular abnormality.
No acute neurosurgical intervention indicated. Admitted to Stroke Neurology
and presented to SICU for critical care management// Assess lung volumes,
currently intubated Assess lung volumes, currently intubated
IMPRESSION:
Comparison to ___. The patient continues to be intubated. Lung
volumes are low. Moderate cardiomegaly persists. Stable relatively extensive
atelectasis at the level of the right middle lobe. No pneumonia. No
pulmonary edema. No pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ICH// poor respiratory function
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
remain in standard position. Continued very low lung volumes with stable
enlargement of the cardiac silhouette. Elevation of the right
hemidiaphragmatic contour is unchanged, as are the atelectatic changes above
it and volume loss in the left lower lobe. No evidence of pulmonary edema.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new PICC needs tip confirmation// New Lt.
___. 52cm DL PICC ___ ___ Contact name: ___, Phone: 6Trumpet8! New Lt.
___. 52cm DL PICC ___ ___
IMPRESSION:
ET tube tip is 3.5 cm above the carina. NG tube tip is in the stomach. Right
internal jugular line tip is at the level of cavoatrial junction. Heart size
is enlarged. Mediastinum is stable. Lungs are overall clear. No appreciable
pleural effusion or pneumothorax is seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ICH who has failed multiple SBTs// pneumonia
vs atelectasis vs pulmonary edema pneumonia vs atelectasis vs pulmonary
edema
IMPRESSION:
ETT tube is 2.5 cm above the carina. NG tube tip is in the stomach. Left
PICC line tip is at the cavoatrial junction. Heart size and mediastinum are
stable. Bibasal areas of opacities are new and may represent atelectasis
versus infectious process. There is mild vascular congestion but no overt
pulmonary edema.
No sizable pleural effusion is demonstrated but small amount cannot be
excluded.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ICH who has failed multiple SBTs// Assess
lung volumes Assess lung volumes
IMPRESSION:
Comparison to ___. Stable correct position of the monitoring
and support devices. Lung volumes are low. Moderate cardiomegaly persists.
Stable mild retrocardiac atelectasis. Mild pulmonary edema is unchanged. No
new focal parenchymal opacities.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with ICH// failed SBTs, intubated, possible pna
failed SBTs, intubated, possible pna
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lung volumes remain very low, exaggerating mild to moderate cardiac
enlargement. Severe consolidation left lower lobe has not improved could be
atelectasis alone, but pneumonia is not excluded. Both upper lobes grossly
clear. No pneumothorax. Pleural effusions small on the right if any.
ET tube, left PIC line in standard placements. Nasogastric drainage tube is
folded in the stomach, terminating in the fundus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with ICH and difficulty weaning from vent//
difficulty weaning from vent difficulty weaning from vent
IMPRESSION:
Compared to chest radiographs ___ through ___.
Low lung volumes exaggerate mild to moderate cardiomegaly. No pulmonary edema
pleural effusion. Lungs grossly clear.
Left PIC line ends in the mid SVC.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM ___
INDICATION: ___ year old man with trach// dophoff? dophoff?
IMPRESSION:
Compared to chest radiographs ___ through ___ at 06:18.
New tracheostomy tube midline. Left PIC line ends in the low SVC. Lungs
remain low and there is still substantial bibasilar atelectasis. Cardiomegaly
is mild. Upper lungs clear. Pleural effusions small if any. No
pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p trach with fever.// febrile to ___ s/p
trach, possible pna
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
There are low bilateral lung volumes with increased bibasilar opacities either
reflecting atelectasis or pneumonia. Bronchovascular crowding is present,
presumably secondary to the low lung volumes. There is no pneumothorax. The
size of the cardiac silhouette is unchanged.
A tracheostomy tube is present. The Dobhoff projects over the stomach. A
left PICC projects over the cavoatrial junction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with acute stroke s/p treach, now with fever.//
Fever, is there a new consolidation Fever, is there a new consolidation
IMPRESSION:
The ostomy is in place. Left PICC line tip is at the level of mid SVC. The
up of tube tip is in the stomach. Heart size and mediastinum are unchanged.
There unchanged appearance of elevated right hemidiaphragm and bilateral
retrocardiac opacities most likely representing atelectasis. No definitive
new consolidation to suggest interval development of infection demonstrated.
No definitive pneumothorax.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old man with hemiparesis, now fever// R sided: any DVT,
new fevers can't assess for pain
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right
upper extremity veins.
COMPARISON: Ultrasound scan dated ___
FINDINGS:
There is normal flow with respiratory variation in the right subclavian
veins.
The right internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. The right basilic,
and cephalic veins are patent, compressible and show normal color flow.
Nonspecific edema was seen in the soft tissues within the antecubital fossa.
IMPRESSION:
1). No evidence of deep vein thrombosis in the right upper extremity.
2). Mild nonspecific soft tissue edema in right antecubital fossa. No
increased vascularity to suggest the presence of inflammation.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old man with hemiparesis, now fever// any DVT, new fevers
can't assess for pain
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the right
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old man with replaceing ng tube// ng tube replacement 2
images, half way and after
IMPRESSION:
In comparison with the study of ___, on the final image the Dobhoff tube
is in the upper to mid stomach. Tracheostomy tube and left subclavian
catheter remain in good position.
There are improved lung volumes, but otherwise little change in the appearance
of the heart and lungs.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old man with NG tube, confirm position// confirm position
of ng tube
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The Dobhoff tube and tracheostomy tube are unchanged. Left-sided PICC line
projects to the SVC. Cardiomediastinal silhouette is stable. Small bilateral
effusions. No pneumothorax.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS ___
INDICATION: ___ year old man with NG Tube Placement// 2 images to confirm NG
placement 2 images to confirm NG placement
IMPRESSION:
Compared to chest radiographs ___ through ___.
2 frontal chest radiographs show advancement of the esophageal feeding tube,
with a wire stylet in place, from the low esophagus to the upper stomach.
Left PIC line ends in the upper SVC. Tracheostomy tube midline.
Borderline cardiomegaly is exaggerated by extremely low lung volumes.
Moderate right basal atelectasis unchanged. No pneumothorax. No pulmonary
edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with NGT that fell out a little bit// Confirm NGT
still in appropriate position
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 10:40.
IMPRESSION:
The Dobbhoff enteric tube has been retracted and now terminates in the cardia
of the stomach. Advancement by 7 cm is recommended. No other significant
interval change compared to prior study from earlier today.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with Dobhoff replacement// Assess placement of
Dobhoff
TECHNIQUE: AP radiograph with limited views of the chest and abdomen.
COMPARISON: Prior radiograph dated ___.
FINDINGS:
CHEST:
Lungs are clear. No focal consolidation, effusion, pneumothorax.
Cardiomediastinal silhouette appears normal. Central line likely terminates
in the proximal-mid SVC.
ABDOMEN:
Limited view of the abdomen. No dilated loops of large small bowel on current
view. Interval advancement of Dobhoff tube, terminates in the fundus of the
stomach.
IMPRESSION:
interval advancement of Dobhoff tube. Tip now projects over body of the
stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with basal ganglia hemorrhage// is dobhoff in the
right place
TECHNIQUE: Three sequential AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 05:08.
IMPRESSION:
There has been interval placement of a Dobbhoff enteric tube, which terminates
in the body of the stomach on the final image. No other significant interval
change compared to study from earlier today.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with Basal ganglia IPH// Please evaluate lung
fields
IMPRESSION:
In comparison with the study of ___, there again are low lung volumes and
the monitoring support devices are stable. Continued enlargement of the
cardiac silhouette with left ventricular configuration. No evidence of
vascular congestion or acute focal pneumonia.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: History: ___ with AMS*** WARNING *** Multiple patients with same
last name!// assess for bleed
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
3) Spiral Acquisition 2.9 s, 22.7 cm; CTDIvol = 30.2 mGy (Head) DLP = 687.5
mGy-cm.
Total DLP (Head) = 1,515 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is an intraparenchymal hemorrhage centered in the left putamen with
extension into the frontal and temporal lobes which measures 2.5 x 3.2 x 3.4
cm (AP by TRV by CC). There is surrounding edema. There is mass effect, with
effacement of the left lateral ventricle. No additional hemorrhage is
identified. There is approximately 3 mm of rightward midline shift. There is
no evidence of infarction.
There is fluid layering in both maxillary sinuses. There is partial
opacification of the anterior ethmoid air cells bilaterally. Endotracheal and
nasogastric tubes are in place the visualized portion of the mastoid air
cells,and middle ear cavities are clear. The visualized portion of the orbits
are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. There are
no findings to suggest an arteriovenous malformation. The dural venous
sinuses are not well opacified, and consequently patency cannot be assessed.
IMPRESSION:
1. Large intraparenchymal hemorrhage centered in the left putamen with
extension to the frontal and temporal lobes with 3 mm of rightward midline
shift. There is no evidence of aneurysm or vascular malformation.
2. Fluid in the paranasal sinuses.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with parenchymal hemorrhage. Evaluate for
underlying lesion, CAA, ischemic strokes.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 12 cc Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CTA head and CTA head dated earlier same day.
FINDINGS:
A left frontal intraparenchymal hemorrhage with surrounding vasogenic edema
appears stable compared to the earlier same day CT allowing for differences in
patient head position, measuring 3.5 x 3.7 cm. There is stable near complete
effacement of the frontal horn and body of the left lateral ventricle, minimal
rightward shift of midline structures and mild effacement and rightward shift
of the third ventricle.
There is restricted diffusion along the margins of the hemorrhage, most
prominent along the medial margin of the hemorrhage, suggestive of an
underlying acute to early subacute infarct. On post-contrast MPRAGE, there is
a 3 mm aneurysm of a small vascular branch within the anteromedial aspect of
the intraparenchymal hemorrhage (14:102), the origin of which is difficult to
localize due to distortion of the vessels. There is also minimal linear
enhancement along the posterior aspect of the hemorrhage, likely reactive.
There is a small focus of restricted diffusion in the posterior left temporal
lobe (06:13), consistent with of an acute to early subacute infarct.
There is a small late subacute to chronic infarct in the right basal ganglia,
with linear chronic blood products on gradient echo images along its lateral
margin (11:15, 10:14).
Fluid is again seen in the azelaic cavity, nasopharynx, bilateral frontal
sinuses, left posterior ethmoid sinus, left sphenoid sinus, and left maxillary
sinus, likely secondary to endotracheal and nasogastric intubation. Mucosal
thickening is also again seen in the paranasal sinuses. There is trace fluid
in the bilateral dependent mastoid tip air cells, likely also secondary to
endotracheal and nasogastric intubation.
IMPRESSION:
1. Left frontal intraparenchymal hemorrhage with surrounding vasogenic edema
are again seen with stable mass effect, include minimal rightward shift of
midline structures, near complete effacement of the frontal horn and body of
the left lateral ventricle, and mild effacement and rightward shift of the
third ventricle.
2. Slow diffusion along the margins of the hemorrhage, particularly along the
medial margin, suggesting an underlying acute to early subacute infarct.
3. There is an additional small acute to early subacute infarct in the
posterior left temporal lobe, and a late subacute to chronic infarct with
chronic blood products in the right basal ganglia. These findings suggest
embolic etiology of infarcts, though hypertensive etiology may also be
considered.
4. Within the anteromedial aspect of the left frontal hemorrhage, there is a 3
mm aneurysm, the origin of which is difficult to localize due to distortion of
the vessels. Diagnostic considerations include a pre-existing aneurysm within
the new infarct, which subsequently bled, versus a septic embolic infarct with
a secondary mycotic aneurysm.
RECOMMENDATION(S):
1. Conventional cerebral angiogram is recommended for further evaluation of
the 3 mm aneurysm within the left frontal intraparenchymal hemorrhage.
2. Clinical correlation regarding a possible embolic source of infarcts and
any possibility of aseptic infarct.
NOTIFICATION: The findings and recommendations were discussed with ___
___, M.D. by ___, M.D. in person on ___ at 4:18 pm, 2
minutes after discovery of the findings.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: ICH, Transfer
Diagnosed with Dyspnea, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UA
level of acuity: 2.0 | Mr. ___ is a ___ male, with no past medical history
as he did not primarily follow-up with a physician, who
presented from an outside hospital after having acute onset
shortness of breath while showering, and requiring intubation by
EMS. He was found to have a left basal ganglia hemorrhage, was
given 1 g of IV Keppra, and transported via ___ to ___
where he was admitted to the neurology stroke service for acute
hemorrhagic stroke.
# Left basal ganglia hemorrhage. Likely secondary to
hypertension. Work-up included stroke risk factors, and
etiology workup. Initially, there was concern for aneurysm based
on MRI findings. He underwent conventional angiogram and review
by neurosurgery. Neurosurgery does not believe there is an
aneurysm, and we agree with their assessment. Patient was not
hypertensive when he arrived to the outside hospital emergency
room, but perhaps has nocturnal hypertension given his report of
OSA symptoms and daytime sleepiness which possibly caused some
significant spikes in his blood pressure causing the bleed.
Patient was subsequently hypertensive throughout his admission,
which was initially treated via IV Nicardipine drip in the ICU,
and was transitioned to amlodipine 10 mg a day, and labetalol
400 mg twice a day. MRI is significant for acute Left frontal
intraparenchymal, Evolving posterior left temporal lobe, and
likely prior right basal ganglia findings, concerning for
central source and embolism source versus hypertension. Further
evaluation with transthoracic echocardiogram found no clear
thrombus or valvular etiology of the stroke. Telemetry or
greater than 3 weeks found no dysrhythmia.
Other risk factor findings, Obesity, type 2 diabetes HbA1c 6.5%,
Hypercholesterolemia with triglycerides 259, HDL 21, LDL 77.
TSH 1.2. Exam at discharge is significant for right-sided
hemiplegia (face, arm, and leg), and anarthria.
-To complete the work-up for etiology of this hemorrhage,
patient will require a Repeat MRI w/ gadolinium in ___ weeks.
## ID - Chronic Sinusitis
In context of fever ___, increased secretions. Patient had
multiple fevers throughout the admission, and was treated with
multiple antibiotics. Throughout the course of the admission
the patient had 9 set of blood cultures that were negative,
multiple UAs and a urine culture that was negative, 3 sputum and
an aspirate that were all negative, and 2 bronchial alveolar
lavages that were also all normal respiratory flora. Patient
also had multiple chest x-rays that just showed atelectasis, CTA
that showed no PE, and ultrasound of his right upper and lower
extremity to look for any concern of DVT. All antibiotics were
discontinued, with the exception of a course of amoxicillin
clavulanate for treatment of chronic sinusitis. Patient no
longer with any fevers.
# Angioedema secondary to Captopril. Captopril Discontinued on
___. Work-up included C1 esterase inhibitor levels which is
normal, C3 and C4 C3 was slightly elevated, and C4 was normal,
with no clear etiology of the edema. Evaluated by ENT, started
on a high-dose steroid challenge with significant improvement.
# Tracheostomy- placed on ___ due to persistent respiratory
failure. On ___, tracheostomy obstructed, requiring ICU
transfer. However, patient was able to tolerate breathing
without the trach and observed in the ICU during that time. On
___ trach removed, and patient has been breathing fine. Basic
dry dressing on wound, with plan for tracheostomy site to close
with time.
# Dysphagia- PEG tube placed by general surgery on ___. Working
fine, receiving feeds.
Patient had ___ on admission with a creatinine of 1.4, now
resolved, with a current creatinine level ranging around 1. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Per PCP ___, "Home ___ called on behalf of the patient because
he has ongoing nausea/vomiting. He has not been able to eat. He
has had
persistently low blood glucoses, blood sugars in the ___
persistently over the past few days, currently it is 133. He has
been vomiting for the past 4 days, he had one good day on ___
but has otherwise been unable to eat/drink and vomits every time
he does take something PO... The patient reports that he feels
very weak. I asked the patient to please come into the ER."
.
Vitals in the ER: 98.9 95 144/63 22 95% RA. He received Zofran,
IV Morphine, Levoflozacin, Vancomycin, and 2L NS.
.
The patient states that he has had intermittant hypoglycemia
from the ___ associated with nausea, vomiting, but no
diaphoresis or shaking. He states that he has fatigue and has
taken Metformin and Glyburide without having eaten much food
secondary to fatigue and poor appetite. He also complains of
left-sided chest pain with vomiting and coughing associated with
the Pleur-X cath. He also has chronic right shoulder and right
foot pain, the latter after surgery on ___. He states that
Oxycodone is slightly effective but does not last long enough
nor does it stop baseline pain.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, photophobia. Denies
headache Denies chest pain or tightness, palpitations, lower
extremity edema. Denies wheezes, diarrhea, constipation,
abdominal pain, melena, hematemesis, hematochezia. Denies
dysuria, stool or urine incontinence. Denies rashes or skin
breakdown. All other systems negative.
.
Past Medical History:
PAST MEDICAL HISTORY (outside nonsmall cell lung cancer):
1. Hypertension;
2. Hyperlipidemia;
3. Type 2 diabetes mellitus;
4. Chronic shoulder pain, arthritis;
5. S/P right toe surgery for a bone cyst ___
6. S/P Pleur-X cath placement for malignant effusion
7. Admitted ___ for sepsis and pneumonia
8. Hypoxemia 88% RA on 2L home O2
9. Cervical stenosis with radiculopathy
.
ONCOLOGY HISTORY: Mr. ___ is a ___ year-old
___ man current smoker (50 pack-years) who
presented
to medical care in ___ with subacute worsening of
shortness of breath and cough productive of purulent sputum. He
also had low grade fever. He denied prior cardio-pulmonary
complaints or constitutional symptoms. At time of admission he
was quite hypoxic on room air and required supplemental
oxygenation.
.
He was admitted to ___ from ___ to ___ for
evaluation.
.
Imaging studies with CT chest from ___ disclosed a
consolidation of the lingula, bronchial narrowing, mediastinal
lymphadenopathy, liver hypodense lesions and a large loculated
left pleural effusion. A PET/CT Scan from ___ disclosed the
presence of extensive FDG-avid consolidative process in the
lingula, lymphangitic carcinomatosis, non-FDG avid pleural
effusion, FDG-avid lymphadenopathy involving the bilateral
supraclavicular regions, mediastinum, subcarinal stations,
hilar,
portacaval and retroperiotenal nodes. FDG-avid liver lesions and
FDG-avid osseous metastases. Head MRI from ___ did not
disclose evidence of lesions.
.
The patient was symptomatically treated with antibiotics
(completed a course of cefpodoxime - 14 days), supplemental
oxygen and a left-sided thoracentesis. The patient referred
significant improvement of his cardio-pulmonary function with
the
pleural drainage.
.
The malignant pleural fluid removed on ___ disclosed a
carcinoma. Immunohistochemical stains of the tumor cells were
positive for CK5/6, and CK7; and negative for CK20, p63, and
TTF-1. This immunoprofile is nonspecific but compatible with a
non-small-cell lung cancer not otherwise specified.
.
Since his inpatient discharge, the patient's condition has
slowly
deteriorated. His dyspnea with exertion has worsened over the
last 2 weeks and he requires intermittent oxygen. He has a ___
that visits once a week. His cough is present but he no longer
has sputum. He is not smoking much. He denies much in the way of
chest pain.
Social History:
___
Family History:
Father with a stroke; mother with cancer; sister
with diabetes, hypertension.
Physical Exam:
VS: T 98.5 bp 120/77 HR 79 RR 18 SaO2 100 2L NC Wt 160 lbs
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP dry and
without lesion
NECK: Supple
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. Pleur-X cath in
place with clean dressings
ABD: Soft, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion; right foot has bandage after
operation on foot ___, not taken down at time of admission
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: appropriate
.
Pertinent Results:
___ 06:35PM LACTATE-4.2*
___ 06:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 06:10PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 03:33PM LACTATE-5.7*
___ 03:25PM GLUCOSE-76 UREA N-27* CREAT-1.0 SODIUM-136
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-21* ANION GAP-23*
___ 03:25PM ALT(SGPT)-137* AST(SGOT)-109* ALK PHOS-512*
TOT BILI-0.2
___ 03:25PM LIPASE-29
___ 03:25PM ALBUMIN-3.6
___ 03:25PM WBC-11.9*# RBC-4.12* HGB-10.9* HCT-34.3*
MCV-83 MCH-26.4* MCHC-31.8 RDW-15.1
___ 03:25PM NEUTS-86.5* LYMPHS-7.8* MONOS-4.7 EOS-0.8
BASOS-0.2
___ 03:25PM PLT COUNT-470*
___ 03:25PM ___ PTT-31.0 ___
.
___
5:30p CT Abd & Pelvis With Contrast -- Preliminary Result
Moderate left nonhemorrhagic pleural effusion with a Pleurx
catheter in place. Multiple liver hypodensities concerning for
metastases. Prominent cluster of periaortic nodes at the level
of the left renal artery.
.
___
3:39p CT Head W/O Contrast -- Full Report
No acute intracranial process. Note that the normal MRI from
___ more effectively exclude metastasis.
.
CXR:
FINDINGS: In comparison with the study of ___, there has been
removal of some pleural fluid from the left. No definite
pneumothorax. Some fissural is again seen.
The right lung is essentially clear
.
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY
.
___ 05:10AM BLOOD WBC-6.3 RBC-3.85* Hgb-9.9* Hct-31.4*
MCV-82 MCH-25.8* MCHC-31.6 RDW-15.0 Plt ___
___ 06:20AM BLOOD WBC-7.9 RBC-3.74* Hgb-9.9* Hct-30.4*
MCV-81* MCH-26.5* MCHC-32.6 RDW-15.8* Plt ___
___ 06:10AM BLOOD WBC-6.0 RBC-3.60* Hgb-9.3* Hct-29.4*
MCV-81* MCH-25.9* MCHC-31.8 RDW-15.9* Plt ___
___ 03:25PM BLOOD WBC-11.9*# RBC-4.12* Hgb-10.9* Hct-34.3*
MCV-83 MCH-26.4* MCHC-31.8 RDW-15.1 Plt ___
___ 03:25PM BLOOD Neuts-86.5* Lymphs-7.8* Monos-4.7 Eos-0.8
Baso-0.2
___ 03:25PM BLOOD ___ PTT-31.0 ___
___ 12:45PM BLOOD K-PND
___ 06:45AM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-135
K-5.5* Cl-100 HCO3-22 AnGap-19
___ 06:30AM BLOOD Na-136 K-4.6 Cl-99
___ 06:55AM BLOOD Glucose-82 UreaN-13 Creat-0.8 Na-135
K-4.7 Cl-100 HCO3-22 AnGap-18
___ 05:10AM BLOOD Glucose-75 UreaN-15 Creat-0.9 Na-134
K-4.9 Cl-97 HCO3-22 AnGap-20
___ 06:20AM BLOOD Glucose-66* UreaN-13 Creat-0.9 Na-135
K-4.9 Cl-99 HCO3-23 AnGap-18
___ 06:10AM BLOOD Glucose-47* UreaN-17 Creat-0.9 Na-137
K-5.3* Cl-103 HCO3-24 AnGap-15
___ 03:25PM BLOOD Glucose-76 UreaN-27* Creat-1.0 Na-136
K-5.0 Cl-97 HCO3-21* AnGap-23*
___ 05:10AM BLOOD CK(CPK)-283
___ 06:20AM BLOOD ALT-118* AST-105* AlkPhos-466*
TotBili-0.3
___ 06:10AM BLOOD LD(LDH)-457*
___ 03:25PM BLOOD ALT-137* AST-109* AlkPhos-512*
TotBili-0.2
___ 03:25PM BLOOD Lipase-29
___ 05:10AM BLOOD TSH-4.3*
___ 06:55AM BLOOD Free T4-1.2
___ 05:10AM BLOOD Cortsol-14.8
___ 05:47AM BLOOD Lactate-3.1*
___ 07:38AM BLOOD Lactate-3.2*
___ 06:35PM BLOOD Lactate-4.2*
___ 03:33PM BLOOD Lactate-5.7*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Benzonatate 100 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. urea *NF* 40 % Topical BID
Apply to affected areas of both feet
7. Simvastatin 10 mg PO DAILY
8. Sildenafil 50 mg PO DAILY:PRN sex
9. Naproxen 500 mg PO Q12H:PRN pain
Please take with food
10. MetFORMIN (Glucophage) 850 mg PO TID
11. GlyBURIDE 5 mg PO BID
12. Senna 1 TAB PO BID
13. Polyethylene Glycol 17 g PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
.
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Benzonatate 100 mg PO TID
3. Sildenafil 50 mg PO DAILY:PRN sex
4. urea *NF* 40 % Topical BID
Apply to affected areas of both feet
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
6. Docusate Sodium 100 mg PO BID
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN prior to
pleurx drainage
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. Simvastatin 10 mg PO DAILY
12. Megestrol Acetate 80 mg PO TID
13. Mirtazapine 15 mg PO HS
14. Morphine SR (MS ___ 15 mg PO Q12H
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Diltiazem 15 mg PO QID
18. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic non-small cell lung cancer
Malignant left pleural effusion
hypoglycemia- medication-induced
prolapsed hemorrhoids
deconditioning
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: History of nausea and vomiting. Lung cancer.
TECHNIQUE: PA and lateral chest radiographs were obtained.
COMPARISON: ___ through ___
FINDINGS:
There has been an increase in the moderate left pleural effusion and fluid
within the left major fissure. A left pleural catheter is in place.The right
lung is clear other than minimal basilar atelectasis. There is no new cardiac
and mediastinal contour.
IMPRESSION:
Increasing size of left pleural effusion since ___ and ___.
Presence of superimposed infection cannot be excluded.
Radiology Report
HISTORY: Metastatic lung cancer presenting with nausea and vomiting.
TECHNIQUE: MDCT data were acquired through the head without intravenous
contrast. Images were displayed in multiple planes.
COMPARISON: MR head ___.
FINDINGS:
There is no acute intracranial hemorrhage, major vascular territory
infarction, edema, mass or shift of the midline structures. Ventricles and
sulci are normal size and shape. Basal cisterns are patent. Gray-white
differentiation is preserved. There are no bone or soft tissue lesions.
There is a mucous retention cyst in the left posterior ethmoid air cells
(3:1). Otherwise the paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
No acute intracranial process. Note that the normal MRI from ___ more
effectively excludes metastasis.
Radiology Report
HISTORY: Diabetes, nausea, abdominal tenderness, non-small cell lung cancer.
TECHNIQUE: MDCT data were acquired through the abdomen and pelvis after
administration of oral and intravenous contrast. Images were displayed in
multiple planes.
COMPARISON: ___ PET-CT ___, CT chest ___
FINDINGS:
A left-sided Pleurx catheter is positioned appropriately within a moderate
left pleural effusion. Adjacent dependent atelectasis is mild. The right
lung base is clear.
Numerous hypodensities throughout the liver parenchyma are again concerning
for metastases. The largest lesion measures 2 cm in segment III (2:25). The
portal veins are patent. There is no intrahepatic or extrahepatic biliary
dilatation. The gallbladder is unremarkable. The pancreas and spleen enhance
homogeneously. The adrenal glands have normal contour and attenuation.
Multiple hypodensities in both kidneys are noted, with the larger ones
compatible with simple cysts; others are too small to characterize. There is
no hydronephrosis. An enlarged node in the porta hepatis measures
approximately 4.2 x 0.9 cm (2: 25, 301b: 26). Prominent para-aortic nodes
are also visualized. There is no ascites. The origins of the celiac and SMA
are patent. The stomach small large bowel are normal caliber and appearance.
A normal caliber appendix is visualized in the right lower quadrant. The
bladder and prostate are unremarkable. Diffuse vas deferens calcifications
are compatible with a history of diabetes.
Bone windows: Extensive osseous metastases are better seen on PET-CT from ___.
IMPRESSION:
1. Numerous hepatic hypodensities concerning for metastases.
2. Extensive osseous metastases better seen on PET-CT.
3. Moderate left pleural effusion with Pleurx catheter in place and adjacent
atelectasis.
4. No acute process otherwise identified.
Radiology Report
HISTORY: Metastatic lung cancer with malignant pleural effusion and Pleurx
drainage, to assess for pneumonia and pneumothorax.
FINDINGS: In comparison with the study of ___, there has been removal of
some pleural fluid from the left. No definite pneumothorax. Some fissural
fluid is again seen.
The right lung is essentially clear.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: NAUSEA AND VOMITING
Diagnosed with FAILURE TO THRIVE,ADULT
temperature: 98.5
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 64.0
level of pain: 4
level of acuity: 2.0 | Pt is a ___ y.o male with h.o metastatic NSCLC with malignant
pleural effusion who was admitted for hypoglycemia, found to
have acidosis.
.
#Hypoglycemia with associated nausea and vomiting - secondary to
taking oral hypoglycemics in the setting of moderate
malnutrition and poor PO intake. Resolved after stopping
metformin and glyburide. Pt was placed on an insulin sliding
scale with minimal requirements. He can continue this while at
rehab. If diet continues to improve, pt may need consideration
of longer acting insulin.
.
#Rib pain secondary to metastatic disease with scapular pain and
right foot pain after operation on toe. Added MSContin as
baseline analgesia and increased oxycodone to ___ Q4 prn.
Dc'd naproxen given poor po intake and concern for future ___.
.
#Anion Gap acidosis with Lactacemia secondary to volume
depletion in the setting of N/V and poor PO intake as well as
concurrent malignancy. Hemodynamics stable currently and on
presentation without fever do not suggest sepsis. Improved with
volume and increased PO intake.
.
#Malignant pleural effusion s/p Pleur-X cath. Drained every
other day during his stay. Last drained ___ for about
125cc. Continued 2L home O2. WOuld premedicate with oxycodone
prior to drainage.
.
#metastatic NSCLC-onc f/u scheduled later this month to
determine if palliative chemo is an option after genotype
studies return. PET concerning for lymphangitic carcinomatosis
with osseous involvement. Will need rehab to increase
performance status. Pt was started on mirtazipine and megace for
anorexia/nausea. Palliative care was involved during admission.
Pain controlled by starting oxycontin and increasing dose of
oxycodone. Pt was consulted who recommended rehab. ___ will be
following up with oncology later this month after genotype
studies return to discuss palliative chemotherapy options. See
appointment scheduled below. ___ was started on remeron and
megace for appetite with good effect and compazine and zofran
for nausea with good effect.
.
#prolapsed hemorrhoids-outpt f/u suggested. Pt ordered for ___
baths, bowel regimen and fiber. Pt should follow up with Dr.
___ ongoing care and evaluation as an outpatient. See
appointment below.
.
#deconditioning/Sinus tachycardia with ambulation/exertion-Pt
would benefit from rehab.
.
#hyperkalemia-unclear etiology. Not on any clear inciting meds.
Could have been due to Hep SC for DVT ppx. This improved with
kayexylate therapy. K 4.9 on the day of discharge. Would recheck
potassium on ___ to consider need for further kayexylate
therapy.
.
#DM2, contiued ___, started scale insulin. Stopped metformin and
glyburide, see above. DM diet, HISS.
.
#HTN, ___. CCB dose was decreased to 15mg QID of
diltiazem.
.
FEN: DM diet .
#PPx - SC heparin
.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Cipro / Keflex / Effexor / Lipitor / lisinopril
Attending: ___.
Chief Complaint:
R MCA aneurysm, pituitary lesion, skull meningioma
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ F with history of anxiety,
hypertension (not on meds), tobacco use, and persistent vomiting
due to slow colonic transit who presents to the ___ ED with
new
findings of a 7mm R MCA bifuracation aneurysm, pituitary lesion
with possible hemorrhage, and L frontal skull meningioma in the
setting of elevated blood pressure and worsening headaches x 2
months.
She has a home BP cuff which reportedly read 230/130 today with
associated chest pain and palpitations. She called her PCP who
advised her to call ___. Upon EMS arrival BP was 166/88. She was
transferred to ___ where a CT and CTA was done with the
above findings and she was transferred to ___ ED for
neurosurgical evaluation.
On review of systems she reports intermittent worsening
bifrontal
headaches x2 months and L ear pain for which she takes Aleve
PRN,
last dose today. She is not on any anticoagulations. She has
daily nausea and vomiting due to her slow colonic transit for
which she sees a gastroenterologist. She reports double vision
and blurred vision. She states she had seizures after a fall ___
years ago but has never been on medications for seizures. The
details surrounding this are unclear. She denies recent
weakness,
falls or trauma. She has numbness in her fingers of her right
hand and in bilateral feet. She reports chest palpitations x1
month and had chest pain earlier today which resolved. EKG at
OSH
showed sinus brady with non-specific T wave abnormality. She
also
reports night sweats which have been going on for many months.
Past Medical History:
PMHx:
HTN - not on medications
HLD
TIA age ___
Chronic nausea and vomiting
Slow colonic transit
Renal artery occlusion repair age ___ at ___
Breast tumor s/p removal (benign)
Uterine fibroids
? TBI about ___ years ago
PSHx:
Tonsillectomy
Adenotonsillectomy
Breast tumor removal
Eustachian tube placement L ear
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Gen: Tearful, states "I'm depressed" regarding new diagnosis.
WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL. EOMs: Left ___ nerve palsy
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, tearful
affect at start of exam. Otherwise normal affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Mild hand tremors
otherwise no abnormal movements, tremors. Strength full power
___
throughout. No pronator drift.
Sensation: Numbness in fingers of R hand and bilateral feet.
Otherwise sensation is intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Handedness: Right
On discharge:
___: Alert and oriented x3. PERRL 3-2mm bilaterally.
Abduction and adduction deficits in L eye. EOMs intact on R eye.
Visual acuity grossly intact in all visual fields of both eyes.
Peripheral vision intact. Face symmetrical. Tongue midline. No
pronator drift. Moves all extremities full strength ___.
Baseline intermittent numbness in fingers of right hand and
bilateral feet.
Pertinent Results:
___ Abdomen Xray
IMPRESSION:
No radiopaque foreign body. Note is made that contrast in the
bladder
obscures the surrounding soft tissues.
___ MRI brain and pituitary
IMPRESSION:
1. 6 mm round lesion of the distal pituitary salk with mild
mass effect on the pituitary gland as described above. The
differential diagnosis is broad and some considerations include
pituitary adenoma, Rathke's cleft cyst, ectopic posterior
pituitary, pituicytoma, germinoma, granular cell tumor of the
pituitary gland.
2. 6 mm aneurysm at the right MCA bifurcation.
3. No hemorrhage or infarction.
___ MRA brain
Brain MRA:
There is a 6 mm aneurysm at the right MCA bifurcation. The
circle of ___ and it major tributaries are otherwise within
normal limits without stenosis or occlusion.
___ CTA Head and Neck
WET READ on ___ 5:45 ___
CT HEAD WITHOUT CONTRAST:
Again seen is a 6 mm hyperdense lesion in the region of the
distal pituitary stalk, better Characterized on recent MRI. No
acute intracranial process.
CTA HEAD:
Again seen is a 6 mm aneurysm at the bifurcation of the right
MCA, not
significantly changed (11:308).
CTA NECK:
The carotid and vertebral arteries and their major branches
appear normal with no evidence of stenosisorocclusion.
Medications on Admission:
Bisacodyl 5mg PO qpm
Valium 2mg PRN
Lasix 20mg PRN
Hyoscyamine Sulfate 0.125mg TID
Inulin/Chromium Picolinate (fiber gummies) 1tab PO daily
Lubiprostone 24mcg PO BID 8am and 12pm
Naproxen sodium 220mg PO PRN
Omeprazole 20mg PO daily
Prochlorperazine 10mg po Daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Do not exceed 4GM acetaminophen in 24 hours.
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Nicotine Patch 14 mg TD DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
Hold for sedation. Do not drive while taking this medication
RX *oxycodone 5 mg 1 tablet(s) by mouth q8h PRN Disp #*10 Tablet
Refills:*0
5. Bisacodyl 5 mg PO QHS
6. Hyoscyamine 0.125 mg PO TID
7. Lubiprostone 24 mcg PO DAILY BID 8AM AND 12PM
8. Omeprazole 20 mg PO DAILY
9. Prochlorperazine 10 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
6mm R MCA bifurcation aneurysm
Pituitary lesion- Rathke's Cleft Cyst
Skull meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ year old woman with pituitary apoplexy, incidentally
discovered R MCA aneurysm.// Eval R MCA 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 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 9.0 s, 15.3 cm; CTDIvol = 48.8 mGy (Head) DLP =
746.1 mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7
mGy-cm.
3) Stationary Acquisition 4.0 s, 1.0 cm; CTDIvol = 29.9 mGy (Head) DLP =
29.9 mGy-cm.
4) Spiral Acquisition 9.9 s, 37.9 cm; CTDIvol = 35.5 mGy (Head) DLP =
1,289.5 mGy-cm.
Total DLP (Head) = 2,111 mGy-cm.
COMPARISON: MRI/MRA brain on ___, CTA head on ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Again seen is a 6 mm hyperdense lesion in the region of the distal pituitary
stalk (4:11). There is no evidence of infarction, hemorrhage or edema. The
ventricles and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses and and middle ear cavities
are clear. There is partial opacification of the mastoid air cells, similar
to prior. The visualized portion of the orbits are unremarkable.
CTA HEAD:
Again seen is a 6 mm aneurysm at the bifurcation of the right MCA, not
significantly changed (11:308). The vessels of the circle of ___ and
their principal intracranial branches appear normal with no evidence of
stenosis or occlusion. The dural venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. 6 mm aneurysm at the bifurcation of the right MCA, similar to prior.
2. Re-demonstration of a 6 mm hyperdense lesion in the region of the distal
pituitary stalk, better characterized on recent MRI.
Radiology Report
EXAMINATION: MRI BRAIN AND PITUITARY; MRA BRAIN W/O CONTRAST PT78; T___ MR
___ HEAD.
INDICATION: ___ year old woman with OSH imaging concerning for aneurysm and
pituitary mass. Evaluate for pituitary mass and aneurysm
TECHNIQUE: Sagittal and coronal T1 weighted imaging were performed along with
coronal T2 imaging. Sagittal and coronal T1 weighted imaging were repeated
after the uneventful intravenous administration of Gadavist contrast.
Sequences through the brain include axial T1, axial T2, axial GRE, axial
FLAIR, axial postcontrast T1 and sagittal postcontrast MP RAGE with axial and
coronal constructions. 3D time-of-flight MR angiogram of the head was also
performed and maximum intensity projection reconstructions were it are
reviewed.
COMPARISON ___ outside noncontrast head CT and head CTA.
FINDINGS:
Brain MRI with dedicated pituitary imaging:
There is no parenchymal signal abnormality. There is no focus of slow
diffusion. There is no evidence of hemorrhage or infarction. The ventricles
and sulci are age-appropriate. Principal intracranial vascular flow voids are
preserved. There is fluid signal partially opacifies the mastoid air cells
bilaterally. Orbits are grossly unremarkable.
Intimately associated with the distal pituitary stalk and exerting mass effect
on the pituitary gland is a 6 mm round lesion intrinsically T1 hyperintense
lesion without definite enhancement. A central focus of hypointense signal on
T2 weighted images within the lesion seen as hyperdensities on CT may
represent hemorrhage or mineralization (series 12, image 7; series 13, image
6). The pituitary gland enhances homogeneously. There is no expansion of the
sella. The proximal portion of the pituitary stalk is normal in caliber and
enhances appropriately. The optic chiasm is within normal limits.
Brain MRA:
There is a 6 mm aneurysm at the right MCA bifurcation. The circle of ___
and it major tributaries are otherwise within normal limits without stenosis
or occlusion.
IMPRESSION:
1. 6 mm round lesion of the distal pituitary salk with mild mass effect on
the pituitary gland as described above. The differential diagnosis is broad
and some considerations include pituitary adenoma, Rathke's cleft cyst,
ectopic posterior pituitary, pituicytoma, germinoma, granular cell tumor of
the pituitary gland.
2. 6 mm aneurysm at the right MCA bifurcation.
3. No hemorrhage or infarction.
Radiology Report
INDICATION: History: ___ with need for MRI// Eval for any metallic objects
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
No upright or decubitus view was obtained and the diaphragms are not included
on these views, limiting assessment for free intraperitoneal air. No findings
suggestive of free intraperitoneal on the available views.
Contrast is seen in the bilateral collecting systems and bladder related to
recent CTA.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
Incidental note made of degenerative changes of lower lumbar spine and SI
joints.
IMPRESSION:
No radiopaque foreign body. Note is made that contrast in the bladder
obscures the surrounding soft tissues.
Radiology Report
EXAMINATION: MRI BRAIN AND PITUITARY; MRA BRAIN W/O CONTRAST PT78; T___ MR
___ HEAD.
INDICATION: ___ year old woman with OSH imaging concerning for aneurysm and
pituitary mass. Evaluate for pituitary mass and aneurysm
TECHNIQUE: Sagittal and coronal T1 weighted imaging were performed along with
coronal T2 imaging. Sagittal and coronal T1 weighted imaging were repeated
after the uneventful intravenous administration of Gadavist contrast.
Sequences through the brain include axial T1, axial T2, axial GRE, axial
FLAIR, axial postcontrast T1 and sagittal postcontrast MP RAGE with axial and
coronal constructions. 3D time-of-flight MR angiogram of the head was also
performed and maximum intensity projection reconstructions were it are
reviewed.
COMPARISON ___ outside noncontrast head CT and head CTA.
FINDINGS:
Brain MRI with dedicated pituitary imaging:
There is no parenchymal signal abnormality. There is no focus of slow
diffusion. There is no evidence of hemorrhage or infarction. The ventricles
and sulci are age-appropriate. Principal intracranial vascular flow voids are
preserved. There is fluid signal partially opacifies the mastoid air cells
bilaterally. Orbits are grossly unremarkable.
Intimately associated with the distal pituitary stalk and exerting mass effect
on the pituitary gland is a 6 mm round lesion intrinsically T1 hyperintense
lesion without definite enhancement. A central focus of hypointense signal on
T2 weighted images within the lesion seen as hyperdensities on CT may
represent hemorrhage or mineralization (series 12, image 7; series 13, image
6). The pituitary gland enhances homogeneously. There is no expansion of the
sella. The proximal portion of the pituitary stalk is normal in caliber and
enhances appropriately. The optic chiasm is within normal limits.
Brain MRA:
There is a 6 mm aneurysm at the right MCA bifurcation. The circle of ___
and it major tributaries are otherwise within normal limits without stenosis
or occlusion.
IMPRESSION:
1. 6 mm round lesion of the distal pituitary salk with mild mass effect on
the pituitary gland as described above. The differential diagnosis is broad
and some considerations include pituitary adenoma, Rathke's cleft cyst,
ectopic posterior pituitary, pituicytoma, germinoma, granular cell tumor of
the pituitary gland.
2. 6 mm aneurysm at the right MCA bifurcation.
3. No hemorrhage or infarction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, Transfer
Diagnosed with Cerebral aneurysm, nonruptured
temperature: 98.2
heartrate: 62.0
resprate: 14.0
o2sat: 98.0
sbp: 143.0
dbp: 91.0
level of pain: 3
level of acuity: 2.0 | Ms. ___ is a ___ F who was transferred to ___ ED with R
MCA aneurysm, pituitary lesion with possible hemorrhage, and L
skull meningioma. On exam she has concerning visual deficits
including double vision and blurred vision in the left upper
quadrant of her left eye concerning for pituitary apoplexy.
Endocrine and ophthalmology were consulted in the ED and the
patient was admitted to the ___ for monitoring.
#Pituitary lesion: An MRI confirmed 6mm round lesion of the
distal pituitary stalk with mild mass effect on the pituitary
gland without hemorrhage or infaraction. The patient was started
on decadron given the visual deficits however after
ophthalmology evaluation it was felt the adduction and abduction
deficits of the left eye had been long standing. Endocrine
followed and based on the lab results it was felt the lesion was
unlikely a pituitary adenoma. The decadron was discontinued.
Labs were ordered for pheochromocytoma work up given reported
severe hypertension, headaches, and night sweats prior to
admission. The lesion is likely a Rathke's cleft cyst. The
patient was advised to follow-up with visual field testing at
discharge as well as in 3 months with a 3 month follow-up MRI
pituitary and appointment in the ___ clinic.
#Hypertension: Patient required a few doses of hydralazine early
in her admission however blood pressure remained stable over the
following days and did not require PRN medications. Her EKG was
stable and her troponin levels were flat. She was advised to
follow-up with her PCP after discharge.
#R MCA aneurysm: MRI/A confirmed a 6mm R MCA bifurcation
aneurysm. The neurovascular team recommends outpatient follow-up
in the clinic at discharge for surgical planning. CTA Head and
Neck was done prior to discharge for surgical planning. Results
to be reviewed with patient at outpatient follow-up appointment.
#Skull meningioma: On OSH non-contrast head CT there was an
incidental finding of a L fronto-temporal skull meningioma.
#Dispo: The patient was instructed to follow-up with
neurovascular, endocrine, ophthalmology, and neurosurgery at
discharge. The patient expressed understanding and agreed with
the multidisciplinary outpatient follow-up plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Pancreatic duct stent removal
History of Present Illness:
Patient is a ___ year old man with history of chronic
pancreatitis, alcohol abuse, pancreatic pseudocyst, recent left
inguinal hernia repair ___ ___, who presents with
___ days of worsening epigastric abdominal pain with radiation
to the back.
Patient has recurrent admission for alcoholic pancreatitis at
___ and ___. He is followed by Dr ___ at ___ and Dr
___. Most recently, he was admitted in ___ with
pancreatitis and found to have ascites thought to be due to
pancreatic duct disruption. He required pancreatic
sphincterotomy and pancreatic duct stenting on ___. There
was an associated 3.5 cm pseudocyst in the head of the pancreas.
He was discharged on ___. He then returned to ___ on
___ with alcoholic pancreatits (lipase 116). He continues to
drink ETOH intermittently, but has recently enrolled at the
___ for his alcoholism. He has been treating his
chronic abdominal pain with shrt scruipts of oxycodone from PCP
and was also recently started on gabapentin.
Yesterday, he had a few drinks last night with no sxs
afterwards. This morning, he woke up and drank OJ and
subsequently had sharp epigastric pain radiating to back
associated with nausea, vomiting. He also reports few days of
loose stools. Patient denies any drugs other than occasional
marijuana. No fevers. No shortness of breath no chest pain no
cough.
In the ___, initial VS were: 97.9 92 124/90 16 100% RA
___ physical exam was recorded as:
Positive voluntary guarding, diffuse tenderness to palpation.
Lungs clear bilaterally
Point of care ultrasound with an enlarged hollow viscous organ
in the left upper quadrant of the abdomen
Fast exam negative for free fluid within the abdomen.
___ labs were notable for:
Lip: 107
Lactate:3.4
WBC 10
Imaging showed:
-Non-enhancing pancreatic head, uncinate process, and proximal
body are similar to prior exam in ___ with a small
amount of surrounding nonspecific peripancreatic fluid,
compatible with necrotizing pancreatitis.
-Re- demonstration of a pancreatic stent from the duodenum and
extending into the mid pancreatic duct. Pancreatic duct is
dilated measuring up to 9 mm, also similar to prior study.
-The previously noted pancreatic pseudocyst is not seen on
today's exam.
-Substantial interval improvement in previously noted ascites
from ___.
Patient was given:
___ 10:09 IV Ondansetron 4 mg ___
___ 10:09 IV HYDROmorphone (Dilaudid) 1 mg
___
___ 10:09 IVF NS ___ Started
___ 12:06 IV Ondansetron 4 mg ___
___ 12:06 IVF LR ___ Started
___ 12:06 IV HYDROmorphone (Dilaudid) 1 mg ___
___
___ 12:07 IVF NS 1 mL ___ Stopped (1h ___
___ 13:42 IV Lorazepam 1 mg ___
___ 13:58 IV HYDROmorphone (Dilaudid) 1 mg ___
___
___ 14:00 IVF LR 1 mL ___ Stopped (1h ___
___ 15:21 TD Nicotine Patch 21 mg ___
Applied
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
EtOH abuse
alcoholic pancreatitis
BPH
Chronic neck pain
Social History:
___
Family History:
Mother with DM, HTN
Father deceased prostate ca and colitis
Physical Exam:
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, tender to palpation of epigastrium, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
Pertinent Results:
___ 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 12:40PM URINE MUCOUS-RARE
___ 10:10AM ALT(SGPT)-12 AST(SGOT)-21 ALK PHOS-90 TOT
BILI-0.2
___ 10:10AM WBC-10.6* RBC-4.67 HGB-12.0* HCT-34.7*
MCV-74* MCH-25.7* MCHC-34.6 RDW-19.0* RDWSD-51.1*
___ 10:10AM NEUTS-72.9* ___ MONOS-6.7 EOS-0.2*
BASOS-0.6 IM ___ AbsNeut-7.74* AbsLymp-2.04 AbsMono-0.71
AbsEos-0.02* AbsBaso-0.06
1. Non-enhancing pancreatic head, uncinate process, and proximal
body are
similar to prior exam in ___ with a small amount of
surrounding
nonspecific peripancreatic fluid, compatible with necrotizing
pancreatitis.
2. Re- demonstration of a pancreatic stent from the duodenum and
extending
into the mid pancreatic duct. Pancreatic duct is dilated
measuring up to 9
mm, also similar to prior study.
3. The previously noted pancreatic pseudocyst is not seen on
today's exam.
4. Substantial interval improvement in previously noted ascites
from ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Creon 12 2 CAP PO TID W/MEALS
3. FLUoxetine 30 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. alfuzosin 10 mg oral DAILY
9. Ondansetron 4 mg PO Q8H:PRN n/v
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. alfuzosin 10 mg oral DAILY
3. Creon 12 2 CAP PO TID W/MEALS
4. FLUoxetine 30 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN n/v
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
for pain Disp #*15 Tablet Refills:*0
10. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with pancreatitis // ?effusion, eval size of
pancreatic pseudocyst ?effusion, eval size of pancreatic pseudocyst
IMPRESSION:
In comparison with study of ___, the patient has taken a better
inspiration. Cardiac silhouette is within normal limits and there is no
evidence of vascular congestion, pleural effusion, or acute focal pneumonia.
Evaluation of the pancreatic pseudocyst would require ultrasound or CT.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with abdominal pain // ?eval size of pancreatic
pseudocyst
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis with and without contrast from ___.
FINDINGS:
LIVER: The visualized portions of hepatic parenchyma appears within normal
limits. The contour of the liver is smooth.
GALLBLADDER: The visualized portions of the gallbladder appear normal without
evidence of stones.
PANCREAS: The pancreatic ductal stent is in place. The pancreatic duct is
enlarged, measuring up to 9 mm. Calcifications are noted again in the
pancreatic head. The previously seen pancreatic head cystic structure is not
seen on today's exam, possibly improved.
SPLEEN: Normal echogenicity, measuring 6.8 cm.
KIDNEYS: The right kidney measures 11.1 cm with a small amount of right
perinephric fluid. The left kidney measures 11.2 cm. Normal cortical
echogenicity and corticomedullary differentiation is seen bilaterally. There
is no evidence of masses, stones, or hydronephrosis in the kidneys.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Pancreatic ductal stent is in place with continued enlargement of the
pancreatic duct, now on measuring up to 9 mm.
2. The previously noted multiloculated pseudocyst is not seen on today's
exam.
3. Multiple foci of calcification within the pancreatic parenchyma compatible
with changes of chronic pancreatitis.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: NO_PO contrast; History: ___ with epigastric abdominal painNO_PO
contrast // eval size of pancreatitic psuedocyst, eval pseudocyst vs walled
peripancreatic necrosis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol
= 26.5 mGy (Body) DLP = 13.2 mGy-cm. 2) Spiral Acquisition 4.2 s, 46.0 cm;
CTDIvol = 6.2 mGy (Body) DLP = 286.2 mGy-cm. Total DLP (Body) = 299 mGy-cm.
COMPARISON: CT abdomen pelvis with and without contrast from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: A pancreatic stent is redemonstrated within the duodenum and
extending into the mid pancreatic duct. The pancreatic duct again appears
dilated, measuring up to 9 mm, which is similar in size since the prior exam
in ___. There is a small amount of nonspecific peripancreatic fluid
without evidence of focal enhancing collection. The previously noted
pseudocyst is not seen on today's exam. The pancreatic parenchyma in the head,
uncinate process and proximal body is not well enhancing, compatible with
necrotizing pancreatitis, similar to the prior exam in ___. There
are features of chronic pancreatitis, with calcifications noted in the
pancreatic parenchyma. There are multiple enlarged enhancing homogenous
prominent lymph nodes, likely reactive.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: Air-fluid level is noted in the mid esophagus. The stomach
is distended. There is some edema within the duodenal wall, adjacent to the
stent. The remaining small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. The colon and rectum are within normal
limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Non-enhancing pancreatic head, uncinate process, and proximal body
demonstrates features of necrotizing pancreatitis similar to prior exam in
___ with a small amount of surrounding peripancreatic fluid.
Scattered punctate foci of calcification throughout the pancreatic parenchyma
is compatible with chronic pancreatitis.
2. Re- demonstration of a pancreatic stent from the duodenum into the mid
pancreatic duct- in unchanged position. Unchanged main pancreatic ductal
dilation measuring up to 9 mm .
3. The previously noted pancreatic pseudocyst is not seen on today's exam.
4. Interval complete resolution in previously noted ascites.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Acute pancreatitis with uninfected necrosis, unspecified
temperature: 97.9
heartrate: 92.0
resprate: 16.0
o2sat: 100.0
sbp: 124.0
dbp: 90.0
level of pain: 10
level of acuity: 3.0 | A/P: Patient is a ___ year old man with history of chronic
pancreatitis, alcohol abuse, pancreatic pseudocyst, recent left
inguinal hernia repair ___ ___, who presents with
___ days of worsening epigastric abdominal pain with radiation
to the back, presentation consistent with acute on chronic
pancreatitis.
# Acute on chronic pancreatitis: Presented with typical pain,
mildly elevataed lipase (not 3 times above ULN) and findingfs of
necrotizing pancreatitis on CT. The previously noted pancreatic
pseudocyst was not visible on today's exam. He is
hemodynamically stable with mildly elevated lipase. He tolerated
pancreatic stent removal and was discharged the next day with a
7 day course of oxycodone.
# HTN: Noted to be hypertensive on floor, likely partially
related to pain and nausea from pancreatits. Also likely has
underlying essential HTH. WIll focus on pain control for now,
initiation of anti hypertensive deferred to PCP, patient advised
to follow up.
# EtOH abuse: Continues to use despite recurrent pancreatitis.
Currently enrolled in outpatient program. Social work saw him.
# Depression. Continue home Prozac
#BPH: Home medication (alfuzosin) was held as it is not
formulary |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Penicillins / Dicloxacillin / Morphine / Compazine /
Reglan / Amicar / Verapamil / Ambien / Valtrex / Percocet
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ hx of lupus, renal failure on HD, sz d/o,
anti-phospolipid antibody syndrome, htn, osteoporosis, severe
right hand steal and esophegeal spasms presented to ED with w/
CP. Pt was paying bills this afternoon when pain developed in
her back. She wasn't sure if it was just intermittent MSK pain
that she occassionally so she laid down. The pain did not
resolve and radiated to her chest. She took SLNGT which has been
prescribed by GI for esophageal spasm but unfortunately it did
not help. Pt also believes the nitro may have dropped her
pressure as well as she felt dizzy. She then called EMS to be
taken the the hospital. Had some SOB and pain in neck also. Her
pain resolved in the ambulance ride to the hosptial w/o further
intervention. Of note the pt recently had a normal stress test
in ___.
In ED initial VS were 98.3 68 125/57 19 100%. She was given full
dose ASA and hydromorhone for pain. Her EKG showed no concerning
ischemic changes from prior and Trop of .11 is at her baseline
due to CKD. She was sent for CTPA which was negative for PE. She
was admitted for dialysis as she just received contrast dye
load.
On the floor she is walking around her room joking with the
examiner. She is feeling well and currently CP free.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Past Medical History:
# ESRD DUE TO: Thrombotic microangiopathy, s/p renal transplant
___, graft failed and started on RRT in ___ previously on PD,
switched to HD in ___, (tunneled catheter placed ___,
s/p right transplant nephrectomy ___
# ACCESS: Left AVF created ___ Right brachiocephalic AV
fistula placed ___.
- Thrombotic microangiopathy s/p renal transplant in ___
- Antiphospholipid antibody syndrome
- SLE
- ___ deficiency
- DVT (___) involving the left internal jugular, left
axillary and one of the left proximal brachial veins, on
warfarin
- OSA on CPAP (auto CPAP ___ with 50 mL EERS and two liters
oxygen per Dr. ___ recent note)
- Depression
- Anxiety
- Seizure disorder, unclear etiology
- ?bipolar disorder
- H/o malignant HTN c/b hypertensive encephalopathy and PRES
- Hyperlipidemia
- Raynaud's phenomenon in ___
- GERD
- Gastritis in ___
- Migraine headaches (remote)
- s/p TAH-BSO at ___ for heavy menses and bleeding ovarian cysts
- H/o aspiration pneumonia, pulmonary hemorrhage and ___
- H/o gout, on chronic prednisone
- H/o seizures with dialysis
- Diplopia thought to be due to lamotrigine, followed by
neurology
- s/p cholecystectomy
- H/o T7 compression fracture
- H/o tardive dyskinesia
Social History:
___
Family History:
Father with anti-phospholipid syndrome, HTN, DM. Sister with MS.
___ siblings with asthma, HTN.
Physical Exam:
Admission:
VS: 97.6, 118/66, 64, 16, 100% RA
GENERAL: well appearing, walking around room, joking with
examiner
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, L sided engorged neck VV from prior failed
LUE fistula
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: old fistual present in LUE, fistula also present in
RUE with palpable thrill
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
.
Discharge:
VS: 97.3, 138/50, 69, 18, 100% RA
GENERAL: well appearing, walking around room
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, L sided engorged neck VV from prior failed
LUE fistula
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: old fistual present in LUE, fistula also present in
RUE with palpable thrill, extremely tender fingers on right hand
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
LABS:
___ 04:30PM BLOOD WBC-6.3 RBC-3.75* Hgb-12.3 Hct-38.2
MCV-102* MCH-32.8* MCHC-32.2 RDW-18.2* Plt ___
___ 04:30PM BLOOD Neuts-78* Bands-0 Lymphs-8* Monos-11
Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-0
___ 04:30PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-NORMAL
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL
___ 06:30AM BLOOD WBC-5.7 RBC-3.55* Hgb-11.8* Hct-37.3
MCV-105* MCH-33.3* MCHC-31.6 RDW-18.7* Plt ___
___ 04:30PM BLOOD ___ PTT-52.7* ___
___ 06:30AM BLOOD ___
___ 04:30PM BLOOD Glucose-73 UreaN-29* Creat-4.6* Na-135
K-4.3 Cl-91* HCO3-27 AnGap-21*
___ 06:30AM BLOOD Glucose-72 UreaN-42* Creat-5.8*# Na-134
K-4.8 Cl-90* HCO3-27 AnGap-22*
___ 04:30PM BLOOD cTropnT-0.11*
___ 06:30AM BLOOD cTropnT-0.10*
___ 06:30AM BLOOD Calcium-8.6 Phos-6.9*# Mg-2.4
CXR PA/LAT ___:
Slight prominence of the interstitial markings may be due to
interstitial edema, appears slightly increased since the prior
study.
CTA CHEST ___:
(Preliminary Report) No CT evidence for pulmonary embolus. Mild
pulmonary edema, unchanged compared to prior. Persistent
mediastinal lymphadenopathy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
hold for sbp <100
2. Nephrocaps 1 CAP PO DAILY
3. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral q6hrs
HA
4. Calcitriol 0.5 mcg PO EVERY OTHER DAY
5. Calcium Acetate 1334 mg PO TID W/MEALS
6. Restasis *NF* (cycloSPORINE) 0.05 % ___ BID
7. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
hold for sedation or RR <10
8. Ketoconazole 2% 1 Appl TP BID
apply to rash
9. Labetalol 200 mg PO BID
hold for sbp <100 or HR <60
10. LaMOTrigine 200 mg PO BID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
12. Omeprazole 40 mg PO BID
13. Ondansetron 4 mg PO BID:PRN nausea
14. Quetiapine Fumarate 150 mg PO QHS
15. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
16. Sodium Polystyrene Sulfonate 7.5 gm PO 3X/WEEK (___)
17. Warfarin 3 mg PO 3X/WEEK (MO,WE,SA)
18. Warfarin 4 mg PO 4X/WEEK (___)
19. Docusate Sodium 100 mg PO BID
20. Acetaminophen 325 mg PO Q8H:PRN pain
21. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
22. Ranitidine 150 mg PO HS
23. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Medications:
1. Acetaminophen 325 mg PO Q8H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
4. Calcitriol 0.5 mcg PO EVERY OTHER DAY
5. Calcium Acetate 1334 mg PO TID W/MEALS
6. Docusate Sodium 100 mg PO BID
7. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
8. Ketoconazole 2% 1 Appl TP BID
9. Labetalol 200 mg PO BID
10. LaMOTrigine 200 mg PO BID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
12. Nephrocaps 1 CAP PO DAILY
13. Omeprazole 40 mg PO BID
14. Ondansetron 4 mg PO BID:PRN nausea
15. Quetiapine Fumarate 150 mg PO QHS
16. Ranitidine 150 mg PO HS
17. Restasis *NF* (cycloSPORINE) 0.05 % ___ BID
18. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
19. Warfarin 3 mg PO 3X/WEEK (MO,WE,SA)
20. Warfarin 4 mg PO 4X/WEEK (___)
21. butalbital-acetaminophen-caff *NF* 50 mg ORAL Q6HRS HA
22. Sodium Polystyrene Sulfonate 7.5 gm PO 3X/WEEK (___)
23. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Atypical chest pain
Esophageal spasm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest, frontal and lateral views.
CLINICAL INFORMATION: Chest pain.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. There is
mild prominence of the interstitial markings, suggesting minimal interstitial
edema, although the possibility of underlying chronic lung disease is also
raised. No focal consolidation is seen. There is no pleural effusion or
pneumothorax. The cardiac and mediastinal silhouettes are stable.
IMPRESSION: Slight prominence of the interstitial markings may be due to
interstitial edema, appears slightly increased since the prior study.
Radiology Report
HISTORY: ___ female with coagulopathy, chest pain, and shortness of
breath.
TECHNIQUE: Axial CT images of the chest were acquired after administration of
intravenous contrast. Coronal, sagittal, and bilateral oblique maximum
intensity projection reformatted images were created and reviewed.
COMPARISON: ___.
FINDINGS:
Diffuse ground glass opacification of the lungs appears unchanged; this may be
secondary to mild edema or due to expiratory phase imaging. 2-mm right lower
lobe pleural based nodule has been present since at least ___ (2:46).
Mild bilateral dependent atelectasis, right greater than left, is again seen.
Right lower lobe linear atelectasis or scarring appears unchanged. No pleural
effusion or pneumothorax is detected. The pulmonary arteries appear patent to
the subsegmental levels without evidence for pulmonary embolus. The remainder
of the great vessels appear patent and normal in caliber with arterial
atherosclerotic calcification. Prominent mediastinal lymph nodes persist.
Extensive venous collaterals in the left chest wall are again seen, likely
related to occlusion of the left subclavian and brachiocephalic venous
systems, incompletely evaluated on this study.
This study is not optimized for evaluation of subdiaphragmatic structures, but
no acute abnormalities are detected in the visualized portion of the upper
abdomen.
No concerning lytic or sclerotic osseous lesions are detected. A mid thoracic
vertebral body compression deformity appears unchanged.
IMPRESSION:
No CT evidence for pulmonary embolus. Mild pulmonary edema, unchanged
compared to prior. Persistent mediastinal lymphadenopathy.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS
temperature: 98.3
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 118.0
dbp: 66.0
level of pain: 5
level of acuity: 3.0 | ___ w/ complex medical history including ESRD on dialysis who
presents to the hospital with atypical chest pain most likely
related to esophageal spasm or GERD and admitted to the medicine
service from the ED for possible dialysis in the setting of
getting CT contrast for CTA chest to rule out PE.
Patient's chest pain was somewhat concerning for cardiac chest
pain given that it was associated with SOB, while her other
episodes of esophageal spasm chest pain had not been. EKG was
not concerning for ischemia, and troponins x2 were reassuring
(elevated at 0.10-0.11, but this is her baseline given her
ESRD). No PE. Patient can follow up with her PCP and
gastroenterologist for further management of her esophageal
spasm.
We spoke with the renal team. Patient is anuric and does not
require urgent dialysis to remove CT contrast, as there is no
residual kidney function at risk of being lost due to contrast
nephropathy. She will get her regular outpatient dialysis
tomorrow ___.
Patient's INR was subtherapeutic at 1.3-1.4 (goal is 1.5 for hx
of thrombotic microangiopathy), but she will be stopping
warfarin tomorrow ___ for upcoming surgery on ___ anyway, so
we did not change her dose of warfarin and did not initiate a
bridging therapy.
Home medications were continued.
Patient was full code during this admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Low speed MVC, flexion-extension injury, head ache, blurry
vision, dizziness, nausea.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ female s/p low-speed motor
vehicle accident in which she hit the back of her head against
the chair headrest. She has a past medical history significant
for paroxysmal supraventricular tachycardia, for which she takes
no medication, and she otherwise has no known health conditions.
The patient was rear-ended this morning at 7:40 am as she was
stopped on Rt. 14 on her way to work. Upon impact, her head
accelerated forward and on its return arc slammed into the
headrest. Mrs. ___ immediately felt ___ sharp occipital
pain, nausea and her vision became blurry; she reports no
emesis,
loss of consciousness, double vision, loss of vision, or other
neurologic symptoms. The patient was able to pull her car over
the to the side of the road, but felt dizzy and increased
occipital pain and nausea. She then drove home and had her son
take her to the ED at ___. A non-contrast head CT
was initially read as non-concerning and she was discharged
home.
The patient was called back to the hospital after the imaging
studies were reviewed because the final read was suggestive of a
left-sided occipital fracture. She was advised to come to ___
for neurosurgical evaluation.
On the author's read, the CT scan shows a left-sided, lateral
basilar skull fracture approximately 2 cm and non-displaced that
is within 4 mm of the foramen magnum. There is no evidence of
subdural or other hemorrhage. On exam the patient is
neurologically intact, however she recalled ___ objects at 5
minutes; she continues to complain of headache and now occipital
soreness, tenderness to palpation with neck stiffness and
diffuse
paraspinal tenderness to palpation. When Mrs. ___ moves her
neck she hears a crackling sound, but I was not able to elicit
crepitus, albeit the exam was limited secondary to pain. There
is some soft tissues swelling in the medial and left occiput,
but
no evidence of displaced bone or lacerations. She has not had
facial droop, difficulty with speech, swallowing or respiration.
She has felt tired and sore, but otherwise denies any changes in
mental status, strength or coordination.
Past Medical History:
Paroxysmal supraventricular tachycardia
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On Admission:
PHYSICAL EXAM:
Tm: 98.5 Tc: 98 BP: 128/84 HR: 99 RR: 18 O2Sats: 99% RA
Gen: WD/WN, comfortable, NAD, patient wearing a hard C-collar.
Husband and son in room at bedside.
HEENT: Pupils: 5->3.5 brisk, EOMI
Neck: Supple.
Abd: Soft, NT.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 3.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice and finger rub.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezii normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout.
Sensation: Intact to light touch and proprioception bilaterally.
Reflexes: B T Br Pa Ac
Right 1 1+ 0 2+ 0
Left 1+ 1+ 0 2+ 0
Toes downgoing bilaterally
On Discharge:
Stable and intact
Pertinent Results:
___ 08:00PM GLUCOSE-146* UREA N-9 CREAT-0.8 SODIUM-140
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
___ 08:00PM CALCIUM-9.4 PHOSPHATE-2.7 MAGNESIUM-2.1
___ 08:00PM WBC-11.4* RBC-4.15* HGB-12.7 HCT-35.6* MCV-86
MCH-30.6 MCHC-35.7* RDW-13.1
___ Lumbo-sacral spine AP/Lat
No acute fracture or dislocation.
___: CT Thoracolumbar spine: No fracture or malalignment
___: CT head noncontrast: no hemorrhage.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hrs Disp #*40
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Basilar Skull fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman status post MVA with back pain.
COMPARISON: None available.
TECHNIQUE: Helical axial MDCT sections were obtained from the skullbase
through the thoracic spine. Reformatted images in sagittal and coronal axes
were obtained.
Total Exam DLP: 755mGy-cm
CTDIvol 32mGy
FINDINGS:
No disc, vertebral, or paraspinal abnormality is seen. There is no fracture
or traumatic malalignment. The vizualized lungs are clear. The thyroid is
normal. No lymphadenopathy is present by CT size criteria. CT is not able to
provide intrathecal detailed compatible MRI, but the visualized outline of the
thecal sac is unremarkable.
IMPRESSION:
1. No fracture or traumatic malalignment of the thoracic spine.
Radiology Report
HISTORY: ___ woman status post MVA with back pain
COMPARISON: None available.
TECHNIQUE: Helical axial MDCT sections were obtained from the skullbase
through the lumbar spine. Reformatted images in sagittal and coronal axes were
obtained.
Total Exam DLP: 869mGy-cm
CTDIvol:32mGy
FINDINGS:
There is no evidence of fracture or traumatic malalignment within the lumbar
spine. There is mild disc bulging at the level of L4-L5 and L5-S1. No
lymphadenopathy is present by CT size criteria. The visualized soft tissues
are unremarkable.
IMPRESSION:
1. No fracture or traumatic malalignment of the lumbar spine.
2. Mild disc buldging at the level of L4-L5 and L5-S1.
Radiology Report
INDICATION: ___ woman status post motor vehicle collision with
history of occipital fracture, here to evaluate for vascular injury.
COMPARISON: Non-contrast head CT performed at ___ on ___.
TECHNIQUE: MDCT-acquired axial images were obtained through the head without
intravenous contrast. The patient declined IV contrast and, therefore, no CTA
of the head was performed. Coronal and sagittal reformatted images were
generated and reviewed.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass
effect, or shift of normally midline structures. The gray-white matter
interface is preserved without evidence of acute major vascular territorial
infarct. The ventricles and sulci are normal in size and configuration for
the patient's age.
A nondisplaced fracture of the left occipital bone extending into a venous
foramen (102:3) is again seen, with up to a 3 mm gap between the fracture
fragments at the level of the cerebellum, image 102:8. The fracture margins
are sharp and smooth, suggesting chronicity. There is no overlying soft tissue
swelling or hematoma. There is no underlying epidural or subdural collection.
Fluid and aerosolized secretions are redemonstrated in the right sphenoid
sinus and multiple bilateral ethmoidal air cells. The imaged mastoid air
cells are well aerated.
IMPRESSION:
1. Nondisplaced left occipital bone fracture, without overlying soft tissue
injury or underlying extraaxial hematoma. This fracture has sharp and smooth
margins, and it is not clear whether it is acute or chronic. Please correlate
with any associated acute symptoms and clinical history.
2. No evidence of acute intracranial abnormalities.
3. Fluid in the right sphenoid and bilateral ethmoid sinuses, which may
indicate acute sinusitis in an appropriate clinical setting.
Radiology Report
HISTORY: Rule out fracture.
COMPARISON: None available.
TECHNIQUE: Frontal and lateral views of the lumbar spine.
FINDINGS:
There are 5 non-rib-bearing vertebral bodies. Vertebral height is maintained.
No acute fractures are identified. There is no significant degenerative
disease noted. Visualized portions of the pelvis are within normal limits.
IMPRESSION: No acute fracture or dislocation.
Gender: F
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by AMBULANCE
Chief complaint: MVC, Transfer
Diagnosed with CLOSE SKULL FRACTURE NEC, UNSPECIFIED FALL
temperature: 98.5
heartrate: 105.0
resprate: 20.0
o2sat: 100.0
sbp: 133.0
dbp: 93.0
level of pain: 5
level of acuity: 2.0 | On ___, Mrs. ___ is a ___ female who presented
to the ___ ED with headache, occipital and neck pain, s/p
low-speed MVC in which she sustained a flexion-extension neck
injury and hit her head on the car headrest. The patient had a
non-contrast head CT at ___ which showed an
occipital fracture and she was advised to seek neurosurgical
consultation at ___. On arrival the patient's imaging study
was reviewed and she was evaluated by the Acute Care Surgery
service, Orthopedic Spine service and Neurosurgery and was
subsequently admitted to the Neurosurgical service for
observation. In the ED, several imaging studies were ordered,
including CTA Neck, C-Spine and T/L-spine CT scans to rule out
injuries to vasculature, spinal cord and vertebral bodies or
other bony elements of the spinal column.
On ___ she underwent CT of the thoracolumbar spine that was
negative for fx or malalignment. She could not tolerate the
administration of contrast through her IV for the CTA of the
head and neck and the patient refused the scan. Ativan was
offered for anxiety to aid with attempting the scan again
however the patient refused. She was counselled on the need for
the CTA to rule out vascular injury or arterial dissection in
the setting of her skull fracture due to the risk of stroke with
vascular injury but the patient continued to refuse the imaging
study. She was informed that her refusal of the scan would be
documented as her skull fracture carried the risk of vascular
injury, stroke and aneurysm. Her husband was present for this
conversation. Dr. ___ was made aware of the events. She
was continued in a hard cervical collar, placed in an Aspen
Collar until follow up.
At the time of discharge she was tolerating a regular diet,
ambulating without difficulty, afebrile with stable vital signs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left femoral neck fracture
Major Surgical or Invasive Procedure:
___ Left hip hemiarthroplasty
___ Dual-chamber pacemaker placement ___ Azure XT ___
MRI W1DR01)
History of Present Illness:
___ y/o man w/PMH of NASH cirrhosis, pancreatic insufficiency,
presenting with the above fracture s/p mechanical fall. He is a
community ambulator and uses a cane to walk. His children have
been pressuring him to use a walker. He fell last year and had
a similar injury and is s/p R hemi on ___ ___.
He is not happy with his hemi and wonders about a THA. He
denies antecedent hip pain.
Past Medical History:
New diagnoses this admission:
- Left femoral neck fracture s/p left hemiarthroplasty
- Paroxysmal AF/AT, sinus pauses, sick sinus syndrome s/p
dual-chamber pacemaker (___)
PMH:
- NASH cirrhosis complicated by portal hypertension, esophageal
varices
- pancreatic insufficiency secondary due to Whipple in ___
- pernicious anemia
- prostate cancer in remission
- DM2, diet controlled (A1c 7.1%)
- HTN
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: Temp: 97.5 PO BP: 134/78 HR: 58 RR: 16 O2 sat: 98% O2
General: Well-appearing male in no acute distress.
Left lower extremity:
- Dressing w/ slight strikethrough otherwise c/d/i
- 2+ edema to the lower leg
- Pain with log roll/ROM
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
DISCHARGE EXAM:
VITALS: ___ 1507 Temp: 97.8 PO BP: 129/82 HR: 59 RR: 16 O2
sat: 94% O2 delivery: Ra
GENERAL: Friendly well appearing older man sitting comfortably
in chair.
HEENT: NC/AT. No icterus or injection. MMM.
CV: RRR, no murmurs. Right-sided pacemaker without erythema or
hematoma.
RESP: CTAB.
GI: Soft, NDNT.
EXTR: Warm, mild pitting edema in bilateral ___ L>R (baseline per
patient).
SKIN: No rashes or lesions.
NEURO: Alert, oriented, attentive.
Pertinent Results:
ADMISSION LABS:
___ 08:30PM BLOOD WBC-5.7 RBC-4.26* Hgb-12.5* Hct-39.1*
MCV-92 MCH-29.3 MCHC-32.0 RDW-15.1 RDWSD-50.6* Plt ___
___ 08:30PM BLOOD Neuts-81.7* Lymphs-9.4* Monos-6.7 Eos-1.6
Baso-0.2 Im ___ AbsNeut-4.62 AbsLymp-0.53* AbsMono-0.38
AbsEos-0.09 AbsBaso-0.01
___ 08:30PM BLOOD ___ PTT-27.6 ___
___ 08:30PM BLOOD Glucose-161* UreaN-19 Creat-0.9 Na-143
K-3.8 Cl-105 HCO3-23 AnGap-15
___ 09:00PM BLOOD Calcium-8.8 Phos-4.0 Mg-1.5*
___ 08:30PM URINE Color-Straw Appear-Clear Sp ___
___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
DISCHARGE LABS:
___ 09:30AM BLOOD WBC-5.4 RBC-3.33* Hgb-10.0* Hct-31.0*
MCV-93 MCH-30.0 MCHC-32.3 RDW-15.2 RDWSD-52.3* Plt ___
___ 06:20AM BLOOD ___
___ 06:20AM BLOOD Glucose-134* UreaN-23* Creat-0.8 Na-137
K-4.7 Cl-101 HCO3-24 AnGap-12
___ 06:20AM BLOOD ALT-12 AST-30 AlkPhos-122 TotBili-0.9
___ 06:20AM BLOOD Albumin-2.7* Calcium-8.4 Phos-2.7 Mg-2.1
___ 03:59AM BLOOD %HbA1c-7.1* eAG-157*
___ 09:34AM BLOOD TSH-1.4
MICROBIO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING & STUDIES:
___ HIP 1 VIEW IN O.R.
Status post left hip prosthesis in overall anatomic alignment.
___ CHEST (PORTABLE AP)
There has been interval placement of a right chest wall dual
lead pacemaker with the leads projecting over the right atrium
and right ventricle. There is no focal consolidation, pleural
effusion or pneumothorax identified. The size of the cardiac
silhouette is unchanged.
___ Transthoracic Echo Report
Mild basal septal left ventricular hypertrophy with normal
cavity size and mild global systolic dysfunction in the setting
of intraventricular dyssynchrony. Moderate tricsupid
regurgitation. Mild pulmonary artery systolic hypertension.
Trivial pericardial effusion.
___ Pacemaker Interrogation Report
Interrogation:
Battery voltage/time to ERI: N/A
Presenting rhythm: Atrial fibrillation
Underlying rhythm: Sinus rhythm
Mode,base and upper track rate:
Lead Testing
P waves: 3.4 mv A thresh: 0.375 V@ 0.4 ms A imp:
399 ohms
R waves: 11.1 mv RV thresh: 0.375 V@ 0.4 ms RV imp:
418 ohms
Diagnostics:
AP: 19.1
VP: 0.4
Events: Many AHR events overnight
Summary:
1. Pacer function normal with acceptable lead measurements and
battery status
2. Programming changes: None
3. Follow-up: Follow-up in device clinic in one week and with
Dr. ___ in one month.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon 12 2 CAP PO TID W/MEALS
2. Omeprazole 20 mg PO DAILY
3. Propranolol 10 mg PO TID
4. Ursodiol 500 mg PO DAILY
5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY
3. Cephalexin 500 mg PO Q6H Duration: 2 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*8 Tablet Refills:*0
4. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate Duration: 7 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*42 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Propranolol 40 mg PO TID
RX *propranolol 40 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
9. Creon 12 2 CAP PO TID W/MEALS
10. Omeprazole 20 mg PO DAILY
11. Ursodiol 500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
# Displaced Left Femoral Neck Fracture
# Paroxysmal Atrial Fibrillation
# Paroxysmal Atrial Tachycardia
# Sinus Conversion Pauses
# Sick Sinus Syndrome
# Presence of Pacemaker
# Acute Blood Loss Anemia
# ___ Cirrhosis
# Esophageal Varices
# Type 2 diabetes mellitus with hyperglycemia
SECONDARY DIAGNOSES:
# Thrombocytopenia
# Venous stasis
# Pancreatic insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - may require assistance or aid
(walker or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: LEFT HEMI, FX.
TECHNIQUE: Portable frontal/cross-table view of the left hip
COMPARISON: ___
FINDINGS:
The patient is status post left hip hemi arthroplasty, in overall anatomic
alignment. No periarticular fracture is detected. Soft tissue swelling, and
subcutaneous emphysema, are compatible with recent surgery.
IMPRESSION:
Status post left hip prosthesis in overall anatomic alignment.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man following hemiarthroplasty, now with oxygen
requirement.// Observe for atelectasis, pneumonia, scarring Observe for
atelectasis, pneumonia, scarring
IMPRESSION:
Comparison to ___. No relevant change. Borderline size of the
cardiac silhouette. Mild elongation of the descending aorta. No pneumonia,
no pulmonary edema, no pleural effusions.
Radiology Report
INDICATION: ___ year old man with atrial fib s/p dual chamber ppm (initially
attempted on left, and subsequently placed on right)// Rule out pneumothorax
(bilaterally)
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There has been interval placement of a right chest wall dual lead pacemaker
with the leads projecting over the right atrium and right ventricle. There is
no focal consolidation, pleural effusion or pneumothorax identified. The size
of the cardiac silhouette is unchanged.
IMPRESSION:
Interval placement of a right chest wall dual lead pacemaker. Confirmation of
lead placement is recommended with a frontal and lateral chest radiograph. No
pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Hip pain, s/p Fall, Transfer
Diagnosed with Fracture of unsp part of neck of left femur, init, Other fall on same level, initial encounter
temperature: 98.0
heartrate: 85.0
resprate: 18.0
o2sat: 94.0
sbp: 136.0
dbp: 99.0
level of pain: 5
level of acuity: 2.0 | BRIEF SUMMARY
=============================
Mr. ___ is an ___ y/o man with h/o NASH cirrhosis c/b varices,
admitted for left hip fracture after mechanical fall s/p
successful hemiarthroplasty. Course was complicated by newly
diagnosed paroxysmal AFib/ATach, sick sinus syndrome, and
symptomatic sinus pauses requiring pacemaker placement. He was
discharged in good condition to acute rehab with close follow
up.
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
ACUTE ISSUES
============================
# Left femoral neck fracture s/p hemiarthroplasty (___):
The patient was initially admitted to the Orthopedic Surgery
service and taken to the OR on ___ for L hip
hemiarthroplasty, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient worked with ___ who determined that
discharge to acute rehab was appropriate.
# Paroxysmal atrial fibrillation / atrial tachycardia:
# Sick sinus syndrome:
# Symptomatic sinus pauses s/p dual-chamber pacemaker (___):
On POD#2 the patient was noted to have sinus pauses on telemetry
with accompanying mild hypotension and dizziness. Telemetry and
EKGs also demonstrated paroxysmal bouts of rapid AFib/ATach. The
patient was transferred to the Medicine service and EP was
consulted. Evaluation for reversible etiologies was negative
including infection, hypovolemia/hemorrhage, ischemia, and
thyroid dysfunction. He underwent successful dual-chamber
pacemaker placement on ___ (right-sided due to difficult with
left-sided access). Prophylactic vancomycin was given while
inpatient, switched to cephalexin on discharge. Apixiban was
started for anticoagulation. The patient continued to have
intermittent bouts of AT/AF on telemetry without symptoms.
Propranolol was titrated up with improved suppression of AT/AF
but more v-pacing. (Non-selective beta-blockade was continued
instead of metoprolol due to dual indication of variceal
bleeding prophylaxis, which patient's hepatologist felt was
important.) He may require further adjustment as an outpatient
based on pacemaker interrogations.
# Acute blood loss anemia:
Hgb fell to 9.6 from baseline 12.5 post-op and then stabilized.
Apixiban was started without evidence of further bleeding. No
transfusions were required.
# NASH cirrhosis c/b portal hypertension, esophageal varices:
No history of major complications. MELD labs remained at
baseline. Propranolol was continued for variceal prophylaxis and
increased for AT/AF as above.
#DM2 with reactive hyperglycemia:
Diet controlled at home with A1c at goal (7.1%). Patient had
mild asymptomatic hyperglycemia to the 200s post-op, likely
reactive to hip fracture, improving by discharge. He was
discharged on conservative sliding-scale insulin which can be
discontinued or transitioned to an oral agent.
CHRONIC ISSUES
===========================
#Thrombocytopenia:
From cirrhosis, remained stable at baseline.
#Venous stasis:
Patient's chronic lower extremity edema remained at baseline. No
evidence of cardiac, hepatic, or renal dysfunction to account
for edema. Continued compression stockings.
#Pancreatic insufficiency:
Due to Whipple in 1980s. Continued home Creon.
TRANSITIONAL ISSUES
===============================
Discharge weight: 85.6 kg (bed weight)
Discharge Hgb: 10.0
Discharge Cr: 0.8
Discharge MELD score: 12 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy
History of Present Illness:
___ with no PMH who presents with a two day history of
constant RUQ/right back pain. He States that the has had several
episodes of similar pain in the past all of which have been much
shorter lived. He went to an OSH last night and discharged after
a negative CT scan. He presents to ___ today because the pain
has not resolved. He denies any fevers, chills, nausea, vomiting
or changes in his bowel habits.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
General: Awake and alert
CV: Regular rate and rhythm
Resp: CTAB
Abd: Soft, appropriately tender, incisions healing appropriately
Ext: Warm and well-perfused
Pertinent Results:
___
21:35
Lactate:0.9
___
15:50
RED
Color
Yellow Appear
Hazy SpecGr
1.021 pH
8.0 Urobil
Neg Bili
Neg
Leuk
Neg Bld
Neg Nitr
Neg Prot
Tr Glu
Neg Ket
Neg
RBC
<1 WBC
1 Bact
Few Yeast
None Epi
1
Other Urine Counts
Mucous: Rare
___
14:44
Blue-Hold:Hold
Comments: HoldBLu: Discard Greater Than 24 Hrs Old
LtGreen-Hold:Hold
Green-Hold:Hold
Comments: GreenHd: Discard Greater Than 4 Hours Old
137 99 11 97 AGap=17
3.8 25 0.8
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
estGFR: >75 (click for details)
ALT: 44 AP: 79 Tbili: 1.0 Alb: 4.6
AST: 24 LDH: Dbili: TProt:
___: Lip: 19
84
11.0 15.1 141
43.9
N:73.1 L:13.6 M:12.1 E:0.7 Bas:0.3 ___: 0.2 Absneut: 8.04
Abslymp: 1.49 Absmono: 1.33 Abseos: 0.08
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with abdominal pressure and "chest tightness" with
minor cough.
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: ___ male with multiple days of abdominal pressure/pain
with no significant past medical history. A CT from an outside hospital
raised suspicion for a small bowel obstruction versus ileus. Evaluate for
progression of small obstruction versus ileus. Evaluate for cholecystitis.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS. No oral
contrast was administered.
DOSE: This study involved 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
4) Spiral Acquisition 5.1 s, 55.5 cm; CTDIvol = 16.0 mGy (Body) DLP = 887.8
mGy-cm.
Total DLP (Body) = 896 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Lung bases are clear. Dependent atelectasis is noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. There is pericholecystic fluid/gallbladder
wall edema a subtle haziness of the adjacent fat. Multiple gallstones are
also seen. (series 2:image 37).
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is collapsed and not well evaluated. Small
bowel loops demonstrate normal caliber, wall thickness and enhancement
throughout. Colon and rectum are within normal limits. Appendix is normal in
size without evidence of fat stranding. There is no evidence of mesenteric
lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden in
the abdominal aorta and great abdominal arteries. The abdominal aorta and its
major branches are patent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Prostate and seminal vesicles are unremarkable.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions.
There is no fracture. Abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Mildly distended gallbladder with gallstones and pericholecystic
fluid/gallbladder wall edema with subtle haziness of the adjacent fat is
concerning for acute cholecystitis. Recommend clinical correlation, and a
right upper quadrant ultrasound can be obtained for further evaluation as
indicated.
2. No small-bowel obstruction.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with abdominal pain, ?cholecystitis // presence of
cholecystitis
TECHNIQUE: Gray scale and color Doppler sonographic evaluation of the right
upper quadrant was obtained.
COMPARISON: No prior ultrasound available for comparison. Reference made to
CT abdomen pelvis from earlier today.
FINDINGS:
The liver ishomogeneous but intrahepatic lesion seen. There may be slight
prominence of the intrahepatic bile ducts without frank dilatation. The
common bile duct is normal in caliber and measures4 mm. The gallbladder
contains multiple stones. Some stones at the gallbladder neck do not appear
mobile. The gallbladder wall is thickened. The gallbladder itself is not
dilated. The main portal vein is patent with hepatopetal flow. Limited image
of the right kidney demonstrates no hydronephrosis. No free fluid is seen.
IMPRESSION:
Nondilated gallbladder contains multiple stones; stones at the gallbladder
neck are seen which do not appear mobile. Gallbladder wall thickening.
Absent sonographic ___ sign. In the appropriate clinical setting, acute
cholecystitis is not excluded and should be considered.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with CHOLELITH W AC CHOLECYST
temperature: 99.0
heartrate: 103.0
resprate: 20.0
o2sat: 98.0
sbp: nan
dbp: nan
level of pain: 2
level of acuity: 2.0 | Mr. ___ was admitted on ___ under the acute care surgery
service for management of her acute cholecystitis. He was taken
to the operating room and underwent a laparoscopic
cholecystectomy. Please see operative report for details of this
procedure. He tolerated the procedure well and was extubated
upon completion. He was subsequently taken to the PACU for
recovery.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and she remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. His diet was advanced on the morning of POD #1
to regular, which he tolerated without abdominal pain, nausea,
or vomiting. He was voiding adequate amounts of urine without
difficulty. He was encouraged to mobilize out of bed and
ambulate as tolerated, which he was able to do independently.
His pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed.
On POD 1, he was discharged home with scheduled follow up in ___
clinic in 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right basal ganglia IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old right-handed man who presents with left
leg weakness, R side HA found with 2x3 basal ganglia IPH
The patient has no known past medical history. He woke early at
2:30 in his usual state of health (he is a ___, he normally
gets up this early). He was walking down the hall when his left
leg suddenly became weak. He had no other complaints. He had to
slide himself down the stairs because he could not walk and when
he got to the bottom, he had trouble pulling himself up to
stand. He called for his wife who arrived to help. Because he
thought he was having an ischemic stroke, he took two 325mg
aspirin. EMS was called and he was brought to ___
___ where he was found to have an ovoid 2x3cm right basal
ganglia hemorrhage. There, he developed a mild to moderate right
sided headache.
On arrival here, he was hypertensive to the 180s and nicardipine
was started (full vitals pain=5 98.8 86 187/118 16 96% RA).
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness other than that in
his leg, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
none
Social History:
___
Family History:
No history of stroke or MI in the young
Physical Exam:
Admission Physical Exam:
VS: 5 98.8 86 187/118 16 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects as
allowed by his vision (he does not have his glasses with him).
Able to read without difficulty as allowed by vision. Speech was
mildly dysarthric (dentured firmly in place, ? lingual). Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation without
neglect. Fundoscopic exam deferred
III, IV, VI: EOMI without nystagmus. Coarse saccades.
V: Facial sensation intact to light touch but diminished to pin
prick in V1-3 on the left.
VII: Mild lower left facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Left pronator drift. Left
toe is up. Right is down.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 4- 5- 4+ ___- 4- 4+ 4 5- 5 4+ 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: Left hemibody including trunk is diminished to pin
prick. However, no deficits to light touch, or proprioception.
Vibration is diminsihed bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 3
R 2 2 2 2 1
-Coordination: Mild clumsiness left hand but no frank intention
tremor noted. No obvious dysmetria on FNF or HKS bilaterally.
-Gait: Deferred
Pertinent Results:
ADMISSION LABS:
___ 06:20AM BLOOD WBC-11.2* RBC-5.33 Hgb-15.6 Hct-48.5
MCV-91 MCH-29.2 MCHC-32.1 RDW-13.5 Plt ___
___ 06:20AM BLOOD Neuts-83.8* Lymphs-9.6* Monos-4.9 Eos-0.9
Baso-0.8
___ 06:20AM BLOOD ___ PTT-29.5 ___
___ 06:20AM BLOOD Glucose-150* UreaN-14 Creat-0.7 Na-140
K-3.4 Cl-105 HCO3-28 AnGap-10
___ 06:20AM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD Calcium-9.1 Phos-1.2* Mg-1.9
URINE:
___ 06:30AM URINE Color-Straw Appear-Clear Sp ___
___ 06:30AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:30AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-<1
IMAGING:
CT HEAD ___:
IMPRESSION:
Overall, there has been no significant change in the size of the
right
thalamic/basal ganglia intraparenchymal hemorrhage. There has,
however, been further increase of intraventricular hemorrhage
with new hemorrhage seen in the atria of the left lateral
ventricle.
CXR ___:
FINDINGS: No previous images. Cardiac silhouette is within
normal limits and there is no evidence of vascular congestion,
pleural effusion, or acute focal
pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY:PRN pain
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right basal ganglia intraparenchymal hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History of right thalamic basal ganglia intraparenchymal
hemorrhage with intraventricular extension. Please evaluate for interval
change.
COMPARISONS: CT from ___ performed at 4:44 a.m.
TECHNIQUE: ___ MDCT images were obtained through the brain without the
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axis were generated and reviewed.
DLP: 891 mGy-cm.
CTDIVOL: 53 mGy.
FINDINGS: There is a 2.6 cm x 2.1 cm intraparenchymal hemorrhage centered at
the right thalamus with extension to the basal ganglia demonstrating no
significant interval change compared to the prior exam performed on the same
day at 4:44 a.m. Hemorrhage is seen within the frontal and occipital horns of
the right lateral ventricle and a small amount of intraventricular hemorrhage
is seen in the atria of the left lateral ventricle. There is mild surrounding
edema. The basilar cisterns are patent and there is otherwise preservation of
the gray-white matter differentiation. The ventricles and sulci are normal in
size.
There is no evidence of fracture or malalignment. Visualized paranasal
sinuses, mastoid air cells and middle ear cavities are clear. The globes are
unremarkable.
IMPRESSION:
Overall, there has been no significant change in the size of the right
thalamic/basal ganglia intraparenchymal hemorrhage. There has, however, been
further increase of intraventricular hemorrhage with new hemorrhage seen in
the atria of the left lateral ventricle.
Radiology Report
HISTORY: IPH, to assess for cardiomegaly.
FINDINGS: No previous images. Cardiac silhouette is within normal limits and
there is no evidence of vascular congestion, pleural effusion, or acute focal
pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L SIDE WEAKNESS
Diagnosed with INTRACEREBRAL HEMORRHAGE
temperature: 98.8
heartrate: 86.0
resprate: 16.0
o2sat: 96.0
sbp: 187.0
dbp: 118.0
level of pain: 5
level of acuity: 2.0 | ___ no known PMHx (likely undiagnosed HTN) p/w right basal
ganglia/thalamic bleed with intraventricular extension. He did
take two 325mg tabs of ASA prior to admission. The etiology is
probably hypertensive; underlying vascular malformations or
metastases are relatively unlikely but should be evaluated by
MRI brain with and without contrast in eight weeks when some of
the acute blood has resolved.
In the ICU, follow up NCHCT were stable. He was started on
nicardipine to manage BP closely. Oral agents ultimately
replaced this gtt (HCTZ and labetalol). NCHCT 24 hours after
was stable. DVT ppx was added 48 hours after initial event. He
was transferred out of the ICU on ___ and continued to do well.
He had episodes of near vagal syncope likely due to the
labetalol. His labetalol was weaned and he was started on
lisinopril. He no longer had episodes of near syncope. He was
seen by physical therapy who recommended rehab. He had an echo
that showed LVH but otherwise was unremarkable.
====================================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () Not
confirmed - () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
4. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
5. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
==================================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
sulfa / tramadol
Attending: ___.
Chief Complaint:
Diarrhea, Failure to Thrive
Major Surgical or Invasive Procedure:
___ Placement of dobhoff tube
___ ___ Guided advancement of dobhoff
___ ___ Guided placement of Gastro-Jejunal Tube
History of Present Illness:
Ms. ___ is a ___ female with locally advanced
pancreatic adenocarcinoma initially on chemotherapy with
FOLFIRINOX but transitioned to mFOLFOX with cycle 3 due to
severe diarrhea, colitis, and weight loss as well as s/p CK SBRT
completed ___ who presents with diarrhea and failure
to thrive.
Patient had recent fall about four weeks ago when she was in her
bathroom and had a mechanical fall in which she fell forward and
hit hear nose resulting in a brief nosebleed. She spends most of
the day in bed and is very fatigued. She has no appetite, food
tastes "like dirt" and has decreased thirst. She has primarily
eating cream of wheat. She notes significant weight loss, about
60 pounds over the past 6 months. Also notes up to four episodes
of green stool daily with occasional incontinence. Her sister is
concerned she may have had more frequent falls as the patient
has multiple bruises. Of note, she lives with her ___
mother who is unable to care for the patient at home. She was
seen in clinic this morning with plan for direct admission for
failure to thrive and starting tube feeds but was sent to the ED
as no beds were available.
Of note, patient was in clinic on ___ for her C5D15 FOLFOX.
At that time plan for was a four week treatment break. She has
recently started on pancreatic enzyme supplementation in
addition to dronabinol and remeron. She had been using marijuana
lollipops and believes this helped with her appetite but she ran
out.
On arrival to the ED, initial vitals were 97.8 85 85/52 16 99%
RA. Exam notable for cachectic, soft abdomen, dry mucuous
membranes. Labs were notable for WBC 3.0, H/H 11.9/32.0, Plt
204, Na 130, K 3.2, BUN/Cr ___, Mg 1.5, LFTs wnl, lactate 1.2.
CT head was negative for acute process. Patient was given 2L NS.
Prior to transfer vitals were
On arrival to the floor, patient is without acute complaint.
Denies fevers or chills. No SOB or cough. No dysphagia or
odynophagia. Reports all food tastes like dirt. No N/V. Reports
up to 4 loose stools per day with occaisional incontinence. No
dysuria. Uses cane at baseline. No new rashes or joint pains.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ has a prior history of IPMN diagnosed on CT in ___
that had been performed to evaluate for diverticulitis. She has
been followed with annual MRCP. In ___ she was
diagnosed with diabetes mellitus. This was associated with a
55-pound intentional weight loss over the following six months.
Routine surveillance MRCP ___, however, identified a
new 2.9 cm mass in the pancreatic body involving the celiac
artery, SMA, SMV, and portal vein. Biopsy of this by endoscopic
ultrasound showed adenocarcinoma. Ms. ___ was diagnosed with
locally advanced unresectable pancreatic adenocarcinoma and
initiated FOLFIRINOX systemic chemotherapy ___. With cycle
3 she transitioned to mFOLFOX due to severe diarrhea and weight
loss. She received CK SBRT ___.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. History of obesity.
3. Status post cholecystectomy.
4. Status post hernia repair.
5. History of hyperplastic polyp on colonoscopy.
6. Hypertension.
7. Hypercholesterolemia.
8. UE DVT sp 3 months treatment with lovenox (DC'd ___
Social History:
___
Family History:
The patient's father was treated for colon cancer in his ___ and
had coronary artery disease. Her mother and sister are treated
for coronary artery disease. Her maternal grandmother was
treated for colon cancer. A maternal cousin was treated for
breast cancer in her ___ and maternal aunt was treated for lung
cancer and another maternal aunt was treated for liver cancer. A
paternal aunt was treated for lung cancer. She has no children.
Physical Exam:
========================
Admission Physical Exam:
========================
VS: T98.0 BP 90/59 HR 68 RR 16 O2 98%RA.
GENERAL: Pleasant, lying in bed comfortably.
EYES: Anicteric sclerea, PERLL, EOMI.
ENT: Dry MM with mild thrush over tongue. JVD not elevated.
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses.
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi.
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly.
MUSKULOSKELATAL: Warm, well perfused extremities, no edema;
Normal bulk.
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact.
SKIN: No significant rashes.
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses.
======================================
Discharge Physical Exam:
======================================
VS:97.8 120/70 76 16 96%RA
GENERAL: Pleasant, lying in bed comfortably.
EYES: Anicteric sclerea, PERLL, EOMI.
ENT: MMM . JVD not elevated.
CARDIOVASCULAR: RRR, no murmurs, rubs, or gallops; 2+ radial
pulses.
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi.
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly. GJ site covered with clean dressings.
MUSKULOSKELETAL: Warm, well perfused extremities, no edema;
normal bulk.
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact.
SKIN: No significant rashes.
Pertinent Results:
===============
Admission Labs:
===============
___ 10:30AM BLOOD WBC-3.0* RBC-3.65* Hgb-11.9 Hct-32.0*
MCV-88 MCH-32.6* MCHC-37.2* RDW-15.6* RDWSD-49.4* Plt ___
___ 10:30AM BLOOD UreaN-7 Creat-0.5 Na-130* K-3.2* Cl-97
HCO3-20* AnGap-16
___ 10:30AM BLOOD ALT-18 AST-23 AlkPhos-94 Amylase-28
TotBili-0.2
___ 10:30AM BLOOD Lipase-10
___ 10:30AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.0 Mg-1.5*
___ 12:32PM BLOOD Lactate-1.2
___ 12:02AM BLOOD TSH-1.2
___ 12:02AM BLOOD Cortsol-5.0
___ 12:02AM BLOOD ___ PTT-39.5* ___
===============
Discharge Labs:
===============
___ 06:15AM BLOOD WBC-6.2 RBC-2.49* Hgb-8.2* Hct-22.1*
MCV-89 MCH-32.9* MCHC-37.1* RDW-15.4 RDWSD-50.0* Plt ___
___ 06:17AM BLOOD Glucose-126* UreaN-6 Creat-0.3* Na-138
K-4.0 Cl-103 HCO3-25 AnGap-14
___ 05:10AM BLOOD LD(LDH)-156 TotBili-0.2
___ 06:17AM BLOOD Calcium-8.1* Phos-4.6* Mg-1.5*
=============
Microbiology:
=============
___ C. Diff PCR - Negative
========
Imaging:
========
CT Head w/o Contrast ___
1. No evidence of acute intracranial process. No evidence of
hemorrhage.
2. Age-advanced cerebral volume loss.
3. Nonspecific periventricular and subcortical ___ matter
hypodensities are likely sequelae of chronic small vessel
ischemic disease. However given lack of prior imaging, nonurgent
MRI may be considered for further characterization.
CXR ___
Impression: The Dobhoff tube is seen at the GE junction should
be advanced for optimal positioning.
___ Tube Placement w/ Fluoro ___
Impression: Successful post-pyloric advancement of a Dobhoff
feeding tube. The tube is ready to use.
Gastro-jejunostomy placement ___
Successful placement of a 16 ___ MIC gastrojejunostomy tube
with its tip in the proximal jejunum.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 10 mg PO DAILY
2. LOPERamide 2 mg PO QID:PRN diarrhea
3. LORazepam 0.5-1 mg PO Q6H:PRN nausea/insomnia
4. Potassium Chloride 20 mEq PO BID
5. Pravastatin 40 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Dronabinol 2.5 mg PO DAILY
9. Dexamethasone 4 mg PO ASDIR
10. Creon 12 2 CAP PO TID W/MEALS
11. Mirtazapine 15 mg PO QHS
12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
13. pegfilgrastim 6 mg/0.6mL subcutaneous ASDIR
Discharge Medications:
1. Famotidine 20 mg PO Q12H
2. Opium Tincture (morphine 10 mg/mL) 3 mg PO BID
RX *opium tincture 10 mg/mL (morphine) 3 mL by mouth twice a day
Refills:*0
3. Psyllium Wafer 2 WAF PO BID
4. Creon 12 3 CAP PO BID
5. LOPERamide 4 mg PO BID diarrhea
6. Dronabinol 2.5 mg PO DAILY
7. LORazepam 0.5-1 mg PO Q6H:PRN nausea/insomnia
8. MetFORMIN (Glucophage) 1000 mg PO DAILY
9. Mirtazapine 15 mg PO QHS
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. HELD- Enalapril Maleate 10 mg PO DAILY This medication was
held. Do not restart Enalapril Maleate until your primary care
doctor recommends you to
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
Failure to thrive
Diarrhea, osmotic
Mechanical falls
SECONDARY
Advanced Pancreatic Adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with FTT, cancer, falls with headstrike // Hemorrhage or
hematoma
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 14.0 s, 15.2 cm; CTDIvol = 46.2 mGy (Head) DLP =
702.4 mGy-cm.
2) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute infarction, hemorrhage, edema, or mass. There
is prominence of the ventricles and sulci suggestive of age- advanced cerebral
volume loss. Scattered periventricular and subcortical white matter
hypodensities, which are slightly asymmetric, right greater than left. These
hypodensities are nonspecific, though likely sequelae of chronic small vessel
ischemic disease.
There is no evidence of acute fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial process. No evidence of hemorrhage.
2. Age-advanced cerebral volume loss.
3. Nonspecific periventricular and subcortical white matter hypodensities are
likely sequelae of chronic small vessel ischemic disease. However given lack
of prior imaging, nonurgent MRI may be considered for further
characterization.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman s/p dobhoff placement. ___ need 2 x-rays. //
Evaluate for dobhoff placement.
TECHNIQUE: Portable AP view of the chest
COMPARISON: Chest radiograph from ___
FINDINGS:
The Dobhoff tube is seen at the GE junction and should be advanced for optimal
positioning. A left Port-A-Cath tip is in unchanged position at the
cavoatrial junction. Otherwise, lung volumes are low without focal
consolidation. There is no pulmonary edema or pneumothorax. The
cardiomediastinal silhouette and hilar contours are unchanged.
IMPRESSION:
The Dobhoff tube is seen at the GE junction should be advanced for optimal
positioning.
RECOMMENDATION(S): Recommend advancement of the enteric tube for optimal
positioning.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:10 AM, 1 minutes after discovery
of the findings.
Radiology Report
INDICATION: ___ year old woman with pancreatic cancer and severe weight loss
s/p NG tube placement. // Please advance NG tube post-pyloric. Please place
bridle.
DOSE: Acc air kerma: 1.95 mGy; Accum DAP: 50.53 uGym2; Fluoro time: 00:21 min
COMPARISON: None.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, the existing Dobhoff feeding tube was advanced
post-pylorically using a guidewire.
10 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the tip of the feeding tube in the
fourth portion of the duodenum.
Bridle placement was attempted, but unsuccessful. This may be related to the
larger caliber of the feeding tube. Therefore, the feeding tube was affixed
to the patient's nose and cheek using tape.
IMPRESSION:
Successful post-pyloric advancement of a Dobhoff feeding tube. The tube is
ready to use.
Radiology Report
INDICATION: ___ year old woman with locally advanced pancreatic cancer and
failure to thrive. 20kg weight loss so need for >3mo TFs. // Please place G-J
tube for feeding
COMPARISON: ___ tube placement from ___.
TECHNIQUE: OPERATORS: Dr. ___ resident and Dr. ___,
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 46 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, Versed, 1% lidocaine.
CONTRAST: 15 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.4 min, 205 mGy
PROCEDURE: 1. Placement of a MIC gastrojejunostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. The needle
trajectory was directed towards the pylorus. A Amplatz wire was introduced and
coiled within the stomach. A small skin incision was made along the needle,
and the needle was removed.
A 6 ___ sheath was placed. A Kumpe catheter was then introduced over the
wire and the Amplatz wire was exchanged for ___ wire. The wire and a
Kumpe cathter was used to advance the wire into the ___ part of the duodenum.
The wire was removed, and contrast was hand injected to confirm positioning in
a post pyloric position. The sheath was then removed, and the gastrostomy
tract was serially dilated. A peel-away sheath was placed over the wire. A 16
___ MIC gastrojejunostomy catheter was advanced over the wire into
position. The sheath was then peeled away.
The wire and sheath were removed. The catheter was locked by instilling 9 ml
of dilute contrast into the balloon in the distal stomach and then pulled back
after confirming the position of the catheter with a contrast injection. The
catheter was then flushed, capped and secured to the skin. Sterile dressings
were applied. The patient tolerated the procedure well and there were no
immediate complications.
FINDINGS:
1. Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip
in the proximal jejunum.
IMPRESSION:
Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in
the proximal jejunum. The gastric port should not be used for 24 hours.
Radiology Report
INDICATION: ___ year old woman with severe persistent diarrhea for months
following chemotherapy - prior CTs show diffuse colitis that was never clearly
explained and off chemo for a while now so shouldn't be still ongoing // eval
for presence/progression/worsening of previously seen colitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 12.0 s, 0.2 cm; CTDIvol = 204.7 mGy (Body) DLP =
40.9 mGy-cm.
3) Spiral Acquisition 8.5 s, 54.9 cm; CTDIvol = 7.7 mGy (Body) DLP = 415.2
mGy-cm.
Total DLP (Body) = 458 mGy-cm.
COMPARISON: CTA ___
FINDINGS:
LOWER CHEST: New areas of opacity at both lung bases are likely related to
atelectasis. There are small bilateral pleural effusions. There is central
line with tip at cavoatrial junction
ABDOMEN:
HEPATOBILIARY: The liver appears diffusely hypoattenuating suggestive of
hepatic steatosis. A small lesion in segment 8 of the liver (series 5, image
12) appears essentially stable in size measuring 9 mm and was previously
characterized as a probable hemangioma. There is no biliary ductal
dilatation. The gallbladder the patient is status post cholecystectomy.
There is small volume free peritoneal air, may be related to percutaneous
gastrostomy, clinically correlate
PANCREAS: The patient's known pancreatic head mass appears stable in size
measuring 3.7 cm x 3.0 cm x 3.7 cm. There is dilation of the pancreatic duct
in the body and tail of the pancreas. The mass is seen to completely encase
the patent proximal SMA, and infiltrates about patent celiac trunk
bifurcation, main portal vein is occluded or nearly occluded at the level of
the mass with surrounding venous collaterals, stable to prior. SMV is patent.
Splenic vein is occluded, stable.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a percutaneous gastrojejunostomy tube in place.
There is a small amount of intraperitoneal free air, including air layering in
the porta hepatis, which may be related to a percutaneous gastrojejunostomy
tube placement. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. There is diverticulosis in the sigmoid colon.
Prominence of the colonic wall predominantly involving the transverse colon
and right colon appear similar to the prior exam. Wall thickening of the
descending colon and sigmoid appears improved.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
mild pelvic ascites increased since prior.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: Prominent lymph nodes in the porta hepatis and adjacent to the
pancreas appear stable. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Small fat only containing bilateral inguinal hernias.
IMPRESSION:
1. Improvement of wall thickening involving the descending and sigmoid colon.
There is persistent wall thickening in the transverse colon and right ___,
___ be reactive, from venous congestion, or represent colitis.
2. Stable appearance of the patient's known pancreatic mass with surrounding
upper abdominal lymphadenopathy.
3. Small volume of free peritoneal air, may be related to percutaneous
gastrostomy, clinically correlate.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Failure to thrive, Diarrhea
Diagnosed with Weakness
temperature: 97.8
heartrate: 85.0
resprate: 16.0
o2sat: 99.0
sbp: 85.0
dbp: 52.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a ___ female with locally advanced
pancreatic adenocarcinoma initially on chemotherapy with
FOLFIRINOX but transitioned to mFOLFOX with cycle 3 due to
severe diarrhea, colitis, and weight loss as well as s/p CK SBRT
completed ___ who presents with diarrhea and failure
to thrive.
# Failure to Thrive / Severe Protein-Calorie Malnutrition: Has
been monitored closely by her outpatient oncologist. Have
trialed pancreatic enzyme supplementation along with
dronabionol, mirtazapine, and marijuana lollipops (while holding
dronabinol). Had hoped toavoid supplemental TF's, however given
progressive weight loss of >20kg along with multiple falls at
home, nutritional support with tube feeding was started. She had
dobhoff placed on ___ and tube feeds were started.
She had dobhoff advanced to post-pyloric. As she needs to gain
at least 20kg more she a G-J tube was placed and tube feeds were
started and adjusted until goal rate.
She was continued on dronabinol, mirtazapine, pancreatic enzymes
and glucerna tid as tolerated. Her weight on admission was 56kg
and it was 64 kg on discharge. She was tolerating osmolite but
with some ongoing diarrhea, see below, which seemed to improve
when changed to vital 1.5, so she was discharged on Vital 1.5
full strength, at 95 cc/hr starting at 7 pm cycling through 11
am daily. flush with 200cc water q4 hours.
# Diarrhea: Had it since prior to admission, she did not
havefevers or abdominal pain. C. diff negative was on admission.
Given multiple NPO/resume feed cycles for procedures it became
quite clear that diarrhea was worse when eating or getting tube
feeds, this is highly consistent with an osmotic diarrhea and
seemed to make colitis less likely. Diarrhea had initially
improved with scheduled loperamide and
pancreatic enzyme supplementation. When changed to GJ diarrhea
worsened significantly to up to 6 large loose stools per day.
She was switched to Osmolite from Jevity. Psyllium wafers,
standing loperamide and tincture of opium were initiated. Prior
history of colitis on imaging (C.diff neg) and repeat CT a/p
showed some residual likely portal colopathy (known portal vein
occlusion), reviewed briefly with GI who felt this was not
likely to explain symptoms and plan with anti-diarrheals
reasonable, can uptitrate loperamide to QID if needed or
uptitrate tincture of opium. Pt finally had a formed BM after
changing her tube feeds to Vital 1.5 full strength. Diarrhea had
improved on Osmolite but improved further when switched to Vital
1.5, but if needed she could resume Osmolite tube feeds (if that
is resumed, she was on osmolite 1.5 Cal Full strength, rate 95
ml/hr cycling overnight from 7pm to 11 AM. Flush with 200ml
water q4 hours).
# Cognitive Changes: Per primary Oncologist, patient with
cognitive changes with short term memory loss and poor
concentration as well as weakness/imbalance. Perhaps related to
severe malnutrition. Head CT negative. Less concern for brain
metastases as non-focal. Neurology consulted and recommended
ordering outpatient Neuropsychiatric testing.
# Hyponatremia: Likely hypovolemic and improved with IVF and
nutrition. TSH and
AM cortisol normal. Normal Na upon discharge.
# Anemia: Hemoconcentrated on admission. Likely related to
malignancy and chemotherapy. Did find borderline B12 levels at
288 though no macrocytosis, initiated B12 IM supplementation on
___ with plan for 1 week of IM supplementation at 1000mcg daily
through ___, then pt can start b12 po daily repletion. She was
given 1u RBC on ___ with appropriate response.
# Locally Advanced Unresectable Pancreatic Adenocarcinoma: SP
XRT and 6 cycles mFOLFOX. Currently on hold for at least 4 week
treatment break. No evidence of biliary obstruction at present.
# Hypokalemia/Hypomagnesemia: Secondary to malnutrition.
Repleted per sliding scale. pt continued to have low magnesium
despite repletion. She was started on BID mg oxide repletion.
Please check electrolytes including magnesium on ___ and
continue checking daily if needs repletion on ___ until pt is
fully repleted, otherwise check every other day for the next 6
days if diarrhea persists.
# Type II Diabetes: Home metformin was held and resumed on
discharge.
# Hypertension: Helld home enalapril and was normotensive in
house.
# Hyperlipidemia: Held home statin
# Oropharygneal Thrush: Nystatin QID was given to good effect.
Stopped upon discharge
# LUE DVT: Per OMR, discontinued lovenox ___ s/p treatment
for 3+ months. Received DVT prophylaxis with heparinSC while in
house.
TRANSITIONAL ISSUES
====================
-___ titrate standing loperamide and standing tincture of opium
to 2 formed bowel movements every 24h if any change in stool
output. Can go up to QID loperamide and TID tincture of opium
needed. Can increase psyllium wafers as these really helped her.
-Will need intensive education and skill development for tube
feeding and troubleshooting of common issues with tube feeding.
Currently using Vital 1.5 full strength, at 95 cc/hr starting at
7 pm cycling through 11 am daily. flush with 200cc water q4
hours.
- IM B12 repletion through ___ then please initiate po daily
repletion moving forward subsequently
-Please weight every 3 days to see rising trend. Her weight on
discharge was 64 kg.
- pt continued to have low magnesium despite repletion. She was
started on BID mg oxide repletion. Please check electrolytes
including magnesium on ___ and continue checking daily if needs
repletion on ___ until pt is fully repleted, otherwise check
every other day for the next 6 days if diarrhea persists.
-Please contact Dr. ___ office (___)
prior to discharge to schedule for follow-up.
-Has neuro-psych testing and replacement of G-J tube scheduled,
please see appointments sheet. |